Evaluation of cost of disease: assessing the burden to society of asthma in children in the European Union

Cost-effectiveness of omalizumab for the treatment of severe pediatric allergic asthma-Results of a real-life study in Spain

BACKGROUND

Severe pediatric allergic asthma (SPAA) induces a huge economic burden in terms of direct, indirect, and intangible costs. The use of omalizumab for the treatment of these patients has produced a significant improvement in several clinical outcomes, but at the same time, the cost for the management of the disease has also increased. The aim of this report was to evaluate whether the use of omalizumab is cost-effective.

METHODS

A sample of 426 children with SPAA from the ANCHORS (Asthma iN CHildren: Omalizumab in Real-life in Spain) study was used to calculate the incremental cost-effectiveness ratio (ICER) for the avoidance of moderate-to-severe exacerbations (MSE) and also for the improvement in childhood Asthma Control Test (c-ACT) or the Asthma Control Questionnaire (ACQ5). We retrospectively collected data on health encounters and drug consumption before and up to 6 years after the beginning of the treatment with omalizumab.

RESULTS

The ICER per avoided MSE was €2107 after 1 year, and it consistently decreased to €656 in those followed up to 6 years. Similarly, the ICER for the minimally important difference in control tests showed a decrease from €2059 to €380 per each 0.5 points of improvement in ACQ5 and from €3141 to €2322 per each 3 points improvement in c-ACT, at years 1 and 6, respectively.

CONCLUSION

The use of OMZ is a cost-effective option for most children with uncontrolled SPAA, especially those who have frequent exacerbations; the costs are progressively reduced in successive years of treatment.

Estimating the causal effect of liability to disease on healthcare costs using Mendelian Randomization

Accurate measurement of the effects of disease status on healthcare costs is important in the pragmatic evaluation of interventions but is complicated by endogeneity bias. Mendelian Randomization, the use of random perturbations in germline genetic variation as instrumental variables, can avoid these limitations. We used a novel Mendelian Randomization analysis to model the causal impact on inpatient hospital costs of liability to six prevalent diseases and health conditions: asthma, eczema, migraine, coronary heart disease, Type 2 diabetes, and depression. We identified genetic variants from replicated genome-wide associations studies and estimated their association with inpatient hospital costs on over 300,000 individuals. There was concordance of findings across varieties of sensitivity analyses, including stratification by sex and methods robust to violations of the exclusion restriction. Results overall were imprecise and we could not rule out large effects of liability to disease on healthcare costs. In particular, genetic liability to coronary heart disease had substantial impacts on costs.

Current strategies for phenotyping and managing asthma in preschool children

PURPOSE OF REVIEW

Half of all children will experience an episode of wheezing by 6 years. Recurrent preschool wheezing is associated with early lung function loss and has a lifelong impact on airway health, so deciding which children should be treated to prevent exacerbations while also avoiding irreversible health consequences is crucial. The purpose of this review is to provide a practical approach to the pediatric patient under 5 years of age with asthma, with particular attention to the recent enhanced identification of wheeze phenotypes.

RECENT FINDINGS

Here, we note the difficulty of defining 'asthma' for this age group and advocate that it be determined by the set of respiratory symptoms presented, without assumptions about the underlying mechanisms of the disease. In addition, we propose a forward-looking approach, what treatment to apply to particular phenotypes, which child should be treated, and, if so, which treatment strategy to choose. No clear recommendation exists for the management of nonallergic preschool wheezing, a substantial clinical and research gap.

SUMMARY

We recommend an empathetic approach to parent anxiety and considering objective markers: timing, severity, and frequency of symptoms, along with an assessment of other biomarkers, including viral etiology, aeroallergen sensitization, and blood eosinophils, that contribute to successful decision-making.

European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years

Diagnosing asthma in children represents an important clinical challenge. There is no single gold standard test to confirm the diagnosis. Consequently, both over-, and under-diagnosis of asthma are frequent in children.A Task Force (TF) supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine PICO (Population, Intervention, Comparator and Outcome) questions. The TF conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full text articles. All TF members approved the final decision for inclusion of research papers. The TF assessed the quality of the evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.The TF then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The TF formulated recommendations using the GRADE Evidence to Decision framework.Based on the critical appraisal of the evidence and the Evidence to Decision Framework the TF recommends spirometry, bronchodilator reversibility testing and FeNO as first line diagnostic tests in children under investigation for asthma. The TF recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.

Protocolled practice nurse-led care for children with asthma in primary care: protocol for a cluster randomised trial

INTRODUCTION

In children with asthma, daily symptoms and exacerbations have a significant impact on the quality of life of both children and parents. More effective use of asthma medication and, consequently, better asthma control is advocated, since both overtreatment and undertreatment are reported in primary care. Trials in adults suggest that asthma control is better when patients receive a regular medical review. Therefore, protocolled care by the general practitioner may also lead to better asthma control in children. However, such protocolled care by the general practitioner may be time consuming and less feasible. Therefore, this study aims to determine whether protocolled practice nurse-led asthma care for children in primary care provides more effective asthma control than usual care.

