Gina Burden Report

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Matthew Masoli

Denise Fabian

Shaun Holt

Richard Beasley

Medical Research Institute of New ZealandWellington, New Zealand

University of SouthamptonSouthampton, United Kingdom

Developed for the Global Initiative for Asthma

TM


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Preface ............................................................................................................ii

Global Burden of Asthma - Summary ..............................................................1

Barriers to Reducing the Burden of Asthma......................................................3

Actions Required to Reduce the Burden of Asthma..........................................5Ranking of the Prevalence of Current Asthma Symptoms in Childhood by

Country (1)..................................................................................................6

Ranking of the Prevalence of Current Asthma Symptoms in Childhood byCountry (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......................................................11Disability-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

TABLE OF CONTENTS

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IT IS NOW estimated that as many as 300 million people of all ages, and all ethnicbackgrounds, 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. TheGINA program recommends a management program based on the best availablescientific evidence to allow doctors to provide effective medical care for asthmatailored to local health care systems and resources.

Working in continued collaboration with leaders in asthma care from manycountries, and with GINA Sponsors, World Asthma Day (first Tuesday in May) has

been extremely successful, increasing in numbers of participants each year. We areindebted to the vast number of people in many countries of the world who havemade a commitment to bring awareness about the burden of asthma to their localhealth 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 ofAsthma." GINA commissioned Professor Richard Beasley, Wellington, New Zealand(and a member of the GINA Dissemination Committee) to provide available data onthe burden of asthma. In this report, Professor Beasley and his colleagues obtaineddata on the burden of asthma in 20 different regions worldwide from literature

primarily published through the International Study of Asthma and Allergies inChildhood (ISAAC) and the European Community Respiratory Health Survey(ECHRS). Methodologies differ in these studies, and epidemiological data onasthma are very difficult to collect, as Professor Beasley carefully describes in hissegment on Methodological Issues. Nonetheless, this document provides a wealth ofinformation, along with a large number of scientific references. The study regionshave been grouped according to geographical, political, historical, and racialconsiderations based on official data from WHO, the United Nations (UN), and othersources, and to some extent, the availability of asthma epidemiological data withinthe study region. Using the United Nations World Population Prospect Population

Database (http://esa.un.org/unpp) as a source within each region, all countrieswere included, and in some cases territories and dependencies if specific asthmaepidemiological data were available. For simplicity some data from small territorieshave been omitted or lumped in a larger sub-regional unit. The report will beupdated as new information becomes available and following feedback fromindividual countries and regions. (Additional references, data, and feedback may besubmitted at www.ginasthma.com.)

The GINA Executive Committee is indebted to Professor Beasley and his colleaguesfor 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 beextremely useful to develop background materials for World Asthma Day activitiesin 2004 and well into the future.

_______________

Tim Clark, MDChair, GINA Executive Committee

(Information about GINA can be found at www.ginasthma.com)

PREFACE

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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 peoplein the world currently have asthma. Considerably higherestimates can be obtained with less conservative criteriafor the diagnosis of clinical asthma.

2.The international patterns of asthma prevalence are notexplained by the current knowledge of the causation ofasthma. 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 andadults around the world in recent decades. The increasein the prevalence of asthma has been associated with anincrease in atopic sensitisation, and is paralleled bysimilar increases in other allergic disorders such as

eczema and rhinitis.

4.The rate of asthma increases as communities adoptwestern lifestyles and become urbanised. With theprojected increase in the proportion of the world'spopulation that is urban from 45% to 59% in 2025, thereis likely to be a marked increase in the number ofasthmatics worldwide over the next two decades. It is

estimated that there may be an additional 100 millionpersons with asthma by 2025.

5. In many areas of the world persons with asthma do nothave access to basic asthma medications or medical care.Increasing the economic wealth and improving thedistribution of resources between and within countriesrepresent important priorities to enable better health care

to be provided.

