Increasing use of inhaled steroids associated with declining asthma mortality

Trends in international asthma mortality: analysis of data from the WHO Mortality Database from 46 countries (1993-2012)

BACKGROUND

International time trends in asthma mortality have been strongly affected by changes in management and in particular drug treatments. However, little is known about how asthma mortality has changed over the past decade. In this study, we assessed these international trends.

METHODS

We collated age-standardised country-specific asthma mortality rates in the 5-34 year age group from the online WHO Mortality Database for 46 countries. To be included in the analysis, we specified that a country must have 10 years of complete data in the WHO Mortality Database between 1993 and 2012. In the absence of consistent and accurate asthma prevalence and prescribing data, we chose to use a locally weighted scatter plot smoother (LOESS) curve, weighted by the individual country population in the 5-34-year age group to show the global trends in asthma mortality rates with time.

FINDINGS

Of the 46 countries included in the analysis of asthma mortality, 36 were high-income countries, and 10 were middle-income countries. The LOESS estimate of the global asthma mortality rate was 0·44 deaths per 100 000 people (90% CI 0·39-0·48) in 1993 and 0·19 deaths per 100 000 people (0·18-0·21) in 2006. Despite apparent further reductions in some countries and regions of the world, there was no appreciable change in global asthma mortality rates from 2006 through to 2012, when the LOESS estimate was also 0·19 deaths per 100 000 people (0·16-0·21).

INTERPRETATION

The trend for reduction in global asthma mortality observed since the late 1980s might have stalled, with no appreciable difference in a smoothed LOESS curve of asthma mortality from 2006 to 2012. Although better implementation of established management strategies that have been shown to reduce mortality risk is needed, to achieve a further substantive reduction in global asthma mortality novel strategies will also be required.

FUNDING

The Medical Research Institute of New Zealand, which is supported by Health Research Council of New Zealand Independent Research Organisation.

Trends in asthma mortality in the 0- to 4-year and 5- to 34-year age groups in Brazil

Objective:

To provide an update on trends in asthma mortality in Brazil for two age groups: 0-4 years and 5-34 years.

Methods:

Data on mortality from asthma, as defined in the International Classification of Diseases, were obtained for the 1980-2014 period from the Mortality Database maintained by the Information Technology Department of the Brazilian Unified Health Care System. To analyze time trends in standardized asthma mortality rates, we conducted an ecological time-series study, using regression models for the 0- to 4-year and 5- to 34-year age groups.

Results:

There was a linear trend toward a decrease in asthma mortality in both age groups, whereas there was a third-order polynomial fit in the general population.

Conclusions:

Although asthma mortality showed a consistent, linear decrease in individuals ≤ 34 years of age, the rate of decline was greater in the 0- to 4-year age group. The 5- to 34-year group also showed a linear decline in mortality, and the rate of that decline increased after the year 2004, when treatment with inhaled corticosteroids became more widely available. The linear decrease in asthma mortality found in both age groups contrasts with the nonlinear trend observed in the general population of Brazil. The introduction of inhaled corticosteroid use through public policies to control asthma coincided with a significant decrease in asthma mortality rates in both subsets of individuals over 5 years of age. The causes of this decline in asthma-related mortality in younger age groups continue to constitute a matter of debate.

Time trends in 30 day case-fatality following hospitalisation for asthma in adults in Scotland: a retrospective cohort study from 1981 to 2009

BACKGROUND

The risk of case-fatality following hospitalisation for asthma has not been well characterised. We describe trends in 30 day case-fatality following hospitalisation for asthma in adults in Scotland from 1981 to 2009.

METHODS

Using the Scottish Morbidity Record Scheme (SMR01) with all asthma hospitalisations for adults (≥18 years) with ICD9 493 and ICD10 J45-J46 in the principal diagnostic position at discharge (1981-2009). These data were linked to mortality data from the General Register Office for Scotland (GROS), with asthma case-fatality defined as death within 30 days of asthma admission (in or out of hospital). Logistic regression was used to explore the impact of age, sex, previous asthma admission (in the 12 months prior to hospitalisation), socioeconomic deprivation, year of admission and co-morbidity on 30-day case-fatality.

RESULTS

There were a total of 116,457 asthma hospitalisations; a total of 1000 (0.9%) hospitalisations resulted in a post-admission death (within 30 days of admission). Odds ratios for unadjusted and adjusted case-fatality showed a decreased risk of case-fatality from the mid-1990s onwards when compared to case-fatality in 1981. Advancing age and co-morbid diagnoses of respiratory failure, cancer, renal failure, cor pulmonale, coronary heart disease and respiratory infection were associated with increased likelihood of death.

CONCLUSIONS

30 day case-fatality has declined over the last three decades, comparable to case-fatality reported in other parts of the U.K. This decline may be in part due to improved guidelines, protocols and disease management for asthma over the last 30 years. The likelihood of death 30 days following an asthma admission increased with age group and was associated with respiratory failure, renal failure and cancer.

