TM
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
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
i
PREFACE
I
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)
1
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.
2
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.
4
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.
5
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)
0
5
10
15
(Written Questionnaire:
Self-reported wheezing in the
previous 12 month period,
in 13- to 14-year-old children*)
*See Methodological Issues
20
25
30
Prevalence of asthma symptoms (%)
35
40
Country
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 •
0
5
10
15
20
Prevalence of asthma symptoms (%)
25
30
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*)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Country
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
*See Methodological Issues
•
0
5
10
15
20
Prevalence of asthma symptoms (%)
25
30
World Map of the Prevalence of Clinical Asthma
Proportion of population (%)*
≥10.1
2.5-5.0
7.6-10.0
0-2.5
5.1-7.5
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
*See Methodological Issues
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
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ranking of
Asthma Mortality by Country
(Asthma deaths per 100,000 in 5- to 34-year-olds*)
Country
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
0.5
*See Methodological Issues
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
0-5.0
5.1-10.0
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
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
Disorder
Number of
DALYs (x106)
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
12
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
World Map of the Proportion of the Population
with Access to Essential Drugs
WHO Access to Essential Drugs
>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
<50%
81-95%
50-80%
>95%
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
50-80%
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
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
No standardised
data available
<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 data
French Guinea
Costa Rica
Western Sahara
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WHO 2001;79:971-9.
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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.
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:
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respiratory diseases. Geneva 2002.
14
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
21
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
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
6. Middle East
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
22
Austria
Belgium
France
Germany
Italy
Luxembourg
Netherlands
Portugal
Spain
Switzerland
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
12. Oceania
Australia
Fiji
New Zealand
Papua New Guinea
Samoa
Tahiti
Other Pacific Islands
Regions
13. North America
14. Central America
Canada
Belize
United States of America
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
15. Caribbean
Barbados
Cuba
Dominican Republic
Haiti
Jamaica
Puerto Rico
Trinidad & Tobago
Other Caribbean Islands
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
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
23
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.
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30
United Kingdom/Republic of Ireland
England
Guernsey
Isle of Man
Jersey
Northern Ireland
Republic of Ireland
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Scotland
Wales
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.
31
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.
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36
Western Europe
Austria
Belgium
France
Germany
Italy
Luxembourg
Netherlands
Portugal
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Spain
Switzerland
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.
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adult European population. J Invest Allergol Clin Immunol 2001; 11: 94102.
Asher MI, Keil U, Anderson HR et al. International study of asthma and
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1995; 8: 483-91.
Basagana X, Sunyer J, Zock J-P, Kogevinas M, Urrutia I, Maldonado JA,
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43
44
Balkans/Turkey/Caucasus/Mediterranean Islands
Albania
Armenia
Azerbaijan
Bosnia-Herzegovina
Croatia
Cyprus
Georgia
Greece
FYR Macedonia
Malta
Serbia
Slovenia
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Turkey
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.
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48
Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén B, Burr M, Keill U,
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49
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,
Russia’s 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.
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asthma in Moscow and in Russia. (Abstract).
51
Björkstén B, Dumitrascu D, Foucard T, Khetsuriani N, Khaitov R, Leja M, Lis
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54
Middle East
Bahrain
Iran
Iraq
Israel
Jordan
Kingdom of Saudi Arabia
Kuwait
Lebanon
Occupied Territory of
Palestine
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Oman
Qatar
Syria
United Arab Emirates
Yemen
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.
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59
Central Asia & Pakistan
Afghanistan
Kazakhstan
Kyrgyzstan
Pakistan
Tajikistan
Turkmenistan
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Uzbekistan
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
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Hazir T, Das C, Piracha F, Waheed B, Azam M. Carers' perception of
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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.
61
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 region’s industrialisation and urban growth is occurring at an
unprecedented rate in what was previously a predominately
agrarian society. India is projected to become the world’s 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.
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63
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European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis
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351: 1225-32.
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Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D,
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Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén 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.
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65
Smith KR. National burden of disease in India from indoor air pollution.
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66
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
67
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.
68
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71
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.
72
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.
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74
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76
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.
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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.
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therapy in children with chronic asthma. Paediatr International 2000;
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Charoentatanakul S. Problems of application of asthma guidelines in
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implementing GINA management strategies for asthma, 5-6 November
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Chew FT, Goh DYT, Lee BW. The economic cost of asthma in Singapore.
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ambient air-pollution levels with acute asthma exacerbation among
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351: 1225-32.
78
International Study of Asthma and Allergies in Childhood (ISAAC) Steering
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allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35.
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Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén 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:
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80
Oceania
Australia
Fiji
New Zealand
Papua New Guinea
Samoa
Tahiti
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Other Pacific Islands
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.
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1995; 8: 483-91.
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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
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European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis
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International Study of Asthma and Allergies in Childhood (ISAAC) Steering
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351: 1225-32.
International Study of Asthma and Allergies in Childhood (ISAAC) Steering
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allergies in childhood (ISAAC). Eur Respir J 1998; 12: 315-35.
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Kuenzli N, Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst
M on behalf of the European Community Respiratory Health Survey. The
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85
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
86
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%.
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91
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.
92
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.
93
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.
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and Latino cultures: different prevalence reported among groups sharing
the same environment. Am J Pub Health 2000; 90(6): 929-35.
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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, Björkstén 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.
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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.
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Etzel RA, Hernandez-Avila M. Effects of intermittent ozone exposure on
peak expiratory flow and respiratory symptoms among asthmatic children
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94
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childhood asthma in Mexico City. Am J Epidemiol 1995; 141(6): 546-53.