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Gl obal Burden of Ast hma - Summary(continued)

6.The number of disability-adjusted life years (DALYs) lostdue to asthma worldwide has been estimated to becurrently about 15 million per year. Worldwide, asthmaaccounts for around 1% of all DALYs lost, which reflectsthe high prevalence and severity of asthma. The numberof 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 disorderin government health strategies. Particular resources needto be provided to improve the care of disadvantagedgroups with high morbidity, including certain racialgroups and those who are poorly educated, live in largecities, or are poor. Resources also need to be provided toaddress preventable factors, such as air pollution, thattrigger exacerbations of asthma.

8. It is estimated that asthma accounts for about 1 in every250 deaths worldwide. Many of the deaths arepreventable, being due to suboptimal long-term medicalcare and delay in obtaining help during the final attack.

9.The economic cost of asthma is considerable both interms 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 thatcause asthma and novel public health andpharmacological measures become available to reducethe prevalence of asthma, the priority is to ensure thatcost-effective management approaches which have been

proven to reduce morbidity and mortality are available toas many persons as possible with asthma worldwide.

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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 otherrespiratory illnesses such as tuberculosis and pneumoniaand 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 diseasesincluding asthma.

5. Unsustainable generalisations across cultures and healthcare systems which may make management guidelines

developed in high-income countries difficult to implementin low and middle-income countries.

6. Inherent barriers in the organisation of health care servicesin terms ofa. geographyb. type of professional respondingc. education and training systems

d. public and private caree. tendency of care to be "acute" rather than "routine."

7.The limited availability and use of medications includinga. omission of basic medications from WHO or national

essential drug listsb. poor supply and distribution infrastructurec. cost

d. cultural attitudes towards drug delivery systems, e.g.inhalers

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Barr i ers to Reduci ng t he Burden of A st hma(continued)

8. Patient barriers including

a.cultural factors

b. lack of informationc. underuse of self-managementd. over-reliance on acute caree. use of alternative unproven therapies.

9. Inadequate government resources provided for health careincluding asthma.

10.The requirement of respiratory specialists and relatedorganisations required to care for a wide variety ofdiseases, which has in some regions resulted in a failure toadequately promote awareness of asthma.

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Actions Required toReduce 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 themorbidity and mortality due to asthma throughout the world.

3. Identify and address the economic and political factorswhich limit the availability of health care.

4. Improve accessibility to essential drugs for the managementof asthma in low- and middle-income countries.

5. Identify and address the environmental factors includingindoor and outdoor pollution which affect respiratorymorbidity including that due to asthma.

6. Promote and implement anti-tobacco public health

policies to reduce tobacco consumption.

7. Adapt international asthma guidelines for developingcountries to ensure they are practical and realistic in termsof different health care systems. This includesdissemination strategies for their implementation.

8. Integrate the GINA guidelines with other global respiratory

guidelines for children and adults. In this respect, there isa requirement to merge the key elements of the differentrespiratory guidelines into an algorithm for use at the firstpoint of entry of a respiratory patient's contact with healthservices.

9. Promote cost-effective management approaches whichhave been proven to reduce morbidity and mortality,

thereby ensuring optimal treatment is available to as manypersons as possible with asthma worldwide.

10. Research the causation of asthma, primary and secondaryintervention strategies, and management programmesincluding those for use in developing countries.

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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

*See Methodological Issues

Ranking of the Prevalenceof Current Asthma Symptoms

in Childhood by Country (I)(Written Questionnaire:Self-reported wheezing in the

previous 12 month period,

in 13- to 14-year-old children*)

Country

Prevalence of asthma symptoms (%)

0 5 10 15 20 25 30 35 40


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Ranking of the Prevalence ofCurrent 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

Prevalence of asthma symptoms (%)

0 5 10 15 20 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


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Scotland 18.4Jersey 17.6Guernsey 17.5Wales 16.8Isle of Man 16.7England 15.3New Zealand 15.1Australia 14.7Republic of Ireland 14.6Canada 14.1Peru 13.0Trinidad & Tobago 12.6Costa Rica 11.9Brazil 11.4United States of America 10.9Fiji 10.5

