Matthew Masoli Denise Fabian Shaun Holt Richard Beasley Medical Research Institute of New Zealand Wellington, New

Zealand University of Southampton Southampton, United Kingdom

Developed for the Global Initiative for Asthma

TM

TABLE OF CONTENTS
Preface ............................................................................................................ii Global Burden of Asthma - Summary ..............................................................1 Barriers to Reducing the Burden of Asthma ......................................................3 Actions Required to Reduce the Burden of Asthma ..........................................5 Ranking of the Prevalence of Current Asthma Symptoms in Childhood by Country (1) ..................................................................................................6 Ranking of the Prevalence of Current Asthma Symptoms in Childhood by Country (2) ..................................................................................................7 Ranking of the Prevalence of Current Asthma Symptoms in Adults by Country ....8 World Map of the Prevalence of Clinical Asthma ............................................9 Ranking of Asthma Mortality by Country........................................................10 World Map of Asthma Case Fatality Rates ......................................................11 Disability-Adjusted Life Years Lost Due to Asthma Worldwide - Ranking with Other Common Disorders ................................................12 World Map of the Proportion of the Population with Access to Essential Drugs....13 Key References ..............................................................................................14 Methodological Issues ....................................................................................15 - Prevalence of Current Asthma Symptoms................................................15 - Prevalence of "Clinical Asthma" ..............................................................17 - Asthma Mortality ....................................................................................18 - Disability-Adjusted Life Years..................................................................19 - Populations with Regular Access to Essential Drugs ................................20 Burden of Asthma in Different Study Regions ................................................21 - Regions ..................................................................................................22 - Scandinavia/Baltic States ........................................................................24 - United Kingdom/Republic of Ireland ......................................................31 - Western Europe ......................................................................................37 - Balkans/Turkey/Caucasus/Mediterranean Islands ....................................45 - Russia and Former Socialist Republics of Eastern Europe ........................50 - Middle East ............................................................................................55 - Central Asia and Pakistan........................................................................60 - Southern Asia..........................................................................................62 - China/Taiwan/Mongolia ..........................................................................67 - Northeast Asia ........................................................................................72 - Southeast Asia ........................................................................................77 - Oceania ..................................................................................................81 - North America ........................................................................................86 - Central America ......................................................................................92 - Caribbean ..............................................................................................96 - South America ........................................................................................99 - North Africa ..........................................................................................104 - West Africa ..........................................................................................107 - East Africa..............................................................................................111 - Southern Africa......................................................................................115 Acknowledgements ......................................................................................119

PREFACE

T IS NOW estimated that as many as 300 million people of all ages, and all ethnic backgrounds, suffer from asthma and the burden of this disease to governments, health care systems, families, and patients is increasing worldwide.

In 1989 the Global Initiative for Asthma (GINA) program was initiated with the U.S. National Heart, Lung, and Blood Institute, NIH and the World Health Organization (WHO) in an effort to raise awareness among public health and government officials, health care workers, and the general public that asthma was on the increase. The GINA program recommends a management program based on the best available scientific evidence to allow doctors to provide effective medical care for asthma tailored to local health care systems and resources. Working in continued collaboration with leaders in asthma care from many countries, and with GINA Sponsors, World Asthma Day (first Tuesday in May) has been extremely successful, increasing in numbers of participants each year. We are indebted to the vast number of people in many countries of the world who have made a commitment to bring awareness about the burden of asthma to their local health care officials, and to implement programs of effective asthma care. In 2003, and again in 2004, the theme of World Asthma Day is the "Global Burden of Asthma." GINA commissioned Professor Richard Beasley, Wellington, New Zealand (and a member of the GINA Dissemination Committee) to provide available data on the burden of asthma. In this report, Professor Beasley and his colleagues obtained data on the burden of asthma in 20 different regions worldwide from literature primarily published through the International Study of Asthma and Allergies in Childhood (ISAAC) and the European Community Respiratory Health Survey (ECHRS). Methodologies differ in these studies, and epidemiological data on asthma are very difficult to collect, as Professor Beasley carefully describes in his segment on Methodological Issues. Nonetheless, this document provides a wealth of information, along with a large number of scientific references. The study regions have been grouped according to geographical, political, historical, and racial considerations based on official data from WHO, the United Nations (UN), and other sources, and to some extent, the availability of asthma epidemiological data within the study region. Using the United Nations World Population Prospect Population Database (http://esa.un.org/unpp) as a source within each region, all countries were included, and in some cases territories and dependencies if specific asthma epidemiological data were available. For simplicity some data from small territories have been omitted or lumped in a larger sub-regional unit. The report will be updated as new information becomes available and following feedback from individual countries and regions. (Additional references, data, and feedback may be submitted at www.ginasthma.com.) The GINA Executive Committee is indebted to Professor Beasley and his colleagues for providing this report that will be an invaluable source of information for those who wish to explore available data on the burden of asthma by region. It will be extremely useful to develop background materials for World Asthma Day activities in 2004 and well into the future. _______________

Tim Clark, MD Chair, GINA Executive Committee (Information about GINA can be found at www.ginasthma.com)

ii

Global Burden of Asthma - Summary

1. Asthma is one of the most common chronic diseases in the world. It is estimated that around 300 million people in the world currently have asthma. Considerably higher estimates can be obtained with less conservative criteria for the diagnosis of clinical asthma. 2. The international patterns of asthma prevalence are not explained by the current knowledge of the causation of asthma. Research into the causation of asthma, and the efficacy of primary and secondary intervention strategies, represent key priority areas in the field of asthma research. 3. Asthma has become more common in both children and adults around the world in recent decades. The increase in the prevalence of asthma has been associated with an increase in atopic sensitisation, and is paralleled by similar increases in other allergic disorders such as eczema and rhinitis. 4. The rate of asthma increases as communities adopt western lifestyles and become urbanised. With the projected increase in the proportion of the world's population that is urban from 45% to 59% in 2025, there is likely to be a marked increase in the number of asthmatics worldwide over the next two decades. It is estimated that there may be an additional 100 million persons with asthma by 2025. 5. In many areas of the world persons with asthma do not have access to basic asthma medications or medical care. Increasing the economic wealth and improving the distribution of resources between and within countries represent important priorities to enable better health care to be provided.

(continued)

Global Burden of Asthma - Summary (continued)

6. The number of disability-adjusted life years (DALYs) lost due to asthma worldwide has been estimated to be currently about 15 million per year. Worldwide, asthma accounts for around 1% of all DALYs lost, which reflects the high prevalence and severity of asthma. The number of DALYs lost due to asthma is similar to that for diabetes, cirrhosis of the liver, or schizophrenia. 7. The burden of asthma in many countries is of sufficient magnitude to warrant its recognition as a priority disorder in government health strategies. Particular resources need to be provided to improve the care of disadvantaged groups with high morbidity, including certain racial groups and those who are poorly educated, live in large cities, or are poor. Resources also need to be provided to address preventable factors, such as air pollution, that trigger exacerbations of asthma. 8. It is estimated that asthma accounts for about 1 in every 250 deaths worldwide. Many of the deaths are preventable, being due to suboptimal long-term medical care and delay in obtaining help during the final attack. 9. The economic cost of asthma is considerable both in terms of direct medical costs (such as hospital admissions and cost of pharmaceuticals) and indirect medical costs (such as time lost from work and premature death). 10. Until there is a greater understanding of the factors that cause asthma and novel public health and pharmacological measures become available to reduce the prevalence of asthma, the priority is to ensure that cost-effective management approaches which have been proven to reduce morbidity and mortality are available to as many persons as possible with asthma worldwide.

Barriers to Reducing the Burden of Asthma

1. Generic barriers including poverty, poor education, and poor infrastructure. 2. Environmental barriers including indoor and outdoor air pollution, tobacco smoking, and occupational exposures. 3. Low public health priority due to the importance of other respiratory illnesses such as tuberculosis and pneumonia and the lack of data on morbidity and mortality from asthma. 4. The lack of symptom-based rather than disease-based approaches to the management of respiratory diseases including asthma. 5. Unsustainable generalisations across cultures and health care systems which may make management guidelines developed in high-income countries difficult to implement in low and middle-income countries. 6. Inherent barriers in the organisation of health care services in terms of a. geography b. type of professional responding c. education and training systems d. public and private care e. tendency of care to be "acute" rather than "routine." 7. The limited availability and use of medications including a. omission of basic medications from WHO or national essential drug lists b. poor supply and distribution infrastructure c. cost d. cultural attitudes towards drug delivery systems, e.g. inhalers

(continued) 3

Barriers to Reducing the Burden of Asthma (continued)

8. Patient barriers including a. cultural factors b. lack of information c. underuse of self-management d. over-reliance on acute care e. use of alternative unproven therapies. 9. Inadequate government resources provided for health care including asthma. 10. The requirement of respiratory specialists and related organisations required to care for a wide variety of diseases, which has in some regions resulted in a failure to adequately promote awareness of asthma.

Actions Required to Reduce the Burden of Asthma

1. Recognise asthma as an important cause of morbidity, economic cost, and mortality worldwide. 2. Measure and monitor the prevalence of asthma, and the morbidity and mortality due to asthma throughout the world. 3. Identify and address the economic and political factors which limit the availability of health care. 4. Improve accessibility to essential drugs for the management of asthma in low- and middle-income countries. 5. Identify and address the environmental factors including indoor and outdoor pollution which affect respiratory morbidity including that due to asthma. 6. Promote and implement anti-tobacco public health policies to reduce tobacco consumption. 7. Adapt international asthma guidelines for developing countries to ensure they are practical and realistic in terms of different health care systems. This includes dissemination strategies for their implementation. 8. Integrate the GINA guidelines with other global respiratory guidelines for children and adults. In this respect, there is a requirement to merge the key elements of the different respiratory guidelines into an algorithm for use at the first point of entry of a respiratory patient's contact with health services. 9. Promote cost-effective management approaches which have been proven to reduce morbidity and mortality, thereby ensuring optimal treatment is available to as many persons as possible with asthma worldwide. 10. Research the causation of asthma, primary and secondary intervention strategies, and management programmes including those for use in developing countries.

Scotland Jersey Guernsey Wales Isle of Man England New Zealand Australia Republic of Ireland Canada Peru Trinidad & Tobago Costa Rica Brazil United States of America Fiji Paraguay Uruguay Israel Barbados Panama Kuwait Ukraine Ecuador South Africa Finland Malta Czech Republic Ivory Coast Colombia Turkey Lebanon Kenya Germany France Japan Norway Thailand Sweden Hong Kong United Arab Emirates Philippines Belgium Austria Saudi Arabia Argentina Iran Estonia Nigeria Spain Chile Singapore Malaysia Portugal Uzbekistan FYR Macedonia Italy Oman Pakistan Tunisia Latvia Cape Verde Poland Algeria South Korea Bangladesh Morocco Occupied Territory of Palestine Mexico Ethiopia Denmark India Taiwan Cyprus Switzerland Russia China Greece Georgia Romania Nepal Albania Indonesia Macau

Country

Ranking of the Prevalence of Current Asthma Symptoms in Childhood by Country (I)

(Written Questionnaire: Self-reported wheezing in the previous 12 month period, in 13- to 14-year-old children*)

*See Methodological Issues

10

15

20

25

30

35

40

Prevalence of asthma symptoms (%)

Peru New Zealand Australia Uruguay Kuwait United States of America Canada Kenya Chile Japan Hong Kong Paraguay Singapore Philippines Malta Argentina France Pakistan Spain Ranking of the Prevalence Morocco of Current Asthma Symptoms Thailand South Africa in Childhood by Country (II) Portugal (Video Questionnaire: Malaysia Positive response to clinical asthma scene, Austria in 13- to 14-year-old children*) Germany Italy Sweden Finland Lebanon Taiwan Bangladesh Poland South Korea Iran India Ivory Coast Estonia China Indonesia Latvia Russia *See Methodological Issues Uzbekistan Albania

Country

10

15

20

25

30

Prevalence of asthma symptoms (%)

Wales Australia Scotland Republic of Ireland Canada Estonia New Zealand United States of America England Malta Norway Denmark Spain Poland Sweden Finland Netherlands Portugal Iceland Germany Switzerland Turkey Belgium Greece France Austria Argentina Costa Rica Thailand Romania Italy Hong Kong Colombia Albania Bangladesh Algeria India Ethiopia Taiwan Gambia Tunisia

Ranking of the Prevalence of Current Asthma Symptoms in Adults by Country

(Written Questionnaire: Self-reported wheezing in the previous 12 month period, in 20- to 44-year-old adults*)

0 5 10 15 20 25 30 Prevalence of asthma symptoms (%) *See Methodological Issues

Country

World Map of the Prevalence of Clinical Asthma

Proportion of population (%)*

10.1 7.6-10.0 5.1-7.5 2.5-5.0 0-2.5 No standardised data available

Scotland Jersey Guernsey Wales Isle of Man England New Zealand Australia Republic of Ireland Canada Peru Trinidad & Tobago Costa Rica Brazil United States of America Fiji Paraguay Uruguay Israel Barbados Panama Kuwait Ukraine Ecuador South Africa Czech Republic Finland Malta

18.4 17.6 17.5 16.8 16.7 15.3 15.1 14.7 14.6 14.1 13.0 12.6 11.9 11.4 10.9 10.5 9.7 9.5 9.0 8.9 8.8 8.5 8.3 8.2 8.1 8.0 8.0 8.0

Ivory Coast Colombia Turkey Lebanon Kenya Germany France Norway Japan Sweden Thailand Hong Kong Philippines United Arab Emirates Belgium Austria Spain Saudi Arabia Argentina Iran Estonia Nigeria Chile Singapore Malaysia Portugal Uzbekistan FYR Macedonia Italy

7.8 7.4 7.4 7.2 7.0 6.9 6.8 6.8 6.7 6.5 6.5 6.2 6.2 6.2 6.0 5.8 5.7 5.6 5.5 5.5 5.4 5.4 5.1 4.9 4.8 4.8 4.6 4.5 4.5

Oman Pakistan Tunisia Cape Verde Latvia Poland Algeria South Korea Bangladesh Morocco Occupied Territory of Palestine Mexico Ethiopia Denmark India Taiwan Cyprus Switzerland Russia China Greece Georgia Nepal Romania Albania Indonesia Macau

4.5 4.3 4.3 4.2 4.2 4.1 3.9 3.9 3.8 3.8 3.6 3.3 3.1 3.0 3.0 2.6 2.4 2.3 2.2 2.1 1.9 1.8 1.5 1.5 1.3 1.1 0.7

*See Methodological Issues

Kazakhstan Kyrgyzstan Turkmenistan South Africa Azerbaijan Cuba Uzbekistan China - rural Mauritius Luxembourg Malta Singapore Colombia Hungary Moldova Ukraine New Zealand Russia Belarus Japan United States of America Australia Scotland China - urban Republic of Ireland England Wales Mexico Norway Costa Rica Belgium Lithuania France Israel Thailand Czech Republic FYR Macedonia Germany Hong Kong Slovak Republic Portugal Argentina Armenia Latvia Denmark Spain Albania Northern Ireland Poland Croatia Canada Romania Brazil Uruguay Ecuador Netherlands South Korea Chile Bulgaria Estonia Italy Switzerland Austria Finland Sweden Slovenia Greece Iceland 0

Ranking of Asthma Mortality by Country

(Asthma deaths per 100,000 in 5- to 34-year-olds*)

Country

*See Methodological Issues

0.5

1 1.5 2.0 Mortality Rate (per 100,000)

2.5

3.0

World Map of Asthma Case Fatality Rates

(Asthma deaths per 100,000 asthmatics)

Countries shaded according to case fatality rate (per 100,000 asthmatics)*

>10.0 5.1-10.0 0-5.0 No standardised data available

China........................................................36.7 Russia ......................................................28.6 Uzbekistan................................................27.2 Albania ....................................................20.8 South Africa ..............................................18.5 Singapore..................................................16.1 Romania ..................................................14.7 Mexico ....................................................14.5 Malta ........................................................11.6 Colombia..................................................10.1 Denmark ....................................................9.3 Ukraine ......................................................8.7 Japan ..........................................................8.7 FYR Macedonia ..........................................8.2 Belgium ......................................................7.7 Latvia..........................................................7.1 Norway ......................................................7.1 Switzerland ................................................7.0 Portugal ......................................................6.9 Poland ........................................................6.6 France ........................................................6.5 Thailand ....................................................6.2 Argentina ....................................................5.8 Hong Kong ................................................5.6 United States of America ............................5.2

Germany ....................................................5.1 Spain ..........................................................4.9 South Korea ................................................4.9 Czech Republic ..........................................4.8 Israel ..........................................................4.7 New Zealand ..............................................4.6 Costa Rica ..................................................3.9 Australia ....................................................3.8 Republic of Ireland ....................................3.6 Italy ............................................................3.6 Chile ..........................................................3.5 England ......................................................3.2 Scotland......................................................3.0 Estonia ........................................................3.0 Wales..........................................................2.9 Austria ........................................................2.6 Ecuador ......................................................2.3 Greece........................................................2.1 Uruguay......................................................2.1 Sweden ......................................................2.0 Brazil ..........................................................1.8 Canada ......................................................1.6 Finland ......................................................1.6 Cape Verde ................................................0.0

*See Methodological Issues

Disability-Adjusted Life Years Lost Due to Asthma Worldwide Ranking with Other Common Disorders
Asthma was the 25th leading cause of disability-adjusted life years (DALYs) lost worldwide in 2001.
Rank Disorder Number of DALYs (x106)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Perinatal conditions Lower respiratory tract infections HIV/AIDS Unipolar depressive disorders Diarrhoeal disease Ischaemic heart disease Cerebrovascular disease Malaria Road traffic accidents Tuberculosis Maternal conditions Chronic obstructive pulmonary disease Congenital abnormalities Measles Hearing loss - adult onset Violence Self-inflicted injuries Alcohol use disorders Protein-energy malnutrition Osteoarthritis Schizophrenia Falls Diabetes mellitus Cirrhosis of the liver ASTHMA Bipolar affective disorder Pertussis Alzheimers and other dementias Sexually transmitted diseases excluding HIV Iron deficiency anaemia

98.4 90.7 88.4 65.9 62.5 58.7 45.9 42.3 37.7 36.0 30.9 29.9 28.1 26.5 25.9 20.2 19.9 19.8 16.7 16.4 15.9 15.7 15.4 15.1 15.0 13.8 12.5 12.4 12.4 12.0

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World Map of the Proportion of the Population with Access to Essential Drugs

WHO Access to Essential Drugs

<50% 50-80%
>95% USA Canada New Zealand Australia Libya UAE Saudi Arabia Oman Israel Turkey Kuwait Japan S Korea UK France Germany Spain Portugal Netherlands Denmark Finland Sweden Norway Italy Belgium Ireland Austria Greece Turkey Luxembourg Iceland 81-95% Brunei Malaysia Singapore Slovenia Albania Macedonia Bulgaria Serbia BosniaHerzegovina Czech Rep Poland Latvia Estonia Romania Slovakia Hungary Croatia Argentina Chile Colombia Cuba Tunisia Algeria Egypt Jordan Syria Iran India Turkmenistan Pakistan Uzbekistan Kyrgyzstan China Kazakhstan Azerbaijan Armenia Georgia Russian Fed Mongolia Indonesia Philippines Vietnam Thailand Laos Taiwan Bangladesh PNG Belarus Ukraine Moldova Lithuania Uruguay Bolivia Peru Ecuador Venezuela Suriname Brazil 50-80% Panama Guatemala Belize Mexico Dominican Rep South Africa Namibia Botswana Zimbabwe Zambia Tanzania Kenya Ethiopia Djibouti Chad Niger Cameroon Mali Togo Cote D'Ivoire Senegal Mauritania Morocco Madagascar Lesotho Gambia Iraq

81-95% >95%
<50% Paraguay Guyana Nicaragua Honduras El Salvador Mozambique Malawi Angola Congo Dem Rep of Congo Gabon Burundi Rwanda Uganda Somalia Eritrea Sudan Yemen Central African Rep Nigeria Ghana Burkina Faso Liberia Sierra Leone Guinea-Bissau Equatorial Guinea Afghanistan Tajikistan Burma Cambodia Nepal N Korea

No standardised data available

No data French Guinea Costa Rica Western Sahara

KEY REFERENCES
Ait-Khaled N, Enarson D, Bousquet J. Chronic respiratory diseases in developing countries: the burden and strategies for prevention and management. Bull WHO 2001;79:971-9. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. Integrated Management of Childhood Illness Strategy Initiative. Bull WHO 1997; 75(Suppl 1). International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M. European Community Respiratory Health Survey II. The European Community Respiratory Health Survey: what are the main results so far? European Community Respiratory Health Survey II. Eur Respir J 2001; 18: 598-611. Jarvis D, Burney P. Epidemiology of asthma. In: Asthma and Rhinitis. Eds: Holgate S, Busse W. Blackwell Scientific Press, Oxford: 1995, 17-32. Murray CJL, Lopez AD. Regional patterns of disability-free life expectancy and disability-adjusted life expectancy: Global Burden of Disease Study. Lancet 1997; 349: 1347-52. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997; 349: 1436-42. National Institutes of Health. Global initiative for asthma. Natl Heart Lung Blood Inst Publ No. 95-3659. Bethesda, MD: NHLBI 1995; 6. Sheffer AL (Ed). Fatal Asthma. New York: Marcel Dekker Inc 1998, 115: 607p. Shibuya K, Mathers CD, Lopez AD. Chronic Obstructive Pulmonary Disease (COPD): consistent estimates of incidence, prevalence and mortality by WHO region. Global Programme on Evidence for Health Policy, World Health Organisation, 30 November 2001. Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. World Health Organisation. Integrated management of the sick child. Bull WHO 1995; 73: 735-40. World Health Organisation. Achieving health for all. In: World Health Report 1998. World Health Organisation, Geneva: 1998, 158-62. World Health Organisation. WHO consultation on the development of a comprehensive approach for the prevention and control of chronic respiratory diseases. Geneva 2001. World Health Report 2001. Fifty facts from the World Health Report 1998: Global health situation and trends 1955-2025. World Health Organisation. World Health Report 2002. Reducing risks, promoting health life. World Health Organisation. World Health Report 2002. Message from the Director-General, Dr GH Brundtland. pp ix-xx and 68-76. World Health Organisation. World Health Organisation. WHO strategy for prevention and control of chronic respiratory diseases. Geneva 2002.

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Methodological Issues
A. Prevalence of Current Asthma Symptoms
The large standardised international and national studies of the prevalence of asthma in both children and adults have utilised written questionnaires of asthma symptoms. These questionnaires have been based on the symptom of wheezing, which has been shown to be the most important symptom for the identification of individuals with asthma. Due to the intermittent nature of asthma symptoms, wheezing occurring at any time within the previous 12 months has been used to define current asthma symptoms. Responses to questions about self-reported wheezing in the previous 12-month period have been shown to have good specificity and sensitivity for both bronchial hyperresponsiveness and a diagnosis of asthma in both children and adults. This was the core question used in both the International Study of Asthma and Allergies in Childhood (ISAAC) and the European Community Respiratory Health Survey (ECRHS), the large standardised international studies which compared the prevalence of asthma symptoms in countries worldwide. For these reasons, "wheezing in the last 12 months" has been used in this report as the response to determine the prevalence of current asthma symptoms in each country. In this report, data on this question have been preferentially obtained from ISAAC and ECRHS as data were collected in a standardised manner between centres in different countries in these studies. The ISAAC study obtained symptom prevalence data from children in the 13- to 14-year age group, whereas in the ECRHS the 20- to 44-year age group was studied. In countries where more than one centre participated in ISAAC or ECRHS, the mean symptom prevalence value for the country was used. For countries which did not participate in ISAAC or ECRHS, comparable data from published studies were used if self-reported wheezing in the previous 12-month period was obtained from written questionnaires in defined populations in children or adults. Despite the general acceptance of this approach, a number of limitations need to be recognised in the interpretation of such standardised data. The first is that self-reported current wheezing is not diagnostic of asthma in an individual. Wheezing is not a symptom specific to the diagnosis of asthma and there is no agreed
15

way of grading the severity or frequency of wheezing symptoms to identify the presence of asthma. For example, the occasional transient episode of mild wheezing in an individual requiring no treatment would not necessarily be considered to be diagnostic of clinical asthma. From a clinical standpoint, a diagnosis of asthma is made on the basis of combined information from history, physical examination, and physiological tests, often over a period of time. There is no single test or clinical feature which defines the presence or absence of asthma, particularly from epidemiological studies of large populations. As a result, the prevalence of current asthma symptoms is not equivalent to the prevalence of clinical asthma. Another issue is that in both children and adults, wide variations in the prevalence of current asthma symptoms are often observed between centres within the same country. This indicates that the asthma symptom prevalence rate reported for each country is dependent to some extent on the number of centres studied. The population sample chosen, on the basis of a defined geographical area, also influences the reported asthma symptom prevalence rates. In both ECRHS and ISAAC predominantly urban populations were studied, but it is recognised that the prevalence of asthma symptoms is generally higher in urban than in rural areas. Despite the use of standardised simple written questionnaires, validated study protocols (including those for translation of questionnaires), and stringent quality control measures in both ISAAC and ECRHS, biases in the comparability of information were unavoidable. This is evident from the simple observation that in the studies data have been presented from standardised written questionnaires which have been translated into over 50 languages, some of which have no colloquial term for wheezing. In an attempt to reduce the biases inherent in international comparisons of asthma symptom prevalence data based on written questionnaires, a video questionnaire has been developed which shows rather than describes the symptoms and signs of asthma, thereby allowing comparisons between populations with different cultures and languages. While the video questionnaire probably provides the most accurate comparable estimates of asthma prevalence between populations worldwide, its use has been confined to the ISAAC programme and insufficient validation has been undertaken to date for it to be used as the primary outcome variable in this report.

16

B. Prevalence of "Clinical Asthma"

The true prevalence of asthma is difficult to determine due to the lack of a single objective diagnostic test, different methods of classification of the condition, differing interpretation of symptoms in different countries, as well as the uncertain influence of increasing public and professional awareness of asthma. In this report an arbitrary figure of 50% of the prevalence of "current wheezing" in children (selfreported wheezing in the previous 12-month period in 13- to 14-yearold children) has been used as the prevalence of "clinical asthma." In support of this approach, in different populations from high- and lowincome countries: 1. The prevalence of "clinically important" (severe) asthma symptoms shows a similar degree of variation to mild wheezing, with a strong correlation at the national level. This indicates that the wide variation in prevalence of current wheezing is not explained by a relative over-reporting of mild symptoms in highprevalence countries, and that current wheezing can be used as the basis for detecting the prevalence of "clinical asthma". 2. The proportion of individuals with bronchial hyperresponsiveness (BHR) plus current wheeze is around 40% to 60% of that reporting current wheeze. This criteria of BHR plus current wheeze has been proposed as the "gold standard" for identifying clinical asthma in population-based studies, having been shown to identify a group with greater severity of clinical and physiological measures and treatment requirements for asthma than alternative criteria. 3. In children the prevalence rate determined by a positive response to the video sequence of wheezing is about 50% of that of current wheezing from the written questionnaire. 4. In adults the prevalence rate of breathlessness with wheeze (indicative of clinically significant asthma) is about 50% of the prevalence rate of current wheezing. 5. There is a strong correlation observed between ISAAC and ECRHS asthma symptom prevalence data, with 74% of the variation in the prevalence of current wheezing in adults at the centre level explained by the variation in the childhood data. The mean

17

prevalence rate of current wheezing in children was 88% of that recorded in adults, in the countries which participated in both studies. 6. There is a close correlation between the ISAAC asthma prevalence data for teenagers (13- to 14-year age group) and young children (6- to 7-year age group). In the countries which studied both age groups in the ISAAC programme, the mean prevalence rate of current wheezing in the 6- to 7-year age group was 105% of that recorded in the 13- to 14-year age group. The prevalence of doctor-diagnosed asthma, of asthma attacks, or of asthma medication use was avoided due to the marked variation in the recognition and presentation to a doctor by an individual with recurrent wheezing episodes, and the considerable differences in diagnostic labelling and treatment by doctors between populations. As a result the prevalence rates for "clinical asthma" reported in this report represent a conservative estimate. To determine the number of persons with asthma in each country, the mean prevalence of asthma calculated for each country was multiplied by the population of the country, which was derived from the WHO population statistics for 2001. For countries in which data on asthma symptom prevalence were not available, the mean prevalence of clinical asthma in the specific region was used. While the major limitations of this approach are evident, it does provide a crude estimate for the prevalence of clinical asthma in these countries. This approach enabled the total number of asthmatics in each region to be estimated and thereby the total number of persons with asthma worldwide.

C. Asthma Mortality
The asthma mortality comparison between countries has been made using the asthma mortality rates in the 5- to 34-year age group because the diagnosis of asthma mortality is firmly established in this group. It has been shown that in this age group false-positive reporting (i.e., deaths from other causes being falsely attributed to asthma) and false-negative reporting (i.e., asthma deaths being falsely assigned to other categories) are extremely low. However, the accuracy of this approach declines with increasing age, with falsepositive reporting rates of >30% in those aged 65 years or more.
18

In this report, WHO country-specific mortality data for ICD codes 490 to 493 have been used. These codes incorporate mortality data from asthma, emphysema, chronic bronchitis, and bronchitis not specified as acute or chronic. In the 5- to 34-year age group, these mortality figures are similar to the asthma mortality rates, due to the rarity of mortality from chronic bronchitis or emphysema in this age group. This approach was supported by a validation study based on data from 14 countries in 7 regions, in which the asthma mortality rates in the 5- to 34-year age group as published by the national statistics were compared with the WHO mortality rates for ICD codes 490 to 493. This validation showed that the asthma mortality rates in the 5- to 34-year age group were on average 89% of the WHOderived figures. For each country, the mean mortality rate from the two most recent years in which it was available was presented. The mean period in which mortality data were available was 1996 to 1997; mortality data were not reported if they were only available prior to 1992. When making international comparisons of asthma mortality it is necessary to also consider the asthma prevalence rates in the countries being compared. In this way a more accurate determination of the case fatality rate can be achieved and with this type of analysis a different perspective of the international differences in asthma mortality rates is obtained. In this report, case fatality rates have been derived for each country, in which the asthma mortality rate in the 5 to 34 year age group has been determined as a proportion of the prevalence of clinical asthma, where data were available. It is recognised that the case fatality rates represent a crude estimate, dependent on many factors including the accuracy of the mortality and prevalence statistics available in the different age groups, diagnostic coding, and the recognition and management of the condition. It has not been possible to document overall asthma mortality rates or the number of deaths due to asthma in each country as these data were not available from the WHO in a standardised format.

