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Backgrounder: Asthma Control

The theme of World Asthma Day 2013, an awareness-raising event organized bythe Global Initiative for Asthma (GINA), is You Can Control Your Asthma. TheGINA Board of Directors has chosen this theme to emphasize that effectiveasthma treatments exist and, with proper diagnosis, education, and treatment,the great majority of asthma patients can achieve and maintain good control oftheir disease. When asthma is under control, patients can live full and active lives

and can prevent visits to the emergency department and hospital.

According to the GINA Global Strategy for Asthma Management and Prevention(2012), asthma control means that a person with asthma has:

No (or minimal) asthma symptoms.

No waking at night due to asthma.

No (or minimal) need to use reliever medication.

The ability to do normal physical activity and exercise.

Normal (or near-normal) lung function test results (PEF and FEV1).

No (or very infrequent) asthma attacks.

More than 300 million people around the world have asthma 1, and the diseaseimposes a heavy burden on individuals, families, and societies. The GlobalBurden of Asthma Report, a compilation of published data on the prevalence andimpact of asthma around the world that was launched on World Asthma Day2004, indicates that asthma control often falls short and there are many barriersto asthma control around the world.

Lack of Asthma Control

Proper long-term management of asthma will permit most patients to achieve

good control of their disease. Yet the Global Burden of Asthma Reportdocuments ample evidence that, in many regions around the world, this goal is

1Unless otherwise noted, all information in this backgrounder comes from the Global Burden of

Asthma Report. The Report was commissioned by GINA and written by Richard Beasley,Matthew Masoli, Denise Fabian, and Shaun Holt, of the Medical Research Institute of NewZealand and the University of Southampton in the UK. For more information about the unmetneeds of asthma, and an explanation of the regions mentioned in this backgrounder, downloadthe full Report from www.ginasthma.org.

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often not met:

Hospitalizations, emergency room visits, and other urgent care occur

when a persons asthma is not under control. Although the rates of thesemedical visits generally increase as the prevalence of asthma rises, the

very high proportions of people with asthma who require such care inmany countries is an indication that lack of control is widespread.

o In Western Europe, for example, one in four people with asthma

required an emergency room visit or unscheduled urgent care inthe previous year.

o One in five Israeli children with asthma visits the emergency room

per year, and one in ten requires hospitalization.o In the China/Taiwan/Mongolia region, one-third of people with

asthma require urgent care, emergency room visits, or hospitaladmission for asthma.

o In North America, 40 percent of people with asthma required such

care in the previous year. The above facts indicate that there is a major opportunity to reduce

hospitalizations by improving asthma control, and on World Asthma Day2010 GINA launched an initiative encouraging governments and healthdepartments around the world to improve asthma control and reduceasthma hospitalization 50% over 5 years. On World Asthma Day 2011,GINA began the next phase of the Asthma Control Challenge with anonline data collection system for countries around the world to track theirprogress in reducing hospitalizations.

Poor asthma control is also seen in the lifestyle limitations experienced

by some people with asthma. In Egypt, for example, up to one in four

children with asthma is unable to attend school regularly because of poorasthma control.

Asthma deaths are the ultimate, tragic evidence of uncontrolled asthma.

According to the Global Burden of Asthma Report, the majority of asthmadeaths in some regions of the world are preventable.

What are the Barriers to Asthma Control?

Although the barriers to asthma control vary from country to country and fromregion to region around the world, the Global Burden of Asthma Reportidentifiesseveral patterns:

Diagnosis. Some people with asthma symptoms may never receive a

diagnosis of asthma, and thus do not have the opportunity for goodasthma treatment and control. Various factors such as poor access tomedical care, underrecognition by health professionals, lack of awarenessamong patients, and overlap of asthma symptoms with those of otherdiseases contribute to underdiagnosis of asthma in regions including the

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Baltic states, the Middle East, Southern Asia, China/Taiwan/Mongolia, andEast, West, and Southern Africa.

Treatment. Barriers relating to treatment are the most commonly cited in

the Global Burden of Asthma Report, occurring in one form or another inalmost all regions around the world:

o The high cost of medicines means that many people with asthmain the Baltic states, the Balkans/Turkey/Caucasus/MediterraneanIslands region, the Middle East, Central and South America, Eastand West Africa, and other areas may not receive sufficientmedication to control their disease. In Turkey, the cost of a year oftreatment for a person with moderate persistent asthma is abouthalf the monthly salary of a nurse; in Syria, it is greater than anurses monthly salary.

o Asthma medications are not available in some areas, such as

parts of the Middle East, Southern Asia, Central America, andNorth, West, and East Africa.

o Treatment that is not consistent with evidence-based guidelinesmay hamper asthma control in, for example, the UK/Republic ofIreland, Western Europe, China/Taiwan/Mongolia, Central America,the Caribbean, and West and East Africa. There are widevariations in prescribing practices in different areas of the world,and even when cost is not a barrier undertreatment may still occur.

o The underuse of inhaled corticosteroids for long-term

management of asthma is a particular problem in many regions,including the Middle East, the Caribbean, and West Africa. Thesemedications diminish chronic inflammation in the lungs of asthmapatients, and are a key to controlling the disease.

o A general lack of access to medical care limits asthma treatmentand control in areas such as theBalkans/Turkey/Caucasus/Mediterranean Islands region, EasternEurope, Russia, Central Asia and Pakistan, Southern Asia,Southern Africa, and China. This lack of access may arise fromsocioeconomic factors, or may be a matter of scarce infrastructureand poor transport, especially in rural areas.

Education. People with asthma may not understand how to use their

medications properly, or may not understand concepts such as asthmacontrol and when to seek help for worsening asthma that would help themmanage their disease effectively. Misconceptions about asthma and its

treatment represent are widespread in regions including Southeast Asia,Central Asia and Pakistan, Eastern Europe, the UK/Republic of Ireland,Northeast Asia, and Russia.

Environmental Health. Avoiding risk factors that cause asthma

symptoms is an important strategy for improving control. However, inmany regions of the world, people with asthma may be exposed toconditions such as outdoor or indoor air pollution, cigarette smoke, orchemicals on the job that make their asthma worse.

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Improving Control

The Global Burden of Asthma Reportalso details a number of instances whereimproving asthma control has reduced the burden of this disease. For example:

Declining asthma mortality rates over the last 10 years have been

attributed to the increased use of inhaled corticosteroid therapy inareas including Scandinavia, the UK/Republic of Ireland, Western Europe,and Argentina. In Northeast Asia, increased use of inhaledglucocorticosteroids has led to a reduction in asthma severity.

National asthma campaigns in Finland and other Scandinavian

countries, the UK, Australia, New Zealand, and elsewhere have reducedasthma morbidity and mortality. These programs often includeeducational components for both health professionals and the generalpublic.

A strategy for achieving and maintaining asthma control is set out in the GINAGlobal Strategy for Asthma Management and Prevention. The strategy requiresfour interrelated components of therapy:

Develop patient/doctor partnership.

Identify and reduce exposure to risk factors.

Assess, treat, and monitor asthma.

Manage asthma exacerbations.

Under this strategy, asthma is treated in a stepwise manner to achieve andmaintain control of the disease. Medication is increasedstepped upwhenasthma is not controlled, and gradually stepped down once good control isachieved and maintained for a period of time.

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