Paraguay 9.7Uruguay 9.5Israel 9.0Barbados 8.9Panama 8.8Kuwait 8.5Ukraine 8.3Ecuador 8.2South Africa 8.1Czech Republic 8.0Finland 8.0Malta 8.0

Ivory Coast 7.8Colombia 7.4Turkey 7.4Lebanon 7.2Kenya 7.0

Germany 6.9France 6.8Norway 6.8Japan 6.7Sweden 6.5Thailand 6.5Hong Kong 6.2Philippines 6.2United Arab Emirates 6.2Belgium 6.0Austria 5.8Spain 5.7Saudi Arabia 5.6Argentina 5.5Iran 5.5Estonia 5.4Nigeria 5.4Chile 5.1Singapore 4.9Malaysia 4.8Portugal 4.8Uzbekistan 4.6FYR Macedonia 4.5Italy 4.5

Oman 4.5Pakistan 4.3Tunisia 4.3Cape Verde 4.2

Latvia 4.2Poland 4.1Algeria 3.9South Korea 3.9Bangladesh 3.8Morocco 3.8Occupied Territory of Palestine 3.6Mexico 3.3Ethiopia 3.1Denmark 3.0India 3.0

Taiwan 2.6Cyprus 2.4Switzerland 2.3Russia 2.2China 2.1Greece 1.9Georgia 1.8Nepal 1.5Romania 1.5Albania 1.3Indonesia 1.1Macau 0.7


World Map of the Prevalence of Clinical Asthma

10.1

7.6-10.0

5.1-7.5

2.5-5.0

0-2.5

No standardised data available

Proportion of population (%)*


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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

Country

Ranking ofAsthma Mortality by Country

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


Mortality Rate (per 100,000)

0 0.5 1 1.5 2.0 2.5 3.0


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China........................................................36.7Russia ......................................................28.6Uzbekistan................................................27.2Albania ....................................................20.8

South Africa..............................................18.5Singapore..................................................16.1Romania ..................................................14.7Mexico ....................................................14.5Malta........................................................11.6Colombia..................................................10.1Denmark ....................................................9.3Ukraine ......................................................8.7

Japan ..........................................................8.7FYR Macedonia ..........................................8.2Belgium......................................................7.7Latvia..........................................................7.1

Norway ......................................................7.1Switzerland ................................................7.0Portugal ......................................................6.9Poland........................................................6.6France ........................................................6.5

Thailand ....................................................6.2Argentina....................................................5.8Hong Kong ................................................5.6United States of America ............................5.2

Germany ....................................................5.1Spain ..........................................................4.9South Korea................................................4.9Czech Republic ..........................................4.8

Israel ..........................................................4.7New Zealand..............................................4.6Costa Rica ..................................................3.9Australia ....................................................3.8Republic of Ireland ....................................3.6Italy ............................................................3.6Chile ..........................................................3.5England ......................................................3.2Scotland......................................................3.0Estonia........................................................3.0Wales..........................................................2.9Austria........................................................2.6

Ecuador ......................................................2.3Greece........................................................2.1Uruguay......................................................2.1Sweden ......................................................2.0Brazil ..........................................................1.8Canada ......................................................1.6Finland ......................................................1.6Cape Verde ................................................0.0

World Map of Asthma Case Fatality Rates(Asthma deaths per 100,000 asthmatics)

>10.0

5.1-10.0

0-5.0

No standardised data available

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



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Disability-Adjusted Life Years Lost Dueto Asthma Worldwide Ranking with

Other Common Disorders

Asthma was the 25th leading cause of disability-adjusted lifeyears (DALYs) lost worldwide in 2001.