D. Disability-Adjusted Life Years

In considering the impact of a disease in terms of mortality, it is informative to extend the concept of life expectancy to that of health expectancy. In this way an attempt is made to generalise the concept
19

of years of life lost to that of years of healthy life lost, representing a health gap measure which incorporates both loss of life and the loss of quality of life. This allows a composite measure of the burden of both fatal and non-fatal disease. As a result, the years lost to disability (YLD) is added to the years of life lost to premature mortality (YLL) to yield an integrated unit of health - the "disabilityadjusted life-year" (DALY), with one DALY representing the loss of one year of healthy life. The DALYs lost due to asthma worldwide in 2001 are presented, together with the 30 leading causes of DALYs. These data were obtained from the recently published WHO World Health Report 2002.

E. Populations with Regular Access to Essential Drugs

The world map documenting the percentage of the population in each country with regular access to essential drugs was reproduced from the WHO World Health Report 1998.

20

Burden of Asthma in Different Study Regions

The burden of asthma has been assessed in twenty different regions worldwide. These study regions have been grouped according to geographical, political, historical, and racial considerations, and to some extent according to the availability of asthma epidemiological data within the study region. A broad overview of some, but by no means all, of the relevant issues and interesting features of the burden of asthma within each region has been provided. Likewise, for many regions the lists for further reading provide some, but not all, of the key references relevant to the burden of asthma in countries within the region. Scandinavia/Baltic States United Kingdom/Republic of Ireland Western Europe Balkans/Turkey/Caucasus/Mediterranean Islands Russia and former Socialist Republics of Eastern Europe Middle East Central Asia and Pakistan Southern Asia China/Taiwan/Mongolia Northeast Asia Southeast Asia Oceania North America Central America Caribbean South America North Africa West Africa East Africa Southern Africa

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Regions
1. Scandinavia/ Baltic States Denmark Estonia Finland Iceland Latvia Lithuania Norway Poland Sweden 2. United Kingdom/ Republic of Ireland England Guernsey Isle of Man Jersey Northern Ireland Republic of Ireland Scotland Wales 3. Western Europe Austria Belgium France Germany Italy Luxembourg Netherlands Portugal Spain Switzerland 6. Middle East Bahrain Iran Iraq Israel Jordan Kingdom of Saudi Arabia Kuwait Lebanon Occupied Territory of Palestine Oman Qatar Syria United Arab Emirates Yemen 9. China/Taiwan/ Mongolia China Hong Kong Macau Mongolia Taiwan

4. Balkans/Turkey/ Caucasus/ Mediterranean Islands Albania Armenia Azerbaijan Bosnia-Herzegovina Croatia Cyprus Georgia Greece FYR Macedonia Malta Serbia Slovenia Turkey

5. Russia & Former Socialist Republics of E. Europe Belarus Bulgaria Czech Republic Hungary Moldavia Romania Russian Federation Slovakia Ukraine

7. Central Asia & Pakistan 8. Southern Asia Afghanistan Kazakhstan Kyrgyzstan Pakistan Tajikistan Turkmenistan Uzbekistan 10. Northeast Asia Japan North Korea South Korea Bangladesh Bhutan India Nepal Seychelles Sri Lanka

11. Southeast Asia Brunei Cambodia Indonesia Laos Malaysia Myanmar Philippines Singapore Thailand Vietnam

12. Oceania Australia Fiji New Zealand Papua New Guinea Samoa Tahiti Other Pacific Islands

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Regions
13. North America 14. Central America Canada Belize United States of America Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama 16. South America Argentina Bolivia Brazil Chile Colombia Ecuador French Guiana Guyana Paraguay Peru Suriname Uruguay Venezuela 17. North Africa Algeria Chad Egypt Libya Morocco Niger Sudan Tunisia 15. Caribbean Barbados Cuba Dominican Republic Haiti Jamaica Puerto Rico Trinidad & Tobago Other Caribbean Islands 18. West Africa Benin Burkina Faso Cameroon Cape Verde Central African Republic Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Ivory Coast Liberia Mali Mauritania Nigeria Senegal Sierra Leone Togo Western Sahara

19. East Africa Burundi Djibouti Eritrea Ethiopia Kenya Madagascar Malawi Mauritius Mozambique Rwanda Somalia Tanzania Uganda

20. Southern Africa Angola Botswana Congo Namibia South Africa Swaziland Zaire Zambia Zimbabwe

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Scandinavia/Baltic States
Denmark Estonia Finland Iceland Latvia Lithuania Norway Poland Sweden

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

3.4 m 70.2 m 4.9%

Key Points: 1. The prevalence of asthma symptoms is similar throughout the region, with generally higher rates in Scandinavian countries, and somewhat lower rates in the former socialist countries in the Baltic region. 2. The prevalence of asthma has increased throughout the region over recent decades. The data reporting the increased prevalence of asthma in young army recruits in a number of countries within the Scandinavian region provide some of the most convincing data worldwide of the increase in asthma prevalence that has occurred over recent decades. The increase in asthma prevalence began in the 1960s/70s and has increased steadily since this time. 3. The prevalence of asthma is greater in urban communities compared with rural communities throughout the region. The reasons for these differences are uncertain. 4. The trend of increasing asthma prevalence has been associated with an increase in other allergic disorders such as rhinitis and eczema. 5. It is expected that during the next decade the increase in the prevalence of asthma is likely to be particularly marked in the former socialist countries of the Baltics as these communities increasingly adopt the Western lifestyle. 6. There is considerable underdiagnosis of asthma within the former socialist countries in the Baltic region compared with Scandinavia. This is illustrated by the considerably lower percentage of individuals with asthma symptoms who receive a diagnosis of asthma in these countries. 7. The cost of asthma medications is a major barrier to the delivery of health care to asthmatics within the former socialist countries in the Baltic region. In these countries a considerably lower percentage of individuals with asthma symptoms receives asthma medication. 24

8. Asthma mortality rates have declined markedly over the last 10 years in Scandinavian countries, a trend which has been attributed to improvements in asthma management, including the increased use of inhaled corticosteroid therapy. These countries have amongst the lowest case fatality rates worldwide and indicate the potential that exists to reduce asthma mortality in other countries. 9. The national asthma public health programmes developed in a number of Scandinavian countries can be used by other countries as models of programmes which have been shown to markedly reduce morbidity and mortality from asthma. The national programme developed in Finland represents a particularly successful multidisciplinary programme in which the strategic planning, principles, implementation, and evaluation have been clearly outlined. 10. Work is an important cause for the development of asthma in both men and women within the region. The risk is particularly high for agricultural, forestry, fishing, and manufacturing workers. The potential for prevention is considerably greater and more widely spread than generally assumed.

FURTHER READING
berg N, Hesselmar B, berg B, Eriksson B. Increase of asthma, allergic rhinitis and eczema in Swedish schoolchildren between 1979 and 1991. Clin Exper Allergy 1995; 25: 815-9. Annus T, Bjrkstn B, Mai X-M, Nilsson L, Riikjrv M-A, Sandin A, Brbck L. Wheezing in relation to atopy and environmental factors in Estonian and Swedish schoolchildren. Clin Exper Allergy 2001; 31: 1846-53. Arshad SH, Karmaus W, Matthews S, Mealy B, Dean T, Frischer T, Tsitoura S, Bojarskas J, Kuehr J, Forster J. SPACE study group. Association of allergyrelated symptoms with sensitisation to common allergens in an adult European population. J Invest Allergol Clin Immunol 2001; 11: 94-102. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Asthma Programme in Finland 1994-2004: Report of a Working Group. Clin Exper Allergy 1996; 26(Suppl 1): 1-24. Backer V, Dirksen A, Bach-Mortensen N, Hansen KK, Laursen EM, Wendelboe D. The distribution of bronchial responsiveness to histamine and exercise in 527 children and adolescents. J Allergy Clin Immunol 1991; 88: 68-76. Backer V, Ulrik CS. Bronchial responsiveness to exercise in a random sample of 494 children and adolescents from Copenhagen. Clin Exper Allergy 1992; 22: 741-7. Bakke PS, Baste V, Gulsvik A. Bronchial responsiveness in a Norwegian community. Am Rev Respir Dis 1991; 143: 317-22.

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Bergstrm S-E, Forngren H, Foucard T, Hedlin G, Hrte L-G, Spetz-Nystrm U. Decreasing asthma mortality in Sweden. Am J Respir Crit Care Med 1997; 155(4Pt2): A83. Bjrkstn B, Dumitrascu D, Foucard T, Khetsuriani N, Khaitov R, Leja M, Lis G, Pekkanen J, Priftanji A, Riikjarv MA. Prevalence of childhood asthma, rhinitis and eczema in Scandinavia and Eastern Europe. Eur Respir J 1998; 12: 432-7. Bjrnsson E, Plaschke P, Norrman E, Janson C, Lundbck B, Rosenhall A, Lindholm N, Rosenhall L, Berglund E, Boman G. Symptoms related to asthma and chronic bronchitis in three areas of Sweden. Eur Respir J 1994; 7: 2146-53. Brbck L, Breborowicz A, Dreborg S, Knutsson A, Pieklik H, Bjrkstn B. Atopic sensitization and respiratory symptoms among Polish and Swedish schoolchildren. Clin Exper Allergy 1994; 24: 826-35. Breborowicz A, Burchardt B, Pieklik H. Asthma, allergic rhinitis and atopic dermatitis in schoolchildren. Pneumonologia i Alergologia Polska 1995; 63: 157-61. Breborowicz A, Swiatly A, Alkiewicz J, Moczko J. Use of a video questionnaire for assessment of asthma prevalence in schoolchildren as part of the ISAAC epidemiology study. Pneumonologia i Alergologia Polska 1998; 66: 368-72. Brogger J, Bakke P, Eide GE, Johansen B, Andersen A, Gulsvik A. Long-term changes in adult asthma prevalence. Eur Respir J 2003; 21: 468-72. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Emeryk A, Chojna E, Skibinska-Kawiak G, Postepski J, Barkowiak-Emeryk M. Increased prevalence of asthma and allergic rhinitis during 1995-2000 years among schoolchildren from rural region in Poland. Eur Respir J 2002; 20(Suppl.38): 118s. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. Farber HJ, Wattigney W, Berenson G. Trends in asthma prevalence: the Bogalusa heart study. Ann Allergy Asthma Immunol 1997; 78: 265-9. Gislason T, lafsson , Sigvaldason A. Users of antiasthma drugs in Iceland: a drug utilization study. Eur Respir J 1997; 10: 1230-4. Gniazdowska B, Jefimow A. Epidemiologic studies on allergic diseases among rural and urban schoolchildren in Poland. Polski Tygodnik Lekarski 1990; 45: 855-60. Haahtela T, Klaukka T, Koskela K, Erhola M, Laitinen LA on behalf of the Working Group of the Asthma Programme in Finland 1994-2004. Asthma programme in Finland: a community problem needs community solutions. Thorax 2001; 56: 806-14.

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Haahtela T, Lindholm H, Bjorksten F, Koskenvuo K, Laitinen LA. Prevalence of asthma in Finnish young men. BMJ 1990; 301: 266-8. Hansen EF, Rappeport Y, Vestbo J, Lange P. Increase in prevalence and severity of asthma in young adults in Copenhagen. Thorax 2000; 55: 833-6. Hansen EF, Rappeport Y, Vestbo J, Lange P. Prevalence of asthma among young adults in Copenhagen. Ugeskrift for Laeger 2001; 163: 6128-30. Harju T, Tuuponen T, Keistinen T, Kivel S-L. Seasonal variations in hospital treatment periods and deaths among adult asthmatics. Eur Respir J 1998; 12: 1362-5. Henriksen AH, Lingaas-Holmen T, Sue-Chu M, Bjermer L. Combined use of exhaled nitric oxide and airway hyperresponsiveness in characterizing asthma in a large population survey. Eur Respir J 2000; 15: 849-55. Hjern A, Rasmussen F, Johansson M, berg N. Migration and atopic disorder in Swedish conscripts. Pediatr Allergy Immunol 1999; 10: 209-15. Huovinen E, Kaprio J, Laitinen LA, Koskenvuo M. Incidence and prevalence of asthma among adult Finnish men and women in the Finnish cohort from 1975 to 1999, and their relation to hay fever and chronic bronchitis. Chest 1999; 115: 928-36. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Jannus-Pruljian L, Loit HM. The prevalence of asthma in Estonia. Int J Tuberc Lung Dis 1994; 75: 117. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Jogi R, Janson C, Bjrnsson E, Boman G, Bjrkstn B. Atopy and allergic disorders among adults in Tartu, Estonia compared with Uppsala Sweden. Clin Exper Allergy 1998; 28: 1072-80. Jogi R, Janson C, Bjrnsson E, Boman G, Bjrkstn B. The prevalence of asthmatic respiratory symptoms among adults in Estonian and Swedish university cities. Eur J Allergy Clin Immunol 1996; 51: 331-6. Jonasson G, Lodrup Carlsen KC, Leegaard J, Carlsen KH, Mowinckel P, Halvorsen KS. Trends in hospital admissions for childhood asthma in Oslo, Norway, 1980-95. Allergy 2000; 55: 232-9. Karjalainen A, Kurppa K, Maartikainen R, Klaukka T, Karjalainen J. Work is related to a substantial portion of adult-onset asthma incidence in the Finnish population. Am J Respir Crit Care Med 2001; 164: 565-8. Keistinen T, Tuuponen T, Kivel S-L. Asthma related hospital treatment in Finland: 1972-86. Thorax 1993; 48: 44-7. Kiivet RA, Kaur I, Lang A, Aaviksoo AIN, Nirk L. Costs of asthma treatment in Estonia. Eur J Pub Health 2001; 11: 89-92.

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Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Korhonen K, Reijonen TM, Malmstrm K, Klaukka T, Remes K, Korppi M. Hospitalization trends for paediatric asthma in eastern Finland: a 10-yr survey. Eur Respir J 2002; 19: 1035-9. Krause TG, Koch A, Poulsen LK, Kristensen B, Olsen OR, Melbye M. Atopic sensitization among children in an Arctic environment. Clin Exp Allergy 2002; 32: 367-72. Krzyzanowski M, Lebowitz MD. Changes in chronic respiratory symptoms in two populations of adults studied longitudinally over 13 years. Eur Respir J 1992; 5: 12-20. Lagerlv P, Veninga CCM, Muskova M, Hummers-Pradier E, StlsbyLundborg C, Andrew M, Haaijer-Ruskamp FM. Asthma management in five European countries: doctors knowledge, attitudes and prescribing behaviour. Eur Respir J 2000; 15(1): 25-9. Lange P, Ulrik CS, Vestbo J for the Copenhagen City Heart Study Group. Mortality in adults with self-reported asthma. Lancet 1996; 347: 1285-9. Leynaert B, Neukirch C, Jarvis D, Chinn S, Burney P, Neukirch F on behalf of the European Community Respiratory Health Survey. Does living on a farm during childhood protect against asthma, allergic rhinitis and atopy in adulthood? Am J Respir Crit Care Med 2001; 164: 1829-34. Linneberg A, Nielsen NH, Madsen F, Frolund L, Dirksen A, Jorgensen T. Secular trends of allergic asthma in Danish adults. The Copenhagen Allergy Study. Respir Med 2001; 95: 258-64. Lis G, Breborowicz A, Swiatly A, Pietrzyk JJ, Alkiewicz J, Moczko J. Prevalence of allergic diseases in schoolchildren in Krakow and Poznan (based on a standardized ISAAC questionnaire). Pneumonologia i Alergologia Polska 1997; 65: 621-7. Lis G, Pietrzyk JJ. The effect of air pollution on the prevalence of asthma in schoolchildren from Krakow. Pneumonologia i Alergologia Polska 1997; 65: 611-20. Lundbck B, Stjernberg N, Nystrm L, Lundbck K, Lindstrm M, Rosenhall L. An interview study to estimate prevalence of asthma and chronic bronchitis. Eur J Epidemiol 1993; 9: 123-33. Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM and the EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in western Europe. Lancet 349: 1655-9. Malolepszy J, Liebhart J, Dobek R, Liebhart E, Obojski A, Barkw K, Machaj Z. Prevalence of asthma and its selected symptoms in Wroclaw, Poland. Eur Respir J 1998; 12(Suppl.28); 200s. May K. Asthma in Poland. Kongres Interasma Poznad 1995; 30: 8Meredith S, Nordman H. Occupational asthma: measures of frequency from four countries. Thorax 1996; 51: 435-40. Meren M, Jannus-Pruljian L, Loit H-M, Jnsson E, Kiviloog J, Lundbck B. Asthma, chronic bronchitis and respiratory symptoms among adults in Estonia according to a postal questionnaire. Respir Med 2001; 95: 954-64. Norrman E, Nystrom L, Jonsson E, Stjernberg N. Prevalence and incidence of asthma and rhinoconjunctivitis in Swedish teenagers. Allergy 1998; 53: 28-35.

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Norrman E, Rosenhall L, Nystrm L, Bergstrm E, Stjernberg N. High prevalence of asthma and related symptoms in teenagers in Northern Sweden. Eur Respir J 1993; 6: 834-9. Nystad W, Magnus P, Gulsvik A. Increasing risk of asthma without other atopic diseases in schoolchildren: a repeated cross-sectional study after 13 years. Eur J Epidemiol 1998; 14: 247-52. Nystad W, Magnus P, Gulsvik A, Skarpaas IJK, Carlsen K-H. Changing prevalence of asthma in schoolchildren: evidence for diagnostic changes in asthma in two surveys 13 yrs apart. Eur Respir J 1997; 10: 1046-51. Pallasaho P, Lundbck B, Lsp SL, Jnsson E, Kotaniemi J, Sovijrvi ARA, Laitinen LA. Increasing prevalence of asthma but not of chronic bronchitis in Finland. Report from FinEsS-Helsinki study. Respir Med 1999; 93: 789-809. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Pedersen PA, Weeke ER. Epidemiology of asthma in Denmark. Chest 1987; 91(Suppl): 107S-14S. Pekkanen J, Remes ST, Husman T, Lindberg M, Kajosaari M, Koivikko A, Soininen L. Prevalence of asthma symptoms in video and written questionnaires among children in four regions of Finland. Eur Respir J 1997; 10: 1787-94. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000; 16: 802-7. Reijula K, Haahtela T, Klaukka T, Rantanen J. Incidence of occupational asthma and persistent asthma in young adults has increased in Finland. Chest 1996; 110: 58-61. Remes ST, Korppi M, Remes K, Pekkanen J. Prevalence of asthma at school age: a clinical population-based study in Eastern Finland. Acta Paediatr 1996; 85: 59-63. Riikjarv M, Annus T, Braback L, Rahu K, Bjrkstn B. Similar prevalence of respiratory symptoms and atopy in Estonian schoolchildren with changing lifestyle over 4 yrs. Eur Respir J 2000; 16: 86-90. Rnmark E, Jnsson E, Lundbck B. Remission of asthma in the middle aged and elderly: report from the Obstructive Lung disease in Northern Sweden Study. Thorax 1999; 54: 611-3. Siersted HC, Hansen HS, Hansen N-CG, Hyldebrandt N, Mostgaard G, Oxhoj H. Evaluation of peak expiratory flow variability in an adolescent population sample. The Odense Schoolchild Study. Am J Respir Crit Care Med 1994; 149: 598-603. Siersted HC, Mostgaard G, Hyldebrandt N, Hansen HS, Boldsen J, Oxhoj H. Interrelationships between diagnosed asthma, asthma-like symptoms, and abnormal airway behaviour in adolescence: the Odense Schoolchild Study. Thorax 1996; 51: 503-9. Skarpaas IJK, Gulsvik A. Prevalence of bronchial asthma and respiratory symptoms in schoolchildren in Oslo. Allergy 1985; 40: 295-9. Skjonsberg OH, Clenchass J, Leehaard J et al. Prevalence of bronchial asthma in schoolchildren in Oslo, Norway: comparison of data in 1993 and 1981. Allergy 1995; 50: 806-10.

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Smedje G, Norbck D, Edling C. Asthma among secondary schoolchildren in relation to the school environment. Clin Exper Allergy 1997; 27: 1270-8. Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Vartiainen E, Jousilahti P, Juolevi A, Sundvall J, Alfthan G, Salminen I, Puska P. FINRISKI 1997: Tutkimus kroonisten kansantautien riskitekijist, niihin liittyvist elintavoista, oireista ja terveyspalveluiden kytst. Publications of the National Public Health Institute B 1/1998. Vasar M, Braback L, Julge K, Knutsson A, Riikjarv M-A, Bjrkstn B. Prevalence of bronchial hyperreactivity as determined by several methods among Estonian schoolchildren. Pediatr Allergy Immunol 1996; 7: 141-6.

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United Kingdom/Republic of Ireland

England Guernsey Isle of Man Jersey Northern Ireland Republic of Ireland Scotland Wales

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

10.1 m 63.3 m 16.1%

Key Points: 1. This region has amongst the highest prevalence rates of asthma in the world. 2. There has been a marked increase in the incidence of asthma attacks diagnosed by general practitioners over the last few decades, such that it is now about five times higher than it was 25 years ago. About 20,000 first or new episodes of asthma present each week to general practitioners in the region. 3. Asthma disproportionately affects certain ethnic minority groups and low socioeconomic groups, which represent a priority for management initiatives. 4. Asthma is one of the leading causes of hospital admission in children. There are over 75,000 emergency hospital admissions due to asthma each year, a quarter of which are in children below 4 years of age. The number of hospital admissions has gradually declined over the last decade. 5. Asthma places a high burden on the primary health care system, with over 4 million consultations for asthma each year. An average primary care organisation in the United Kingdom of 330,000 people can expect to treat 25,000 people with asthma, with over 400 patients with asthma admitted to hospital and 8 asthma deaths each year. 6. It has been estimated that one in four people have severe or moderately severe asthma that might be relieved if treatment were reviewed and made more appropriate. However, one in 10 people living with asthma has severe or moderately severe asthma that is inadequately controlled despite the best clinical and preventive management.

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7. Currently over 1,500 people die from asthma each year within the region. Confidential inquiries have shown that suboptimal routine care, delay in obtaining help during the final attack, and poor adherence to medication contribute to many of the deaths. 8. Mortality from asthma has declined steadily in the last 10 years. This reduction is considered to be due to improvements in the management of asthma, particularly the increased use of inhaled corticosteroid therapy. 9. The total cost of asthma in the region has been estimated to be about 2.5 billion. This includes the cost of about 900 million to the public health service. It is estimated that 50% of all annual healthcare costs for asthma come from the most severe 20% of the asthmatic population. About 20 million working days are lost due to asthma each year. 10. The United Kingdom National Asthma Campaign is a successful model of a national education, management, and research-based programme which has contributed to reducing the burden of asthma in the region. It could be used as a basis for similar public health programmes in other countries, as well as a resource for educational material and management programmes.

FURTHER READING
Anderson HR. Trends and district variations in the hospital care of childhood asthma: results of a regional study 1970-85. Thorax 1990; 45: 431-7. Anderson HR et al. Trends in prevalence and severity of childhood asthma. BMJ 1997; 315: 1014. Arshad SH, Karmaus W, Matthews S, Mealy B, Dean T, Frischer T, Tsitoura S, Bojarskas J, Kuehr J, Forster J. SPACE study group. Association of allergy-related symptoms with sensitisation to common allergens in an adult European population. J Invest Allergol Clin Immunol 2001; 11: 94102. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Barraclough R, Devereux G, Hendrick DJ, Stenton SC. Apparent but not real increase in asthma prevalence during the 1990s. Eur Respir J 2002; 20: 826-33. Berrill WT. Death certification in asthma is inaccurate. BMJ 1997; 315: 1013. British Thoracic Society. The burden of lung disease. A statistics report from the British Thoracic Society, 2001. Broadfield E, McKeever TM, Scrivener S, Venn A, Lewis SA, Britton J. Increase in the prevalence of allergen skin sensitizatoin in successive birth cohorts. J Allergy Clin Immunol 2002; 109: 969-74.

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Bucknall CE, Slack R, Godley CC, Mackay TW, Wright SC on behalf of SCIAD collaborators. Scottish Confidential Inquiry into Asthma Deaths (SCIAD), 1994-6. Thorax 1999; 54: 978-84. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burney PGJ, Chinn S, Rona RJ. Has the prevalence of asthma increased in children? Evidence from the national study of health and growth 197386. BMJ 1990; 300: 1306-10. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Burr ML, Butland BK, King S, Vaughan-Williams E. Changes in asthma prevalence: two surveys 15 years apart. Arch Dis Child 1989; 64: 1452-6. Burr ML, Davies BH, Hoare A, Jones A, Williamson IJ, Holgate SK, Arthurs R, Hodges IGC. A confidential inquiry into asthma deaths in Wales. Thorax 1999; 54: 985-9. Campbell MJ, Cogman GR, Holgate ST, Johnston SL. Age specific trends in asthma mortality in England and Wales, 1983-95: results of an observational study. BMJ 1997; 314: 1439-41. Campbell MJ, Holgate ST, Johnston SL. Trends in asthma mortality. BMJ 1997; 315: 1012. Capewell S. Asthma in Scotland: epidemiology and clinical management. Health Bulletin 1993; 51(2): 118-27. Chang AB, Newson TP. Labelling of cough alone as asthma may partially explain increase. BMJ 1997; 1015. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Dow L, Fowler L, Phelps L, Waters K, Coggon D, Kinmonth AL, Holgate ST. Prevalence of untreated asthma in a population sample of 6000 older adults in Bristol, UK. Thorax 2001; 56: 472-6. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Fleming DM, Cross KW, Sunderland R, Ross AM. Comparison of the seasonal patterns of asthma identified in general practitioner episodes, hospital admissions and deaths. Thorax 2000; 55: 662-5. Fletcher HJ, Ibrahim SA, Speight N. Survey of asthma deaths in the Northern region, 1970-85. Arch Dis Child 1990; 65: 163-7. Smith A, Partridge MR. Greater Expectations? Findings from the National Asthma Campaigns representative study of the needs of people with asthma (NOPWA) in the UK. Asthma Journal 2000; 5(3): 106-7. Hyndman SJ, Williams DRR, Merrill SL, Lipscombe JM, Palmer CR. Rates of admission to hospital for asthma. BMJ 1994; 308: 1596-600.

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International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Joint Health Surveys Unit. Health Survey for England 1991. Joint Health Surveys Unit. Health Survey for England 1996. Stationery Office, 1998. Joint Health Surveys Unit. Health Survey for England: the health of young people 1995-1997. Stationery Office, 1998. Joint Health Surveys Unit. Scottish Health Survey 1998. Johnson CA, Mannino DM, Ashizawa A. Asthma mortality in United States has risen but is similar to that in England and Wales. BMJ 1997; 315: 1012-3. Jones AP, Bentham G. Health service accessibility and deaths from asthma in 401 local authority districts in England and Wales, 1988-92. Thorax 1997; 52: 218-22. Kaur B, Anderson HR, Austin J, Burr M, Harkins LS, Strachan DP, Warner JO. Prevalence of asthma symptoms, diagnosis, and treatment in 12-14 year old children across Great Britain (ISAAC). BMJ 1998; 316: 118-24. Kaur B, Butland B. Asthma mortality is falling in most age groups in Scotland. BMJ 1997; 315: 1014. Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Lewis S. Study of the aetiology of wheezing illness at age 16 in 2 national British Birth Cohorts. Thorax 1996; 51: 670-6. Lung and Asthma Information Agency. Trends in asthma mortality in the elderly. Factsheet 92/1. Lung and Asthma Information Agency. Trends in hospital admissions for asthma. Factsheet 95/1. Lung and Asthma Information Agency. Trends in hospital admissions for asthma. Factsheet 96/2. Lung and Asthma Information Agency. Trends in asthma mortality in Great Britain. Factsheet 97/3. Mackay T, Wathen CG, Elton RA, Sudlow MF, Elton RA. Factors affecting asthma mortality in Scotland. Scott Med J 1992; 37: 5-7. Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM and the EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in western Europe. Lancet 349: 1655-9. Manning PJ, Curren K, Kirby B, Taylor M, Clancy L. Asthma, hay fever and eczema in Irish teenagers (ISAAC Protocol). Irish Med J 1997; 90: 110-1.