METHODS AND ANALYSIS

The study will be a cluster-randomised open-label trial with an 18-month follow-up. Practice nurses will be the units of randomisation and children with asthma the units of analysis. It is planned to include 180 children aged 6-12 years. Primary outcome will be average asthma control during the 18-month follow-up measured by the Childhood Asthma Control Test (C-ACT). Secondary outcomes include C-ACT scores at t=3, t=6, t=12 and t=18 months; the frequency and severity of exacerbations; cost-effectiveness; quality of life; satisfaction with delivered care; forced expiratory volume in 1 s and forced expiratory flow at 75% and the association of high symptoms scores at baseline and baseline characteristics. Besides, we will conduct identical measurements in a non-randomised sample of children.

ETHICS AND DISSEMINATION

This will be the first trial to evaluate the effectiveness of protocolled practice nurse-led care for children with asthma in primary care. The results may lead to improvements in asthma care for children and can be directly implemented in revisions of asthma guidelines.The study protocol was approved by the Medical Research Ethics Committee of the Erasmus Medical Centre in Rotterdam.

TRIAL REGISTRATION

NTR6847.

Role of house dust mite-derived extracellular vesicles in a murine model of airway inflammation

BACKGROUND

House dust mite (HDM) is the major source of indoor allergens that cause airway disease. Recent evidence suggests that Gram-negative/positive bacteria produce nano-sized extracellular vesicles (EVs) containing diverse components, including various immunostimulatory molecules. However, the association between bacteria-derived EVs and development of airway disease is unclear.

OBJECTIVE

To identify and isolate HDM-derived EVs and to evaluate their effect on the development of airway inflammation.

METHODS

Extracellular vesicles were isolated from crude HDM extracts by ultra-centrifugation, and their physical and immunological characteristics and roles in airway inflammation were tested in vitro and in murine models of airway inflammation. In addition, 16s metagenome analysis of nucleic acid from EVs was performed to identify their origin.

RESULTS

Round, bilayered vesicles measuring 80-100 nanometres and containing abundant amounts of LPS were isolated. These vesicles induced innate immune responses both in vitro and in vivo. Intranasal exposure of naïve mice to HDM EVs induced production of cytokines associated with development of Th2-mediated and mixed (Th1-/Th2-/Th17-mediated) airway inflammation to allergen. Metagenome analysis identified Bacteroidetes and Proteobacteria as the probable sources of HDM EVs.

CONCLUSION

House dust mite EVs originating from Gram-negative bacteria may play an important role on the development of airway inflammation.

Estimated cost of asthma in outpatient treatment: a real-world study

OBJECTIVE

To estimate the cost of diagnosis and treatment of asthma.

METHODS

We used the perspective of society. We sequentially included for 12 months, in 2011-2012, 117 individuals over five years of age who were treated for asthma in the Pneumology and Allergy-Immunology Services of the Piquet Carneiro Polyclinic, Universidade do Estado do Rio de Janeiro. All of them were interviewed twice with a six-month interval for data collection, covering 12 months. The cost units were identified and valued according to defined methods. We carried out a sensitivity analysis and applied statistical methods with a significance level of 5% for cost comparisons between subgroups.

RESULTS

The study consisted of 108 patients, and 73.8% of them were women. Median age was 49.5 years. Rhinitis was present in 83.3% of the individuals, and more than half were overweight or obese. Mean family income was U$915.90/month (SD = 879.12). Most workers and students had absenteeism related to asthma. Total annual mean cost was U$1,291.20/patient (SD = 1,298.57). The cost related to isolated asthma was U$1,155.43/patient-year (SD = 1,305.58). Obese, severe, and uncontrolled asthmatic patients had higher costs than non-obese, non-severe, and controlled asthmatics, respectively. Severity and control level were independently associated with higher cost (p = 0.001 and 0.000, respectively). The direct cost accounted for 82.3% of the estimated total cost. The cost of medications for asthma accounted for 62.2% of the direct costs of asthma.

CONCLUSIONS

Asthma medications, environmental control measures, and long-term health leaves had the greatest potential impact on total cost variation. The results are an estimate of the cost of treating asthma at a secondary level in the Brazilian Unified Health System, assuming that the treatment used represents the ideal approach to the disease.

Montelukast Treatment of Acute Asthma Exacerbations in Children Aged 2 to 5 Years: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Although montelukast has an established role in the management of chronic asthma in children, its efficacy in acute asthma exacerbations (AAEs) in children aged 2 to 5 years is not fully known. This study aimed to evaluate the effectiveness and safety of montelukast for treating AAE in children aged 2 to 5 years in China.

METHODS

In total, 120 Chinese children with AAE, aged 2 to 5 years, were randomly divided into 2 groups, each with 60 patients. All patients received either montelukast or placebo along with standard therapy for acute asthma between January 2011 and December 2015. The outcome measurements included the difference in peak expiratory flow and lung function improvements, as well as adverse events.

RESULTS

A total of 117 patients completed the study. Montelukast showed no greater effectiveness than did placebo in increasing the peak expiratory flow during the period of hospital stay (P = 0.92 at day 2, P = 0.86 at day 3, and P = 0.82 at day 4) and at discharge (P = 0.84). Similarly, the forced expiratory volume in 1 second at discharge also did not show significant difference between the 2 groups (P = 0.80). In addition, no serious adverse events were found during the intervention period of the study.