Temporal trends of asthma mortality rates in Brazil from 1980 to 2010

OBJECTIVE

Mortality from asthma has varied among countries during the last several decades. This study aimed to identify temporal trends of asthma mortality in Brazil from 1980 to 2010.

METHOD

We analyzed 6840 deaths of patients aged 5-34 years that occurred in Brazil with the underlying cause of asthma. We applied a log-linear model using Poisson regression to verify peaks and trends. We also calculated the point estimation and 95% confidence interval (CI 95%) of the annual percent change (APC) of the mortality rates, and the average annual percent change (AAPC) for 2001-2010.

RESULTS

A decline was observed from 1980 to 1992 [APC = -3.4 (-5.0 to -1.8)], followed by a nonsignificant rise until 1996 [APC = 6.8 (-1.4 to 15.6)], and a new downward trend from 1997 to 2010 [APC = -2.7 (-3.9 to -1.6)]. The APCs varied according to age strata: 5-14 years from 1980 to 2010 [-0.3 (-1.1 to 0.5)]; 15-24 years from 1980 to 1991 [-2.1 (-5.0 to 0.9)], from 1992 to 1996 [6.8 (-6.7 to 22.2)], and from 1997 to 2010 [-3.9 (-5.7 to -2.0)]; 24-25 years from 1980 to 1992 [-2.5 (-4.6 to -0.3)], from 1993 to 1995 [12.0 (-21.1 to 59.1)], and from 1996-2010 [-1.7 (-3.0 to -0.4)]. AAPC from 2001 to 2010 was -1.7 (-3.0 to -0.4); the decline for this period was significant for patients over 15 years old, women, and those living in the Southeast region.

CONCLUSION

Asthma mortality rates in Brazil have been declining since the late 1990s.

'You have to learn to live with it': a qualitative and quantitative study of older people with asthma

INTRODUCTION

Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known.

OBJECTIVES

We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care.

METHODS

Fifty-five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in-depth, and the quantitative and qualitative data were triangulated.

RESULTS

Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings.

CONCLUSIONS

Self-management strategies for older people need to be tailored according to the time of disease onset and the duration of disease.

Allergies in Asia: differences in prevalence and management compared with western populations

There is wide variability in the epidemiology and management of childhood asthma and related atopic diseases globally. Urbanized, affluent Western countries tend to have a higher prevalence of these diseases compared with Asian nations. However, recent studies have shown that the prevalence in Asia is increasing, although the rate of increase has slowed in the more developed Asian cities. Some possible causes for these differences are socioeconomic status, degree of urbanization, rates of infection, healthcare practices and genetic factors. Importantly, there are significant differences in the way asthma and allergic diseases are managed within Asia. This is of great concern because of the health implications, as these diseases are some of the most common chronic conditions that affect both adults and children. This review compares the differences in prevalence and management between Asia and the West, and discusses some of the possible reasons behind these variations.

International trends in asthma mortality rates in the 5- to 34-year age group: a call for closer surveillance

BACKGROUND

International time trends in asthma mortality have played an important sentinel role in the identification of two epidemics of asthma mortality in some countries in the 1960s and the 1970s and 1980s. Since then, little attention has been paid to the ongoing international time trends.

METHODS

Country-specific data on asthma mortality rates since 1960 in the 5- to 34-year-old age group were collated. To be included in the analysis, countries were required to have data available prior to 1980. A scatter plot smoothing technique was used to model the change in asthma mortality rates with time.

RESULTS

Asthma mortality rates from 20 countries were included in the analysis. An increase in asthma mortality rates was found in the 1960s, with a mean increase of 53% from 0.55 per 100,000 in 1960 and 1961 to a peak of 0.84 in 1966 and 1967. This trend was followed by a progressive decline to a nadir of 0.45 per 100,000 in 1974 and 1975. A gradual increase was then found in asthma mortality rates to a peak of 0.62 per 100,000 in 1985 and 1986, with a mean increase of 38% during this period. Since the late 1980s, there has been a widespread and progressive reduction in mortality rates to a level of 0.23 per 100,000 in 2004 and 2005, with a mean reduction of 63% during this period.

CONCLUSIONS

The widespread increase in asthma mortality in the 1980s and the subsequent, even greater reduction has largely gone unrecognized. We propose that awareness of such trends and their causes is important and that they are investigated contemporaneously.

Validation of a single survey that can be used for case identification and assessment of asthma control: the Breathmobile Program

BACKGROUND

Underdiagnosis of asthma and underrecognition of disease severity in lower socioeconomic populations continue to be significant health care concerns despite national efforts to better educate health care providers.