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Manning P, Murphy E, Clancy L, Callaghan B. Asthma mortality in the Republic of Ireland 1970-84 and an analysis of the hospital death in a single year. Irish Med J 1987; 80: 406-9. Manning P, Sinclair H, Clancy L. Regional differences in mortality and hospital admission rates for asthma in the Republic of Ireland (ROI). Am J Respir Crit Care Med 1996; 153(4): A859. McLoone P, Morrison DS. Short term fluctuations may obscure more meaningful, longer term changes. BMJ 1997; 315: 1013-4. Mohan G, Harrison BDW, Badminton RM, Mildenhall S, Wareham NJ. A confidential enquiry into deaths caused by asthma in an English health region: implications for general practice. Brit J Gen Practice 1996; 46: 529-32. Morrison DS, McLoone P. Changing patterns of hospital admission for asthma, 1981-97. Thorax 2001; 56: 687-90. National Asthma Campaign. Out in the Open: a true picture of asthma in the United Kingdom today. The Asthma Journal 2001; 6(Suppl): 3-14. National Asthma Campaign. Starting as we mean to go on: an audit of childrens asthma in the UK. National Asthma Campaign Asthma Audit 2002. The Asthma Journal 2002; 8(Suppl): 3-11. Ng Man Kwong G, Proctor A, Billings C, Duggan R, Das C, Whyte MKB, Power CVE, Primhak R. Increasing prevalence of asathma diagnosis and symptoms in children is confined to mild symptoms. Thorax 2001; 56: 312-4. Ninan TK, Russell G. Respiratory symptoms and atopy in Aberdeen schoolchildren: evidence from two surveys 25 years apart. BMJ 1992; 304: 873-5. Ormerod LP, Stableforth DE. Asthma mortality in Birmingham 1975-7: 53 deaths. BMJ 1980; 8 March: 687-90. Pararajasingam CD, Sittampalam L, Damani P et al. Comparison of the prevalence of asthma among Asian and European children in Southampton. Thorax 1992; 47 529-33. Partridge MR. In what way may race, ethnicity or culture influence asthma outcomes? Thorax 2000; 55: 175-6. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000; 16: 802-7. Rona RJ, Chinn S, Burney PGJ. Trends in the prevalence of asthma in Scottish and English primary school children 1982-92. Thorax 1995; 50: 992-3. Russell G, Helms PJ. Reporting of common respiratory and atopic symptoms has increased. BMJ 1997; 315: 1014-5. Sinclair H, Allwright S, Prichard J. Secular trends in mortality from asthma in children and young adults: Republic of Ireland 1970-91. Irish J Med Sci 1995; 45-7. Strachan DP, Butland BK, Anderson HR. Incidence and prognosis of asthma and wheezing illness from early childhood to age 33 in a national British cohort. BMJ 1996; 312: 1195-9.

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Strachan D, Gerritsen J. Long-term outcome of early childhood wheezing: population data. Eur Respir J 1996; 9: 42-7. Strachan D, Griffiths JM, Johnston IDA, Anderson HR. Ventilatory function in British adults after asthma or wheezing illness at ages 0-35. Am J Respir Crit Care Med 1996; 154: 1629-35. Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. Taylor M, Holland C, OLorcain P. Asthma and wheeze in schoolchildren. Irish Med J 1996; 89: 34-5. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Upton MN, McConnachie A, McSharry C, Hart CL, Davey Smith G, Gillis CR, Watt GCM. Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the Midspan family study surveys of parents and offspring. BMJ 2000; 321: 88-92. Wright SC, Evans AE, Sinnamon DG, MacMahon J. Asthma mortality and death certification in Northern Ireland. Thorax 1994; 49: 141-3. Yarnell JWG, Stevenson MR, MacMahon J, Shields M, McCrum EE, Patterson CC, Evans AE, Manning PJ, Clancy L. Smoking, atopy and certain furry pets are major determinants of respiratory symptoms in children: the International Study of Asthma and Allergies in Childhood Study (Ireland). Clin Exp Allergy 2003; 33: 96-100.

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Western Europe
Austria Belgium France Germany Italy Luxembourg Netherlands Portugal Spain Switzerland

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

17.2 m 290.8 m 5.9%

Key Points: 1. The prevalence of asthma is generally high within Western Europe. The prevalence of other atopic diseases such as allergic rhinitis and eczema are amongst the highest in the world. 2. The prevalence of asthma is generally higher in urban areas compared with suburban areas, and lower in communities living at high altitude. The lowest levels are in individuals who have lived on a farm in childhood. 3. The available evidence indicates that the prevalence of asthma has increased markedly in both children and adults over recent decades within the region. The increase has been particularly marked in the former East Germany, which now has prevalence rates which are similar to those in former West Germany. 4. There are wide variations in the treatment of asthma within Western Europe; however, in general asthma is often undertreated and management generally falls short of that recommended in international guidelines. 5. The burden of asthma is considerable within the region, with over one in four children and adults with asthma requiring an unscheduled urgent care visit in the previous twelve-month period. 6. Asthma remains an important cause of hospital admissions. For example, in Switzerland there are over 40,000 asthma-related hospitalizations annually, representing the largest category of direct medical expenditures for asthma. 7. The experience with the soybean epidemic asthma in Barcelona demonstrates the potential impact of exposure to a workplace sensitizing agent within the general community. It also suggests that episodes of severe asthma in the community which are considered idiopathic may be due to the inhalation of airborne occupational agents and illustrates the importance of vigilance with respect to the patterns of asthma exacerbations in communities. 37

8. Asthma is a major health-care cost in countries within this region with both significant direct medical and indirect costs for asthmarelated morbidity. For example, in the Netherlands it has been estimated that the annual direct medical cost per person with asthma is about US $500. 9. There has been a general trend of declining asthma mortality in most countries within Western Europe. This pattern has been primarily attributed to changes in management, in particular the increasing use of inhaled corticosteroids. For example, in Germany, in the 1990s there was a strong and significant negative correlation between asthma mortality and prescribed inhaled corticosteroid use. 10. There are a number of countries within Western Europe, such as France, in which the asthma mortality rate has not fallen over the last decade to the degree observed in other countries. One of the priorities within these countries is public health strategies to reduce the number of deaths from asthma.

FURTHER READING
Aguinaga O, Arnedo PA, Belido J, Guillen GF, Suarez Varela MM. The prevalence of asthma-related symptoms in 13-14 year old children from 9 Spanish populations. The Spanish Group of the ISAAC Study (International Study of Asthma and Allergies in Childhood). Med Clin (Barc) 1999; 112: 171-5. Anto JM, Sunyer J, Newman Taylor AJ. Comparison of soybean epidemic asthma and occupational asthma. Thorax 1996; 51: 743-9. Anto JM, Sunyer J, Rodriguez-Roisin R, Suarez-Cervera M, Vazquez L and the Toxicoepidemiological Committee. Community outbreaks of asthma associated with inhalation of soybean dust. N Engl J Med 1989; 320: 1097-102. Arshad SH, Karmaus W, Matthews S, Mealy B, Dean T, Frischer T, Tsitoura S, Bojarskas J, Kuehr J, Forster J. SPACE study group. Association of allergy-related symptoms with sensitisation to common allergens in an adult European population. J Invest Allergol Clin Immunol 2001; 11: 94102. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Basagana X, Sunyer J, Zock J-P, Kogevinas M, Urrutia I, Maldonado JA, Almar E, Payo F, Anto JM on behalf of the Spanish Working Group of the European Community Respiratory Health Survey. Incidence of asthma and its determinants among adults in Spain. Am J Respir Crit Care Med 2001; 164: 1133-7. Bellido JB, Sunyer J. The evolution of mortality due to asthma in the age groups 5-34 and 5-44, Spain, 1975-1991. Gac Sanit 1997; 11: 171-5.

38

Benito J, Bayon JL, Montiano J, Sanchez J, Mintegui S, Vazquez C. Time trends in acute childhood asthma in Basque Country, Spain. Pediatr Pulmonol 1995; 20: 184-8. Boezen HM, Postma DS, Schouten JP, Kerstjens HAM, Rijcken B. PEF variability, bronchial responsiveness and their relation to allergy markers in a random population (20-70 yr). Am J Respir Crit Care Med 1996; 154(1): 30-5. Braun-Fahrlnder C, Riedler J, Herz U, Eder W, Waser M, Grize L, Maisch S, Carr D, Gerlach F, Bufe A, Lauener RP, Scherl R, Renz H, Nowak D, von Mutius E for the Allergy and Endotoxin Study Team. Environmental exposure to endotoxin and its relation to asthma in school-age children. N Engl J Med 2002; 347: 869-77. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Busquets RM, Anto JM, Sunyer J, Sancho N, Vall O. Prevalence of asthmarelated symptoms and bronchial responsiveness to exercise in children aged 13-14 years in Barcelona, Spain. Eur Respir J 1996; 9: 2094-8. Chatenoud L, Soler M, Negri E, La Vecchia C. The recent fall in asthma mortality in Italy and Spain. Int Rev Asthma 2002; 4(1): 92-9. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Ciprandi G, Vizzaccaro A, Cirillo I et al. Increase of asthma and allergic rhinitis prevalence in young Italian men. Int Arch Allergy Immunol 1996; 111: 279-83. Corbo G, Forastiere F, Dell'Orco V et al. Effects of environment on atopic status and respiratory disorders in children. J Allergy Clin Immunol 1993; 92: 616-23. Cortes X, Soriano JB, Sanchez-Ramos JL, Azofra J, Almar E, Ramos J. European study of asthma. Prevalence of atopy in young adults of 5 areas in Spain. Spanish Group of European Asthma Study. Med Clin (Barc) 1998; 111: 573-7. Cuijpers CE, Wesseling GJ, Swaen GM, Sturmans F, Wouters EF. Asthmarelated symptoms and lung function in primary school children. J Asthma 1994; 31: 301-12. de Almeida MM, Gaspar A, Rosado Pinto J. Epidemiology of asthma in Portugal, Cape Verde and Macao. Pediatr Pulmonol 2001; 23(Suppl): 35-7. de Almeida MM, Rosado Pinto J. Bronchial asthma in children: clinical and epidemiologic approach in different Portuguese speaking countries. Pediatr Pulmonol 1999; (Suppl 18): 49-53. de Gooijer A, Brand PLPO, Gerritsen J, Koter GH, Postma DS, Knol K. Changes in respiratory symptoms and airway hyperresponsiveness after 27 years in a population-based sample of school children. Eur Respir J 1993; 6: 848-54. de Marco R, Poli A, Ferrari M, Accordini S et al. The impact of climate and traffic-related NO2 on the prevalence of asthma and allergic rhinitis in Italy. Clin Exp Allergy 2002; 32: 1405-12. Downs SH, Marks GB, Sporik R et al. Continued increase in the prevalence of asthma and atopy. Arch Dis Child 2001; 84: 20-3.

39

Dubois P, Degrave E, Vandenplas O. Asthma and airway hyperresponsiveness among Belgian conscripts, 1978-91. Thorax 1998; 53; 101-5. Duhme H, Weiland SK, Rudolph P, Wienke A, Kramer A, Keil U. Asthma and allergies among children in West and East Germany: a comparison between Mnster and Greifswald using the ISAAC Phase 1 protocol. Eur Respir J 1998; 11: 840-7. Eder W, Gamper A, Oberfeld G, Riedler J. Clinical follow-up of an epidemiologic study on asthma and allergies in childhood. Wiener Klinische Wochenschrift 1998; 110: 678-85. Eder W, Gamper A, Oberfeld G, Riedler J. Prevalence and severity of bronchial asthma, allergic rhinitis and atopic dermatitis in Salzburg school children. Wiener Klinische Wochenschrift 1998; 10: 669-77. European Asthma Study. The prevalence of asthma-related symptoms in 5 Spanish areas. The Spanish Group of the European Asthma Study. Med Clin (Barc) 1995; 104: 487-92. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Frye C, Heinrich J, Wjst M, Wichmann H-E for the Bitterfeld Study Group. Increasing prevalence of bronchial hyperresponsiveness in three selected areas in East Germany. Eur Respir J 2001; 18: 451-8. Godard P, Chanez P, Siraudin L, Nicoloyannis N, Duru G. Costs of asthma are correlated with severity: a 1-yr prospective study. Eur Respir J 2002; 19: 61-7. Grize L, Braun-Fahrlnder Ch, Gassner M et al. Time trend of asthma and allergy prevalence in Swiss children using the ISAAC core questions. Am J Respir Crit Care Med 2001; 163: A367. Grber C, Illi S, Plieth A, Sommerfeld C, Wahn U. Cultural adaptation is associated with atopy and wheezing among children of Turkish origin living in Germany. Clin Exp Allergy 2002; 32: 526-31. Heinrich J, Hoelscher B, Frye C, Meyer I, Wjst M, Wishmann H-E. Trends in prevalence of atopic diseases and allergic sensitization in children in Eastern Germany. Eur Respir J 2002; 19: 1040-6. Heinrich J, Hoelscher B, Jacob B, Wjst M, Wichmann H-E. Trends in allergies among children in a region of former East Germany between 1992-1993 and 1995-1996. Eur J Med Res 1999; 4: 107-13. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611.

40

Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Kerkhof M, Schouten JP, De Monchy JG. The association of sensitization to inhalant allergens with allergy symptoms: the influence of bronchial hyperresponsiveness and blood eosinophil count. Clin Exp Allergy 2000; 30(10): 1387-94. Klein K, Dathe R, Gllwitz S, Jger L. Allergies - a comparison between two vocational schools in East and West Germany. Allergy 1992; 47: 259. Kogevinas M, Anto JM, Soriano JB, Tobias A, Burney P and the Spanish Group of the European Asthma Study. The risk of asthma attributable to occupational exposures: a population-based study in Spain. Am J Respir Crit Care Med 1996; 154: 137-43. Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Kossler W, Stelzhammer V, Stohlhofer B, Zwick H. Changes in sensitization to air allergens and bronchial hyperresponsiveness in a cross-sectional survey of Viennese school children in 1988 and 1997. Pneumologie 1999; 53: 544-7. La Socit de Pneumologie de Langue Franaise. Revue des Maladies Respiratoires. Enqute ISAAC-France, Phase 1. Novembre 1997; (Suppl 4): S1-S72. La Veechia C, Levi F, Lucchini F. Trends in mortality from bronchial asthma in Switzerland, 1969-1993. Rev Epidemiol Saute Publ 1996; 44: 155-61. Lagerlv P, Veninga CCM, Muskova M, Hummers-Pradier E, StlsbyLundborg C, Andrew M, Haaijer-Ruskamp FM. Asthma management in five European countries: doctor's knowledge, attitudes and prescribing behaviour. Eur Respir J 2000; 15(1): 25-9. Leynaert B, Neukirch C, Jarvis D, Chinn S, Burney P, Neukirch F on behalf of the European Community Respiratory Health Survey. Does living on a farm during childhood protect against asthma, allergic rhinitis and atopy in adulthood? Am J Respir Crit Care Med 2001; 164: 1829-34. Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM and the EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in western Europe. Lancet 349: 1655-9. Mommers M, Derkx R, Swaen G, van Schayck OCP. Changing prevalence of respiratory symptoms and treatment in Dutch schoolchildren: 19891997. Prim Care Resp J 2002; 11(2): 38-41. Mormile F, Chiappini F, Feola G, Ciappi G. Deaths from asthma in Italy (1974-1988): is there a relationship with changing pharmacological approaches? J Clin Epidemiol 1996; 49: 1459-66. Neukirch F, Pin I, Knani J et al. Prevalence of asthma and asthma-like symptoms in three French cities. Respir Med 1995; 99: 685-92. Nowak D, Heinrich J, Jorres R et al. Prevalence of respiratory symptoms, bronchial hyperresponsiveness and atopy among adults: West and East Germany. Eur Respir J 1996; 9: 2541-52. Nowak D, Tews JT, Rohbacher R, Volmer T. Negative correlation between use of inhaled corticosteroids and asthma outcomes in Germany in the time period of 1990-1999. Am J Respir Crit Care Med 2002; 165(8): A122.

41

Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Picado C. Barcelona's asthmatic epidemics: clinical aspects and intriguing findings. Thorax 1992; 47: 197-200. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000; 16: 802-7. Renzoni E, Forastiere F, Biggeri A, Viegi G, Bisanti L, Chellini E, Ciccone G, Corbo G, Galassi C, Rusconi F, Sestini P on behalf of the SIDRIA collaborative Group. Differences in parental- and self-report of asthma rhinitis and eczema among Italian adolescents. Eur Respir J 1999; 14: 597-604. Riedler J, Gamper A, Eder W, Oberfeld G. Prevalence of bronchial hyperresponsiveness to 4.5% saline and its relation to asthma and allergy symptoms in Austrian children. Eur Respir J 1998; 11: 355-60. Robertson CF, Bishop J, Sennhauser FH, Mallol J. International comparison of asthma prevalence in children: Australia, Switzerland, Chile. Pediatr Pulmonol 1993; 16: 219-26. Ronchetti R, Villa MP, Barreto M et al. Is the increase in childhood asthma coming to an end? Findings from three surveys of schoolchildren in Rome, Italy. Eur Respir J 2001; 17: 881-6. Rutten-van Mlken MPMH, Postma MJ, Joore MA, Van Genugten MLL, Leidl R, Jager JC. Current and future medical costs of asthma and chronic obstructive pulmonary disease in the Netherlands. Respir Med 1999; 93: 779-87. Saiz SC, Cortes VC, Gimenez Fernandez FJ, Calderon MC, Sabater PA, Hernandez GA. Epidmiological observations on the evolutive tendency of asthma mortality in Spain. Rev Clin Esp 1991; 189: 314-9. Schramm B, Ehlken B, Smala A, Quednau K, Berger K, Nowak D. Cost of illness of atopic asthma and seasonal allergic rhinitis in Germany: 1-yr retrospective study. Eur Respir J 2003; 21: 116-22. Sennhauser FH, Kuhni CE. Prevalence of respiratory symptoms in Swiss children: is bronchial asthma really more prevalent in boys? Paediatr Pneumonol 1995; 19: 161-6. SIDRIA Collaborative Group. Asthma and respiratory symptoms in 6-7 year old Italian children: gender, latitude, urbanization and socioeconomic factors. Eur Respir J 1997; 10: 1780-6. Sistek D, Tschopp J-M, Schindler C, Brutsche M, Ackermann-Liebrich U, Perruchoud A-P, Leuenberger P and SAPALDIA team. Clinical diagnosis of current asthma: predictive value of respiratory symptoms in the SAPALDIA Study. Eur Respir J 2001; 17: 214-9. Soler M, Chatenoud L, Negri E, La Vecchia C. Trends in asthma mortality in Italy and Spain, 1980-1996. Eur J Epidemiol 2001; 17: 545-9. Soriano JB, Anto JM, Sunyer J, Tobias A, Kogevinas M, Almar E et al. Risk of asthma in the general Spanish population attributable to specific immunoresponse. Spanish Group of the European Community Respiratory Health Survey. Int J Epidemiol 1999; 28: 728-34. Spee-van der Wekke J, Meulmeester JF, Radder JJ, Verloove-Vanhorick SP. School absence and treatment in school children with respiratory symptoms in The Netherlands: data from the Child Health Monitoring System. J Epidemiol Comm Health 1998; 52: 359-63.

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Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. Sunyer J, Spix C, Qunel P, Ponce-de-Len A, Pnka A, Barumandzadeh T, Touloumi G, Bacharova L, Wojtyniak B, Vonk J, Bisanti L, Schwartz J, Katsouyanni K. Urban air pollution and emergency admissions for asthma in four European cities: the APHEA Project. Thorax 1997; 52: 760-5. Szucs TD, Anderhub H, Rutishauser M. The economic burden of asthma: direct and indirect costs in Switzerland. Eur Respir J 1999; 13: 281-6. Tirimanna PR, van Schayck CP, den Otter JJ, van Weel C, van Herwaarden CL, van den Boom G, van Grunsven PM, van den Bosch WJ. Prevalence of asthma and COPD in general practice in 1992: has it changed since 1977? Br J Gen Pract 1996; 46(406): 277-81. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Union Rgionale des Caisses d'Assurance Maladie d'Ile-de-France. tude de la Prise en charge de l'Asthme chez les 10-44 ans en Ile-de-France. Juin 2001. Upton MN, McConnachie A, McSharry C et al. Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the Midspan family study surveys of parents and offspring. BMJ 2000; 321: 88-92. Viegi G, Baldacci S, Vellutini M, Carrozzi L, Modena P, Pedreschi M, Maggiorelli F, Di Pede F, Paoletti P, Giuntini C. Prevalence rates of diagnosis of asthma in general population samples of Northern and Central Italy. Monaldi Arch Chest Dis 1994; 49: 3: 191-6. von Mutius E, Fritzsch C, Weiland SK, Rll G, Magnussen H. Prevalence of asthma and allergic disorders among children in united Germany: a descriptive comparison. BMJ 1992; 305: 1395-9. von Mutius E, Martinez FD, Fritzsch C, Nicolai T, Rll G, Thiemann H-H. Prevalence of asthma and atopy in two areas of West and East Germany. Am J Respir Crit Care Med 1994; 149: 358-64. Wever-Hess J, Wever AMJ. Asthma statistics in the Netherlands, 1980-94. Respir Med 1997; 91: 417-22. Wieringa MH, Weyler JJ, Van Bastelaer FJ, Nelen VJ, Van Sprundel MP, Vermeire PA. Higher asthma occurrence in an urban than a suburban area: role of house dust mite skin allergy. Eur Respir J 1997; 10: 1460-6. Wttrich B et al. Prevalence of atopy, hay fever and asthma in eight areas of Switzerland (SAPALDIA-Study). All Clin Immunol 1994; (Suppl. 2): s112. Zacharasiewicz A, Zidek T, Haidinger G, Waldhor T, Suess G, Vutuc C. Indoor factors and their association to respiratory symptoms suggestive of asthma in Austrian children aged 6-9 years. Wiener Klinische Wochenschrift 1999; 111: 882-6.

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44

Balkans/Turkey/Caucasus/Mediterranean Islands
Albania Armenia Azerbaijan Bosnia-Herzegovina Croatia Cyprus Georgia Greece FYR Macedonia Malta Serbia Slovenia Turkey

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

6.9 m 112.4 m 6.1%

Key Points: 1. There is a wide range of asthma prevalence rates from countries within this region. The prevalence rates for asthma are amongst the lowest in the world in the Balkans and Caucasus regions, whereas in some countries, such as Turkey and Malta, the prevalence rates are generally higher. 2. The rates of reported asthma symptoms and diagnosed asthma have increased markedly in a number of countries in the region over the last few decades. 3. It is likely that the greatest future increase in the number of persons with asthma in the region will occur in Turkey, due to its large population and the forecast major changes in lifestyle and urbanisation. 4. The human and socioeconomic burden of asthma in many countries within the region is marked, with considerable time lost from work and frequent emergency room visits and hospital admissions. 5. There has been a progressive and marked increase in the rate of hospital admissions due to asthma in children in a number of countries. The trends differ in some respects compared with other regions of the world. For example, in Greece the increase has been most marked in the 5- to 14-year age group, in contrast to most countries worldwide where the greatest increase has occurred in the 0- to 4-year age group. 6. The availability of asthma medicines is limited in part by the cost. For example, in Turkey the cost of a year of treatment for a person with moderate persistent asthma is about half the monthly salary of a nurse. 7. Occupational asthma constitutes a substantial cause of asthma in the region. As in other regions of the world, occupational asthma remains an important preventable public health problem. 45

8. Asthma mortality rates are generally low in countries within this region, reflecting to some degree the low prevalence rates. 9. Asthma mortality rates increase with increasing age, a pattern which is seen in most other regions of the world. Even taking into consideration the decline in certification accuracy in the older age groups, it does indicate a considerably greater risk of death in older asthmatics and the importance of asthma care in this group. 10. Socioeconomic factors play an important role in the adverse health outcomes, including those surrounding asthma, caused by the lack of access to appropriate health care.

FURTHER READING
Ait-Khaled N, Auregan G, Bencharif N, Camara LM, Dagli E, Djankine K, Keita B, Ky C, Mahi S, Ngoran K, Pham DL, Sow O, Yousser M, Zidouni N, Enarson DA. Affordability of inhaled corticosteroids as a potential barrier to treatment of asthma in some developing countries. Int J Tuberc Lung Dis 2000; 4: 268-71. Akcakaya N, Kulak K, Hassanzadeh A, Camcioglu Y, Cokugras H. Prevalence of bronchial asthma and allergic rhinitis in Istanbul school children. Eur J Epidemiol 2000; 16: 693-9. Anthracopoulos M, Karatza A, Liolios E, Triga M, Triantou K, Priftis K. Prevalence of asthma among schoolchildren in Patras, Greece: three surveys over 20 years. Thorax 2001; 56: 569-71. Arshad SH, Karmaus W, Matthews S, Mealy B, Dean T, Frischer T, Tsitoura S, Bojarskas J, Kuehr J, Forster J. SPACE study group. Association of allergy-related symptoms with sensitisation to common allergens in an adult European population. J Invest Allergol Clin Immunol 2001; 11: 94102. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Bardagi S, Agudo A, Gonzalez CA, Romero PV. Prevalence of exerciseinduced airway narrowing in schoolchildren from a Mediterranean town. Am Rev Respir Dis 1993; 147: 1112-5. Barnes M, Cullinan P, Athanasaki P, Macneill S, Hole AM, Harris J, Kalogeraki S, Chatzinikolaou M, Drakonakis N, Bibaki-Liakou V, Newman Taylor AJ, Bibakis I. Crete: does farming explain urban and rural differences in atopy? Clin Exper Allergy 2001; 31: 1822-8. Bavbek S, Celik G, Ediger D, Mungan D, Sin B, Demirel YS, Misirligil Z. Severity and associated risk factors in adult asthma patients in Turkey. Ann Allergy Asthma Immunol 2000; 85: 134-9. Black ME. Collapsing health care in Serbia and Montenegro. BMJ 1993; 307: 1135-7. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39.

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Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Cacciottolo JM, Balzan MV, Buhagiar A. Hospitalization of adults for asthma and inhaled corticosteroid use in an island population. Respir Med 1997; 91: 411-6. Celik G, Mungan D, Bavbek S, Sin B, Ediger D, Demirel Y, Misiligil Z. The prevalence of allergic diseases and atopy in Ankara, Turkey: a two-step population-based epidemiological study. J Asthma 1999; 36: 281-90. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Dimitrova ZD, Getov IN, Petrova GI. Study on prescribing habits and antiasthmatic drug utilisation in Bulgaria. J Soc Admin Pharmacy 1997; 14: 56-61. Dutu ST, Paun G. Prevalenta astmului bronsic a bronsitei cornice si a BPOC pe esantioane representative de populatie adulta. Pneumoftiziologia 1996; XLV: 139-43. Dutu ST, Paun G. Prevalenta unor simptome respiratorii, a astmului bronsic si a bronsitei cronice (simple si obstructive) ntr-un esantion reprezentativ pentru o populatie adulta rurala. Pneumoftiziologia 1998; XLVII: 151-60. Ece A, Ceylan A, Saraclar Y, Saka G, Gurkan F, Haspolat K. Prevalence of asthma and other allergic disorders among schoolchildren in Diyarbakir, Turkey. Turk J Pediatr 2001; 43: 286-92. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Gaga M. Implementing GINA management strategies for asthma in Greece. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp 26-7. Gamkrelidze O, Khetsuriani N, Gotua M, Gumia N. ISAAC study in the Republic of Georgia: childhood asthma. Allergy 1996; 51: 44. Grech V, Agius-Muscat H, Montefort S, Lenicker H. Recognition of asthmatic symptoms in the pediatric age group. Pediatr Allergy Immunol 2001; 12: 49-53. Grech V, Balzan M, Asciak RP, Buhagiar A. Seasonal variations in hospital admissions for asthma in Malta. J Asthma 2002; 39: 263-8. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35.

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Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Jazbec A, Simic D, Hrsak J, Peros-Golubicic T, Kujundzic D, Sega K, Pavlovic M. Short-term effects of ambient nitrogen oxides on the number of emergency asthma cases in Zagreb, Croatia. Arhiv za Higijenu Rada i Toksikologiju 1999; 50: 171-82. Kabesch M, Schaal W, Nicolai T, von Mutius E. Lower prevalence of asthma and atopy in Turkish children living in Germany. Eur Respir J 1999; 13: 577-82. Kalayci O, Saraclar Y, Sekerel BE, Adalioglu G, Kuyucu S, Egor G, Bozer HK, Tuncer A. Prevalence of asthma symptoms among Turkish Cypriot schoolchildren. Turk J Pediatr 1999; 41: 413-20. Kalyoncu AF, Demir AU, Ozcakar B, Bozkurt B, Artvinli M. Asthma and allergy in Turkish university students: two cross-sectional surveys 5 years apart. Allergologia et Immunopathologia 2001; 29: 264-71. Kalyoncu AF, Selcuk ZT, Enunlu T, Demir AU, Coplu L, Sahin AA, Artvinli M. Prevalence of asthma and allergic disease in primary school children in Ankara, Turkey: two cross-sectional studies, five years apart. Ped Allergy Immunol 1999; 10: 261-5. Kocabas A, Kuleci S, Bugdayci R, Gcmen T, Avsar M. Asthma-related symptoms among adults in Adana, Turkey. Eur Respir J 1998; 12(Suppl.28): 198s. Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Mackenbach JP, Kunst AE, Cavelaars AEJM, Groenhof F, Geurts JJM and the EU Working Group on Socioeconomic Inequalities in Health. Socioeconomic inequalities in morbidity and mortality in western Europe. Lancet 349: 1655-9. Montefort S, Lenicker HM, Caruna S, Agius Muscat H. Asthma, rhinitis and eczema in Maltese 13-15 year old schoolchildren - prevalence, severity and associated factors [ISAAC]. Clin Exper Allergy 1998; 28: 1089-99. Montefort S, Lenicker HM, Caruana S, Agius Muscat H. Asthma and other allergic conditions in 5-8 year old children in the Maltese Islands. Pediatr Allergy Immnol 2002; 13: 98-104. Oreskovic S, Bozicevic I, Mastilica M, Bakran I, Popovic SG, Ben-Joseph R. Health-care resource use by asthmatics in Croatia. J Asthma 2002; 39: 351-8. Ozdemir N, Ucgun I, Metintas S, Kolsuz M, Metintas M. The prevalence of asthma and allergy among university freshmen in Eskisehir, Turkey. Respir Med 2000; 536-41. Papageorgiou N, Gaga M, Marossis C, Avarlis CRP, Kyriakou M, Tsipra S, Zeibecoglou K, Tracopoulos G. Prevalence of asthma and asthma-like symptoms in Athens, Greece. Resp Med 1997; 91: 83-8.