CONCLUSIONS

The results of this study demonstrate no benefit of montelukast over placebo in the treatment of AAE in a cohort of 2- to 5-year-old children.

The need for precision medicine clinical trials in childhood asthma: rationale and design of the PUFFIN trial

A 'one-size fits all'-approach does not fit all pediatric asthma patients. Current evidence suggests that in children with persistent asthma, ADRB2 genotype-guided treatment can improve treatment outcomes, yet this evidence is mainly derived from observational and genotype-stratified studies. Implementation of precision medicine-guided asthma treatment in clinical practice will only occur if randomized clinical trials can show that this approach will improve patient outcomes and is cost effective. In this paper, we will discuss why precision medicine trials are currently needed to improve childhood asthma management and present the rationale and design of the PUFFIN trial, that has been set up to address this need.

The Danish National Database for Asthma: establishing clinical quality indicators

Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.

National and regional asthma programmes in Europe

This review presents seven national asthma programmes to support the European Asthma Research and Innovation Partnership in developing strategies to reduce asthma mortality and morbidity across Europe. From published data it appears that in order to influence asthma care, national/regional asthma programmes are more effective than conventional treatment guidelines. An asthma programme should start with the universal commitments of stakeholders at all levels and the programme has to be endorsed by political and governmental bodies. When the national problems have been identified, the goals of the programme have to be clearly defined with measures to evaluate progress. An action plan has to be developed, including defined re-allocation of patients and existing resources, if necessary, between primary care and specialised healthcare units or hospital centres. Patients should be involved in guided self-management education and structured follow-up in relation to disease severity. The three evaluated programmes show that, thanks to rigorous efforts, it is possible to improve patients' quality of life and reduce hospitalisation, asthma mortality, sick leave and disability pensions. The direct and indirect costs, both for the individual patient and for society, can be significantly reduced. The results can form the basis for development of further programme activities in Europe.

Recurrent Wheezing in Infants: A Population-Based Study

Recurrent wheezing (RW) has a significant impact on infants, caregivers, and society, but morbidity and related medical resource utilization (MRU) have not been thoroughly explored. The burden of RW needs to be documented with population-based data. The objective was to assess the characteristics, medical management, and MRU of RW infants identified from national claims data. Infants aged from 6 to 24 months, receiving ≥2 dispensations of respiratory drugs within 3 months, and presenting a marker of poor control (index date), were selected. During the 6 months after index date, MRU was described in the cohort and among 3 subgroups with more severe RW, defined as ≥4 dispensations of respiratory drugs, ≥3 dispensations of oral corticosteroids (OCS), or ≥1 hospitalization for respiratory symptoms. A total of 115,489 infants had RW, corresponding to 8.2% of subjects in this age group. During follow-up, 68.7% of infants received inhaled corticosteroids, but only 1.8 U (unit) were dispensed over 6 months, suggesting discontinuous use. Control was mostly inadequate: 61.7% of subjects received OCS, 80.2% antibiotics, and 71.2% short-acting beta-agonists, and medical/paramedical visits were numerous, particularly for physiotherapy. Severe RW concerned 39.0% of the cohort; 32.8% and 11.7% of infants had repeated use of respiratory drugs and OCS, respectively, and 5.5% were hospitalized for respiratory symptoms. In this real-life nation-wide study, RW was common and infants had poor control and high MRU. Interventions are needed to support adequate use of controller therapy, and to improve medical care.

Asthma prevalence and risk factors in early childhood at Northern Portugal

Asthma is the commonest and most important chronic non-infectious disease in childhood and it has become more prevalent in recent years. There is a shortage of studies in relation to early childhood and so, as part of the INAIRCHILD project, this cross-sectional study aimed to assess the prevalence of asthma and its associated risk factors, namely demographic, environmental, psychosocial and clinical factors for infants and preschoolers living in Northern Portugal. Data concerning asthma prevalence were collected through questionnaires based on those from the International Study of Asthma and Allergies in Childhood (ISAAC-derived), the questionnaires were distributed to 1042 children attending the 17 nurseries involved in the INAIRCHILD project (10 in urban and suburban context, and 7 in rural context). The response rate was 48%. Prevalence of asthma based on symptomatology and odds ratio was calculated. Around 52% of the studied children presented at least one of the respiratory symptoms investigated (wheeze, dyspnea and cough) in the absence of upper respiratory infections. The prevalence of asthma was 10.7%, comparable to the figures for Portuguese schoolchildren (6-7 years old) reported by the national Directorate-General of Health, thus showing that an early diagnosis might be possible and helpful for the mitigation of childhood asthma. Environmental context (urban, suburban or rural), gender and family asthma history showed clear associations with asthma prevalence, namely non-rural location, male gender, and having an asthmatic parent were found to be risk factors.

Decreased importance of environmental risk factors for childhood asthma from 1996 to 2006

BACKGROUND

The large increase in asthma prevalence continues in several, but not all areas. Despite the individual risk factors that have been identified, the reasons for the observed trends in prevalence are largely unknown.