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Rank Disorder Number ofDALYs (x106)

1 Perinatal conditions 98.4

2 Lower respiratory tract infections 90.73 HIV/AIDS 88.44 Unipolar depressive disorders 65.95 Diarrhoeal disease 62.56 Ischaemic heart disease 58.77 Cerebrovascular disease 45.98 Malaria 42.39 Road traffic accidents 37.7

10 Tuberculosis 36.011 Maternal conditions 30.912 Chronic obstructive pulmonary disease 29.913 Congenital abnormalities 28.114 Measles 26.515 Hearing loss - adult onset 25.916 Violence 20.217 Self-inflicted injuries 19.9

18 Alcohol use disorders 19.819 Protein-energy malnutrition 16.720 Osteoarthritis 16.421 Schizophrenia 15.922 Falls 15.723 Diabetes mellitus 15.424 Cirrhosis of the liver 15.125 ASTHMA 15.0

26 Bipolar affective disorder 13.827 Pertussis 12.528 Alzheimers and other dementias 12.429 Sexually transmitted diseases excluding HIV 12.430 Iron deficiency anaemia 12.0


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USACanadaNew ZealandAustraliaLibyaUAESaudi Arabia

OmanIsraelTurkeyKuwaitJapanS KoreaUKFranceGermanySpainPortugalNetherlandsDenmarkFinland

SwedenNorwayItalyBelgiumIrelandAustriaGreeceTurkeyLuxembourgIceland

BruneiMalaysiaSingaporeSloveniaAlbaniaMacedoniaBulgaria

SerbiaBosnia-HerzegovinaCzech RepPolandLatviaEstoniaRomaniaSlovakiaHungaryCroatiaArgentinaChileColombia

CubaTunisiaAlgeriaEgyptJordanSyriaIran

IndiaTurkmenistanPakistanUzbekistanKyrgyzstanChinaKazakhstan

AzerbaijanArmeniaGeorgiaRussian FedMongoliaIndonesiaPhilippinesVietnamThailandLaosTaiwanBangladeshPNGBelarus

UkraineMoldovaLithuaniaUruguayBoliviaPeruEcuadorVenezuelaSurinameBrazil

PanamaGuatemalaBelizeMexicoDominican RepSouth AfricaNamibia

BotswanaZimbabweZambiaTanzaniaKenyaEthiopiaDjiboutiChadNigerCameroonMaliTogoCote D'IvoireSenegal

MauritaniaMoroccoMadagascarLesothoGambiaIraq

ParaguayGuyanaNicaraguaHondurasEl SalvadorMozambiqueMalawi

AngolaCongoDem Rep ofCongoGabonBurundiRwandaUgandaSomaliaEritreaSudanYemenCentral African RepNigeria

GhanaBurkina FasoLiberiaSierra LeoneGuinea-BissauEquatorial GuineaAfghanistanTajikistanBurmaCambodiaNepalN Korea

French GuineaCosta RicaWestern Sahara

World Map of the Proportion of the Populationwith Access to Essential Drugs

95%No standardiseddata available

WHO Access to Essential Drugs

>95% 81-95% 50-80%


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Ait-Khaled N, Enarson D, Bousquet J. Chronic respiratory diseases in developingcountries: the burden and strategies for prevention and management. BullWHO 2001;79:971-9.

Burney P. The changing prevalence of asthma? Thorax2002; 57(Suppl II): ii36-ii39.European Community Respiratory Health Survey. Variations in the prevalence ofrespiratory symptoms, self-reported asthma attacks, and use of asthmamedication 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) SteeringCommittee. Worldwide variation in prevalence of symptoms of asthma,allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet1998; 351:1225-32.

International Study of Asthma and Allergies in Childhood (ISAAC) SteeringCommittee. Worldwide variations in the prevalence of asthma and allergiesin childhood (ISAAC). Eur Respir J 1998; 12: 315-35.

Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N,Leynaert B, Luczynska C, Neukirch F, Svanes C, Sunyer J, Wjst M. EuropeanCommunity Respiratory Health Survey II. The European CommunityRespiratory Health Survey: what are the main results so far? EuropeanCommunity Respiratory Health Survey II. Eur Respir J 2001; 18: 598-611.

Jarvis D, Burney P. Epidemiology of asthma. In:Asthma and Rhinitis. Eds:Holgate S, Busse W. Blackwell Scientific Press, Oxford: 1995, 17-32.