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Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Pesut DP, Basara Z, Pesic I. Comparative analysis of asthma and COPD incidence in Serbia - a 10 year period. Eur Respir J 2002; 20(Suppl.38): 315s. Priftanji AV, Qirko E, Burr ML, Layzell JCM, Williams KL. Factors associated with asthma in Albania. Allergy 2002; 57: 123-8. Priftanji AV, Qirko E, Layzell JCM, Burr ML, Fifield R. Asthma and allergy in Albania. Allergy 1999; 54: 1042-7. Priftanji A, Strachan D, Burr M, Sinamati J, Shkurti A, Grabocka E, Kaur B, Fitzpatric S. Asthma and allergy in Albania and the UK. Lancet 2001; 358: 1426-7. Priftis K, Anagnostakis J, Harokopos E, Orfanou I, Petraki M, SaxoniPapageorgiou P. Time trends and seasonal variation in hospital admissions for childhood asthma in the Athens region of Greece: 197888. Thorax 1993; 48: 1168-9. Radic S. Adolescent asthma - seven years follow up period. Thesis: Medical School University of Belgrade, 1997. Saraclar Y. GINA in Turkey. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp 27-9. Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Toros Seluk Z, aglar T, Ennl T, Topal T. The prevalence of allergic diseases in primary school children in Edirne, Turkey. Clin Exper Allergy 1997; 27: 262-9. Turktas I, Selcuk ZT, Kalyoncu AF. Prevalence of asthma-associated symptoms in Turkish children. Turk J Pediatr 2001; 43: 1-11. Zivkovic Z. Correlation between clinical score, laboratory findings and radiographic changes in acute asthma in children. Thesis: Medical School University of Belgrade, 1991. Zivkovic Z. Asthma and allergic rhinitis in children after ten years. Eur Respir J 2002; 20(Suppl.38): 332s. Zuskin E, Kancelijak B, Schachter N, Godnic-Cvar J, Mustajbegovic J, Budak A. Respiratory function and immunological status in cocoa and flour processing workers. Am J Indust Med 1998; 33: 24-32.

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Russia & Former Socialist Republics of Eastern Europe

Belarus Bulgaria Czech Republic Hungary Moldova Romania Russian Federation Slovakia Ukraine

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

9.8 m 264.0 m 3.7%

Key Points: 1. The prevalence of asthma is generally low in countries within this region, with some of the lowest prevalence rates recorded worldwide. 2. The prevalence of asthma is likely to increase markedly during the next decade due to the rapid changes in lifestyle that are currently occurring within the region. Indeed, in some countries within the region, such as the Czech Republic, asthma is already of a similar prevalence as in countries in Western Europe. The prevalence of asthma is generally higher in urban areas compared with rural areas. With the trend of increasing urbanisation it is likely that this social phenomenon will lead to further increases in the prevalence of asthma. 3. The speed and magnitude of the increase in asthma (and associated bronchial hyperresponsiveness and atopic sensitisation) in the former East Germany (with the changes in lifestyle that have occurred since reunification) indicate the potential burden of asthma facing Eastern Europe, in terms of the likely increase in the prevalence of asthma, as socioeconomic conditions improve. 4. The underestimation of severity of exacerbations, lack of access to medical care, and inadequate treatment contribute to asthma morbidity and mortality within the region. 5. The implementation of locally adapted asthma education and management programmes based on the GINA guidelines has been shown to be effective in terms of changing prescribing and management practices, and reducing morbidity in patients with severe asthma in a number of countries within the region. 6. The poor economic conditions in many countries within the region, together with the low expenditure on health by national governments, represent major barriers to the delivery of health 50

care services, including those related to asthma. For example, Russias national government expenditure on health, which is currently around 4% of the Gross National Product, is too low to provide adequate health care. 7. Many communities within the region are exposed to high levels of air pollution, greater than those observed in Western Europe. Developing strategies to reduce the level of air pollution remains one of the many public health priorities for the region. 8. Political and public health measures to reduce tobacco smoking also represent important priorities. Russia is the fourth-largest cigarette market in the world and one of the fastest growing. While cigarette sales have fallen in many Western countries over the last decade, they have increased in Eastern Europe and the former Soviet Union during this period. 9. Occupational asthma remains an important problem in the region, with workplace exposures to various substances often considerably greater than that recommended by national and international standards. Reducing the workplace exposures to within safe limits represents one of the priorities in terms of occupational safety and health. Epidemiological investigations of adults exposed to radiation while working in the contaminated zone after the Chernobyl accident, in which the prevalence of asthma was observed to be over five times greater than in a nonexposed population, illustrate that an increased risk of asthma is amongst the health risks in people exposed to significant levels of radiation in nuclear accidents. 10. The mortality rate due to asthma is generally higher than would be expected given the relatively low prevalence rates in the region. This is suggested by the high case fatality rates which are likely to be due to a number of factors including access to medical care, particularly medications and acute medical services.

FURTHER READING
Antonov NS, Stulova O, Khlopova TG. The prevalence of respiratory organ diseases among those who cleaned up the accident at the Chernobyl Atomic Electric Power Station. Terapevticheskii Arkhiv 1996; 68: 17-9. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Bilitchenko TN, Nikitina N, Tchoutchalin AG. Prevalence rates of bronchial asthma in Moscow and in Russia. (Abstract).

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Bjrkstn B, Dumitrascu D, Foucard T, Khetsuriani N, Khaitov R, Leja M, Lis G, Pekkanen J, Priftanji A, Riikjarv MA. Prevalence of childhood asthma, rhinitis and eczema in Scandinavia and Eastern Europe. Eur Respir J 1998; 12: 432-7. Bobak M, Koupilova L, Williams HC, Leon DA et al. Prevalance of asthma, atopic eczema and hay fever in preschool children. Praktlek 1995; 75: 480-5. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Chuchalin AG. Bronchial Asthma, Moscow 1995; 1-159. Czech Initiative for Asthma. World Asthma Day in the Czech Republic, Praha 2000. JALNA Prague 1-12. Dostalova M, Kachlik P et al. Modern strategy of treatment significantly decreased severity of bronchial athma in children. Respirace 1999; 5: 24-5. Dotterud LK, Odland JO, Falk ES. Atopic diseases among adults in the two geographically related arctic areas Nikel, Russia and Sor-Varanger, Norway: possible effects of indoor and outdoor air pollution. J Eur Acad Dermatol Venereol 2000; 14: 107-11. Dutu S, Paun G. The prevalence of respiratory symptoms, bronchial asthma and chronic bronchitis (simple and obstructive) in a representative sample of the adult rural population. Pneumoftiziologie 1998; 47: 151-60. Elkina TN, Kondiourina EG, Likhanov AV. Prevalence of asthma and associated rhinitis and atopic eczema in schoolchildren in Novosibirsk from 1996 to 2002. Eur Respir J 2002; 20(Suppl.38): 145s. Endre L, Vamos A, Dinya E, Farkas I. Increase in prevalence of childhood asthma in Budapest in relation to the air pollution data and the total pollen counts. Orvosi Hetilap 2000; 141: 2815-20. Faierajzlova V, Svandova E. Allergy and the environment. Alergie 1999; 1: 13-18. Garfield R, Devin J, Fausey J. The health impact of economic sanctions. Bull NY Acad Med 1995; 72: 454-69. Gherghe S, Nanulescu MV, Panta-Chereches P, Popa M. The prevalence of bronchial asthma in 13- to 14-year old schoolchildren in the city of Bistri. Pneumologia 2000; 49: 95-9. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Lagerlv P, Veninga CCM, Muskova M, Hummers-Pradier E, StlsbyLundborg C, Andrew M, Haaijer-Ruskamp FM. Asthma management in five European countries: doctor's knowledge, attitudes and prescribing behaviour. Eur Respir J 2000; 15(1): 25-9. Lasitsa OI, Akopian AZ. The interrelationship of bronchial hyperreactivity and wheezing in children. Likarska Sprava 1999; 6: 60-4. Lazic ZM, Mojsilovic SD, Gajovic OM. The rates of admission asthma patients in last ten years. Eur Respir J 2002; 20(Suppl.38): 317s. Leonardi GS, Houthuijs D, Nikiforov B, Volf J, Rudnai P, Zejda J, Gurzau E, Fabianova E, Fletcher T, Brunekreef B. Respiratory symptoms, bronchitis and asthma in children of Central and Eastern Europe. Eur Respir J 2002; 20: 890-8.

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Leschenko IV, Livshitz AA. Epidemiologic features of asthma in a large industrial city. Eur Respir J 1998; 12(Suppl.28): 198s. Markov A. The problem of asthma in the Ukraine. Allergy Proc 1995; 16: 269-73. Maslennikova GY, Morosova ME, Salman NV, Kulikov SM, Oganov RG. Asthma education programme in Russia: educating patients. Patient Educ Counsel 1998; 33: 113-27. Maslennikova GA, Shmarova LM, Lapidus JA, Oganov RG. Asthma education in Russia: effectiveness of a training programme for primary care doctors. Asthma J 2001; 6: 134-8. McNabb SJN, Reichrtova E, Ciznar P, Palkovicova L, Adamcakova A, Lang Dunlop A. Predictors of allergic diseases among pregnant women, Slovak Republic 1997-1998. ACI International 2003; 15: 30-6. Mednikov BL, Mednikova OB, Piiavski SA, Chuchalin AG. The economic expenses related to bronchial asthma morbidity. Terapevticheskii Arkhiv 1997; 69: 37-9. Oganov RG, Maslennikova GY. Asthma mortality in Russia between 1980 and 1989. Eur Respir J 1999; 13: 287-9. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Petrovic D et al. Predicting the hospitalization trends of asthma using autoregression and time-delay neural networks. Eur Respir J 2002; 20(Suppl.38): 316s. Pikhart H, Bobak M, Gorynski P, Wojtyniak B, Danova J, Celko MA, Kriz B, Briggs D, Elliott P. Outdoor sulphur dioxide and respiratory symptoms in Czech and Polish schoolchildren: a small-area study (SAVIAH). Int Arch Occup Environ Health 2001; 74: 574-8. Pohunek P, Spicak V. Current situation of bronchial asthma in the Czech Republic. ACI International 2001; 2: 54-9. Pohunek P, Slamova A, Zvirova J, Svato J. Prevalence of bronchial asthma, eczema and allergic rhinitis in schoolchildren in the Czech Republic. Cs Pediatr 1999; 54: 60-8. Puchlik BM, Bondarchuk OB, Koritskaya IB et al. Prevalence of allergic diseases. Ukranian Pulm J 1993; 1: 11-15. Radu JR. GINA activities in Romania. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp 29-30. Selnes A, Odland JO, Bolle R, Holt J, Dotterud LK, Lund E. Asthma and allergy in Russian and Norwegian schoolchildren: results from two questionnaire-based studies in the Kola Peninsula, Russia and northern Norway. Allergy 2001; 56: 344-8. Spiewak R, Gra A, Horoch A, Dutkiewicz J. Atopy, allergic diseases and work-related symptoms among students of agricultural schools: first results of the Lublin Study. Ann Agric Environ Med 2001; 8: 261-7. Stoicescu IP, Strambu I, Basca N, Petrui I, Ghergan A, Munteanu I, Pisel N, Grecu E, Bena D, Petrui M. The results of using a simplified questionnaire for determining the prevalence of bronchial asthma. Pneumoftiziologie 1998; 47: 89-94. Tcherniak BA, Buinova SN, Tyarenkova SV. Epidemiology of bronchial asthma (BA) in East Siberia. Eur Respir J 1998; 12(Suppl.28): 198s.

53

Vartiainen E, Petays T, Haahtela T, Jousilahti P, Pekkanen J. Allergic diseases, skin prick test responses, and IgE levels in North Karelia, Finland and the Republic of Karelia, Russia. J Allergy Clin Immunol 2002; 109: 643-8. Vondra V, Maly M, Svandova E, Reisova M. Mortality due to chronic obstructive pulmonary disease in the Czech Republic in the past 50 years. Studia Pneumologica et Phthiseologica 2002; 62(5): 159-65. Vondra V, Prazakova J, Reisova M, Mazakova H, Baly J, Machova A, Fuchs B, Jira J. The prevalence of bronchial asthma in a selected sample of the adult Prague population. Vnitrni Lekarstvi 1990; 36(7): 654-9. Vondra V, Reisov M. Asthma bronchialc v detstvi a v dospelosti. Zv zprva vzk kolu Z 208 MZ CR 1995; s 1-89. Vondra V, Reisov M, Mazkov H, Bal J, Prakov J, Jira M. Prevalence of bronchial hyperreactivity in adult health population. Stud Pneumol Phtiseol Cechoslov 1990; 50(8): 518-22. Vondra V, Reisov M, Prakov J, Mazkov H, Bal J, Roth Z, Vyhnnek R, Nemec L. Prevalence of bronchial asthma, chronic bronchitis and bronchial hyperresponsiveness in adult population of Prague. Casopis Lekaru Ceskych 1993; 132: 113-8. Vondra V, Reisov M. The prevalence of bronchial asthma is increasing and mortality varies. Casopis Leka ru Ceskych 1996; 135: 471-6. Vondra V, Reisov M, Branis M, Maly M. Prevalence of symptoms of bronchial asthma in elementary schoolchildren in a Prague district and in a rural district. Cs Pediat 1997; 52: 827-30. Vondra V, Reisov M, Branis M, Maly M, Kotesovic F. Asthma symptoms prevalence in primary schoolchildren living in Czech urban and rural areas. Eur Respir J 1998; 12(Suppl28): 199s. Vuleva A, Tashev T. An epidemiological study of bronchial asthma in the Stara Zagora District. Vutreshni Bolesti 1990; 29: 75-80. Zejda JE, Skiba M, Zlotkowska R. Bronchial asthma and chronic respiratory symptoms in the population of children in the Katowice voivodship prevalence and risk factors. Pneumonologia i Alergologia Polska 1996; 64: 169-77.

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Middle East
Bahrain Iran Iraq Israel Jordan Kingdom of Saudi Arabia Kuwait Lebanon Occupied Territory of Palestine Oman Qatar Syria United Arab Emirates Yemen

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

10.3 m 177.5 m 5.8%

Key Points: 1. The prevalence of asthma is generally low within the Middle East, although high rates have been recorded in the Kingdom of Saudi Arabia, Kuwait, Lebanon, and Israel. 2. The prevalence of asthma in migrant communities often differs from that in the resident population in countries in the region. In Israel the prevalence of asthma is three times greater among adults of Ethiopian origin compared with the general population. In contrast, in the Kingdom of Saudi Arabia asthma is less common in the non-Saudi population. 3. Children from refugee camps in the Occupied Territory of Palestine appear to be at greater risk of asthma than children from neighbouring villages and cities. This observation adds further evidence of the major adverse health and socioeconomic conditions present within this community. 4. The available evidence indicates that the prevalence of asthma has increased over recent decades throughout the Middle East. 5. The burden of severe asthma is considerable within the Middle East, with hospital admission rates in excess of 150-200 per 100,000 per year in some of the high prevalence countries. For example, in Israel, one in five asthmatic children visits the emergency room per year, and one in ten asthmatic children is hospitalised in the same period due to severe asthma. 6. There remains a gap between available medical knowledge and medical therapy and its utilisation for the benefit of the asthmatic population in the Middle East. Underdiagnosis of asthma is a common problem. In terms of management, both undertreatment and treatment different from that recommended by national and international guidelines commonly occur. In particular, there is an inadequate use of inhaled corticosteroids in the long-term treatment of asthma. 55

7. The cost and availability of medications represent important barriers to effective management in a number of low- and middle-income countries within the region. For example, in Syria, the cost of a year of treatment for a person with moderate persistent asthma is greater than the monthly salary of a nurse. 8. Programmes based on locally adapted asthma management guidelines have been shown to result in marked changes in prescribing patterns, and reductions in morbidity and mortality from asthma. 9. The level of major air pollutants is considerably above internationally recognised standards, which contributes to severe exacerbations of asthma and to respiratory and all-cause mortality. 10. The use of WHO management guidelines for childhood illnesses, including asthma, is complicated by the similar presentations of respiratory infectious diseases including tuberculosis and pneumonia. This suggests that a more practical, symptom-based approach to the diagnosis of asthma and other respiratory conditions may be required for use at the primary-care level within the region.

FURTHER READING
Abuekteish F, Alwash R, Hassan M, Daoud AS. Prevalence of asthma and wheeze in primary school children in Northern Jordan. Ann Tropical Paediatr 1996; 16: 227-31. Abul AT, Nair PC, Behbehani A, Sharma PN. Hospital admissions and death rates from asthma in Kuwait during pre- and post-Gulf War periods. Ann Allergy Asthma Immunol 2001; 86: 465-8. At-Khaled N, Auregan G, Bencharif N, Mady Camara L, Dagli E, Djankine K, Keita B, Ky C, Mahi S, Ngoran K, Pham DL, Sow O, Yousser M, Zidouni N, Enarson DA. Affordability of inhaled corticosteroids as a potential barrier to treatment of asthma in some developing countries. In J Tuberc Lung Dis 2000; 4: 268-71. Al-Dawood KM. Epidemiology of bronchial asthma among school boys in Al-Khobar city, Saudi Arabia. Saudi Med J 2001; 22: 61-6. Al Frayh AR. Asthma patterns in Saudi Arabian children. J Royal Soc Health 1990; 110: 98-100. Al Frayh AR, al Nahdi M, Bener AR, Jawadi TQ. Epidemiology of asthma and allergic rhinitis in two coastal regions of Saudi Arabia. Allerg Immunol 1989; 21: 389-93. Al Frayh A, Bener A, Al Juwadi TQ. Prevalence of asthma among Saudi schoolchildren. Saudi Med J 1992; 13: 521-4. Al Frayh AR, Shakoor Z, Gad El Rab MO, Hasnain SM. Increased prevalence of asthma in Saudi Arabia. Ann Allergy Asthma Immunol 2001; 86: 292-6.

56

Ali MM, Shah IH. Sanctions and childhood mortality in Iraq. Lancet 2000; 355: 1851-7. Al-Khalaf B. Pilot study: the onset of asthma among the Kuwaiti population during the burning of oil wells after the Gulf War. Environ Internat 1998; 24: 221-5. Al Khayat AA, Habibullah J. Epidemiology of childhood asthma in Dubai. Emir Med J 1993 (Suppl 1): 42-4. Al-Maskari F, Bener A, al-Kaabi A, al-Suwaidi N, Brebner NN, Brebner J. Asthma and respiratory symptoms among schoolchildren in United Arab Emirates. Allergie et Immunologie 2000; 32: 159-63. Amir J, Horev Z, Jaber L et al. Prevalence of asthma in Israeli schoolchildren. Isr J Med Sci 1992; 28: 789-92. Asgari MM, Dubois A, Asgari M, Gent J, Beckett WS. Association of ambient air quality with children's lung function in urban and rual Iran. Arch Environ Health 1998; 53: 222-30. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Auerbach I, Springer C, Godfrey S. Total population survey of the frequency and severity of asthma in 17 year old boys in an urban area in Israel. Thorax 1993; 48: 139-41. Behbehani NA, Abal A, Syabbalo NC, Abd AA, Shareef E, Al Momen J. Prevalence of asthma, allergic rhinitis, and eczema in 13- to 14-year old children in Kuwait: an ISAAC Study. Ann Allergy Asthma Immunol 2000; 85: 58-63. Bener A, Abdulrazzaq YM, Debuse P, Al-Mutawwa J. Prevalence of asthma among Emirates schoolchildren. Eur J Epidemiol 1994; 10: 271-8. Bener A, Abdulrazzaq YM, Debuse P, Abdin AH. Asthma and wheezing as the cause of school absence. J Asthma 1994; 31: 93-8. Bener A, al-Jawadi TQ, Ozkaragoz F, al-Frayh A, Gomes J. Bronchial asthma and wheeze in a desert country. Indian J Pediatr 1993; 60: 791-7. Bener A, al-Jawadi TQ, Ozkaragoz F, Anderson JA. Prevalence of asthma and wheeze in two different climatic areas of Saudi Arabia. Indian J Chest Dis Allied Sci 1993; 35: 9-15. Boskabady MH, Kolahdoz GH. Prevalence of asthma symptoms among the adult population in the city of Mashhad (north-east of Iran). Respirology 2002; 7: 267-72. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Dawod ST, Hussain AA. Childhood asthma in Qatar. Ann Allergy Asthma Immunol 1995; 75: 360-4. Dawson KP, Abdullah AM, Alkawari AR, Alkawari A, Al Khayat A, Arora SC, Ashurst K, Ezzat M, Fahmy N, Harron D, Issac J, Izzeldin A, Campbell Murdoch J, Nicholl K, Rahman H, Simrin K, Van Asperen P. Towards a national consensus on the management of asthma in childhood. Emir Med J 1994; 12(3): 215-9. Dawson KP, Harron DWG. Drug use for asthma in the United Arab Emirates. Int Pharmacy J 1994; 8: 245-7. El-Sharif N, Abdeen Z, Barghuthy F, Nemery B. Familial and environmental determinants for wheezing and asthma in a case-control study of schoolchildren in Palestine. Clin Exp Allergy 2003; 33: 176-86. El-Sharif N, Abdeen Z, Qasrawi R, Moens G, Nemery B. Asthma prevalence in children living in villages, cities and refugee camps in Palestine. Eur Respir J 2002; 19: 1026-34.

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El-Sharif NA, Nemery B, Barghuthy F, Mortaja S, Qasrawi R, Abdeen Z. Geographical variations of asthma and asthma symptoms among schoolchildren aged 5-8 years and 12-15 years in Palestine. (in press) Eshel G, Raviv R, Ben-Abraham R, Barr J, Berkovitch M, Efrati O, Vardi A, Barzilay Z, Paret G. Inadequate asthma treatment practices and noncompliance in Israel. Pediatr Pulmonol 2002; 33: 85-9. Frankish H. Health of the Iraqi people hangs in the balance. Lancet 2003; 361: 623-5. Garfield R, Devin J, Fausey J. The health impact of economic sanctions. Bull NY Acad Med 1995; 72: 454-69. Glazier I. Epidemiology of bronchial asthma in the Middle East. Ann Allergy 1988; 61: 312-4. Goldman M, Rachmiel M, Gendler L, Katz Y. Decrease in asthma mortality rate in Israel from 1991-1995: is it related to increased use of inhaled corticosteroids? J Allergy Clin Immunol 2000; 105: 71-4. Golshan M, Esteki B, Dadvand P. Prevalence of self-reported respiratory symptoms in rural areas of Iran in 2000. Respirology 2002; 7: 129-32. Golshan M, Faghihi M, Mohammad Masood M. Indoor women jobs and pulmonary risks in rural areas of Isfahan, Iran 2000. Respir Med 2002; 96: 382-8. Golshan M, Mohammad-Zadeh Z, Khanlar-Pour A, Iran-Pour R. Prevalence of asthma and related symptoms in junior high schoolchildren in Isfahan, Iran. Monaldi Arch Chest Dis 2002; 57: 19-24. Golshan M, Mohammad-Zadeh Z, Zahedi-Nejad N, Rostam-Poor B. Prevalence of asthma and related symptoms in primary schoolchildren of Isfahan, Iran. Asian Pacific J Allergy Immunol 2001; 19: 163-70. Goren AI, Hellmann S. Changing prevalence of asthma among schoolchildren in Israel. Eur Respir J 1997; 10: 2279-84. Goren AI, Hellmann S. Has the prevalence of asthma increased in children? Evidence from a long term study in Israel. J Epidemiol Community Health 1997; 51: 227-32. Hasan MM, Gofin R, Bar-Yishay E. Urbanization and the risk of asthma among schoolchildren in the Palestinian Authority. J Asthma 2000; 37: 353-60. Hijazi N, Abalkhail B, Seaton A. Asthma and respiratory symptoms in urban and rural Saudi Arabia. Eur Respir J 1998; 12: 41-4. Hijazi N, Abalkhail B, Seaton A. Diet and childhood asthma in a society in transition: a study in urban and rural Saudi Arabia. Thorax 2000; 55: 775-9. Hijazia Z, Abdulmalek AK, Al-Taweel F, Al-Shareda S. Hospital management of children with acute asthma exacerbations in Kuwait: adherence to international guidelines. Med Princ Pract 2002; 11: 126-30. Integrated Management of Childhood Illness Strategy Initiative. Bull WHO 1997; 75(Suppl 1). International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Katz I, Moshe S, Sosna J, Baum GL, Fink G, Shemer J. The occurrence, recrudescence and worsening of asthma in a population of young adults. Chest 2002; 116: 614- 8.

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Kivity S, Sade K, Abu-Arisha F, Lerman Y, Kivity S. Epidemiology of bronchial asthma and chronic rhinitis in schoolchildren of different ethnic origins from two neighbouring towns in Israel. Pediatr Pulmonol 2001; 32: 217-21. Laor A, Cohen L, Danon YL. Effects of tie, sex, ethnic origin, and area of residence on prevalence of asthma in Israeli adolescents. BMJ 1993; 307: 841-4. Osborne Daponte B, Garfield R. The effect of economic sanctions on the mortality of Iraqi children prior to the 1991 Persian Gulf War. Am J Public Health 2000; 90: 546-52. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Picard E, Barmeir M, Schwartz S, Villa Y, Goldberg S, Virgilis D, Kerem E. Rate and place of death from asthma among different ethnic groups in Israel. Chest 2002; 122: 1222-7. Ramadan FM, Khoury MN, Haijar TA, Mroueh SM. Prevalence of allergic diseases in children in Beirut: comparison to worldwide data. Lebanese Med J 1999; 47: 216-21. Rennert G, Peterburg Y. Prevalence of selected chronic diseases in Israel. IMAJ 2001; 3: 404-8. Rosenberg R, Vinker S, Zakut H, Kizner F, Nakar S, Kitai E. An unusually high prevalence of asthma in Ethiopian immigrants to Israel. Fam Med 1999; 31: 276-9. Sacher Y, Laor A, Danon YL. Longitudinal study on the prevalence of asthma among Israeli young adults. Isr J Med Sci 1994; 30: 564-72. Shahar E, Lorber M. Prevalence of self-reported allergic conditions in an adult population in Israel. IMAJ 2001; 3: 190-3. Shamssain MH, Shamsian N. Prevalence and severity of asthma, rhinitis, and atopic eczema: the north east study. Arch Dis Child 1999; 81: 313-7. Shohat T, Golan G, Tamir R, Green MS, Livne I, Davidson Y, Harari G, Garty B-Z. Prevalence of asthma in 13-14 year old schoolchildren across Israel. Eur Respir J 2000; 15: 725-9. Shohat T, Green MS, Davidson Y, Livne I, Tamir R, Garty B-Z. Differences in the prevalence of asthma and current wheeze between Jews and Arabs: results from a national survey of schoolchildren in Israel. Ann Allergy Asthma Immunol 2002; 89: 386-92. Strannegard IL, Strannegard O. Childhood bronchial asthma in a desert country. Allergy 1990; 45: 327-33. Torbey PH, Majdalani P, Hejjaoui A. Profile of the asthmatic child in Lebanon. Pediatr Pulmonol 1999 (Suppl 18): 225-7. United Nations UNSCO Report. The impact on the Palestinian economy of recent confrontations, mobility restrictions and border closures: October 2000 to September 2001, 1-23. Varsano S. Bronchial asthma in Israel. IMAJ 2002; 4: 661-3.

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Central Asia & Pakistan

Afghanistan Kazakhstan Kyrgyzstan Pakistan Tajikistan Turkmenistan Uzbekistan

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

9.7 m 224.7 m 4.3%

Key Points: 1. The prevalence of asthma is generally low within Central Asia and Pakistan. 2. The experience in Pakistan, in which the prevalence of asthma symptoms has increased markedly within the last decade, illustrates the potential magnitude by which the prevalence of asthma may increase over a short period. 3. With increasing urbanisation and changes in lifestyle, it is likely that the number of asthmatics will increase further during the next decade. 4. Within the Aral Sea Area, sites with high dust deposition levels do not appear to be associated with higher rates of asthma. 5. The therapy received by many asthmatics is often inadequate, due to numerous factors including the reluctance to use inhaler devices. 6. Inadequate knowledge and widespread misconceptions about asthma and its treatment contribute to the burden of asthma. 7. The lack of access to medications limits the opportunity to obtain good asthma control in many countries in the region. 8. Levels of outdoor and indoor air pollution are generally high within the region and represent an important cause of preventable respiratory illness, including asthma. 9. The mortality data available indicate that asthma case fatality rates are high within the region. This suggests that a disproportionately high proportion of persons with asthma die, compared with other countries. 10. Political, social, and economic factors are major causes of the limited access to health care in the region, which leads to preventable morbidity and mortality from asthma. Improving the political stability and economic wealth of the countries in the region is crucial if the burden of disease, including that from asthma, is to be reduced. 60

FURTHER READING
Annadurdyev OA, Allakov KA, Mashakova DCh, Tashliev AR, Sakhatova IN. Clinico-epidemiologic characteristics, course and outcomes of asthmatic bronchitis and bronchial asthma in the arid climate of Turkmenistan. Terapevticheskii Arkhiv 1991; 63: 65-9. Hazir T, Das C, Piracha F, Waheed B, Azam M. Carers' perception of childhood asthma and its management in a selected Pakistani community. Arch Dis Child 2002; 87: 287-90. Hussain SF, Zahid S, Haqqee R, Khan JA. Impact of asthma management guidelines on the physicians prescribing practices in an Asian community. (submitted) Imanalieva ChA, Abdyldaev TT, Sharshenova AA et al. Epidemiology of allergy diseases among children in the different ecological zones of Kyrgyzstan. Kyrgyz National Institute of Prophylaxis and Medical Ecology (Information Letter No. 1), Bishkek, 1996, 16p. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Khan MA, Hazir T. Management of bronchial asthma in children. J Pak Med Assoc 1995; 45: 46-50. Khan JA, Saghir S, Tabassum G, Husain SF. An audit on hospital management of bronchial asthma. J Pak Med Assoc 1995; 45: 298-300. Ubaydullaev AM, Uzakova GT. Prevalence of bronchial asthma in Uzbekistan. Problemy Tuberkuleza 2002; 2: 7-10. Ubaydullaev AM, Uzakova GT. Bronchial asthma prevalence in Republic of Uzbekistan. Eur Respir J 2002; 20(Suppl.38): 317s. Ubaydullaev AM, Uzakova GT. The prevalence of bronchial asthma in Tashkent City (Uzbekistan). Eur Respir J 2002; 20(Suppl.38): 100s. Wegerdt J, O'Hara S, Wiggs G, Van Der Meer J, Falzon D, Small I, Hubbard R. Association between dust deposition and point prevalence respiratory symptoms amongst Karakalpak children. Am J Respir Crit Care Med 2002; 165(8): A490.