OBJECTIVE

This study sought to characterize what trends in risk factors accompanied trends in asthma prevalence.

METHODS

Two population-based cohorts of 7- to 8-year-old children from the same Swedish study areas examined by expanded International Study of Asthma and Allergy in Childhood questionnaires were compared 10 years apart. In 1996 and 2006, 3430 (97% participation) and 2585 (96% participation) questionnaires were completed, respectively. A subset was skin-prick-tested: in 1996 and 2006, 2148 (88% participation) and 1700 (90% participation) children, respectively. The adjusted population-attributable fraction (aPAF) was calculated using the prevalence and multivariate odds ratio of each risk factor.

RESULTS

The prevalence of current asthma and wheeze was similar in 1996 and 2006. Allergic sensitization, however, increased from 21% to 30%. The prevalence of parental asthma increased from 17% to 24%, while respiratory infections and maternal smoking decreased (60% to 29% and 32% to 16%, respectively). The aPAFs of non-environmental risk factors for current asthma increased in 1996-2006: allergic sensitization from 35% to 41%, parental asthma from 27% to 45% and male sex from 20% to 25%. Conversely, the aPAFs of environmental risk factors decreased: respiratory infections from 36% to 32% and damp home and maternal smoking from 14% and 19%, respectively, to near zero in 2006.

CONCLUSIONS AND CLINICAL RELEVANCE

From 1996 to 2006, the non-environmental risk factors parental asthma, allergic sensitization and male sex had an increasing or constant importance for current asthma in 7- to 8-year-old children. The importance of the environmental exposures damp home, respiratory infections and maternal smoking decreased. This counterbalancing in risk factors may explain the level of prevalence of current asthma.

Educating Asthmatic Children in European Ambulatory Pediatrics: Facts and Insights

The aim of this study was to assess the role of European ambulatory pediatricians in caring for asthmatic children, especially in terms of their therapeutic education. We developed a survey that was observational, declarative, retrospective and anonymous in nature. 436 ambulatory pediatricians in Belgium, France, Germany, Italy, Luxembourg and Slovenia were asked to participate in the survey providing information on three children over 6 years old suffering from persistent asthma, who had been followed for at least 6 months. We considered the pediatricians' profile, and their role in the therapeutic education of children. 277 pediatricians (64%) responded: 81% were primary care pediatricians; 46% participated in networks; 4% had specific training in Therapeutic Patient Education; 69% followed more than 5 asthmatic children per month, and over long periods (7 ± 4 years). The profiles of 684 children were assessed. Answers diverged concerning the provision of a Personalized Action Plan (60-88%), training the child to measure and interpret his Peak Expiratory Flow (31-99%), and the prescription of pulmonary function tests during the follow-up programme of consultations (62-97%). Answers converged on pediatricians' perception of their role in teaching children about their condition and its treatment (99%), about inhalation techniques (96%), and in improving the children's ability to take preventive measures when faced with risk situations (97%). This study highlights the role of European pediatricians in caring for asthmatic children, and their lack of training in Therapeutic Patient Education. Programmes and tools are required in order to train ambulatory pediatricians in Therapeutic Patient Education, and such resources should be integrated into primary health care, and harmonized at the European level.

Effectiveness of Montelukast on asthma control in infants: methodology of a French claims data study

Background

This pilot study, conducted on a 1/97th representative sample of French claims data, prepared a project to assess the effectiveness of Montelukast (MTL-4) as add-on therapy for asthma in infants (6–24 months) compared to inhaled corticosteroids (ICS), based on real-world data. Due to the very recent opening of French claims data for effectiveness research, and the complex structure of this data source, we first tested the feasibility of identifying infants with asthma and outcome criteria, and the ability to perform relevant comparisons.

Methods

We identified a cohort of infants with uncontrolled asthma and receiving ≥2 consecutive dispensations of any respiratory drug (R03 ATC classification) during a 6-month period. Uncontrolled asthma was identified either from exacerbations or from markers of acute loss of asthma control; date of occurrence of an event (exacerbation and/or acute loss of asthma control) was defined as index date. The study groups comprised infants receiving MTL-4 +/− ICS (MTL-4 group) or ICS without MTL-4 (ICS group) at index date. These two groups were matched on gender, age, quarter of index date, therapy before index date, past asthma-related hospitalization (ever), and were followed for 6 months. The outcome was the rate of infants with uncontrolled asthma, defined as above.

Results

This pilot cohort study included 1,149 infants with asthma (mean age 14.1 months, 64% boys). Of these, 51 and 768 were assigned to the MTL-4 and ICS groups, respectively. Uncontrolled asthma occurred in 78.8% and 78.4% of infants in these groups, respectively (oral corticosteroids were dispensed to 49% and 61%, respectively). Assessment of uncontrolled asthma, exposure to MTL-4 and ICS, and occurrence of outcomes were achieved. For the development of matching criteria, we defined a new marker of severity (therapeutic typologies).

Conclusion

These data support the feasibility of the final project, to be conducted on claims data from the whole French population. We also showed that, with appropriate methodology and by using valid criteria, French claims data are an adequate resource for conducting comparative effectiveness studies in pediatric asthma. Finally, the algorithm used to identify infants with asthma could be applied to other studies using claims data.