OBJECTIVE

To validate a 1-page survey as a point-in-time tool identifying uncontrolled vs controlled asthma and moderate-to-severe disease activity in an urban, lower-socioeconomic pediatric population.

METHODS

A previously validated survey (the Breathmobile Case Identification Survey) was evaluated as a point-in-time tool for identifying children with poorly controlled disease. Clinical validation was achieved in children (n = 1,826) presenting to a school-based asthma program for either an initial (n = 666) or a follow-up (n = 1,170) visit. Responses were compared with a comprehensive evaluation by a physician specialist as the gold standard. Response patterns were used to construct multimodel tiered scoring algorithms for baseline and follow-up visits that identify children with uncontrolled asthma, and children are likely to have moderate-to-severe disease activity at that time.

RESULTS

Surveys scored using the developed algorithms identified children with uncontrolled asthma (sensitivity: baseline, 77.0%; follow-up, 71.6%; specificity: baseline, 72.7%; follow-up, 71.5%) and detected moderate-to-severe disease activity (sensitivity: baseline, 69.2%; follow-up, 77.4%; specificity: baseline, 70.2%; follow-up, 70.3%).

CONCLUSIONS

The Breathmobile Case Identification Survey can be used in lower-socioeconomic, urban populations as a point-in-time tool for identifying children with uncontrolled vs controlled asthma and moderate-to-severe disease activity.

The all-powerful and 'happy' drug: the use of steroids among primary care doctors in Hong Kong

BACKGROUND

Steroids are commonly used, but their prescribing pattern and factors associated with their use in the primary care setting are largely unknown.

METHODS

Using diagnosis and drug data obtained from logbooks submitted by participants in the Diploma in Family Medicine course between 1999 and 2004, we selected and analysed all patients with a prescription of steroid as well as conditions in which it was prescribed. Factors, relating to patients or doctors, which could be associated with steroid prescription were recorded for both the prescribed and the non-prescribed groups. The results were compared using chi-square tests.

RESULTS

Steroids were prescribed in 7.1% of all patient encounters, of which dermatological and respiratory diseases were the most two common conditions. Upper respiratory tract infections accounted for a third of all respiratory diseases in which steroid was prescribed. Female or 'minor' patients (OR 1.16, 95% CI 1.01-1.32 and 1.16, 1.00-1.36 respectively) were more likely to be given a steroid and younger doctors (1.52, 1.25-1.86) were more likely to prescribe them.

CONCLUSION

Some patterns of poor prescribing practice were demonstrated in this study. Campaigns by professional bodies may improve prescribing among our community doctors and effective public education programmes are needed to modify the health beliefs and expectations of the general public.

Modest increase in seasonal allergic rhinitis and eczema over 8 years among Estonian schoolchildren

We studied time trends in the prevalence of asthma and allergic diseases in Estonian children born before and after the collapse of the Soviet Union, as this event markedly altered the lifestyle in Estonia. Two identical cross-sectional studies were performed as part of phase I and phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Children, aged 6-7 yr (n = 3070 in 1993-94 and 2383 in 2001-02) and 13-14 yr (n = 3476 and 3576, respectively), completed ISAAC core-written questionnaires, and 13-14-yr olds (n = 3427 and 3259, respectively) also video questionnaires. The prevalence of respiratory symptoms was mostly similar in the two studies. Despite this, the prevalence of diagnosed asthma increased. This was probably due to modified diagnostic criteria and increased awareness. Furthermore, the prevalence of rhinitis during the pollen season increased, e.g., rhinitis in May from 1.7% to 3.5%; sex-adjusted prevalence odds ratio (POR) 2.09 (95% confidence interval 1.47-2.96) in 6-7-yr olds, and from 2.6% to 5.5%; POR 2.22 (1.72-2.87) in 13-14-yr olds. The prevalence of flexural dermatitis also increased from 12.0% to 13.5%; POR 1.20 (1.02-1.41) in 6-7-yr olds, and from 7.7% to 9.4%; POR 1.26 (1.07-1.50) in 13-14-yr olds. The increase was similar in children born before and after the regaining of Estonian independence, indicating that the influence of factors related to a Western lifestyle and affecting the prevalence of allergic symptoms is not restricted to infancy, but may be operative throughout childhood.

Declining asthma prevalence in Hong Kong Chinese schoolchildren

BACKGROUND

Many studies have reported an increase in the prevalence of asthma and related atopic disorders. The lack of standardized methodologies and 'objective' measurements make reliable comparison and monitoring of trends of asthma very difficult.

METHODS

In this study, a total of 3321 schoolchildren aged 13-14 years were recruited for study using the Phase III Protocol of the International Study of Asthma and Allergic disease in Childhood (ISAAC). The results were compared with those obtained in the Phase I ISAAC study (1994-95), which used the identical and validated core questionnaires.