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Southern Asia
Bangladesh Bhutan India Nepal Seychelles Sri Lanka

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

42.2 m 1,210.0 m 3.5%

Key Points: 1. There is a wide variation in the prevalence of asthma within Southern Asia. In India, a tenfold variation in the prevalence of childhood asthma has been observed. 2. There has been a marked increase in the prevalence of asthma in Southern Asia over the last two decades with up to threefold increases in children. There has also been a corresponding increase in the prevalence of severe asthma. 3. The regions industrialisation and urban growth is occurring at an unprecedented rate in what was previously a predominately agrarian society. India is projected to become the worlds most populous nation by the year 2050. As a result, further predicted increases in the prevalence of asthma will result in a marked increase in the number of asthmatics. For example, if the prevalence of asthma in the region increases by an absolute 2%, then this will result in at least an additional 20 million asthmatics in the region. 4. Both underdiagnosis and undertreatment of asthma represent common problems relating to the management of asthma. 5. The limited availability of asthma medications is a major problem in the countries in Southern Asia. 6. The use of WHO management guidelines for childhood illnesses, including asthma, is complicated by the similar presentations of respiratory infectious diseases including tuberculosis and pneumonia. This suggests that a more practical, symptom-based approach to the diagnosis and management of asthma and other respiratory conditions may be required for use at the primarycare level within the region. 7. Low-cost asthma management programmes should be developed to ensure asthma care is available and affordable for all socioeconomic sectors within the population.

62

8. The levels of air pollution in cities in the region are well above the permissible levels recommended by national and international guidelines. Indeed, large parts of the Indian and Bangladeshi urban populations are exposed to some of the highest air pollutant levels in the world. In view of the well documented association between high levels of air pollution and exacerbations of asthma, and the important role of air pollution as a risk factor contributing to respiratory and all-cause mortality, reducing the level of air pollution remains one of the most important public health priorities in Southern Asia. 9. Occupational asthma is an important problem throughout the region, with high rates of asthma occurring in a wide range of common industries. The Bhopal incident illustrates the risk of acute respiratory mortality and prolonged respiratory morbidity from major industrial accidents. It also highlights the need for adequate prevention of major industrial hazards and the implications of exporting hazardous chemicals and work processes to lower-income countries. 10. Indoor air pollution remains a major risk factor for respiratory disease, including asthma, in Southern Asia. It has been estimated that over half a million premature deaths can be attributed annually to the use of biomass fuels in India.

FURTHER READING
Ahasan MR, Ahmad SA, Khan TP. Occupational exposure and respiratory illness symptoms among textile industry workers in a developing country. Appl Occup Environ Hygiene 2000; 15: 313-20. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Bangham CR, Hope RA. Exercise-induced asthma in Nepalese children. Clin Allergy 1981; 111: 273-80. Beckett WS. Persistent respiratory effects in survivors of the Bhopal disaster. Thorax 1998; 53(Suppl 2): S43-S46. Behera D, Chakrabarti T, Khanduja KL. Effect of exposure to domestic cooking fuels on bronchial asthma. Indian J Chest Dis Allied Sci 2001; 43: 27-31. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Chalker J. Effect of a drug supply and cost sharing system on prescribing and utilization: a controlled trial from Nepal. Health Policy and Planning 1995; 10: 423-30. Chhabra SK, Gupta CK, Chhabra P, Rajpal S. Prevalence of bronchial asthma in schoolchildren in Delhi. J Asthma 1998; 35: 291-6.

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Chhabra SK, Gupta CK, Chhabra P, Rajpal S. Risk factors for development of bronchial asthma in children in Delhi. Ann Allergy Asthma Immunol 1999; 83: 385-90. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Chowgule RV, Shetye VM, Parmar JR, Bhosale AM, Khandagale MR, Phalnitkar SV, Gupta PC. Prevalence of respiratory symptoms, bronchial hyperreactivity, and asthma in a megacity: results of the European Community Respiratory Health Survey in Mumbai (Bombay). Am J Respir Crit Care Med 1998; 158: 547-54. Chugh K. Clinical approach to a patient with cough. Indian J Pediatr 2001; 68: S11-19. Consensus Guidelines on Management of Childhood Asthma in India. Indian Pediatr 1999; 36: 157-64. de Silva N, Mendis K. One-day general practice morbidity survey in Sri Lanka. Fam Pract 1998; 15: 323-31. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. George A. Household expenditure in two states: a comparative study of districts in Maharashtra and Madhya Pradesh. Mumbai, Pune: Foundation for Research in Community Health, 1997. Gupta D, Aggarwal AN, Kumar R, Jindal SK. Prevalence of bronchial asthma and association with environmental tobacco smoke exposure in adolescent school children in Chandigarh, North India. J Asthma 2001; 38: 501-7. Hassan MR, Kabir AR, Mahmud AM, Rahman F, Hossain MA, Bennoor KS, Amin MR, Rahman MM. Self-reported asthma symptoms in children and adults of Bangladesh: findings of the National Asthma Prevalence Study. Int J Epidemiol 2002; 31: 483-8. Integrated Management of Childhood Illness Strategy Initiative. Bull WHO 1997; 75(Suppl 1). International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63.

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Jindal SK, Gupta D, Aggarwal AN, Jindal RC, Singh V. Study of the prevalence of asthma in adults in North India using a standarized field questionnaire. J Asthma 2000; 37: 345-51. Kabir ARML, Rahman AKMF, Hassan MQ, Ahamed F. Report on asthma, atopic eczema and allergic rhinoconjunctivitis in schoolchildren of Dhaka, Bangladesh using ISAAC protocol. Institute of Child and Mother Health 2000; 51p. Kabir ARML, Rahman AKM, Mannan MA, Chowdhury AT. Prevalence of wheeze and asthma in children of a coastal community of Bangladesh. Bangladesh J Child Health 1999; 23: 43-7. Kalter HD, Schillinger JA, Hossain M, Burnham G, Saha S, de Wit U et al. Identifying sick children requiring referral to hospital in Bangladesh. Bull WHO 1997; 75(Suppl 1): 65-75. Kurunasekera KA, Jayasinghe JA, Alwis LW. Risk factors of childhood asthma: a Sri Lankan study. J Tropical Pediatr 2001; 47: 142-5. Melsom T, Brinch L, Hessen JO, Schei MA, Kolstrup N, Jacobsen BK, Svanes C, Pandey MR. Asthma and indoor environment in Nepal. Thorax 2001; 56: 477-81. Nemery B. Late consequences of accidental exposure to inhaled irritants: RADS and the Bhopal disaster. Eur Respir J 1995; 9: 1973-6. Pande JN, Bhatta N, Biswas D, Pandey RM, Ahluwalia G, Siddaramaiah NH, Khilnani GC. Outdoor air pollution and emergency room visits at a hospital in Delhi. Indian J Chest Dis Allied Sci 2002; 44: 13-19. Paramesh H. Epidemiology of asthma in India. Indian J Pediatr 2002; 69: 309-12. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Perera BJC. Efficacy and cost effectiveness of inhaled steroids in asthma in a developing country. Arch Dis Child 1995; 72: 312-6. Pokharel PK, Kabra SK, Kapoor SK, Pandey RM. Risk factors associated with bronchial asthma in school going children of rural Haryana. Indian J Pediatr 2001; 68: 103-6. Rajaratnam J, Abel R, Duraisamy S, John KR. Morbidity pattern, health care utilization and per capita health expenditure in a rural population of Tamil Nadu. Natl Med J India 1996; 9: 259-62. Ramamani S. Household survey on health care utilization and expenditure. New Delhi: National Council for Applied Economic Research Working Paper 53, 1995. Ratageri VH, Kabra SK, Dwivedi SN, Seth V. Factors associated with severe asthma. Indian Pediatr 2000; 37: 1072-82. Ray TK, Pandav CS, Anand K, Kapoor SK, Dwivedi SN. Out-of-pocket expenditure on healthcare in a north Indian village. Natl Med J India 2002;15(5):257-60. Rona RJ. Asthma and poverty. Thorax 2000; 55: 239-44. Shah D, Sachdev HP. Evaluation of the WHO/UNICEF algorithm for integrated management of childhood illness between the age of two months to five years. Indian Pediatr 1999; 36: 767-77. Shibichakravarthy K, Singh RB, Swaminathan S, Venkatesan P. Prevalence of asthma in urban and rural children in Tamil Nadu. Natl Med J India 2002; 15(5): 260-3.

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Smith KR. National burden of disease in India from indoor air pollution. PNAS 2000. 97(24): 13286-93, Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Uragoda CG, Wijekoon PNB. Asthma in silk workers. J Soc Occup Med 1991; 41: 140-2. Vijayan VK, Sankaran K. Relationship between lung inflammation, changes in lung function and severity of exposure in victims of the Bhopal tragedy. Eur Respir J 1996; 9: 1977-82.

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China/Taiwan/Mongolia
China Hong Kong Macau Mongolia Taiwan

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

27.8 m 1,324.1 m 2.1%

Key Points: 1. There are marked regional differences in the prevalence of asthma symptoms within this region, with generally higher prevalence rates being found in more affluent communities. In China, a tenfold variation in the prevalence of asthma has been observed, with the lowest rate in Tibet and the highest rate in Chongqing. The prevalence of asthma symptoms is higher in urban compared with rural communities. With increasing urbanisation and adoption of the Western lifestyle in China, it is likely that the number of asthmatics will increase markedly during the next decade. 2. The greatest burden in terms of increasing asthma prevalence worldwide is likely to occur in China, due to its population and the rate of economic development with associated lifestyle changes. An absolute 2% increase in the prevalence of asthma would result in an additional 20 million asthmatics. 3. The experience in Taiwan, where the prevalence of asthma symptoms increased almost fivefold within a 20-year period, illustrates the potential magnitude of the increase in asthma prevalence that may occur over a short period. It is also interesting that there are different time courses for the increase in different allergic disorders, with the increase in asthma occurring before that for allergic rhinitis and eczema. 4. There is a major burden in the region in terms of severe asthma attacks, with over one in three people with asthma requiring urgent medical care, emergency room visits, or hospital admission. The rate of hospitalisations due to asthma is very high in urban populations in this region, with 10% to 15% of asthmatics requiring a hospital admission within a 12-month period. 5. Lack of access to asthma medications among large proportions of the population in China severely limits the opportunity to obtain

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good asthma control. Low-cost asthma management programmes are required to ensure that asthma care is available for all socioeconomic sectors within the population. 6. Difficulties exist in the diagnosis of asthma, in particular the underdiagnosis of asthma. This is likely to be due to multiple factors including the high rates of respiratory symptoms associated with smoking and infectious diseases, poor access to medical care, and patients underestimating the importance of their asthma symptoms. 7. The levels of outdoor air pollution in cities in the region are well above those recommended. Air pollution represents an important cause of exacerbations of asthma and a major risk factor for respiratory (and all-cause) mortality in the region. Indoor air pollution also represents a major risk factor for respiratory disease, including asthma, in the region. Indoor air pollution results from the widespread practice of using unprocessed solid fuels for cooking and heating, often in unventilated situations. Reducing the levels of both indoor and outdoor air pollution remains one of the most important public health priorities. 8. The high rate of tobacco smoking represents a major public health problem in the region. There are an estimated 350 million smokers in China, smoking a total of about 2.0 trillion cigarettes per year. One out of every three cigarettes smoked in the world today is smoked in China. The WHO estimates that in 1993, China gained US$ 4.9 billion in cigarette taxes, but lost US$ 7.8 billion in productivity losses and health care costs due to cigarette smoking. 9. Experience to date with asthma guidelines in the region has indicated poor adherence and lack of understanding by health professionals. This highlights the need for further educational programmes, tailored to health professionals in the region, that will result in the required changes in management. 10. China has one of the highest asthma case fatality rates in the world. The asthma mortality rate in rural areas is about double that recorded in urban areas. One of the public health priorities in the region is to ensure that cost-effective management approaches which have been shown to reduce mortality are available to as many persons as possible with asthma.

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FURTHER READING
Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Chen YZ, Sheng JY, Liu SY, Wang HP, Wang YF. Recent status of popularization of the GINA program in the management of childhood asthma in China. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 10-5. Choy DKL, Hui DSC, Li ST, Ko FWS, Ho S, Woo J, Lai CKW. Prevalence of wheeze, bronchial hyper-responsiveness and asthma in the elderly Chinese. Clin Exp Allergy 2002; 32: 702-7. de Almeida MM, Gaspar A, Rosado Pinto J. Epidemiology of asthma in Portugal, Cape Verde and Macao. Pediatr Pulmonol 2001; 23(Suppl): 35-7. Guo YL, Lin YC, Sung FC, Huang SL, Ko YC, Lai JS, Su HJ, Shaw CK, Lin RS, Dockery DW. Climate, traffic-related air pollutants and asthma prevalence in middle-school children in Taiwan. Environ Health Perspect 1999; 107: 1001-6. Hsieh KH, Shen JJ. Prevalence of childhood asthma in Taipei, Taiwan and other Asian Pacific countries. J Asthma 1988; 25: 73-82. Hsieh HH, Tsai YT. Increasing prevalence of childhood allergic disease in Taipei, Taiwan and the outcome. In: T Miyamoto, M Okuda (eds). Progress in Allergology and Clinical Immunology. Volume 2, Kyoto. Berne: Hogrefe & Huber 1992; 223-5. Huang J-L, Hsieh K-H. Increasing prevalence of childhood allergic diseases and the risk factors for the development of allergy in Taipei, Taiwan. 5th West-Pacific Allergy Symposium, 7th Korea-Japan Joint Allergy Symposium, Korea, 11-14 June 1997. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Jan I-S, Chou W-H, Kuo S-H, Wang J-D. Prevalence of adult bronchial asthma in Taipei City. Thoracic Med 2001; 16(Suppl): S49. Kao CC, See LC, Yan DC, Ou LS, Huang JL. Time trends and seasonal variations in hospital admissions for childhood asthma in Taiwan from 1990 to 1998. Asian Pacific J Allergy Immunol 2001; 19: 63-8. Kong L, Wong L, Wong L. [Epidemiological investigation on incidence of bronchial asthma in urban population of Shenyang] [Chinese]. Chinese J Tuberculosis Respir Diseases 2001; 24(3): 145-7. Kuo L-C, Yang P-C, Kuo S-H. Decrease in mortality rate of asthma in Taiwan. Am J Respir Crit Care Med 2002; 165(Suppl): A489. Kuo S-H. Implementation of GINA management for asthma in Taiwan. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 19-22.

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Lai CKW, de Guia TS, Kim Y-Y, Kuo S-H, Mukhopadhyay A, Soriano JB, Trung PL, Zhong NS, Zainudin N, Zainudin BMZ. Asthma control in the Asia-Pacific region: The Asthma Insights and Reality in Asia-Pacific (AIRIAP) Study. J Allergy Clin Immunol 2003; 111: 263-8. Lai CKW, Douglass C, Ho SS, Chan J, Lau J, Wong G, Leung R. Asthma epidemiology in the Far East. Clin Exper Allergy 1996; 26: 5-12. Lai CKW, Ho SC, Lau J, Yuen YK, Ho SS, Chan CHS, Woo J. Respiratory symptoms in elderly Chinese living in Hong Kong. Eur Respir J 1995; 8: 2055-61. Leung R, Bishop J, Robertson CF. Prevalence of asthma and wheeze in Hong Kong schoolchildren: an international comparative study. Eur Respir J 1994; 7: 2046-9. Leung RC, Carlin JB, Burdon JGW, Czarny D. Asthma, allergy and atopy in Asian immigrants in Melbourne. Med J Aust 1994; 161: 418-25. Leung R, Ho P. Asthma, allergy and atopy in three South East Asian populations. Thorax 1994; 49: 1205-10. Leung R, Jenkins M. Asthma, allergy and atopy in southern Chinese school students. Clin Exper Allergy 1994; 24: 353-8. Leung R, Wong G, Lau J, Ho A, Chan JKW, Choy D, Douglass C, Lai CKW. Prevalence of asthma and allergy in Hong Kong schoolchildren: an ISAAC study. Eur Respir J 1997; 10: 354-60. Lin RS, Sung FC, Huang SI, Gou YI, Ko YC, Gou HW, Shaw CK. Role of urbanization and air pollution in adolescent asthma: a mass screening in Taiwan. J Formos Med Assoc 2001; 100: 649-55. Palmer LJ, Celedon JC, Weiss ST et al. Ascaris lumbricoides infection is associated with increased risk of childhood asthma and atopy in rural China. Am J Respir Crit Care Med 2002; 165: 1489-93. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Tang T, Ding Y, Zhen J. [Epidemiological survey and analysis on bronchial asthma in Guangdong Province] [Chinese]. Chinese J Tuber Respir Diseases 2000; 23(12): 730-3. Vinanen A, Munhbayarlah S, Zevgee T, Tseregmaa T. Sensitization to aeroallergens in Mongolia. Eur Respir J 2002; 20(Suppl.38): 121s. Wan KS, Chen LH, Lin YI. Evaluatoin of the consensus of the national asthma treatment guidelines in Taiwan. Acta Paediatr Taiwanica 2002; 43: 140-3. Wang TN, Ko YC, Chao YY, Huang CC, Lin RS. Association between indoor and outdoor air pollution and adolescent asthma from 1995 to 1996 in Taiwan. Environ Res 1999; 81: 239-47. Wong GWK, Hui DSC, Chan HH, Fok TF, Leung R, Zhong NS, Chen YZ, Lai CKW. Prevalence of respiratory and atopic disorders in Chinese schoolchildren. Clin Exper Allergy 2001; 31: 1225-31. Wong GWK, Li ST, Hui DSC, Fok TF, Zghong NS, Chen YZ, Lai CKW. Individual allergens as risk factors for asthma and bronchial hyperresponsiveness in Chinese children. Eur Respir J 2002; 19: 288-93. World Health Organisation. World Health Report 1998; 158-62. Wu J-H, Lim RS, Hsieh K-H, Chiu W-T, Chen L-M, Chiou S-T, Huang K-C, Liu W-I, Chiu HI, Hsiao H-C, Fang S-H, Chen H-W, Lin J-M, Sung F-C. Adolescent asthma in Northern Taiwan. Chin J Pub Health 1998; 17: 214-25.

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Xu X, Niu T, Chen C, Wang B, Jin Y, Yang J, Weiss ST. Association of airway responsiveness with asthma and persistent wheeze in a Chinese population. Chest 2001; 119(3): 691-700. Yang CY, Wang JD, Chan CC, Hwang JS, Chen PC. Respiratory symptoms of primary schoolschildren living in a petrochemical polluted area in Taiwan. Pediatr Pulmonol 1998; 25: 299-303. Zhang JP, Zhong NS, Wu ZY et al. Prophylactic and therapeutic effects of beclomethasone inhalation on bronchial hyperresponsiveness and asthma, a randomized, double-blind, parallel group controlled trial. Chin J Tuberc Respir Dis 1998; 21: 9-12. Zhang S. The current status of the study on asthma in China. Chin Med J 2000; 113: 483-9. Zhao T, Wang A, Chen Y, Xiao M, Duo L, Liu G, Lau Y, Karlberg J. Prevalence of childhood asthma, allergic rhinitis and eczema in Urumqi and Beijing. J Paediatrics Child Health 2000; 36(2): 128-33. Zhong NS. Adapting GINA guideline for asthma management in China. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 5-8. Zhong NS, Chen RC, O-yang M, Wu JY, Fu WX, Shi LJ. Bronchial hyperresponsiveness in young students of sourthern China: relation to respiratory symptoms, diagnosed asthma, and risk factors. Thorax 1990; 45: 860-5.

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Northeast Asia
Japan North Korea South Korea

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

11.4 m 196.8 m 5.8%

Key Points: 1. Japan has one of the highest asthma prevalence rates within Asia. In both Japan and the Koreas there are regional differences in asthma prevalence, with generally higher rates in urban and temperate regions. 2. The prevalence of asthma symptoms and asthma attacks has increased over the last few decades. This trend has occurred both in cities and in rural areas. 3. In Japan the number of asthma patients treated by medical facilities has increased from three cases per day, per 100,000 people 30 years ago, to over 100 cases per day, per 100,000 people currently. 4. There is a major burden from severe asthma in terms of the requirement for hospital admissions. It has been estimated that the number of inpatients with asthma is around 15 cases per 100,000 in the general population in Japan. 5. A number of asthma programmes based on long-term treatment with inhaled corticosteroids have been shown to lead to a marked reduction in asthma severity in populations in the region. 6. The Japanese Asthma Guidelines are a good example of how international asthma guidelines can be modified to take into account local cultural and health system requirements. It is considered that the introduction and use of these guidelines has contributed to a reduction in asthma mortality in Japan over the last decade. 7. Currently around 10,000 people die from asthma in Japan and the Koreas each year. Mortality surveys have identified similar factors contributing to death as have been reported from communities in other regions. These include delays in seeking medical help, overreliance on beta-agonist therapy, and poor adherence to longterm therapy with underuse of inhaled corticosteroid therapy.

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8. In Japan, after 20 years of increasing asthma mortality rates, during which the death rate in young asthmatics increased over two-fold, asthma mortality has begun to fall again over recent years. 9. Outdoor air pollution represents one of the major causes of asthma attacks in the region, and reducing pollution levels represents one of the public health priorities. 10. Work remains an important cause of asthma in adults in Japan and the Koreas. In a number of high-risk occupations, the prevalence of asthma symptoms is around 10% to 20%. Reducing workplace exposure to agents known to cause occupational asthma is another public health priority.

FURTHER READING
Adachi M, Morikawa A, Ishihara K. Asthma insights and reality in Japan (AIRJ). Arerugi - Japanese Journal of Allergology 2002, S1 (5): 411-20. Agata H, Kondo N, Fukutomi O, Hayashi T, Shinoda S, Nishida T, Yomo A, Sazuki Y, Shimozawa N, Tomatsu S, Orri T. Comparison of allergic disease and specific IgE antibodies in different parts of Japan. Annal Allerg 1994; 72: 447-51. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Beasley R, Nishima S, Pearce N, Crane J. b-agonist therapy and asthma mortality in Japan. Lancet 1998; 351: 1406-7. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Choi IS, Park SC, Jang AS et al. Risk factors of near-fatal asthma. Korean J Med 1999; 57: 52-9. Committee on Asthma Death (Japanese Society of Pediatric Allergy and Clinical Immunology). Asthma Death Committee report 1995. Jap J Ped Allergy Clin Immunol 1995; 9: 54-66. Committee on Asthma Death. The committee report on life-threatening asthma in children. Jap J Ped Allergy Clin Immunol 1997; 11: 33-40. Committee on the Definition, Treatment and Management of Bronchial Asthma. Japanese Society of Allergology. Guidelines for the diagnosis and management of bronchial asthma. Allergy - Eur J Allerg Clin Immunol 1995; Suppl 50(27): 1-42. Furusho M. Trends in the prevalence of asthma in primary school students over the past 20 years. 1993 MHW Comprehensive Research Report on Allergology, 1994; pp. 255-8. Hasegawa T, Koya T, Mashima I, Suzuki E, Gejo F, Muramatsu Y. Investigation of fatal asthma: based on the Niigata prefecture asthma questionnaire survey. Int Rev Asthma 2002; 4(4): 54-9. Hayashi T, Kawakami N, Kondo N, Agata H, Fukutomi O, Shimizu H, Orri T. Prevalence of and risk factors for allergic diseases: comparison of two cities in Japan. Annal Allerg Asthm Immunol 1995; 75 (part 1): 525-9.

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Iikura Y. Japan. In: Silverman M (Ed). Childhood Asthma & Other Wheezing Disorders. 2nd Edition. London: Arnold, 2002; 17d: 448-50. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Ishihara K, Hasegawa T, Nishimura T, Okazaki M, Katakami N, Umeda B. Increased use of inhaled corticosteroids and reduced hospitalization in adult asthmatics: 11 years experience in a Japanese hospital. Respir 1998; 3: 193-7. Ishihara K. The present asthma death situation in Japan: future direction of asthma treatment to decrease asthma deaths. Int Rev Asthma 2002; 4(4): 60-6. Ito Y, Tamakoshi A, Wakai K et al. Trends in asthma mortality in Japan. J Asthma 2002; 39: 633-9. Japanese Society of Pediatric Allergy & Clinical Immunology. The committee report of asthma death in children in 1995. Jap J Ped Allergy Clin Immunol 1996; 10: 104-13. Kang SK, Jee YK, Nahm DH et al. A status of occupational asthma in Korea through the cases reported to the Occupational Asthma Surveillance Center. J Asthma Allergy Clin Immunol 2000; 30: 906-15. Kim GS, Lee SI, Chang GY, Lee KH. Prevalence of skin test positivity in Korean population. Korean J Allergology 1992; 12(3): 285-90. Kim YK, Kim SH, Tak YJ et al. High prevalence of current asthma and active smoking effect among the elderly. Clin Exp Allergy 2002; 32: 1706-12. Kim YY, Cho SH, Kim WK, Park JK, Song SH, Kim YK, Yee YK, Ha MN, Ahn YO, Lee SI, Min KU. Prevalence of childhood asthma based on questionnaires and methacholine bronchial provocation test in Korea. Clin Exp Allergy 1997; 27(7): 761-8. Kokubu F, Adachi M. Prevention against asthma death: education program for doctors and self-management for patients. Arerugi - Japanese Journal of Allergology 1999; 48: 572-5. Korean Institute for Health and Social Affairs. Prevalence of asthma like symptoms in Korean adult population. Korean J Med 2001; 60: 196-205. Kunitoh H, Yahikozawa H, Kakuta T, Ono K, Hamabe Y, Kuroki H, Tsutsumi H, Tanaka T, Watanabe K, Awane Y, Sasaki H. Fatal and near fatal asthma. Annals Allerg 1992; 69: 111-5. Lee JG, Moon HJ, Kim KS et al. Epidemiological study for allergic disease of school-aged children and adolescence in rural area of Korea. J Otolaryngol-Head Neck Surg 1998; 41: 1156-63. Lee JT, Kim H, Song H, Hong YC, Cho YS, Shin SY, Hyun YJ, Kim YS. Air pollution and asthma among children in Seoul, Korea. Epidemiology 2002; 13: 481-4. Lee HB, Lee SI, Shin MH, Lee JS, Son BK, Koh YY, Kim KE, Ahn YO. Prevalence of symptoms of asthma and other allergic diseases in Korean children: a nationwide questionnaire survey. J Korean Med Sci 2001; 16(2): 155-64. Lee MH, Hong SC, Kim TB et al. A prospective study of asthma prevalence and atopy rate in children living in rural area of Cheju Island for 3 years. Pediatr Allergy Respir Dis 2001; 11: 224-32.

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Lee SI, Shin MH, Lee HB et al. Prevalences of symptoms of asthma and other allergic diseases in Korean children: a nationwide questionnaire survey. J Korean Med Sci 2001; 16: 155-64. Makino S, Furusho K, Miyamoto T, Ohta K (Eds). Asthma Prevention and Management Guidelines 1998. Report of the research group for asthma prevention and management guidelines, supported by the Immunology & Allergy Research Study Project, Ministry of Health & Welfare, Japan. Int Arch Allergy Immunol 2000; 121 (suppl 1): 1-78. Makino S, Miyamoto T, Nakajima S, Kabe J, Baba M, Mikawa H, Furusho M, Fukuda K, Nakagawa T, Naitou H. Survey of recognition and utilisation of guidelines for the diagnosis and management of bronchial asthma in Japan. Allergy 2000; 55: 135-40. Matsui T. Asthma death and b2-agonists. In: Shinomiya K (Ed). Current Advances in Pediatric Allergy and Clinical Immunology. Selected Proceedings from the 32nd Annual Meeting of the Japanese Society of Pediatric Allergy and Clinical Immunology. Tokyo: Churchill Livingstone; 1996, pp. 161-4. Matsui T. Asthma death in childhood and young adults in Japan. Proceedings of the Japanese Society of Pediatric Allergy & Clinical Immunology 33rd Annual Meeting, Fukuoka City, Japan, November 1996 (Abstract). Matsui T, Baba M. Death from asthma in children. Acta Paediatrica Japonica 1990; 32: 205-8. Matsuse H, Shimoda T, Kohno S, Fujiwara C, Sakai H, Takao A, Asai S, Hara K. A clinical study of mortality due to asthma. Ann Allergy, Asthma & Immunol 1995; 75: 267-72. Mitsui S. Death from bronchial asthma in Japan. Sino-Jpn J Allergol Immunol 1986; 3: 249-57. Miyamoto T (Chairman). Report of a Study on the Emergency Medical Service for Asthma. Comprehensive Scientific Research Project on Emergency and Disaster Medicine, Ministry of Health and Welfare, 1992. Miyamoto T et al. Report of reassessment committee for guidelines for the assessment of severity of bronchial asthma. Allergy 1994; 43: 71-80. Nakazawa T. Occupational allergy. Saisin Igaku 1994; 49: 709-22. Nishima S. A study on the prevalence of bronchial asthma in school children in western districts of Japan. Jpn J Allergology 1993; 42: 192-204. Park HS, Cho SH, Hong CS et al. Isocyanate-induced occupational asthma in Far-East Asia: pathogenesis to prognosis. Clin Exp Allergy 2002; 32: 198-204. Park KH, Lee HH, Han MY et al. A clinical follow-up study of asthma from childhood to adulthood. Pediatr Allergy Respir Dis 1998; 8: 90-7. Pearce N, Crane J, Beasley R. Isoprenaline, fenoterol and asthma deaths in Japan. Jap J Pediatr Aller Clin Immunol 1997; 11: 307-16. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Shima M, Adachi M. Effect of outdoor and indoor nitrogen dioxide on respiratory symptoms in schoolchildren. International J Epidem 2000; 29: 862-70. Shin TS, Lee KJ, Yoon HS. Survey on the distribution of allergic diseases in primary school children. Korean J Allergy 1990; 10: 201-2.