Improving allergy management in the primary care network--a holistic approach

The incidence, prevalence and costs of allergy have increased substantially in recent decades in many parts of Europe. The dominant model of allergy care within Europe is at the moment specialist-based. This model will become unsustainable and undeliverable with increasing disease prevalence. One solution to increase provision of allergy services is to diversify the providers. A new model for the provision of allergy care in the community with the general practitioner at the forefront is proposed. Pre- and postgraduate allergy education and training, implementation of pathways of care, allergy specialization and political will to generate resources and support are essential to achieve this new model. In parallel the holistic view of allergic diseases should be maintained, including assessment of severity and risk, psychological factors and health-care related costs in the context of the patient-centered decision making process.

Social networks and bronchial asthma

PURPOSE OF REVIEW

To focus on both positive and negative aspects of the interaction between asthmatic patients and the social networks, and to highlight the need of a psychological approach in some individuals to integrate pharmacological treatment is the purpose of review.

RECENT FINDINGS

There is evidence that in some asthmatic patients, the excessive use of social networks can induce depression and stress triggering bronchial obstruction, whereas in others their rational use can induce beneficial effects in terms of asthma management.

SUMMARY

The increasing asthma prevalence in developed countries seen at the end of last century has raised concern for the considerable burden of this disease on society as well as individuals. Bronchial asthma is a disease in which psychological implications play a role in increasing or in reducing the severity of bronchial obstruction. Internet and, in particular, social media are increasingly a part of daily life of both young and adult people, thus allowing virtual relationships with peers sharing similar interests and goals. Although social network users often disclose more about themselves online than they do in person, there might be a risk for adolescents and for sensitive individuals, who can be negatively influenced by an incorrect use. However, although some studies show an increased risk of depression, other observations suggest beneficial effects of social networks by enhancing communication, social connection and self-esteem.

Economic impacts of environmentally attributable childhood health outcomes in the European Union

BACKGROUND

There is increasing evidence of the role that exposure to industrial chemicals plays in the development of childhood disease. The USA and the European Union (EU) have taken divergent policy approaches to managing this issue, and economic estimates of disease costs attributable to environmental exposures in children are available in the USA but not the EU. We undertook the first economic evaluation of the impacts of childhood environmental chemical exposures in the EU.

METHODS

We used a cost-of-illness approach to estimate health care system costs, and used environmentally attributable fraction modelling to estimate the proportion of childhood disease due to environmental exposures. We analysed data on exposures, disease prevalence and costs at a country level, and then aggregated costs across EU member states to estimate overall economic impacts within the EU.

RESULTS

We found the combined environmentally attributable costs of lead exposure, methylmercury exposure, developmental disabilities, asthma and cancer to be $70.9 billion in 2008 (range: $58.9-$90.6 billion). These costs amounted to ~0.480% of the gross domestic product of the EU in 2008.

CONCLUSIONS

Childhood chemical exposures present a significant economic burden to the EU. Our study offers an important baseline of disease costs before the implementation of Registration, Evaluation and Authorization of Chemicals, which is important for studying the impacts of this policy regime.

Role of leukotriene receptor antagonists in the management of pediatric asthma: an update

At present, the main indications for leukotriene receptor antagonists (LTRA) in pediatric asthma are as add-on therapy to inhaled corticosteroids (ICS) and as initial controller therapy in children with mild asthma, especially those who cannot or will not use ICS. LTRA are also useful for patients who have concomitant rhinitis, and patients with viral-induced wheeze and exercise-induced asthma. It should be noted that the benefits of LTRA therapy have been demonstrated in children as young as 6 months of age and recent clinical trials have further proven the benefits of LTRA in acute asthma exacerbations. However, considering the important pro-inflammatory effects that leukotrienes (LT) have in experimental models of asthma, it may seem surprising that LTRA treatment outcomes are not better and that in some clinical trials only a minority of patients could be classified as full responders. This could be explained by potential additional LT receptors that are not affected by LTRA. Such receptors could represent new therapeutic targets in asthma. Furthermore, progress in differentiating between asthma phenotypes that result from different pathogenic mechanisms, some of which may involve LT to a lesser degree, should lead to an improved, personalized use of LTRA for treating asthma.

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

Associations between pre-pregnancy obesity and asthma symptoms in adolescents

Background

The high prevalence of children's asthma symptoms, worldwide, is unexplained. We examined the relation between maternal pre-pregnancy weight and body mass index (BMI), and asthma symptoms in adolescents.

Methods

Data from 6945 adolescents born within the Northern Finland Birth Cohort 1986 were used. Prospective antenatal and birth outcome data, including maternal pre-pregnancy weight and BMI, and asthma symptoms in adolescent offspring at age 15–16 years, were employed. Logistic regression analyses were performed to examine the associations between relevant prenatal factors and asthma symptoms during adolescence.