RESULTS

The prevalence rates of physicians' diagnosis of asthma were similar in the two surveys (11.2% and 10.2%), but the prevalence rates of wheeze (written questionnaire) in the past year have decreased from 12.4% in 1994-95 to 8.7% in 2002 (P<0.001). For the video questionnaire, all asthmatic symptoms in the preceding 12 months were significantly lower in 2002 when compared with those in 1994-95. Among the subjects with diagnosed asthma, the prevalence rates of wheeze in the past 12 months (written questionnaire) has decreased from 39.1% to 27.6% (P<0.001). The prevalence rates of having wheezing attack at least once per month (video questionnaire) has decreased from 10.5% to 5.6% (P=0.013).

CONCLUSION

Using the same standardized and validated ISAAC questionnaire, the prevalence rates of asthma symptoms in Hong Kong Chinese schoolchildren have decreased since 1994. The exact reasons for such trend remain to be explored.

Pharmacokinetics of [14C]ciclesonide after oral and intravenous administration to healthy subjects

BACKGROUND

Ciclesonide is a novel inhaled corticosteroid developed for the treatment of asthma.

OBJECTIVE

To investigate the extent of oral absorption and bioavailability of ciclesonide referenced to an intravenous infusion. This information provides an estimate for the contribution of the swallowed fraction to systemic exposure to ciclesonide after oral inhalation.

METHODS

In a randomised crossover study, six healthy male subjects (age range 19-40 years) received single doses of 6.9 mg (oral administration) and 0.64 mg (intravenous administration) of [14C]ciclesonide, separated by a washout period of at least 14 days. Total radioactivity was determined in whole blood, plasma, urine and faeces. Serum concentrations of ciclesonide and its major metabolite, the pharmacologically active desisobutyryl-ciclesonide (des-CIC), were determined in serum by high-performance liquid chromatography with tandem mass spectrometry detection.

RESULTS

After a 10-minute intravenous infusion, the mean half-life for total radioactivity was 45.2 hours. Elimination of des-CIC was fast with a mean elimination half-life of 3.5 hours. After oral administration, the mean half-life for total radioactivity was 27.5 hours. On the basis of a comparison of dose-normalised areas under the curve of total plasma radioactivity versus time, 24.5% of orally administered [14C]ciclesonide was absorbed. The parent compound ciclesonide was not detected in any of the serum samples after oral administration; serum concentrations of des-CIC were mostly near or below the lower limit of quantification. Thus, systemic bioavailability for des-CIC is <1% and the absolute bioavailability of ciclesonide is even less than this. [14C]Ciclesonide showed no retention in red blood cells. The mean cumulative excretion of total radioactivity was almost complete by 120 hours after oral and intravenous administration. Faecal excretion was the predominant route of excretion for total radioactivity after both routes of administration. Single oral and intravenous administration of ciclesonide was well tolerated.

CONCLUSIONS

Because of an almost complete first-pass metabolism, ciclesonide is undetectable in serum after oral administration. Thus, any ciclesonide swallowed after oral inhalation does not contribute to systemically available ciclesonide or to its active metabolite. Drug-related metabolites are excreted mainly via the faeces, and overall recovery of administered radioactivity is virtually complete after an extended sample collection period.

Is the prevalence of adult asthma and allergic rhinitis still increasing? Results of an Italian study

BACKGROUND

The prevalence of asthma and allergic rhinitis has increased worldwide during the 1970s and 1980s.

OBJECTIVE

This study was aimed at evaluating whether the increasing trend in prevalence persisted during the 1990s in the young adult Italian population.

METHODS

In 1998 to 2000 a screening questionnaire was sent by mail to a general population sample aged 20 to 44 years; nonresponders were contacted again first by mail and then by phone, achieving a final response rate of 78.1% (6876 of 8800). Prevalence estimates, adjusted to correct for nonresponse bias, were compared with those recorded in Italy in 1991 to 1993 during the European Community Respiratory Health Survey, when response rate had been slightly higher (87.6%). Temporal variations in symptom prevalence were analyzed by a logistic regression model, controlling for sex, age, site of residence (urban vs suburban areas), season of response, response rate, and type of contact (mail vs phone).

RESULTS

The prevalence of asthma attacks did not vary significantly from 1991 to 1993 (3.6%) to 1998 to 2000 (3.2%) (P =.188). The prevalence of asthma-like symptoms (wheezing, chest tightness, shortness of breath) tended to decrease in the age classes of 32.5 to 45 years, while increasing in the youngest age class (20 to 26 years). A clear-cut increase from 15.4% to 18.3% was observed for the prevalence of allergic rhinitis (P <.001), whereas the proportion of people under antiasthmatic treatment increased in suburban areas but not in urban areas (interaction time-site of residence, P <.001).

CONCLUSION

Asthma prevalence has not increased during the last decade in Italy. The persistence of an increasing trend in allergic rhinitis prevalence deserves attention.