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Son BK, Lim DH, Kim JH et al. Prevalence of allergic disease and asthma related conditions in primary school-aged children and comparison of pulmonary function test between normal and children with condition related with asthma. Pediatr Allergy Respir Dis 1997; 7: 198-206. Tanaka H, Honma S, Nishi M, Igarashi T, Nishio F, Abe S. Two-year followup study of the effect of acid fog on adult asthma patients. Internal Med 1996; 35(2): 100-4. Tanaka H, Honma S, Nishi M, Igarashi T, Teramoto S, Nishio F, Abe S. Acid fog and hospital visits for asthma: an epidemiological study. Eur Respir J 1998; 11: 1301-6. Tanihara S, Nakamura Y, Matsui T, Nishima S. A case-control study of asthma death and life-threatening attack: their possible relationship with prescribed drug therapy in Japan. J Epidemiol 2002; 12: 223-8.

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Southeast Asia
Brunei Cambodia Indonesia Laos Malaysia Myanmar Philippines Singapore Thailand Vietnam

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

17.5 m 529.3 m 3.3%

Key Points: 1. There is a wide variation of asthma prevalence within this region, with the lowest rates in Indonesia and Vietnam and the highest rates in Thailand, the Philippines, and Singapore. 2. There are marked differences in the prevalence of asthma among different ethnic groups in the same community, and among the same ethnic group in different communities. These differences enable the development of community- or ethnic-group-specific education and management strategies. 3. The prevalence of asthma is generally higher in urban compared with rural populations in Southeast Asia. 4. Asthma prevalence appears to be increasing in most countries in the region where serial data are available. It is likely that the prevalence of asthma will increase further as the countries increasingly adopt Western lifestyles and with greater urbanisation. 5. The burden of asthma within the region is considerable with 1 in 4 adults with asthma losing time from work in the last year, and 1 in 3 children with asthma having missed school in the last year due to their asthma. 6. The rate of hospitalisation for asthma is particularly high in Southeast Asia. Inpatient medical care represents the major proportion of asthma costs in a number of countries within Southeast Asia. This situation underlines the importance of implementing public health strategies based on management regimes which have been shown to be effective in reducing hospital admissions. 7. Both under-recognition of asthma severity and undertreatment of the disease represent common problems leading to high asthma morbidity and mortality within the region. Current levels of asthma control in the region fall short of those that can be achieved with modern management. 77

8. Increasing tobacco consumption represents a major public health problem. Currently Vietnam has the highest male smoking rate in the world, with an estimated 3 of every 4 men smoking. Political and public health initiatives to reduce rates of smoking are a high priority for countries in Southeast Asia. 9. Mortality from asthma is high within the region when underlying asthma prevalence rates are considered. Mortality rates are particularly high in certain defined communities, such as among ethnic Malays in Singapore. 10. Similar to other regions of the world, the highest age-related asthma mortality rates are in the elderly, a group which has often received less attention in terms of intervention strategies.

FURTHER READING
At-Khaled N, Auregan G, Bencharif N, Mady Camara L, Dagli E, Djankine K, Keita B, Ky C, Mahi S, Ngoran K, Pham DL, Sow O, Yousser M, Zidouni N, Enarson DA. Affordability of inhaled corticosteroids as a potential barrier to treatment of asthma in some developing countries. Int J Tuberc Lung Dis 2000; 4: 268-71. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Azizi HO. Respiratory symptoms and asthma in primary school children in Kuala Lumpur. Acta Paediatr Japonica 1990; 32: 183-7. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Chan PW, DeBruyne JA. Parental concern towards the use of inhaled therapy in children with chronic asthma. Paediatr International 2000; 42: 547-51. Charoentatanakul S. Problems of application of asthma guidelines in Thailand. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 25-26. Chew FT, Goh DYT, Lee BW. The economic cost of asthma in Singapore. Aust NZ J Med 1999; 29: 228-33. Chew FT, Goh DYT, Ooi BC, Saharom R, Hui JKS, Lee BW. Association of ambient air-pollution levels with acute asthma exacerbation among children in Singapore. Allergy 1999; 54: 320-9. Goh DYT, Chew FT, Quek SC et al. The prevalence and severity of asthma, rhinitis and eczema in Singapore schoolchildren. Arch Dis Child 1996; 74: 131-5. Goh LG, Ng TP, Hong CY, Wong ML, Koh K, Ling SL. Outpatient adult bronchial asthma in Singapore. Singapore Med J 1994; 35: 190-4. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32.

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International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Jeyaindran S. Acute asthma - can we follow the GINA guidelines? A Malaysian experience of how we faced the challenge. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 33-5. Kunii O, Kanagawa S, Yajimi I, Hisamatsu Y, Yamamura S, Amagai T, Ismail IT. The 1997 haze disaster in Indonesia: its air quality and health effects. Arch Environ Health 2002; 57: 16-22. Lai CKW, de Guia TS, Kim Y-Y, Kuo S-H, Mukhopadhyay A, Soriano JB, Trung PL, Zhong NS, Zainudin N, Zainudin BMZ. Asthma control in the Asia-Pacific region: The Asthma Insights and Reality in Asia-Pacific (AIRIAP) Study. J Allergy Clin Immunol 2003; 111: 263-8. Lai CKW, Douglass C, Ho SS, Chan J, Lau J, Wong G, Leung R. Asthma epidemiology in the Far East. Clin Exper Allergy 1996; 26: 5-12. Lee BW, Chew FT, Goh DYT. Changing prevalence of childhood allergic diseases in Singapore. 5th West-Pacific Allergy Symposium, 7th KoreaJapan Joint Allergy Symposium, Korea, 11-14 June 1997. Lim SH, Goh DY, Tan AY, Lee BW. Parents' perceptions towards their child's use of inhaled medications for asthma therapy. J Paediatr Child Health 1996; 32: 306-9. Ng TP, Hui KP, Tan WC. Prevalence of asthma and risk factors among Chinese, Malay, and Indian adults in Singapore. Thorax 1994; 49: 347-51. Ng TP, Tan WC. Epidemiology of allergic rhinitis and its associated risk factors in Singapore. Int J Epidemiol 1994; 23: 553-8. Ng TP, Tan WC. Temporal trends and ethnic variations in asthma mortality in Singapore, 1976-1995. Thorax 1999; 54: 990-4. Ng TP. Adult asthma prevalence, morbidity and mortality and their relationships with environmental and medical care factors in Singapore. Asian Pac J Allergy Immunol 1999; 17: 127-35. Omar AH. Respiratory symptoms and asthma in primary schoolchildren in Kuala Lumpur. Acta Paediatr Japonica 1990; 32: 183-7. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Phankingthongkum S, Daengsuwan T, Visitsunthorn N, Thamlikitkul V, Udompunthuruk S, Vichyanond P. How do Thai children and adolescents describe asthma symptoms? Pediatr Allergy Immunol 2002; 13: 119-24. Quah BS, Razak AR, Hassan MH. Prevalence of asthma, rhinitis and eczema among schoolchildren in Kelantan, Malaysia. Acta Paediatr Japonica 1997; 39: 329-35. Roa CC, Dantes RBM, Arcadio RL, Javier MAT, Balanag VM Jr, de la Cruz CM, Dizon EM, Dizon MPJR, Francisco NA, Garcia RR, Jorge MC. A prevalence survey of general pulmonary symptoms and acute and chronic lung disease in an urban Philippine community. Phil J Internal Med 1991; 29: 309-21. So SY, Ng MMT, Ip MSM, Lam WK. Rising asthma mortality in Hong Kong, 1976-85. Respir Med 1990; 84: 457-67.

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Teeratakulpisarn J, Pairojkul S, Heng S. Survey of the prevalence of asthma, allergic rhinitis and eczema in schoolchildren from Khon Kaen, Northeast Thailand: an ISAAC study. Asian Pacific J Allergy Immunol 2000; 18: 187-94. Trakultivakorn M. Prevalence of asthma, rhinitis and eczema in Northern Thai children from Chiang Mai. ISAAC. Asian Pacific J Allergy Immunol 1999; 17: 243-8. Tuazon JA. Philippine initiatives towards asthma control and prevention. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 37-8. Tuchinda M. Childhood asthma in Thailand. Acta Paediatr Japonica 1990; 32: 169-72. Vangveeravong M. Asthma: an increasing problem in children? Asian Pacific J Allergy Immunol 1998; 16: 141-7. Vichyanond P, Jirapongsananuruk O, Visitsuntorn N, Tuchinda M. Prevalence of asthma, rhinitis and eczema in children from Bangkok area using the ISAAC questionnaires. J Med Assoc Thai 1998; 81: 175-84. Vichyanond P, Sunthornchart S, Singhirannusorn V, Ruangrat S, Kaewsomboon S, Visitsunthorn N. Prevalence of asthma, allergic rhinitis and eczema among university students in Bangkok. Respir Med 2002; 96: 34-8. Visitsunthorn N, Sittichokananon N, Tuchinda M. Childhood asthma: cases admitted to Siriraj Hospital in 1992. Siriraj Hosp Gaz 1995; 47: 313-21. Zainudin NM, Aziz BA, Haifa AL, Deng CT, Omar AH. Exercise-induced bronchoconstriction among Malay schoolchildren. Respirology 2001; 6: 151-5.

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Oceania
Australia Fiji New Zealand Papua New Guinea Samoa Tahiti Other Pacific Islands

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

4.5 m 30.7 m 14.6%

Key Points: 1. Oceania has some of the highest prevalence rates for asthma in the world for both children and adults. 2. Available evidence indicates that asthma has become more common in both children and adults in the region over recent decades. 3. When people from Southeast Asia and the Pacific Islands emigrate to Australia and New Zealand there is a marked increase in the prevalence of asthma within one generation. For example, the rate of asthma doubles when people emigrate from the Pacific Islands to New Zealand; children born in Australia have about a two-fold greater rate of asthma than those living in Australia but born elsewhere. 4. The hospitalisation rates for asthma have more than doubled in the region over the last 30 years. The rates of increase in hospital admission for asthma have been particularly marked in children. In New Zealand and Australia, asthma is the most common cause of hospital admission in children. Low-income and minority populations experience higher rates of asthma, hospital admissions, and emergency room visits. In Australia more than 60,000 persons with asthma are admitted to hospitals annually. 5. The experience in Papua New Guinea is relevant globally in illustrating the magnitude and speed at which asthma rates can increase when an isolated community makes dramatic changes to its lifestyle. In the highlands of Papua New Guinea asthma was extremely rare in the 1970s, but within 10 years after contact with the outside world and the adoption of certain Western lifestyle practices, asthma had become common and represented a major health problem. 6. Within centres in the region different ethnic groups may have markedly different hospital admission rates, despite similar overall asthma prevalence rates. This indicates that differences in 81

asthma severity and morbidity may occur in different population groups with similar asthma prevalence and provides the basis for targeted asthma management and education programmes in the high-priority groups. 7. Asthma is one of the highest ranking specific diseases in terms of years lost to disability. This high ranking of asthma reflects a combination of the high prevalence of the disease and the prolonged and severe disability it can cause. 8. The national asthma education and management programmes that have been developed and implemented in Australia and New Zealand represent successful models that can be adopted in other countries. The National Asthma Council in Australia has implemented an integrated multidisciplinary programme over a 10-year period, based on their locally developed guidelines in general practice. The New Zealand programme has been based on the promotion of the guided self-management plan system of care in primary-care practice. 9. The importance of government recognition of asthma as a high priority disorder is illustrated by Australia, where this recognition has led to major public health initiatives. Most recently this has led to the Three Plus plan in which general practitioners are funded to review and manage their asthmatics in a series of three structured consultations. 10. Mortality patterns in Australia and New Zealand over the last 40 years have been dominated by drug-related epidemics, but with the restriction of the specific implicated agents and improvements in management, mortality rates are now similar to those observed in other countries.

FURTHER READING
Adams R, Ruffin R, Wakefield M et al. Asthma prevalence, morbidity and management practices in South Australia 1992-1995. Aust NZ J Med 1997; 27: 672-9. Anderson HR. The epidemiological and allergic features of asthma in the New Guinea Highlands. Clin Allergy 1974; 4: 171-83. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Australian Centre for Asthma Monitoring 2003. Asthma in Australia 2003. AIHW Asthma Series 1. AIHW Cat No. ACM1. Canberra: AIHW. Bauman A. Australia's approach to asthma education. Asthma Journal December 1996; 22-5.

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Bauman A. Latest statistical trends. In: A Decade of Coordinated Asthma Management in Australia. National Asthma Campaign Ltd, 1998; 7-8. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Comino EJ, Bauman A. Trends in asthma mortality in Australia, 1960-1996. MJA 1998; 168: 525, 527. Crane J, Burgess C, Pearce N, Beasley R, Durham J. Adult asthma management: the patient takes the helm, health professionals chart the course. Department of Health Therapeutic Note No. 211, Department of Health, Wellington, 1991. Crane J, Lewis S, Slater T et al. The self-reported prevalence of asthma symptoms amongst adult New Zealanders. NZ Med J 1994; 107: 417-21. Crane J, O'Donnell TV, Prior IA, Waite DA. The relationships between atopy, bronchial hyperresponsiveness, and a family history of asthma: a cross-sectional study of migrant Tokelauan children in New Zealand. J Allergy Clin Immunol 1989; 84: 768-72. Crane J, O'Donnell TV, Prior IAM, Waite DA. Symptoms of asthma, methacholine airway responsiveness and atopy in migrant Tokelauan children. NZ Med J 1989; 102: 36-8. Crane J, Pearce N, Flatt A, Burgess C, Jackson R, Kwong T, Ball M, Beasley R. Prescribed fenoterol and death from asthma in New Zealand, 198183: A case control study. Lancet 1989; 1(8644): 917-22. Dowse GK, Smith D, Turner KJ, Alpers MP. The prevalence and features of asthma in a sample survey of urban Goroka, Papua New Guinea. Clin Allergy 1985; 15: 429-38. D'Souza W, Lewis S, Cheng S et al. The prevalence of asthma symptoms, bronchial hyperresponsiveness and atopy in New Zealand adults. NZ Med J 1999; 112: 198-202. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Flynn MG. Hospital admission rates for asthma and pneumonia in Fijian and Indian Children. J Paed Child Health 1994; 30: 19-22. Flynn MGL. Respiratory symptoms of rural Fijian and Indian children in Fiji. Thorax 1994; 49: 1201-4. Flynn MGL. Respiratory symptoms, bronchial responsiveness, and atopy in Fijian and Indian children. Am J Respir Crit Care Med 1994; 150: 415-20. Haby MM, Peat JK, Marks GB, Woolcock AJ, Leeder SR. Asthma in preschool children: prevalence and risk factors. Thorax 2001; 56: 589-95.

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International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Kemp T, Pearce N. The decline in asthma hospitalisations in persons aged 0-34 years in New Zealand. Aust NZ J Med 1997; 27: 588-81. Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Leynaert B, Neukirch C, Jarvis D, Chinn S, Burney P, Neukirch F on behalf of the European Community Respiratory Health Survey. Does living on a farm during childhood protect against asthma, allergic rhinitis and atopy in adulthood? Am J Respir Crit Care Med 2001; 164: 1829-34. McCaul KA, Wakefield MA, Roder DM, Ruffin RE, Heard AR, Alpers JH, Staugas RE. Trends in hospital readmission for asthma: has the Australian National Asthma Campaign had an effect? MJA 2000; 172: 62-6. National Asthma Campaign. Report on the Cost of Asthma in Australia. Melbourne: 1992. Pearce N, Beasley R, Crane J, Burgess C, Jackson R. End of the New Zealand asthma mortality epidemic. Lancet 1995; 345: 41-4. Pearce N, Beasley R, Crane J, Burgess C. Epidemiology of asthma mortality. In: Holgate ST, Busse WW (Eds). Asthma and Rhinitis. 2nd Edition. Blackwell Scientific Press, Oxford: 2000, 56-69. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Peat JK, Haby M, Spijker J, Berry G, Woolcock AJ. Prevalence of asthma in adults in Busselton, Western Australia. BMJ 1992; 305: 1326-9. Peat JK, Toelle BG, Marks GB, Mellis CM. Continuing the debate about measuring asthma in population studies. Thorax 2001; 56: 406-11. Peat JK, Toelle B, Salome CM, Woolcock AJ. Predictive nature of bronchial hyper-responsiveness and respiratory symptoms in a cohort of Sydney schoolchildren studied over one year. Eur Respir J 1993; 6: 662-9. Phelan PD, Robertson CF, Olinsky A. The Melbourne Asthma Study: 19641999. J Allergy Clin Immunol 2002; 109: 189-94. Robertson CF, Bishop J, Sennhauser FH, Mallol J. International comparison of asthma prevalence in children: Australia, Switzerland, Chile. Pediatr Pulmonol 1993; 16: 219-26.

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Robertson CF, Dalton MF, Peat JK, Haby MM, Bauman A, Kennedy JD, Landau LI. Asthma and other atopic diseases in Australian children: Australian arm of the International Study of Asthma and Allergy in Childhood. MJA 1998; 168: 434-8. Robertson CF, Haycock E, Bishop J et al. Prevalence of asthma in Melbourne schoolchildren: change over 26 years. BMJ 1991; 302: 116-8. Shaw RA, Crane J, O'Donnell TV. Increasing asthma prevalence in a rural New Zealand adolescent population: 1975-89. Arch Dis Child 1990; 65: 1319-23. Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Toelle BG, Peat JK, van den Berg R, Dermand J, Woolcock AJ. Comparison of three definitions of asthma: a longitudinal perspective. J Asthma 1997; 34: 161-7. Tukuitonga CR, Bell S, Robinson E. Hospital admission among Pacific children, Auckland 1992-97. NZ Med J 2000; 113: 358-61. Turner KJ, Dowse GK, Stewart GA, Alpers MP. Studies on bronchial hyperreactivity, allergic responsiveness, and asthma in rural and urban children of the highlands of Papua New Guinea. J Allergy Clin Immunol 1986; 77: 558-66. Turner KJ, Stewart GA, Woolcock AJ, Green W, Alpers MP. Relationship between mite densities and the prevalence of asthma: comparative studies in two populations in the Eastern Highlands of Papua New Guinea. Clin Allergy 1988; 18: 331-40. Waite DA, Eyles EF, Tonkin SL, O'Donnell TV. Asthma prevalence in Tokelauan children in two environments. Clin Allergy 1980; 10: 71-5. Woolcock AJ, Bastiampillai SA, Marks GB, Keena VA. The burden of asthma in Australia. Med J Aust 2001; 175: 141-5. Woolcock AJ, Dowse GK, Temple K, Stanley H, Alpers MP, Turnker KJ. The prevalence of asthma in the South-Fore people of Papua New Guinea: a method for field studies of bronchial reactivity. Eur J Respir Dis 1983; 64: 571-81. Woolcock AJ, Green W, Alpers MP. Asthma in a rural highland area of Papua New Guinea. Ann Rev Respir Dis 1981; 123: 565-7. Woolcock AJ, Peat JK, Salome CM, Yan K, Anderson SD, Schoeffel RE, McCowage G, Killalea T. Prevalence of bronchial hyperresponsiveness and asthma in a rural adult population. Thorax 1987; 42: 361-8.

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North America
Canada United States of America

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

35.5 m 316.9 m 11.2%

Key Points: 1. The prevalence of asthma symptoms and diagnosed asthma in Canada and the United States is amongst the highest in the world for both children and adults. 2. The prevalence of asthma is higher in certain racial groups such as Blacks and Hispanics compared with white children, and in urban compared with rural areas. 3. The prevalence of diagnosed asthma and asthma symptoms has increased markedly over recent decades. For example, in the United States the prevalence of diagnosed asthma and asthma symptoms in children and adolescents has been reported to have increased by 25-75% per decade during the period since 1960. 4. The increase in hospital admission rates in the region reflects an increase in the prevalence of severe asthma. In support of this it has been observed that there has been an increase in the percentage of patients hospitalised for asthma requiring intubation, even as the total number of hospital admissions for respiratory diseases has decreased. 5. In the United States the rates of hospital admission for patients of colour compared with white patients are 50% higher in adults and up to 150% higher in children. These trends emphasise the importance of implementing education and management programs that specifically target high-risk groups. 6. The morbidity for asthma is considerable with around 40% of all children and adults with asthma requiring hospitalisation or treatment in the emergency room or requiring other urgent care for the asthma in the previous 12 months. 7. Trends of asthma mortality in the United States contrast with those of most other Western countries in that there has been a progressive increase over the last two decades. The magnitude of

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the increase has been substantial, such that the rate of asthma mortality in the mid-1990s was approximately double that in the mid-1970s. One of the priorities in the United States is the further implementation of public health strategies to reduce the number of deaths from asthma. 8. Investigations of asthma-related deaths in the United States and Canada have shown that mortality rates are greater in disadvantaged groups such as Black and Hispanic populations, as well as in those who are poorly educated, live in large cities, or are poor. The reasons for these findings are multifactorial, including differences in prevalence, risk factors for severe disease, asthma management, and access to medical care. 9. The economic burden of asthma is considerable in North America. For example, in the United States it has been estimated that the total direct medical and indirect economic costs of asthma were around US $12 billion in 1994. This represents an increase of over 50% from 10 years before. It is probable that the current economic burden is considerably higher, if a similar rate of increase has been maintained over the last decade. Inpatient hospital services and pharmaceuticals represent the largest direct medical costs. 10. Occupational asthma remains a major problem in North America, with a population attributable risk for adult-onset asthma in high-risk groups of around 20%.

FURTHER READING
Adams RJ, Fuhlbrigge A, Guilbert T, Lozano P, Martinez F. Inadequate use of asthma medication in the United States: results of the Asthma in America national population survey. J Allergy Clin Immunol 2002; 110: 58-64. American Thoracic Society. Health effects of outdoor pollution (Part I). A Committee of the Environmental and Occupational Health Assembly of the American Thoracic Society. Am J Respir Crit Care Med 1996; 153: 3-50. American Thoracic Society. Health effects of outdoor pollution (Part 2). A Committee of the Environmental and Occupational Health Assembly of the American Thoracic Society. Am J Respir Crit Care Med 1996; 153: 477-98. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Asthma in America: A Landmark Survey. Executive Summary. Research Triangle Park (NC): Glaxo Wellcome Inc, 1998.

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Bimbaum HG, Berger WE, Greenberg PE, Holland M, Auerbach R, Atkins KM, Wanke LA. Direct and indirect costs of asthma to an employer. J Allergy Clin Immunol 2002; 109: 264-70. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Cockcroft DW et al. Sensitivity and specificity of histamine PC20 determination in a random selection of young college students. J Allergy Clin Immunol 1992; 89: 23-30. Coultas DB, Mapel D, Gagnon R, Lydick E. The health impact of undiagnosed airflow obstruction in a national sample of United States adults. Am J Respir Crit Care Med 2001; 164: 372-7. Cunningham J, O'Connor GT, Dockery DW, Speizer FE. Environmental tobacco smoke, wheezing, and asthma in children in 24 communities. Am J Respir Crit Care Med 1996; 153: 218-24. Delfino RJ, Murphy AM, Burnett RT, Brook JR, Becklake MR. Effects of air pollution on emergency room visits for respiratory illness in Montreal Quebec. Am J Respir Crit Care Med 1997; 155: 568-76. English PB, Von Behren J, Harnly M, Neutra RR. Childhood asthma along the United States/Mexico border: hospitalizations and air quality in two California counties. Rev Panam Salud Publica/Pan Am J Public Health 1998; 3: 392-9. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Evans R III, Mullally DI, Wilson RW, Gergen PJ, Rosenberg HM, Grauman JS et al. National trends in the morbidity and mortality of asthma in the US. Chest 1987; 91: 65S-73S. Fuhlbrigge AL, Adams RJ, Guilbert TW, Grant E, Lozano P, Janson SL, Martinez F, Weiss KB, Weiss ST. The burden of asthma in the United States: level and distribution are dependent on interpretation of the National Asthma Education and Prevention Program Guidelines. Am J Respir Crit Care Med 2002; 166: 1044-9. Gautrin D, Lapierre J-G, Malo J-L, Infante-Rivard C. Airway hyperresponsiveness and symptoms of asthma in a six-year follow-up study of childhood asthma. Chest 1999; 116: 1659-64. Gergen PJ, Mullally DI, Evans R. National survey of prevalence of asthma among children in the United States, 1976 to 1980. Pediatr 1988; 81: 1-7. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979 to 1987. JAMA 1990; 264: 1688-92.

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Gergen PJ, Weiss KB. The increasing problem of asthma in the United States. Am Rev Respir Dis 1992; 146: 823-4. Guidotti TL, Jhangri GS. Mortality from airways disorders in Alberta, 19721987: an expanding epidemic of COPD, but asthma shows little change. J Asthma 1994; 31: 277-90. Habbick BF, Pizzichini MMM, Taylor B, Rennie D, Senthilselvan A, Sears MR. Prevalence of asthma, rhinitis and eczema among children in 2 Canadian cities: the International Study of Asthma and Allergies in Childhood. CMAJ 1999; 160: 1824-8. Halfron N, Newacheck PW. Trends in the hospitalization for acute childhood asthma, 1970-84. Am J Public Health 1986; 76: 1308-11. Hemmelgarn B, Ernst P. Airway function among Inuit primary schoolchildren in far northern Quebec. Am J Respir Crit Care Med 1997; 156: 1870-5. Hemmelgarn B, Loozen E, Saralegui S, Chatwood S, Ernst P. Airways hyperresponsiveness and atopy: a comparison of Inuit and Montreal schoolchildren. Can Respir J 1995; 2: 92-6. Homa DM, Mannino DM, Lara M. Asthma mortality in US Hispanics of Mexican, Puerto Rican and Cuban heritage, 1990-1995. Am J Respir Crit Care Med 2000; 161: 504-9. How to Improve Childhood Asthma Outcomes: a Blueprint for Policy Action. RAND Health, RB-4551-RWJ, 2002. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Johnson AR, Dimich-Ward HD, Manfreda J, Becklake MR, Ernst P, Sears MR, Bowie DM, Sweet L, Chan-Yeung M. Occupational asthma in adults in six Canadian communities. Am J Respir Crit Care Med 2000; 162: 2058-62. Kogevinas M, Anto JM, Sunyer J, Tobias A, Kromhout H, Burney P and the European Community Respiratory Health Survey Study Group. Occupational asthma in Europe and other industrialised areas: a population-based study. Lancet 1999; 353: 1750-4. Krahn MD, Berka C, Langlois P, Detsky AS. Direct and indirect costs of asthma in Canada, 1990. Can Med Assoc J 1996; 154: 821-31. Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 to 1991. N Engl J Med 1994; 331: 1542-6. Lara M, Rosenbaum S, Rachelefsky G, Nicholas W, Morton SC, Emont S, Branch M, Genovese B, Vaiana ME, Smith V, Wheeler L, Platts-Mills T, Clark N, Lurie N, Weiss KB. Improving childhood asthma outcomes in the United States: a blueprint for policy action. Pediatr 2002; 109: 919-30.

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Lieberman JS. Asthma mortality: the worldwide response. J Royal Soc Med 1997; 89: 265-7. Mak H, Johnston P, Abbey H, Talamo RC. Prevalence of asthma and health service utilization of asthmatic children in an inner city. J Allergy Clin Immunol 1982; 70: 367-72. Manfreda J, Becker AB, Wang P-Z et al. Trends in physician-diagnosed asthma prevalence in Manitoba between 1980 and 1990. Chest 1993; 103: 151-7. Manfreda J, Becklake MR, Sears MR, Chan-Yeung M, Dimich-Ward H, Siersted H, Ernst P, Sweet L, Van Til L, Bowie DM, Anthonisen NR, Tate RB. Prevalence of asthma symptoms among adults aged 20-44 years in Canada. CMAJ 2001; 164: 995-1001. Mannino DM, Homa DM, Pertowski CA, Ashizawa A, Nixon LL, Johnson CA et al. Surveillance of asthma - United States, 1960-1995. Morbid Mortal Weekly Report 1998; 47: 1-28. Massey DG, Hope BE, Fournier-Massey G. Asthma in Hawaii: a tradition of excess mortality. J Asthma 1997; 34: 113-7. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993; 329: 103-9. Pattemore PK, Asher MI, Harrison AC et al. The interrelationship among bronchial hyperresponsiveness, the diagnosis of asthma, and asthma symptoms. Am Rev Respir Dis 1990; 142: 549-54. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Perrin JM, Homer CJ, Berwick DM, Woolf AD, Freeman JL, Wennberg JE. Variations in rates of hospitalization of children in three urban communities. N Engl J Med 1989; 320: 1183-7. Schwartz J, Gold D, Dockery DW, Weiss ST, Speizer FE. Predictors of asthma and persistent wheeze in a national sample of children in the United States. Am Rev Respir Dis 1990; 142: 555-62. Senthilselvan A. Effect of readmissions on increasing hospital admissions for asthma in children. Thorax 1995; 50: 934-6. Senthilselvan A, Habbick BF. Increased asthma hospitalizations among registered Indian children and adults in Saskatchewan, 1970-1989. J Clin Epidemiol 1995; 48: 1277-83. Senthilselvan A. Trends and rural-urban differences in asthma hospitalizations in Saskatchewan 1970-1989. Can Respir J 1994; 1: 229-34. Smith DH, Malone DC, Lawson KA, Okamoto LH, Battista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med 1997; 156: 787-93. Stafford RS, Ma J, Finkelstein SN, Haver K, Cockburn I. National trends in asthma visits and asthma pharmacotherapy, 1978-2002. J Allergy Clin Immunol 2003; 111: 729-35. Sullivan S, Elixhauser A, Buist S, Luce BR, Eisenberg J, Weiss KB. National Asthma Education and Prevention Program Working Group Report on the Cost Effectiveness of Asthma Care. Am J Respir Crit Care Med 1996; 154: S84-S95.