Results

Current wheeze (within the past year) was reported by 10.6% of adolescents, and physician-diagnosed asthma by 6.0%. High maternal pre-pregnancy BMI was a significant predictor of wheeze in the adolescents (increase per kilogram per square metre unit; 2.7%, 95% CI 0.9 to 4.4 for ever wheeze; 3.5%, 95% CI 1.3 to 5.8 for current wheeze), and adjusting for potential confounders further increased the risk (2.8%, 95% CI 0.5 to 5.1; 4.7%, 95% CI 1.9 to 7.7, respectively). High maternal pre-pregnancy weight, in the top tertile, also significantly increased the odds of current wheeze in the adolescent by 20% (95% CI 4 to 39), and adjusting for potential confounders further increased the risk (OR=1.52, 95% CI 1.19 to 1.95). Results were similar for current asthma. Furthermore, these significant associations were observed only among adolescents without parental history of atopy but not among those with parental history of atopy.

Conclusions

The association demonstrated here between maternal pre-pregnancy overweight and obesity, and asthma symptoms in adolescents suggests that increase in asthma may be partly related to the rapid rise in obesity in recent years.

Profiling allergic asthma volatile metabolic patterns using a headspace-solid phase microextraction/gas chromatography based methodology

Allergic asthma represents an important public health issue with significant growth over the years, especially in the paediatric population. Exhaled breath is a non-invasive, easily performed and rapid method for obtaining samples from the lower respiratory tract. In the present manuscript, the metabolic volatile profiles of allergic asthma and control children were evaluated by headspace solid-phase microextraction combined with gas chromatography-quadrupole mass spectrometry (HS-SPME/GC-qMS). The lack of studies in breath of allergic asthmatic children by HS-SPME led to the development of an experimental design to optimize SPME parameters. To fulfil this objective, three important HS-SPME experimental parameters that influence the extraction efficiency, namely fibre coating, temperature and time extractions were considered. The selected conditions that promoted higher extraction efficiency corresponding to the higher GC peak areas and number of compounds were: DVB/CAR/PDMS coating fibre, 22 °C and 60 min as the extraction temperature and time, respectively. The suitability of two containers, 1L Tedlar® bags and BIOVOC®, for breath collection and intra-individual variability were also investigated. The developed methodology was then applied to the analysis of children exhaled breath with allergic asthma (35), from which 13 had also allergic rhinitis, and healthy control children (15), allowing to identify 44 volatiles distributed over the chemical families of alkanes (linear and ramified) ketones, aromatic hydrocarbons, aldehydes, acids, among others. Multivariate studies were performed by Partial Least Squares-Discriminant Analysis (PLS-DA) using a set of 28 selected metabolites and discrimination between allergic asthma and control children was attained with a classification rate of 88%. The allergic asthma paediatric population was characterized mainly by the compounds linked to oxidative stress, such as alkanes and aldehydes. Furthermore, more detailed information was achieved combining the volatile metabolic data, suggested by PLS-DA model, and clinical data.

A multi-center survey of childhood asthma in Turke--I: the cost and its determinants

Successful management of childhood asthma requires a thorough idea of the economic impact of asthma and its determinants, as policy makers and physicians inevitably influence the outcome. The aim of this study was to define the cost of childhood asthma in Turkey and its determinants. In April 2006, a multi-center, national study was performed where data regarding cost and control levels were collected. Asthmatic children (6-18 yr) with at least a 1-yr follow-up seen during a 1-month period with scheduled or unscheduled visits were included. The survey included a questionnaire-guided interview and retrospective evaluation of files. Cost and its determinants during the last year were analyzed. A total of 618 children from 12 asthma centers were surveyed. The total annual cost of childhood asthma was US$1597.4 +/- 236.2 and there was a significant variation in costs between study centers (p < 0.05). Frequent physician visits [odds ratio (95% confidence intervals)] [2.3 (1.6-3.4)], hospitalization [1.9 (1.1-3.3)], asthma severity [1.6 (1.1-2.8)], and school absenteeism due to asthma [1.5 (1.1-2.1)] were major predictors of total annual costs (p < 0.05 for each). The comparable cost of asthma among Turkish children with that reported in developed countries suggests that interventions to decrease the economic burden of pediatric asthma should focus on the cost-effectiveness of anti-allergic household measures and on improving the control levels of asthma.

International differences in asthma guidelines for children

BACKGROUND

Over the last decade, a number of clinical practice guidelines that include guidance for the management of pediatric asthma have been introduced. The consistency across pediatric asthma guidelines is unknown and the emphasis on establishing asthma control may vary. The objective of this paper was to depict the evolution of guidelines for pediatric asthma and to compare current international guidelines in terms of their organization, presentation of evidence and consideration of children, with special emphasis on definitions of asthma control and severity.

METHODS

A systematic search to identify asthma guidelines was conducted, and guidelines were searched for pediatric terms. The approaches used by guidelines to define assessments of asthma severity and control were compared between the United States, the Global Initiative for Asthma, Canada, the United Kingdom and Australia.

RESULTS

Pediatric considerations in the management of asthma have been integrated into the various guidelines to different degrees and through varied strategies. There were differences in the conceptual and operational approach used to assess asthma which emphasized either asthma severity or control.

CONCLUSIONS

It will be important for future guidelines to clearly define whether the primary assessment parameter is asthma severity or control. Delineating the guideline development process and supporting evidence may improve transparency, consistency and guideline adherence.