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asthma mortality in Mexico. Bol Oficina Sanit Panam 1994; 116: 298-306.
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95
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
96
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.
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351: 1225-32.
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98
South America
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
French Guiana
Guyana
Paraguay
Peru
Suriname
Uruguay
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Venezuela
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.
99
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.
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103
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.
104
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.
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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.
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Bull Int Union Tuberc Lung Dis 1991; 66: 91-3.
Ben-Miled MT, Gorgob K, Maalej M, Achour N, Nacef T, El-Gharbi T.
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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
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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
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Chaulet P. Asthma and chronic bronchitis in Africa - evidence from
epidemiologic studies. Chest 1989; suppl 96(3): 334s-9s.
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European Community Respiratory Health Survey. Chinn S, Burney P, Jarvis
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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
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in the European Community Respiratory Health Survey. Eur Respir J
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Pulmon 1999; (Suppl 18): 223-4.
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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.
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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, Björkstén 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.
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World Health Organisation. The World Health Report 1998: 158-62.
106
West Africa
Benin
Burkina Faso
Cameroon
Cape Verde
Central African Republic
Equatorial Guinea
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Liberia
Mali
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Mauritania
Nigeria
Senegal
Sierra Leone
Togo
Western Sahara
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
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Exercise induced bronchospasm in Ghana: differences in prevalence
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108: 363-8.
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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.
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and a non-affluent country. Thorax 1999; 54: 606-10.
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International Study of Asthma and Allergies in Childhood (ISAAC) Steering
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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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2001; 18(5): 531-6.
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Revue des Maladies Respiratoires 1998; 15(4): 507-11.
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total serum IgE in rural and urban adult Gambian communities. Clin Exp
Allergy 2001; 31: 1672-8.
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asthma clinic. Nigerian Journal of Clinical Practice 2000; 3: 22-25.
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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.
109
Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén 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.
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Lancet 1996; 347: 1792-6.
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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.
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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.
110
East Africa
Burundi
Djibouti
Eritrea
Ethiopia
Kenya
Madagascar
Malawi
Mauritius
Mozambique
Rwanda
Somalia
Tanzania
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Uganda
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.
111
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.
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allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998;
351: 1225-32.
International Study of Asthma and Allergies in Childhood (ISAAC) Steering
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112
Mengesha YA, Bekele A. Relative chronic effects of different occupational
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Odhiambo JA, Ng'ang'a LW, Mungai MW, Gicheha CM, Nyamwaya JK,
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Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén 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
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Scrivener S, Yemaneberhan H, Zebenigus M, Tilahun D, Girma S, Ali S,
McElroy P, Custovic A, Woodcock A, Pritchard D, Venn A, Britton J.
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Lancet 2001; 358: 1493-9.
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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.
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semirural area of Tanzania (East Africa). Allergy 2000; 55(8): 762-6.
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Thorax 1997; 52: 605-7.
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114
Southern Africa
Angola
Botswana
Congo
Namibia
South Africa
Swaziland
Number of persons with asthma:
Total population:
Mean prevalence of clinical asthma:
Zaire
Zambia
Zimbabwe
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
115
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.
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ACKNOWLEDGEMENTS
Albania: A Priftanji
Kyrgyzstan: C Imanalieva
Argentina: CE Baena-Cagnani, HE Neffen
Latvia: J Kudzyte, V Svabe
Australia: G Marks, JK Peat, R Tomlins,
K Whorlow
Lithuania: J Kudzyte
Austria: J Riedler
Bangladesh: ARM Luthful Kabir
Barbados: MA Monteil
Belgium: P Vermeire
Malawi: S Gordon
Malta: S Montefort
Netherlands: HM Boezen, P de Boer,
DS Postma, PJ Sterk, O van Schayck
Bolivia: R Pinto
New Zealand: MI Asher, P Ellwood,
A Beasley, G Beasley
Brazil: HS Campos, D Solé
Nigeria: AG Falade
Bulgaria: TA Popov
Norway: F Gallefoss
Canada: P O'Byrne, MR Sears
Occupied Territory of Palestine: N El-Sharif
Chile: J Mallol
Pakistan: IS Burki, JA Khan
China/Hong Kong: YC Chen, CRW Lai
Peru: P Chiarella
Colombia: G Aristizabal
Poland: G Lis
Costa Rica: ME Soto-Quiros
Republic of Ireland: G Loftus, P Manning
Croatia: N Tudoric
Singapore: D Goh, BW Lee, WC Tan
Cuba: R Marina, P Varona
South Africa: E Bateman, H Zar
Czech Republic: P Pohunek, V Spicak
South Korea: H-B Lee, D Rosenberg
Denmark: S Pedersen
Spain: LG Marcos
Ecuador: S Barba
Sweden: B Björkstén
Finland: J Pekkanen
Switzerland: C Braun, Ph Leuenberger
France: D Charpin
Taiwan: J-L Huang, S-H Kuo
Georgia: B Begishvili, M Gotua
Thailand: P Vichyanond
Germany: T Behrens, G Büchele, U Keil,
R Loddenkemper, S Weiland, E von Mutius
Trinidad & Tobago: MA Monteil
India: RB Singh
Israel: S Godfrey
United Kingdom: T Clark, ST Holgate,
MR Partridge
Italy: F Forastiere
United States of America: L Grouse, S Hurd
Japan: M Haida, S Makino, S Nishima,
H Odajima
Vietnam: Nguyen Nang An, TB Nguyen
Jersey: R Goulding
Kenya: J Odhiambo
Tunisia: F Khaldi
World Health Organisation: B Pfleger
FDR Yugoslavia: E Panic, D Pesut,
V Petrovic, Z Zivkovic
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