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Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory Health Survey. Generational increase of self-reported first attack of asthma in fifteen industrialised countries. Eur Respir J 1999: 14: 885-91. To T, Dick P, Feldman W, Hernandez R. A cohort study on childhood asthma admissions and readmissions. Pediatrics 1996; 98: 191-5. Tobias A, Soriano JB, Chinn S, Anto JM, Sunyer J, Burney P for the European Community Respiratory Health Survey. Symptoms of asthma, bronchial responsiveness and atopy in immigrants and emigrants in Europe. Eur Respir J 2001; 18: 459-65. Vollmer WM, Osborne ML, Buist S. 20-year trends in the prevalence of asthma and chronic airflow obstruction in an HMO. Am J Respir Crit Care Med 1998; 157: 1079-84. Weiss KB, Sullivan SD, Lyttle CS. Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin Immunol 2000; 106: 493-9. Weiss KB, Wagener DK. Changing patterns of asthma mortality: identifying target populations at high risk. JAMA 1990; 264: 1683-7. Weitzman M, Gortmaker SL, Sobol AM, Perrin JM. Recent trends in the prevalence and severity of childhood asthma. JAMA 1992; 268: 2673-7. Wilkins K, Mao Y. Trends in rates of admission to hospital and death from asthma among children and young adults in Canada during the 1980s. Can Med Assoc J 1993; 148: 185-90. Williams MH Jr. Increasing severity of asthma from 1960 to 1987. N Engl J Med 1989; 320: 1015-6. Wissow LS, Gittelsohn AM, Szklo M, Starfield B, Mussman M. Poverty, race and hospitalization for childhood asthma. Am J Public Health 1988; 78: 777-82. Yunginger JW, Reed CE, O'Connell EJ, Melton LJ III, O'Fallon WM, Silverstein MD. A community-based study of the epidemiology of asthma. Am Rev Respir Dis 1992; 146: 888-94. Zoratti EM, Havstad S, Rodriguez J, Robens-Paradise Y, Lafata JE, McCarthy B. Health service use by African Americans and Caucasians with asthma in a managed care setting. Am J Respir Crit Care Med 1998; 158: 371-7.

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Central America
Belize Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

5.2 m 137.3 m 3.8%

Key Points: 1. There is a wide range in the reported prevalence of asthma among different countries within Central America. Countries with documented high asthma prevalence rates include Costa Rica and Panama, whereas the prevalence of asthma is considerably lower in Mexico. 2. There has been a marked increase in the prevalence of asthma symptoms over the last 30 to 40 years within the region. In Mexico alone it has been estimated that in 1997, there were over 120,000 new asthma cases. 3. Persons from Central America who emigrate to the United States experience disproportionate morbidity from asthma in the United States. 4. Many asthmatics use the emergency room as primary health care centres for the management of their asthma. This highlights the importance of developing effective management programmes in primary care to reduce morbidity and mortality from asthma. 5. Inpatient hospital care represents a major component of asthmarelated health care costs within Central America. Management programmes focussed on treatment regimes which have been shown to reduce hospital admissions represent a cost-effective strategy for the management of asthma within the region. 6. In most but not all countries in Central America the rates of hospital admission due to asthma have increased markedly over recent decades. For example, in Mexico hospitalisations due to asthma have increased over 10-fold over the last 40 years. This represents a huge toll in terms of morbidity and economic cost. Countries such as Costa Rica, where hospital admission rates have decreased over the last decade, can serve as models of health care which can be established to reduce morbidity from asthma.

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7. The cost and availability of asthma medications vary markedly within Central America. In some countries the government supplies all medications free, while in others there is limited government provision of medications and many patients are unable to afford medications through the private sector. 8. Poor socioeconomic status and limited access to health care are likely to be responsible for the frequent undertreatment of asthma and inappropriate prescribing practices seen in the region, and contribute to the substantial morbidity and mortality from asthma. 9. An important cause of severe attacks of asthma requiring hospital admission is air pollution, particularly photochemical pollutants (of which ozone is an important component). Reducing air pollution remains one of the public health priorities for a number of countries, particularly Mexico, because of its potential to reduce not only asthma morbidity, but also overall mortality, particularly in the elderly. 10. Asthma mortality rates are generally high within Central America. For example, Mexico has a death rate of 5.6 per 100,000 with over 4,000 deaths per year due to asthma.

FURTHER READING
Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Baena-Cagnani CE, Neffen H. Dissemination program of GINA in Mexico. Revista Alergia Mexico 2000; 47(6): 177-85. Baeza-Bacab MA. Prevalencia del asma en Mexico. In: Sienra-Monge JJL (Dir Huesped) Alergia e Immunologia. Temas de Pediatria. Associacion Mexicana de Pediatria 1997; 155. Barraza-Villarreal A, Sanin-Aguirre LH, Tellez-Rojo MM, Lacasana-Navarro M, Romieu I. Prevalence of asthma and other allergic diseases in school children from Juarez City, Chihuahua. Salud Publica de Mexico 2001; 43(5): 433-43. Bascom R. Environmental factors and respiratory hypersensitivity: the Americas. Toxicology Letters 1996; 86: 115-30. Bravo H, Perrin F, Sosa R, Torres R. Incremento de la contaminacion atmosferica en la Ciudad de Mexico. Ing Amb 1988; 1: 8-14. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Cavazos-Galvan M, Contreras-Castillo J, Martinez-Llano E, Soni-Duque D. Un studio economico sobre asma en Mexico. Revista Alergia Mexico 2000; XLVII(3): 96-9. Celedon JC, Soto-Quiros ME, Silverman EK, Hanson LA, Weiss ST. Risk factors for childhood asthma in Costa Rica. Chest 2001; 120(3) 785-90.

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Chelala C. Relations between the United States and Cuba: a proposal for action. JAMA 1996; 275: 559-60. Diaz GS, Vargas MH, Furuya MEY, Lugo A, Direccion de Prestaciones Medicas IMSS Mexico DF Mexico, Hospital de Pediatria IMSS Mexico DF Mexico. Trends of asthma in Mexico. A 10 year analysis in a nationwide health institution. Eur Respir J 2002; 20(Suppl.38): 317s. Gonzalez JG. Symposium on asthma disease management: the role of the asthma expert: a view from Mexico. Allergy and Asthma Proc 1999; 20(5): 299-300. Gonzalez-Gamez JG et al. Prevalencia del asma bronquial en poblacion escolar de la ciudad de Guadalajara, Jal. Mexico. Alergia 1992; XXXIII. I. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Ledogar RL, Penchaszadeh A, Iglesias-Garden CC, Garden-Acosta L. Asthma and Latino cultures: different prevalence reported among groups sharing the same environment. Am J Pub Health 2000; 90(6): 929-35. Martinez-Cairo S, Salas-Ramirez M, Segura-Mendez N. Los aspectos epidemiologicos del asma bronquial en la Republica Mexicana. Gac Med Mex 1992; 131: 277-82. Mendoza-Mendoza A, Romero-Cancio JA, Pena-Rios HD, Vargas MH. Prevalence of asthma in schoolchildren from the Mexican city Hermosillo. Gac Med Mex 2001; 137(5) 397-401. Ministerio de Economia, Industria, y Comercio de Costa Rica. Calculo de Poblacion. San Jose, Costa Rica: Direccion General de Estadistica y Cenos, 1996. Montealegre F, Bayona M. An estimate of the prevalence, severity and seasonality of asthma in visitors to a Ponce shopping center. P R Health Sci J 1996; 15: 113-17. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Rico-Mendez FG, Barquera S, Cabrera DA, Escobedo S, Ochoa LG, MasseyReynaud LF. Bronchial asthma healthcare costs in Mexico: analysis of trends from 1991-1996 with information from the Mexican Institute of Social Security. Journal of Investigational Allergology & Clinical Immunology 2000; 10(6): 334-41. Rojas-Molina N, Legorreta-Soberanis J, Olvera-Guerra F. Prevalence and asthma risk factors in municipalities of the State of Guerrero, Mexico. Revista Alergia Mexico 2001; 48(4): 115-8. Romieu I, Meneses F, Ruiz S, Sienra-Monge JJ, Huerta J, White MC, Etzel RA. Effects of air pollution on the respiratory health of asthmatic children living in Mexico City. Am J Respir Crit Care Med 1996; 154: 300-7. Romieu I, Meneses F, Ruiz-Velasco S, Huerta J, Sienra-Monge JJ, White MC, Etzel RA, Hernandez-Avila M. Effects of intermittent ozone exposure on peak expiratory flow and respiratory symptoms among asthmatic children in Mexico City. Arch Environ Health 1997; 52(5): 368-76.

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Romieu I, Meneses F, Sienra-Monge JJ, Ruiz-Velasco S, White MC, Etzel RA, Hernandez-Avila M. Effects of urban air pollutants on emergency visits for childhood asthma in Mexico City. Am J Epidemiol 1995; 141(6): 546-53. Rosas I, McCartney HA, Payne RW, Calderon C, Lacy J, Chapela R, RuizVelazco S. Analysis of the relationships between environmental factors (aeroallergens, air pollution, and weather) and asthma emergency admissions to a hospital in Mexico City. Allergy 1998; 53: 394-401. Salas-Ramirez M, Segura Mndez N, Martinez-Cairo Cueto S. Trends in asthma mortality in Mexico. Bol Oficina Sanit Panam 1994; 116: 298-306. Salas-Ramirez M. Tendencia de la mortalidad debida a asma en la Republica Mexicana. Org Panam Salud 1994; 116: 14-19. Soto-Quiros ME, Bustamante M, Gutierrez I, Hanson LA, Strannegard I -L, Karlberg J. The prevalence of childhood asthma in Costa Rica. Clin & Exp Allergy 1994; 24: 1130-6. Soto-Quiros ME, Silverman EK, Hanson LA, Weiss ST, Celedon JC. Maternal history, sensitization to allergens, and current wheezing, rhinitis, and eczema among children in Costa Rica. Pediatr Pulmonol 2002; 33: 237-43. Tatto-Cano MI, Sanin-Aguirre LH, Gonzalez V, Ruiz-Velasco S, Romieu I. Prevalence of asthma, rhinitis and eczema in school children in the city of Cuernavaca, Mexico. Salud Publica de Mexico 1997; 39(6): 497-506. Vargas MH, Sienra-Monge JJ, Diaz-Mejia G, DeLeon-Gonzalez M. Asthma and geographical altitude: an inverse relationship in Mexico. J Asthma 1999; 36(6): 511-7.

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Caribbean
Barbados Cuba Dominican Republic Haiti Jamaica Puerto Rico Trinidad & Tobago Other Caribbean Islands

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

3.4 m 32.6 m 10.4%

Key Points: 1. The prevalence of asthma is generally high within Caribbean countries. 2. In children the prevalence of asthma has increased markedly in parts of the Caribbean over recent decades. For example, in Barbadian schoolchildren the prevalence of asthma has reportedly increased from 1% in 1970 to 15% in 1996. 3. The prevalence of severe asthma also appears to have increased markedly over recent decades in many parts of the Caribbean. For example in Barbados between 1970 and 1990, the rate of Accident and Emergency admissions for asthma increased 10-fold. 4. Immigrants from the Caribbean experience a disproportionately higher prevalence and morbidity from asthma following emigration to the United States. 5. The dependency of many asthmatics on the emergency room for asthma management indicates the requirement for improved primary health care programmes within the region. 6. The observation that asthma attacks are more frequent during periods of the Saharan dust cloud cover indicates the potential effect that environmental changes resulting from global warming have on asthma worldwide. 7. Asthma represents an important cause of hospital admissions on many Caribbean islands, particularly in children. The high admission rates represent a major burden in terms of lifethreatening attacks, morbidity, and economic cost. For example, in Puerto Rico in a random population sample, around 1 in 4 persons with asthma reported a previous hospital admission. 8. On some Caribbean islands, prescribing practices are inconsistent with modern management of asthma. For example, on St Lucia, Grenada, and St Kitts and Nevis, oral preparations of

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beta agonists and corticosteroids are prescribed most frequently, with inhaled preparations prescribed far less frequently. 9. The Caribbean Guidelines for Asthma Management and Prevention represent a good model of how international guidelines may be modified for local implementation. This model includes non-pharmaceutical funding for the initiative, a workshop with multidisciplinary local and international experts, and publication in a regional medical journal as part of the implementation strategy. 10. Limited asthma mortality data are available within the region. In Cuba it is apparent that the death rate from asthma increased markedly between the 1970s and 1990s. While the causes for this trend are likely to be multifactorial, the lack of medicines resulting from the trade embargo imposed by the United States is likely to be a significant factor.

FURTHER READING
Barry M. Effect of the US embargo and economic decline on health in Cuba. Ann Intern Med 2000; 132: 151-4. Bayliss M, Burns P. Asthma education in Trinidad. The Michener Institute for Applied Health Sciences Alumni Newsletter 2001; 4: 10. Bleecker ER, Perez-Perdomo R, Arvizu J, Howard S, Meyers DA. Asthma in Puerto Rico. J Allergy Clin Immunol 2003; 111: S159. Carter-Pokras OD, Gergen PJ. Reported asthma among Puerto Rican, Mexican-American, and Cuban children 1982-1984. Am J Pub Health Apr 1993; 83(4): 580-2. Chelala C. Relations between the United States and Cuba: a proposal for action. JAMA 1996; 275: 559-60. Commonwealth Caribbean Medical Research Council. Caribbean Guidelines for Asthma Management and Prevention: a Pocket Guide for Health Care Personnel. Commonwealth Caribbean Medical Research Council. Port of Spain, Trinidad: 1998. Fabre-Ortiz DE, Cabrera-Perez JF, Armas-Perez L, Conzalez-Ochoa E. Asthma mortality in Cuba during 1972-1993. Allergol Et Immunopahol 1997; 25(6): 289-92. Farmer P, Smith Fawzi MC, Nevil P. Unjust embargo of aid for Haiti. Lancet 2003; 361: 420-3. Garfield R, Devin J, Fausey J. The health impact of economic sanctions. Bull NY Acad Med 1995; 72: 454-69. Howitt M, Burnett F. A study of drug utilisation reviews on asthma in three Caribbean countries: St Lucia, Grenada & St Kitts/Nevis. Eur Respir J 1998; 12(Suppl.28): 51s. Howitt M. Prevalence of asthma in the barbadian population. Presentation at the First Caribbean Allergy Symposium, Mt Hope, Trinidad. November 1998: 28-9.

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Howitt ME. Asthma management in the Caribbean: an update. Postgrad Doctor Caribbean 2000; 16: 86-104. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Kirkpatrick A. Medicine and the US embargo against Cuba. JAMA 1996; 275: 1633-7. Knight-Madden JM. The Caribbean. In: Silverman M (Ed). Childhood Asthma & Other Wheezing Disorders. 2nd Edition. London: Arnold, 2002; 17f: 453-68. Lamsee-Ebanks C, Gyan K, Henry W, Lacaille S, Laloo A, McKay S. Final Report: The Association Between Saharan Dust Clouds over Trinidad. Paediatric Asthma Accident and Emergency Visits. Primary Health & Primary Care Unit, Faculty of Medical Sciences, University of the West Indies, St Augustine, October 2002. Monteil MA, Juman S, Hassanally R, Williams KP, Pierre L, Rahaman M, Singh H, Trinidade A. Descriptive epidemiology of asthma in Trinidad, West Indies. J Asthma 2000: 37(8): 677-84. Nichol DJ, Longsworth FG. Prevalence of exercise-induced asthma in schoolchildren in Kingston, St. Andrew and St. Catherine, Jamaica. West Indian Med J 1995; 44(1): 16-9. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Pearson RS. Asthma in Barbados. Clin Allergy 1973: 3(3): 289-97. Pinto Pereira LM, Clement Y, Da Silva CK, McIntosh D, Simeon DT. Understanding and use of inhaler medication by asthmatics in special care in Trinidad. Chest 2002; 121(6): 1833-40. Rodriguez de la Vega A, Tejeiro-Fernandez A, Gomez-Echeverria A, Bacallao-Gallestov J, Rodriguez-Gavalda R. Investigation of the prevalence and inheritance of bronchial asthma in San Antonio de los Banos, Cuba. Bull Pan Am Health Org 1975; 9(3): 221-31. Rodriquez de la Vega A, Tejeiro-Fernandez A, Rubi-Alvarez A. Investigacion de la prevalencia nacional de asma en Cuba. Rev Cubana Adm Salud 1983; 90(2): 95-118. Scott PW, Mullings RL. Bronchial asthma deaths in Jamaica. West Indian Med J 1998; 47(4): 129-32. Tam Tam HB, Deva Taka M, Ganganaidu K, Aiyaroo K. Prevalence of asthma related symptoms in school children in Port-of-Spain, Trinidad. West Indian Med J 1998; 47(Suppl): 22.

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South America
Argentina Bolivia Brazil Chile Colombia Ecuador French Guiana Guyana Paraguay Peru Suriname Uruguay Venezuela

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

34.7 m 350.4 m 9.9%

Key Points: 1. The prevalence of asthma in South America is generally above the average for countries worldwide. Countries with childhood asthma prevalence rates in the top quartile of countries worldwide include Peru, Brazil, Paraguay, and Uruguay. 2. The prevalence of asthma in childhood in many countries in South America is higher than that in Spain and Portugal, and other former Spanish or Portuguese colonies such as Macau, Cape Verde, and Madeira. 3. The prevalence of asthma in South America does not seem to relate to industrialisation or economic wealth. In contrast to the trends seen in other regions of the world, asthma prevalence is higher in poorer cities than in cities with a higher socioeconomic level. This suggests that lower socioeconomic status is a risk factor for asthma within the region. 4. The limited data available suggest that the prevalence of asthma has increased markedly in different countries in South America over recent decades. 5. Throughout the region the lack of adequate treatment of asthma remains a common problem, and is primarily due to the cost of medical care including pharmaceuticals. The lack of government funding of pharmaceuticals has resulted in a situation where the private sector constitutes about three-quarters of the total pharmaceutical market in South America. 6. Despite socioeconomic constraints, there are a number of examples in the region where the health of asthmatic children in low-income communities has been markedly improved through the implementation of adapted asthma management guidelines and related educational programmes.

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8. Asthma mortality is generally high in South America, although there is a wide range of mortality rates in different countries in this region. 9. The effectiveness of modern management in reducing mortality in the region is illustrated by Argentina, where there has been a progressive decline in asthma mortality over the last decade in association with marked changes in management, particularly an increasing use of inhaled corticosteroid therapy. 10. Air pollution is sufficiently severe in some of the major cities in South America that it increases both general mortality rates and death rates due to respiratory disease, including asthma. The different government strategies to reduce air pollution represent important public health initiatives in many countries in South America.

FURTHER READING
Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Baena-Cagnani CE, Patino CM, Cuello MN, Minervini MC, Fernandez AM, Garip EA, Salvucci KD, Sancho ML, Corelli S, Gomez RM. Prevalence and severity of asthma and wheezing in an adolescent population. Int Arch Allergy Immunol 1999; 118: 245-6. Baluga JC, Sueta A, Ceni M. Asthma mortality in Uruguay 1984-1998. Annals Allergy Asthma Immunol 2001; 87: 124-8. Barba S, Landazuri N, Alban F. Alergicas en el Ecuador. Enf Alergicas del Ecuador 2000; 2: 22-6. Batule M, Garcia O, Toledo H, Vidaillet J. Mortalidad por asma bronquial y relacion con condiciones ambientales atmosfericas en Ciudad de la Habana. Rev Cub Med 1990; 29: 473-84. Borja-Aburto VH, Loomis DP, Bangdiwala SI, et al. Ozone, suspended particulates, and daily mortality in Mexico City. Am J Epidemiol 1997; 145: 258-68. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Cabral ALB, Carvalho WAF, Chinen M, Barbiroto RM, Boueri FMV, Matins MA. Are international asthma guidelines effective for low-income Brazilian children with asthma? Eur Respir J 1998; 12: 35-40. Campos H. Some data about the epidemiology of asthma in Brasil. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp 23-5. Caraballo L, Cadavid A, Mendoza J. Prevalence of asthma in a tropical city of Colombia. Ann Allergy 1992; 68: 525-9. Carrasco E. Epidemiologic aspects of asthma in Latin America. Chest 1987 91(6): 93S-97S.

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Cezar-Fritscher C, Donazar-Severo R, Chaves-Fagondes S, Cohen R, Linhares-Bornelles R, Kahan F. Modificacoes na prevalencia de asthma bronquica em escolares de Porto Alegre. J Pneumol 1994; 20(1): 6. Companhia Pernambucana de Controle da Poluicao Ambiental e de Administracao de Recursos Hidricos (CPRH). Estimativa de emissoes de poluentes atmosfericos provenientes de fonts estacionarias. Area de estudo: regiao metropolitana do Recife. Recife: CPRH, 1994. de Almeida MM, Rosado-Pinto J. Bronchial asthma in children: clinical and epidemiologic approach in different Portuguese speaking countries. Pediatr Pulmonol 1999; 18: 49-53. De Britto MCA, Bezerra PGM, Ferreira OS, Maranhao ICV, Trigueiro GA. Asthma prevalence in schoolchildren in a city in north-east Brazil. Ann Trop Paediatrics 2000; 20: 95-100. Ferreira de Noronha M, Campos HS. Hospitalizacoes por asma no Brasil [Asthma hospitalar deaths in public hospitals - Brasil 1996]. Pulmao RJ 2000; 9(4) 10-30. Fortes PAC. Contribuicao para o esudo da asma grave na crianca. Tese, Universidade de Sao Paulo, Sao Paulo 1986. Gouveia N, Fletcher T. Respiratory diseases in children and outdoor air pollution in Sao Paulo, Brazil: a time series analysis. Occup Environ Med 2000; 57: 477-83. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Jave HO, Lopez C. Asthma among university students. Int J Tuberc Lung Dis 2001; 5(Suppl 1): S194-5. Jave HO, Salas A, Uriber A et al. Asthma and asthma-like symptoms among hospital-based outpatients. Int J Tuberc Lung Dis 2002; (Suppl 1): Mallol J, Cortez E, Amarales I, Sanchez I, Calvo M, Soto S, Strickler A, Kyling A, Sanhueza I, Albornoz C. [Prevalence of asthma in Chilean students. Descriptive study of 24,470 children. ISAAC-Chile] [Spanish]. Revista Medica de Chile 2000; 128(3): 279-85. Mallol J, Sole D, Asher I, Clayton T, Stein R, Soto-Quiroz M. Prevalence of asthma symptoms in Latin America: the international study of asthma and allergies in childhood (ISAAC). Pediatr Pulmonol 2000; 30: 439-44. Medina E, Kaempffer AM, Cornejo E, Hernandez E. [Characteristics and management of morbidity in seven Chilean cities] [Spanish]. Revista Medica de Chile 1997; 125(8): 950-5. Neffen H, Baena-Cagnani CE, Malka S, Sole D, Sepulveda R, Caraballo L, Caravajal E, Rodriguez-Gavalda R, Gonzalez-Diaz S, Guggiari-Chase J, Diez C, Baluga J, Capriles-Hulett A. Asthma mortality in Latin America. J Invest Allergol Clin Immunol 1997; 7(4): 249-53. Neffen HE, Baena-Cagnani CE. Asthma mortality in Latin America. ACF Int 1999; 11(5): 171-5. Neffen HE. Epidemiological aspects of asthma in Latin America. J Invest Allergol Clin Immunol 1997; 7(5): 300-1. Orengo JC, Loyo NI, Serrano RA, Mercado HE, Horia H, White MC, et al. Prevalence of Respiratory and Allergic Problems Among School-Aged Children in the Catano Air Basin. Final Report. San Jose, Puerto Rico, April 1996.

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Ortiz DEF, Perez JFC et al. Asthma mortality in Cuba during 1972-1993. Allergol et Immunopathol 1997; 25(6) 289-92. Ostro B, Sanchez JM, Aranda C, et al. Air pollution and mortality: results from a study of Santiago, Chile. J Expo Anal Environ Epidemiol 1996; 6: 97-114. Patino CM, Fernandez AM, Minervini MC. Prevalence of asthma in adults in Crdoba, Argentina. Am J Respir Crit Care Med 2000; 161: A798. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Penny ME, Murad S, Madrid SS, Herrera TS, Pineiro A, Caceres DE, Lanata CF. Respiratory symptoms, asthma, exercise test spirometry, and atopy in schoolchildren from a Lima shanty town. Thorax 2001; 56: 607-12. Perdomo de Ponce D, Benaroch L, Aldrey O, Rodriguez D, Rosales A, Avila E, Bianco N. The influence of environment and parasitism on the prevalence of asthma in two Venezuelan regions. Invest Clin 1991; 32(2): 77-89. Perez R, Jave HO, Pantoja R, Espejo C et al. Asthma, poverty and environment in Lima City. Int J Tuberc Lung Dis 2001; 5(Suppl 1): S194. Riedler J, Gamper O, Schmied R, Eder W, Oberfeld G. Prevalence of asthma and bronchial hyperresponsiveness to hypertonic saline in Austrian schoolchildren (ISAAC). Eur Respir J 1996; 9: 232s. Robertson CF, Bishop J, Sennhauser FH, Mallol J. International comparison of asthma prevalence in children: Australia, Switzerland, Chile. Pediatr Pulmonol 1993; 16: 219-26. Romieu I, Meneses F, Sienra-Monge JJ, et al. Effects of urban air pollutants on emergency visits for childhood asthma in Mexico City. Am J Epidemiol 1995; 141: 546-53. Salinas M, Vega J. The effect of outdoor air pollution on mortality risk: an ecological study from Santiago, Chile. World Health Statistics Quarterly Rapport Trimestriel de Statistiques Sanitaires Mondiales 1995; 48(2): 118-25. Sole D, Yamada E, Vana AT, Werneck G, Solano de Freitas L, Jose-Sologuren M, Brito M, Rosario-Filho NA, Stein RT, Mallol J. International study of asthma and allergies in childhood (ISAAC): Prevalence of asthma and asthma-related symptoms among Brazilian schoolchildren. J Invest Allergol Clin Immunol 2001; 11(2): 123-8. Sole D, Yamada E, Vana AT, Werneck G, Solano de Freitas L, Sologuren MJ, Brito M, Rosario-Filho NA, Stein RT, Mallol J. International study of asthma and allergies in childhood (ISAAC): prevalence of asthma and asthma-related symptoms among Brazilian schoolchildren. J Invest Allergol Clin Immunol 2001; 11(2): 123-8. Teper AM, Kofman CD (Eds). Latin America. In: Childhood Asthma & Other Wheezing Disorders. 2002; 17c: 445-7. Torres LAG, Ferrani VPL. [Asthma prevalence in school children in Ribeiro Preto]. Rev Bras Alerg Imunopatol 1995; 18(6): 230. Valdivia G. [Bronchial asthma and atopic diseases as an emerging problem in public health: new etiological hypothesis. The experience of developed societies] [Spanish]. Revista Medica de Chile Mar 2000; 128(3): 339-46. Valdivieso R, Estupinan M, Acosta ME. Asthma and its relation with Dermatophagoides pteronyssinus and Dermatophagoides farinae in Andean altitudes (Quito, Ecuador). J Invest Allergol Clin Immunol 1997; 7(1): 46-50.

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Valdivieso R, Romero MC, Correa E, Estupinan M. Prevalencia de asma bronquial y sus factores etiologicos en una poblacion infanto-juvenil de Quito. Revista Educacion Medica Continuada 1992; 38: 7-13. Valdivieso R. Prevalencia de sensibilizacion a Dermatophagoides pteronyssinus y Dermatophagoides farinae en rinitis cronica y asma bronquial. Metrociencia 1990; 1: 22-8. Vergara C, Caraballo L. Asthma mortality in Colombia. Ann Allergy Asthma Immunol 1998: 80: 55-60. Werneck G, Ruiz S, Hart R, White M, Romieu I. Prevalence of asthma and other childhood allergies in Brazilian schoolchildren. J Asthma 1999; 36(8): 677-90. Ynez A, Neggen HE, Reyes MS, Martinez Vivot A, Mspero JF. Prevalencia de asma en adultos en la ciudad de Buenos Aires y Gran Buenos Aires. Archivos de Alergia e Immunologia Clinica 2002; 33(Suppl. 1): S29. Zamel N, McClean PA, Sandell PR, Siminovitch KA, Slutsky AS, University of Toronto Genetics of Asthma Research Group. Asthma on Tristan de Cunha: looking for the genetic link. Am J Respir Crit Care Med 1996; 153: 1902-6.

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North Africa
Algeria Chad Egypt Libya Morocco Niger Sudan Tunisia

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

7.7 m 196.5 m 3.9%

Key Points: 1. The prevalence of asthma is generally low in the countries within this region. 2. Marked regional differences in the prevalence of asthma occur within countries in North Africa. For example, over fivefold differences in the prevalence of asthma have been noted in Algeria between the rural mountain and urban coastal areas. 3. The prevalence of asthma has increased markedly over recent decades, having previously been uncommon within North African countries. 4. It is anticipated that, with increasing Westernisation of lifestyle and continued urban shifts in population, the burden of asthma will increase considerably in coming years. 5. Asthma is a common cause of emergency room visits and hospital admissions. For example, in some areas of Egypt asthma is the most common cause of hospital admission for a respiratory complaint in adults. 6. The burden of asthma is higher than generally recognised, particularly in children. For example, in Egypt up to one in four children with asthma is unable to attend school regularly because of poor asthma control. 7. There are major inequities in asthma care in the low-income countries within North Africa. This results in good quality care being limited to high socioeconomic sectors of the community. 8. The limited availability of asthma medications represents a major problem, contributing to the undertreatment of both chronic asthma and acute severe attacks. 9. Although mortality rates for asthma are low in absolute terms throughout the region, when the prevalence rates of severe asthma are considered the derived case fatality rates are relatively higher.

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10. Social and economic factors including the limited access to health care are major contributors to morbidity and mortality from asthma in North Africa. Improving the economic wealth of the countries is crucial if the burden of disease, including that due to asthma, is to be reduced in the region.