Socioeconomic factors and asthma control in children

OBJECTIVES

The objective of this study was to evaluate the association between socioeconomic factors and asthma control in children, as defined by the Canadian Pediatric Asthma Consensus Guidelines.

PATIENTS AND METHODS

Cross-sectional data from a completed study of 879 asthmatic children between the ages of 1 and 18 residing in the Greater Toronto Area were used. The database included data on demographics, health status, asthma control, and health-related quality of life. Stepwise forward modeling multiple regression was used to investigate the impact of socioeconomic status on asthma control, based on six control parameters from the 2003 Canadian Pediatric Asthma Consensus Guidelines.

RESULTS

Only 11% of patients met the requirements for acceptable control, while 20% had intermediate control, and 69% had unacceptable asthma control. Children from families in lower income adequacy levels had poorer control.

CONCLUSIONS

Disparities in asthma control between children from families of different socio-economic strata persist, even with adjustment for utilization of primary care services and use of controller medications.

Ancillary human health benefits of improved air quality resulting from climate change mitigation

BACKGROUND

Greenhouse gas (GHG) mitigation policies can provide ancillary benefits in terms of short-term improvements in air quality and associated health benefits. Several studies have analyzed the ancillary impacts of GHG policies for a variety of locations, pollutants, and policies. In this paper we review the existing evidence on ancillary health benefits relating to air pollution from various GHG strategies and provide a framework for such analysis.

METHODS

We evaluate techniques used in different stages of such research for estimation of: (1) changes in air pollutant concentrations; (2) avoided adverse health endpoints; and (3) economic valuation of health consequences. The limitations and merits of various methods are examined. Finally, we conclude with recommendations for ancillary benefits analysis and related research gaps in the relevant disciplines.

RESULTS

We found that to date most assessments have focused their analysis more heavily on one aspect of the framework (e.g., economic analysis). While a wide range of methods was applied to various policies and regions, results from multiple studies provide strong evidence that the short-term public health and economic benefits of ancillary benefits related to GHG mitigation strategies are substantial. Further, results of these analyses are likely to be underestimates because there are a number of important unquantified health and economic endpoints.

CONCLUSION

Remaining challenges include integrating the understanding of the relative toxicity of particulate matter by components or sources, developing better estimates of public health and environmental impacts on selected sub-populations, and devising new methods for evaluating heretofore unquantified and non-monetized benefits.

Modeling the impact of genetic screening technologies on healthcare: theoretical model for asthma in children

BACKGROUND AND OBJECTIVE

This study focuses on the potential impact of genetic screening technologies on healthcare. Genetic screening for asthma in children was chosen as a case study to explore the cost effectiveness of applying early genetic screening to infants, and preventive treatment to the population at risk. Early intervention could prevent progression and facilitate clinical management of the disease. From the elite group of genetic markers that have been associated with asthma-related phenotypes, ADAM33 was the first published candidate gene detected by a positional cloning approach, marking the entry of asthma research into the genomic era. The model was, therefore, initially set for an ex ante analysis of the cost effectiveness of applying the preventive program to an infant population at risk, i.e. infants presenting wheezing episodes during the first year of life, and the ADAM33 ST+7 genetic marker, with the idea of expanding to further markers and their combinations lat a later date.

METHODS

In accordance with the US National Heart, Lung, and Blood Institute, four categories of asthma were considered. A Markov model was constructed, consisting of six mutually exclusive disease states (including healthy and dead states) with a simulation horizon of 100 years and a cycle length of 1 year. We define a scenario where early genetic screening was applied to infants presenting wheezing episodes during the first year of life and a preventive treatment to those children within this group who tested positive for selected ADAM33 polymorphism (ST+7). The cost-effectiveness analysis was performed from the third-party payer and patient perspective after year 6. We applied our model to a hypothetical cohort of 100 European infants.

RESULTS

The number of quality-adjusted life-years (QALYs) gained during the 6 years was 1.483, and the incremental cost-effectiveness ratio per QALY gained was euro 10,100/QALY. A sensitivity analysis was carried out that varied the discount rate and cost of genetic testing, and considered two different transition matrices for the preventive program. Three main conclusions were drawn from the sensitivity analysis. Firstly, if the discount rate for both cost and health outcomes is increased by 2%, the cost effectiveness of the preventive program does not vary significantly. Discounting costs and benefits at 5%, the preventive program appears cost effective (euro 11,100/QALY). Secondly, if the cost of genetic testing is increased to euro 100, the cost effectiveness of the preventive program remains within the limits of cost effectiveness. Thirdly, the cost of genetic screening, together with transition probabilities between health states, will determine the cost effectiveness of applying a preventive program based on genetic information.

CONCLUSIONS

Preventive treatment based on an early genetic screening of those children who present wheezing episodes during the first year of life, with treatment applied to those who test positive for the asthma-associated genetic marker ADAM33 ST+7, is theoretically cost effective. The model is a valuable tool for the ex ante assessment of the cost effectiveness of preventive schemes based on genetic screening. The value of modeling prior to clinical trials lies in informing study design and setting priorities for future research.

Associations between grass and weed pollen and emergency department visits for asthma among children in Montreal

CONTEXT AND OBJECTIVE

Asthma among children is a major public health problem worldwide. There are increasing number of studies suggesting a possible association between allergenic pollen and exacerbations of asthma. In the context of global climate change, a number of future climate and air pollution scenarios predict increases in concentrations of pollen, an extension of the pollen season, and an increase in the allergenicity of pollen. The goal of the present study is to evaluate the short-term effects of exposure to grass and weed pollen on emergency department visits and readmissions for asthma among children aged 0-9 years living in Montreal between April and October, 1994-2004.

METHODOLOGY AND RESULTS

Time-series analyses were carried out using parametric log-linear overdispersed Poisson models that were adjusted for temporal variations, daily weather conditions (temperature, atmospheric pressure), and gaseous air pollutants (ozone and nitrogen dioxide). We have found positive associations between emergency department visits and concentrations of grass pollen 3 days after exposure. The effect of grass pollen was higher on emergency department readmissions as compared to initial visits. Weak negative associations were found between weed pollen (including ragweed pollen) and emergency department visits 2 days after exposure.

CONCLUSION

The data indicate that among children, emergency department visits increased with increasing concentrations of grass pollen.

[Economic aspects of allergies: status and prospects for Austria]

According to epidemiological studies there has been an increase of allergic diseases and corresponding costs. Health economics analyses intend to offer decision guidance towards a more efficient and effective resource distribution, in the conflicting relationship of medicine and economics. In analogy with the "Global Initiative for Asthma (GINA)-study", one arrives at costs of Euro 227.7-455.4 million for the Austrian health system in 2004 for asthma. Direct costs of allergies in general are in part available from health insurance carriers. Between 1998 and 2005 the number of nasal preparations and antiobstructive therapies prescribed rose by 15% and 50% respectively, whilst the costs of these drugs dramatically increased by 96% and 70% respectively. Expenditure on anti-histamines rose by 31% between 2002 and 2004, whereas costs of topical and systemic anti-allergic drugs remained constant. Costs of allergies also include additional costs carried by the individuals affected, which must be added to those covered by the national health insurance carriers. Furthermore, patients with allergies more frequently turn to alternative and complimentary medicine to treat their condition (above all homeopathic remedies, massages and ointments) than people not suffering from allergies. Indirect costs due to allergies are, for instance, those caused by sick leave and loss of productivity. A continual systematic evaluation of available data on allergies in Austria could contribute to more effective implementation of medicines.

Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study

BACKGROUND

Reduced lung function is a feature of chronic asthma, which becomes apparent at school age. Unknown factors between birth and school age determine the progressive loss of pulmonary function in children with persistent asthma. We investigated the role of allergic sensitisation and allergen exposure early in life.

METHODS

The German Multicentre Allergy Study followed 1314 children from birth to 13 years of age. We regularly interviewed parents about their child's asthma and measured IgE levels. Allergen exposure was assessed at age 6 months, 18 months, and at 3, 4, and 5 years; lung function was assessed at 7, 10, and 13 years; post-bronchodilator response at 10 and 13 years; and a bronchial histamine challenge was done at 7 years.

RESULTS

90% of children with wheeze but no atopy lost their symptoms at school age and retained normal lung function at puberty. By contrast, sensitisation to perennial allergens (eg, house dust mite, cat and dog hair) developing in the first 3 years of life was associated with a loss of lung function at school age. Concomitant exposure to high levels of perennial allergens early in life aggravated this process: forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) ratio was 87.4 (SD 7.4) for those sensitised and with high exposure compared with 92.6 (6.0) for those not sensitised, p<0.0001; and maximal expiratory flow at 50% (MEF50) 86.4 (25.1) for sensitised and with high exposure compared with 101.5 (23.2; p=0.0031) for those not sensitised. Such exposure also enhanced the development of airway hyper-responsiveness in sensitised children with wheeze. Sensitisation and exposure later in life had much weaker effects and sensitisation to seasonal allergens did not play a part.

INTERPRETATION

The chronic course of asthma characterised by airway hyper-responsiveness and impairment of lung function at school age is determined by continuing allergic airway inflammation beginning in the first 3 years of life. However, children with a non-atopic wheezing phenotype lose their symptoms over school age and retain normal lung function at puberty.

Allergy practice worldwide: a report by the World Allergy Organization Specialty and Training Council

In 2004 the World Allergy Organization's Specialty and Training Council conducted a survey of World Allergy Organization (WAO) member societies to obtain information about the status of the specialty of allergy worldwide. Responses were received from 33 countries, representing a population of 1.39 billion people, of whom it was estimated that 22% may suffer from some form of allergic disease. Allergy was reported by 23 respondents to be a certified or accredited specialty in their country, and the number of certified allergists per head of population ranged from 1:25 million to 1:16,000. Allergists were ranked as the fifth most likely clinicians to see cases of allergic asthma, third most likely to see allergic rhinitis, and fourth most likely to see eczema or sinusitis. Nine countries only reported that children with allergic diseases would be seen by a pediatrician with appropriate training. The survey results highlight a pressing need for the development of allergy services worldwide.