FURTHER READING
Abid A. Follow-up of childhood asthma in Morocco. Pediatr Pulmonol 1999; (Suppl 18): 220. Allani-Hassani F. Epidemiologie de l'asthme chez l'enfant scolaire age de 13-14 ans dans la region de Sousse. Sousse: These de Medecine; 1998: 83. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Azzouz K. Contribution a l'etude de l'asthme infantile en Tunisie, d'apres una etude faite a l'Institut de Pneumophyisiologie de l'Ariana. Tunis: These de Medecine; 1990: 103. Bartal M. GINA activities in Morocco. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 35-6. Bassili A, Zaki A, Zaher SR, El-Sawy IH, Ahmed MH, Omar M, Omar T, Bedwani RN, Davies C, Tognoni G. Quality of care of children with chronic diseases in Alexandria, Egypt: The models of asthma, type 1 diabetes, epilepsy, and rheumatic heart disease. Pediatrics 2000; 106(1): E12. Belhocine M, Ait-Khaled N. Prevalence of asthma in a region of Algeria. Bull Int Union Tuberc Lung Dis 1991; 66: 91-3. Ben-Miled MT, Gorgob K, Maalej M, Achour N, Nacef T, El-Gharbi T. Epidemiologie de l'asthme chez l'enfant et l'adolescent tunisien scolarise. Rev Mal Respir 1986; 3: 309. Bennis A, El-Fassy-Fihry MT, Fikri-Benbrahim N, Sayah-Moussaoui Z, SamirRafir A, Biaz A. [The prevalence of adolescent asthma in Rabat. A survey conducted in secondary schools]. [French]. Rev Mal Respir 1992; 9(2): 163-9. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burney P, Malmberg E, Chinn S, Jarvis D, Luczynska C, Lai E on behalf of the European Community Respiratory Health Survey. The distribution of total and specific serum IgE in the European Community Respiratory Health Survey. J Allergy Clin Immunol 1997; 99: 314-22. Chaulet P. Asthma and chronic bronchitis in Africa - evidence from epidemiologic studies. Chest 1989; suppl 96(3): 334s-9s. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey (ECRHS). Variation in bronchial responsiveness in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1997; 10: 2495-501. Djenayah F, Jerray M, El-Gharbi B. L'asthme en Tunisie: aspects dominants. Med Hyg 1981; 39: 137-42. El-Hassani A, Benjelloun BSD, Mahraoui C, El-Madani A, El-Harim L, Jorio M, El-Malki Tazi A. Role of allergic factors in childhood asthma in Morocco. Pediatr Pulmon 1999; (Suppl 18): 221-2.

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European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the European Community Respiratory Health Survey. Variation in bronchial responsiveness in the European Community Respiratory Health Survey. Eur Respir J 1997; 10: 2495-501. Ghoneim AHA. High prevalence of bronchial asthma among adults at the northern area armed forces hospital, King Khalid Military City, Hafer Al Batin, KSA. Eur Respir J 1998; 12(Suppl.28): 198s. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M on behalf of the European Community Respiratory Health Survey. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001; 18: 598-611. Janson C, Chinn S, Jarvis D, Burney P. Individual use of antiasthmatic drugs in the European Community Respiratory Health Survey. Eur Respir J 1998; 12: 557-63. Khaldi F, Bouyahia O. Epidemiology of asthma in Maghrebian countries. Pediatr Pulmon 2001; suppl 23: 30-1. Khaldi F, Joulak M, Jawahdou F. Infant asthma in Tunisia. Pediatr Pulmonol 1999; (Suppl 18): 216-9. Khiati M, Mariche L. Treatment of childhood asthma in Algeria. Pediatr Pulmon 1999; (Suppl 18): 223-4. Laraqui CH, Caubet A, Laraqui O, Benghalem A, Harourate K, Bichara M, Curtes JP, Verger C. [Prevalence of respiratory systems and evaluation of sensitization levels in traditional grain market workers in Casablanca]. [French]. Rev Mal Respir 2000; 17(5): 947-55. Laraqui CH, Harourate K, Belamallem I, Benhaymoud N, Verger C. [Occupational respiratory risks in workers exposed to enzymes in detergents]. [French]. Rev Mal Respir 1996; 13(5): 485-92. Laraqui CH, Laraqui O, Rahhali A, Harourate K, Tripodi D, Mounassif M, Yazidi AA. [Prevalence of respiratory problems in workers at two manufacturing centers of ready-made concrete in Morocco]. [French]. International J Tuberc Lung Dis 2001; 5(11): 1051-8. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Skhiri H, Hsairi M, Fakhfakh R, Maalej M, Nacef T. Epidmiologie de l'asthme et de la rhinite allergique en Tunisie. Publications de l'Institut National de la Saint Publique, Tunisie 1999; 1: 51-63. World Health Organisation. The World Health Report 1998: 158-62.

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West Africa
Benin Burkina Faso Cameroon Cape Verde Central African Republic Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Ivory Coast Liberia Mali Mauritania Nigeria Senegal Sierra Leone Togo Western Sahara

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

13.7 m 239.5 m 5.7%

Key Points: 1. The prevalence of asthma is generally low within countries in West Africa. 2. The prevalence of asthma is higher in urban communities of high compared with low socioeconomic status, and lowest in rural communities. 3. The prevalence of asthma has increased over recent decades, having previously been rare within the countries that make up this region. For example, in 1975 no cases of asthma could be found among over 1,000 children and adults in a rural Gambian community, whereas 3% of a rural Gambian population reported current asthma symptoms in 1997. With increasing urbanisation and lifestyle changes it is likely that the prevalence of asthma will increase further in West Africa over the next decade. 4. While communicable diseases remain the major public health problems within the region, certain non-communicable diseases including asthma are increasingly recognised as contributing significantly to the overall burden of disease. 5. A major barrier to effective management of asthma in the region is the cost and availability of medications. In a number of countries inhaled beta-agonist and corticosteroid therapy are not included in the national essential drug lists, even though they are now recommended for inclusion by the WHO. Drug selection, procurement, and distribution present the greatest problems, especially in countries with the greatest need. 6. Both underdiagnosis and undertreatment of asthma contribute to the morbidity from asthma within the region. The overlap of asthma symptomatology with tuberculosis and other pulmonary infections, which remain common and important respiratory 107

problems within the region, leads to practical difficulties in the diagnosis of asthma. 7. The wide variation in medical practices in West Africa indicates a need for guidelines for asthma management. However, practical constraints which exist in this region preclude the adoption of international guidelines without local modification. Such locally developed guidelines need to take into account local circumstances, such as drug availability and cost and other healthcare resources. 8. The majority of asthma deaths in the region are "preventable." As in other regions of the world, it should be possible to reduce mortality by overcoming the common avoidable factors which contribute to asthma fatalities. 9. Public health campaigns to reduce the rates of tobacco smoking represent an important priority for the region. Although there are severe funding limitations, some of the most successful public health campaigns have been carried out by non-governmental organisations. For example, the Anti-Tobacco Movement of Senegal was awarded the Gold Medal from the WHO for its youth programmes. 10. Social and economic factors including the limited access to health care are major contributors to morbidity and mortality from asthma in West Africa. Improving the economic wealth of the countries is crucial if the burden of disease, including that due to asthma, is to be reduced in the region.

FURTHER READING
Addo-Yobo EOK, Custovic A, Taggart SCO, Asafo-Agyei AP, Woodcock A. Exercise induced bronchospasm in Ghana: differences in prevalence between urban and rural schoolchildren. Thorax 1997; 52: 161-5. Addo-Yobo EO, Custovic A, Taggart SC, Craven M, Bonnie B, Woodcock A. Risk factors for asthma in urban Ghana. J Allergy Clin Immunol 2001; 108: 363-8. Aderele WI. Bronchial asthma in Nigerian children. Arch Dis Child 1979; 54: 448-53. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Bandele EO. A ten-year review of asthma deaths at the Lagos University Teaching Hospital. Afr J Med Med Sci 1996; 25: 389-92. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39.

108

Chaulet P. Asthma and chronic bronchitis in Africa: Evidence from epidemiologic studies. Chest 1989; Suppl 96(3): 334s-9s. de Almeida MM, Gaspar A, Rosado-Pinto J. Epidemiology of asthma in Portugal, Cape Verde, and Macao. Pediatric Pulmon 2001; 23 suppl: 35-7. de Almeida MM, Rosado-Pinto J. Bronchial asthma in children: clinical and epidemiologic approach in different Portuguese speaking countries. Pediatric Pulmon 1999; 18 suppl: 49-53. Falade AG, Olawuyi F, Osinusi K, Onadeko BO. Prevalence and severity of symptoms of asthma, allergic rhino-conjunctivitis and atopic eczema in secondary school children in Ibadan, Nigeria. East African Medical Journal 1998; 75(12): 695-8. Faniran AO, Peat JK, Woolcock AJ. Prevalence of atopy, asthma symptoms and diagnosis, and the management of asthma: comparison of an affluent and a non-affluent country. Thorax 1999; 54: 606-10. Godfrey RC. Asthma and IgE levels in rural and urban communities of the Gambia. Clin Allergy 1975; 5: 201-7. Hesse IFA. Knowledge of asthma and its management in newly qualified doctors in Accra, Ghana. Res Med 1995; 89: 35-9. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Kayantao D, Toloba Y, Kamissoko M, Keita B, Diallo S, M'Baye O, Sangare S. Epidemiological and clinical aspects of asthma and its progression at Bamako, Mali. Sante 2001; 11(2): 101-3. Koffi N, Aka J, Nigue L, Kouassi B, Ngom A, Amon-Dick F, Nibaud A, Fadiga A, Aka-Danguy E. Prevalence of allergic diseases in childhood: Ivory Coast ISAAC study, phase 1. Revue Francaise d'Allergologie et d'Immunologie Clinique 2000; 40(5): 539-47. Koffi N, Kouassi B, Ngom A, Kotchi Z, Yavo J-C, Aka-Danguy E. Role of the pharmacist in asthma care in Africa: A survey of community pharmacists in Adibjan. Revue de Pneumologie Clinique 2001; 57(6): 415-21. Koffi N, Kouassi B, Ngom AK, Kone MS, Aka-Danguy E. Assessment of asthma management of adults in Africa. Revue des Maladies Respiratoires 2001; 18(5): 531-6. Koffi N, Ngom A, Kouassi B, Yavo J-C, Aka-Danguy E. Fatal asthma: seven case reports observed in Black Africans and a review of the literature. Revue des Maladies Respiratoires 1998; 15(4): 507-11. Nyan OA, Walraven GEL, Banya WAS, Milligan P, Van der Sande M, Ceesay SM, Del Prete G, McAdam KPWJ. Atopy, intestinal helminth infection and total serum IgE in rural and urban adult Gambian communities. Clin Exp Allergy 2001; 31: 1672-8. Oviawe O. The contexts of non-hospital deaths among children attending asthma clinic. Nigerian Journal of Clinical Practice 2000; 3: 22-25. Oviawe O. Childhood asthma in Benin. Nigerian Journal of Paediatrics 1986; 13: 141-5. Oviawe O, Oknonghae HO. Acute severe asthma in children: Assessment of response to therapy. Nigerian Journal of Paediatrics 1991; 18: 37-42.

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Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Roudaut M, Meda AH, Seka A, Fadiga D, Pigearias B, Akoto A. [Prevalence of asthma and respiratory diseases in schools in Bouake (Ivory Coast): preliminary results]. [French]. Medecine Tropicale 1992; 52(3): 279-83. Shaheen SO, Aaby P, Hall AJ et al. Measles and atopy in Guinea-Bissau. Lancet 1996; 347: 1792-6. Walraven GEL, Nyan OA, Van der Sande M, Banya WAS, Ceesay SM, Milligan P, McAdam KPWJ. Asthma, smoking and chronic cough in rural and urban adult communities in The Gambia. Clin Exp Allergy 2001; 31: 1679-85. Warrell DA, Fawcett IW, Harrison BD et al. Bronchial asthma in the Nigerian Savanna region: a clinical and laboratory study of 106 patients with a review of the literature on asthma in the tropics. QJ Med. 1975; 44: 32547. Watson JP, Lewis RA. Is asthma treatment affordable in developing countries? Thorax 1997; 52: 605-7. Weber MW, Mulholland EK, Jaffar S, Troedsson H, Gove S, Greenwood BM. Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia. Bull WHO 1997; 75(Suppl 1): 25-32.

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East Africa
Burundi Djibouti Eritrea Ethiopia Kenya Madagascar Malawi Mauritius Mozambique Rwanda Somalia Tanzania Uganda

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

10.1 m 230.2 m 4.4%

Key Points: 1. The prevalence of asthma is variable within East Africa, with low rates in Ethiopia but relatively high rates in Kenya. 2. The prevalence of asthma is higher in urban compared with rural areas. The magnitude of the urban-rural differences has lessened over recent years due to the relatively greater increase in asthma prevalence in rural communities as they increasingly adopt Western lifestyles. 3. With the continued trend for those in rural communities to move to urban centres and the general improvement in living standards, the prevalence of asthma within the region is likely to further increase over the next decade. 4. While the burden of asthma is significant in East Africa, the most prominent health problems remain overwhelmingly those of poor housing, malnutrition, and infectious diseases (amongst which HIV/AIDS is increasingly important). 5. The treatment received by many asthmatics is often inadequate. There is reliance on oral rather than inhaled therapy and prophylactic medicines are insufficiently prescribed. 6. The limited availability and high cost of medications seriously limit the management of asthma in the region, leading to preventable morbidity and mortality. 7. The diagnosis of asthma is difficult due to the lack of health care facilities and the overlap of clinical signs and symptoms with other respiratory conditions such as pneumonia in children. This issue has been addressed with the inclusion of asthma in the Integrated Management of Childhood Illness (IMCI) strategy. 8. Occupational asthma is a significant problem in East Africa with increasing industrialisation. Occupational asthma occurs in a wide range of industries and represents a preventable cause of morbidity.

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9. It has been estimated that only a minority of asthma cases in need of medical care actually receive such review. This provides an insight into the magnitude of the asthma burden that is unrecognised in East Africa. 10. Social and economic factors including the limited access to health care are major contributors to morbidity and mortality from asthma. Improving the economic wealth of the countries is crucial if the burden of disease, including that due to asthma, is to be reduced in the region.

FURTHER READING
Abebe Y, Seboxa T. Byssinosis and other respiratory disorders among textile mill workers in Bahr Dar northwest Ethiopia. Ethiopian Med J 1995; 33(1): 37-49. Armstrong Schellenberg J, Victoria CG, Mushi A, de Savigny D, Schellenberg D, Mshinda H, Bryce J. Inequities among the very poor: health care for children in rural southern Tanzania. Lancet 2003; 361: 561-6. Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Carswell F, Merrett J, Merrett TG, Meakins RH, Harland PS. IgE, parasites and asthma in Tansanian children. Clin Allerg 1977; 7(5): 445-53. Dagoye D, Bekele Z, Woldemichael K et al. Wheezing, allergy and parasite infection in children in urban and rural Ethiopia. Am J Respir Crit Care Med 2003; 167: 1369-73. Esamai F, Anabwani GM. Prevalence of asthma, allergic rhinitis & dermatitis in primary school children in Uasin Gishu district, Kenya. East African Medical Journal 1996; 73(7): 474-8. Fakim N, Subratty AH, Manraj M, Surrun SK, Hoolooman K. Asthma mortality in Mauritius: 1982-1991. Ann Allerg, Asthma, Immunol 1997; 79(5): 423-6. Gove S, Whitesell P, Mason K, Egwaga S, Perry H, Simoes E. Integrated management of childhood illness: field test of WHO/UNICEF training course in Arusha, United Republic of Tanzania. Bull WHO 1997; 75(Suppl 1): 55-64. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Lester FT. Bronchial asthma in Addis Ababa. Ethiop Med J 1977; 15(3): 95-9. Melaku K, Berhane Y. Prevalence of wheeze and asthma related symptoms among school children in Addis Ababa, Ethiopia. Ethiop Med J 1999; 37(4): 247-54.

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Mengesha YA, Bekele A. Relative chronic effects of different occupational dusts on respiratory indices and health of workers in three Ethiopian factories. Am J Indust Med 1998; 34(4): 373-80. Mohamed N, Ng'ang'a L, Odhiambo J, Nyamwaya J, Menzies R. Home environment and asthma in Kenyan schoolchildren: a case-control study. Thorax 1995; 50: 74-8. Ng'ang'a LW, Odhiambo JA, Gicheha CM, et al. The prevalence of bronchial asthma in Nairobi school children. East Afr Med J 1997; 74: 694-8. Ng'ang'a LW, Odhiambo JA, Mungai MW, Gicheha CM, Nderitu P, Maingi B, Macklem PT, Becklake MR. Prevalence of exercise induced bronchospasm in Kenyan school children: an urban-rural comparison. Thorax 1998; 53: 919-26. Ng'ang'a LW, Odhiambo JA, Omwega MJ, et al. Exercise induced bronchospasm: a pilot survey in Nairobi school children. E Afr Med J 1997; 74: 694-8. Nordberg EM. True disease pattern in East Africa, Part 2. E Afr Med J 1983; 60: 530-5. Odhiambo JA, Ng'ang'a LW, Mungai MW, Gicheha CM, Nyamwaya JK, Karimi F, Macklem PT, Becklake MR. Urban-rural differences in questionnaire-derived markers of asthma in Kenyan school children. Eur Respir J 1998; 12: 1105-12. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Perkins BA, Zucker JR, Otieno J, Jafari HS, Paxton L, Redd SC et al. Evaluation of an algorithm for integrated management of childhood illness in an area of Kenya with high malaria transmission. Bull WHO 1997; 75(Suppl 1): 33-42. Perzanowski MS, Ng'ang'a LW, Carter MC, Odhiambo J, Ngari P, Vaughan JW, Chapman MD, Kennedy MW, Platts-Mills TAE. Atopy, asthma, and antibodies to Ascaris among rural and urban children in Kenya. J Ped 2002; 140(5): 582-8. Scrivener S, Yemaneberhan H, Zebenigus M, Tilahun D, Girma S, Ali S, McElroy P, Custovic A, Woodcock A, Pritchard D, Venn A, Britton J. Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study. Lancet 2001; 358: 1493-9. Seyoum B. Amaro JC. Bronchial asthma in Jima: a prospective analysis of 204 patients. Ethiop Med J 1992; 30: 225-32. Simoes EAF, Desta T, Tessema T, Gerbresellasie T, Dagnew M, Gove S. Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia. Bull WHO 1997; 75(Suppl 1): 43-53. Sunyer J, Mendendez C, Ventura PJ, Aponte JJ, Schellenberg D, Kahigwa E, Acosta C, Anto JM, Alonso PL. Prenatal risk factors of wheezing at the age of four years in Tanzania. Thorax 2001; 56: 290-5. Sunyer J, Torregrosa J, Anto JM, Menendez C, Acosta C, Schellenberg D, Alonso PL, Kahigwa E. The association between atopy and asthma in a semirural area of Tanzania (East Africa). Allergy 2000; 55(8): 762-6. Watson JP, Lewis RA. Is asthma treatment affordable in developing countries? Thorax 1997; 52: 605-7.

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Weinberg EG. Urbanization and childhood asthma: an African perspective. J Allerg Clin Immunol 2000; 105(2)(part 1): 224-31. Woldeyohannes M, Bergevin Y, Mgeni AY. Theriault G. Respiratory problems among cotton textile mill workers in Ethiopia. Brit J Indust Med 1991; 48(2) 110-15. Yemaneberhan H, Bekele Z, Venn A, Lewis S, Parry E, Britton J. Prevalence of wheeze and asthma and relation to atopy in urban and rural Ethiopia. Lancet 1997; 350: 85-90.

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Southern Africa
Angola Botswana Congo Namibia South Africa Swaziland Zaire Zambia Zimbabwe

Number of persons with asthma: Total population: Mean prevalence of clinical asthma:

15.1 m 186.3 m 8.1%

Key Points: 1. The prevalence of asthma is higher in Southern Africa than in many other regions in Africa. 2. Asthma is considerably more common in urban compared with rural areas. For example, in Zimbabwe the prevalence of exercise-induced asthma is 25 times higher in urban compared with rural communities, where asthma is rare. 3. There is a major preventable burden of asthma in the region due to under-recognition and undertreatment, which are both in part related to limited access to health care. 4. Asthma is a common cause of admission to hospital in the region, particularly in children. In the case of South Africa, asthma is the third most common cause of hospital admission in children, after pneumonia and gastroenteritis. 5. In South Africa the number of admissions to hospital for asthma has increased markedly over the last few decades, with the greatest increase occurring among infants. This suggests that the burden of severe asthma has increased markedly during this period. 6. In Southern Africa, mining-related diseases such as pneumoconiosis remain the leading occupational respiratory diseases, but occupational asthma is becoming increasingly prevalent as non-mining industrialisation expands. Occupational asthma now represents the second most frequently reported occupational respiratory disease. The surveillance programme established in South Africa (SORDSA) represents a good model for use in other countries to provide useful information on which to base prevention activities. 7. Ethnic factors and socioeconomic status have only a modest effect on asthma prevalence but a large effect on asthma

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hospitalisation and mortality rates. Improving the overall socioeconomic status of communities in the region represents a priority if the burden of disease, including that due to asthma, is to be reduced. 8. The combination of changes in health services designed to improve access to and quality of asthma management and education in South Africa, and a national education programme based on locally adapted guidelines, represents a good model for other countries in Africa to follow. The locally adapted guidelines, including those developed for children, provide a simple and practical approach applicable to local circumstances. 9. Despite progressive reductions over the last few decades, asthma mortality remains high within the region. For example, in South Africa among 5- to 34-year-olds the asthma mortality rate has decreased by 0.13 deaths per 100,000 per year over recent decades, however at 1.5 it still represents a relatively high rate internationally and is associated with the fifth-highest case fatality rate in the world. 10. Asthma mortality rates are disproportionately higher in certain racial groups within the region. In South Africa the rates are highest amongst people of mixed race, followed by Blacks and then whites. The majority of asthma deaths in the region occur outside hospitals. Poor availability of health care, poor transport and emergency services, and inadequate home management of acute asthma are recognised as important contributing factors.

FURTHER READING
Asher MI, Keil U, Anderson HR et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995; 8: 483-91. Burney P. The changing prevalence of asthma? Thorax 2002; 57(Suppl II): ii36-ii39. Burr ML, Limb ES, Andrae S, Barry DMJ, Nagel F. Childhood asthma in four countries: a comparative survey. International J Epidem 1994, 23(2): 341-7. Cookson JB, Makoni G. Prevalence of asthma in Rhodesian Africans. Thorax 1980; 35: 833-7. Cullinan P. Asthma in African cities. Thorax 1998; 53: 909-10. Ehrlich RI, Bourne DE. Asthma deaths among coloured and white South Africans: 1962-1988. Respir Med 1994; 88: 195-202. Ehrlich RI, Weinberg EG, Volmink JA, Potter P. Risk factors for childhood asthma and wheezing. Importance of maternal and household smoking. Am J Resp Crit Care Med 1996; 154: 681-88.

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Ehrlich RI, Weinberg EG. Increase in hospital admissions for acute childhood asthma in Cape Town, 1978-1990. SAMJ 1994; 84: 263-66. Ehrlich RI, Zwarenstein M, Weinberg EG, Volmink JA. Prevalence and reliability of asthma symptoms in primary school children Cape Town. Int J Epidemiol 1995; 24: 1138-45. Esterhuizen TM, Hnizdo E, Rees D. Occurrence and causes of occupational asthma in South Africa - results from SORDSA's occupational asthma registry, 1997-1999. SAMJ 2001; 91(6): 509-13. Foster S. Supply and use of essential drugs in sub-Saharan Africa: some issues & possible solutions. Soc Sci Med 1991; 32: 1201-18. Green R, Luyt D. Clinical characteristics of childhood asthmatics in Johannesburg. S Afr Med J 1997; 87: 878-82. Greenblatt M. The South African experience: the National Asthma Education Programme. Global Initiative for Asthma: International meeting of implementing GINA management strategies for asthma, 5-6 November 1999, Guangzhou, China. pp. 30-3. Hanson K, McPake B. The Bamako initiative: where is it going? Health Policy and Planning 1993; 8: 267-74. Hnizdo E, Esterhuizen TM, Rees D, Lalloo UG. Occupational asthma as identified by the Surveillance of Work-related and Occupational Respiratory Diseases programme in South Africa. Clin Exp Allergy 2001; 31: 32-9. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998; 351: 1225-32. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma and allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35. Keeley DJ, Neill P, Gallivan S. Comparison of the prevalence of reversible airways obstruction in rural and urban Zimbabwean children. Thorax 1991; 46: 549-53. Kolstad PR, Burnham G, Kalter HD, Kenyz-Mugisha N, Black RE. The integrated management of childhood illness in Western Uganda. Bull WHO 1997; 75(Suppl 1): 77-85. MacIntyre UE, de Villiers FPR, Owange-Iraka JW. Increase in childhood asthma admissions in an urbanising population. SAMJ 2001; 91(8): 667-71. Mboussa J. [Respiratory diseases at hospitals in Brazzaville, Congo]. [French]. Rev Pneum Clin 1990; 46(2): 61-5. Moosa SEI, Henley LD. An evaluation of parental knowledge of childhood asthma in a family practice setting. SAMJ 1996; 86: 42-5. Mudiayi TK, Onyanga-Omara A, Gelman ML. Trends of morbidity in general medicine at United Bulawayo Hospitals, Bulawayo, Zimbabwe. Central African J Med 1997; 43: 213-9. Pearce N, Sunyer J, Cheng S, Chinn S, Bjrkstn B, Burr M, Keill U, Anderson HR, Burney P on behalf of the ISAAC Steering Committee and the European Community Respiratory Health Survey. Comparison of asthma prevalence in the ISAAC and the ECRHS. Eur Respir J 2000; 16: 420-6. Poyser MA, Nelson H, Ehrlich RI, Bateman ED, Parnell S, Puterman A, Weinberg E. Socioeconomic deprivation and asthma prevalence and severity in young adolescents. Eur Respir J 2002; 19: 892-8.

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SA Childhood Asthma Working Group. Management of acute asthmatic attacks in children. SAMJ 1993; 83: 286-9. SA Childhood Asthma Working Group. Management of childhood and adolescent asthma - 1991 consensus. SAMJ 1992; 81: 38-41. South African Pulmonology Society Adult Asthma Working Group. Guidelines for the management of chronic asthma in adults - 2000 update. SAMJ 2000; 90: 536-48. Steen TW, Aruwa JEO, Hone NM. The epidemiology of adult lung disease in Botswana. International J Tuberc Lung Dis 2001; 5(8): 775-82. Syabbalo NC. Seasonal and nocturnal asthma in the tropics and subtropics. SAMJ 1990; 77: 268-9. Syabbalo NC. Treatment of bronchial asthma in a developing African country. Chest 1987; 92: 361. Terblanche E, Stewart RI. The prevalence of exercise-induced bronchoconstriction in Cape Town schoolchildren. SAMJ 1990; 78: 744-7. Van Niekerk CH, Weinberg EG, Shore SC, Heese HdeV, Van Schallkwyk DJ. Prevalence of asthma: A comparative study of urban and rural Xhosa children. Clin Allergy 1979; 9: 319-24. Watson JP, Lewis RA. Is asthma treatment affordable in developing countries? Thorax 1997; 52: 605-7. Weinberg EG. The effects of urbanization and other factors on childhood asthma in South Africa. ACI International 2000; 12(6): 262-6. Weinberg EG. Urbanization and childhood asthma: An African perspective. J Allergy Clin Immunol 2000; 105(2)(part1): 224-31. Zar HJ, Stickells D, Toerien A, Wilson D, Klein M, Bateman ED. Changes in fatal and near-fatal asthma in an urban area of South Africa from 19801997. Eur Respir J 2001; 18: 33-7. Zwi S, Davis JC, Becklake MR, Goldman HI, Reinach SG, Kallenbach JM. Respiratory status of children in the eastern Transvaal highveld. SAMJ 1990; 78: 647-53.

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ACKNOWLEDGEMENTS
Albania: A Priftanji Argentina: CE Baena-Cagnani, HE Neffen Australia: G Marks, JK Peat, R Tomlins, K Whorlow Austria: J Riedler Bangladesh: ARM Luthful Kabir Barbados: MA Monteil Belgium: P Vermeire Bolivia: R Pinto Brazil: HS Campos, D Sol Bulgaria: TA Popov Canada: P O'Byrne, MR Sears Chile: J Mallol China/Hong Kong: YC Chen, CRW Lai Colombia: G Aristizabal Costa Rica: ME Soto-Quiros Croatia: N Tudoric Cuba: R Marina, P Varona Czech Republic: P Pohunek, V Spicak Denmark: S Pedersen Ecuador: S Barba Finland: J Pekkanen France: D Charpin Georgia: B Begishvili, M Gotua Germany: T Behrens, G Bchele, U Keil, R Loddenkemper, S Weiland, E von Mutius India: RB Singh Israel: S Godfrey Italy: F Forastiere Japan: M Haida, S Makino, S Nishima, H Odajima Jersey: R Goulding Kenya: J Odhiambo Kyrgyzstan: C Imanalieva Latvia: J Kudzyte, V Svabe Lithuania: J Kudzyte Malawi: S Gordon Malta: S Montefort Netherlands: HM Boezen, P de Boer, DS Postma, PJ Sterk, O van Schayck New Zealand: MI Asher, P Ellwood, A Beasley, G Beasley Nigeria: AG Falade Norway: F Gallefoss Occupied Territory of Palestine: N El-Sharif Pakistan: IS Burki, JA Khan Peru: P Chiarella Poland: G Lis Republic of Ireland: G Loftus, P Manning Singapore: D Goh, BW Lee, WC Tan South Africa: E Bateman, H Zar South Korea: H-B Lee, D Rosenberg Spain: LG Marcos Sweden: B Bjrkstn Switzerland: C Braun, Ph Leuenberger Taiwan: J-L Huang, S-H Kuo Thailand: P Vichyanond Trinidad & Tobago: MA Monteil Tunisia: F Khaldi United Kingdom: T Clark, ST Holgate, MR Partridge United States of America: L Grouse, S Hurd Vietnam: Nguyen Nang An, TB Nguyen World Health Organisation: B Pfleger FDR Yugoslavia: E Panic, D Pesut, V Petrovic, Z Zivkovic

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