Murray CJL, Lopez AD. Regional patterns of disability-free life expectancy anddisability-adjusted life expectancy: Global Burden of Disease Study. Lancet1997; 349: 1347-52.

Murray CJL, Lopez AD. Global mortality, disability, and the contribution of riskfactors: Global Burden of Disease Study. Lancet1997; 349: 1436-42.

National Institutes of Health. Global initiative for asthma. Natl Heart LungBlood Inst Publ No. 95-3659. Bethesda, MD: NHLBI 1995; 6.

Sheffer AL (Ed). Fatal Asthma. New York: Marcel Dekker Inc 1998, 115: 607p.Shibuya K, Mathers CD, Lopez AD. Chronic Obstructive Pulmonary Disease

(COPD): consistent estimates of incidence, prevalence and mortality by WHOregion. Global Programme on Evidence for Health Policy, World Health

Organisation, 30 November 2001.Sunyer J, Anto JM, Tobias A, Burney P for the European Community Respiratory

Health Survey. Generational increase of self-reported first attack of asthma infifteen industrialised countries. Eur Respir J 1999: 14: 885-91.

World Health Organisation. Integrated management of the sick child. BullWHO 1995; 73: 735-40.

World Health Organisation. Achieving health for all. In: World Health Report1998. World Health Organisation, Geneva: 1998, 158-62.

World Health Organisation. WHO consultation on the development of acomprehensive approach for the prevention and control of chronic respiratorydiseases. Geneva 2001.

World Health Report 2001. Fifty facts from the World Health Report 1998:Global health situation and trends 1955-2025. World Health Organisation.

World Health Report 2002. Reducing risks, promoting health life. World HealthOrganisation.

World Health Report 2002. Message from the Director-General, Dr GHBrundtland. pp ix-xx and 68-76. World Health Organisation.

World Health Organisation. WHO strategy for prevention and control of chronicrespiratory diseases. Geneva 2002.

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KEY REFERENCES


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Methodological Issues

A. Prevalence of Current Asthma Symptoms

The large standardised international and national studies of theprevalence of asthma in both children and adults have utilisedwritten questionnaires of asthma symptoms. These questionnaireshave been based on the symptom of wheezing, which has beenshown to be the most important symptom for the identification ofindividuals with asthma. Due to the intermittent nature of asthmasymptoms, wheezing occurring at any time within the previous 12months has been used to define current asthma symptoms. Responses

to questions about self-reported wheezing in the previous 12-monthperiod have been shown to have good specificity and sensitivity forboth bronchial hyperresponsiveness and a diagnosis of asthma inboth children and adults. This was the core question used in boththe International Study of Asthma and Allergies in Childhood (ISAAC)and the European Community Respiratory Health Survey (ECRHS),the large standardised international studies which compared theprevalence of asthma symptoms in countries worldwide. For thesereasons, "wheezing in the last 12 months" has been used in thisreport as the response to determine the prevalence of current asthmasymptoms in each country.

In this report, data on this question have been preferentially obtainedfrom ISAAC and ECRHS as data were collected in a standardisedmanner between centres in different countries in these studies. TheISAAC study obtained symptom prevalence data from children in the

13- to 14-year age group, whereas in the ECRHS the 20- to 44-yearage group was studied. In countries where more than one centreparticipated in ISAAC or ECRHS, the mean symptom prevalencevalue for the country was used. For countries which did notparticipate in ISAAC or ECRHS, comparable data from publishedstudies were used if self-reported wheezing in the previous 12-monthperiod was obtained from written questionnaires in definedpopulations in children or adults.

Despite the general acceptance of this approach, a number oflimitations need to be recognised in the interpretation of suchstandardised data. The first is that self-reported current wheezing isnot diagnostic of asthma in an individual. Wheezing is not asymptom specific to the diagnosis of asthma and there is no agreed

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way of grading the severity or frequency of wheezing symptoms toidentify the presence of asthma. For example, the occasionaltransient episode of mild wheezing in an individual requiring notreatment would not necessarily be considered to be diagnostic ofclinical asthma. From a clinical standpoint, a diagnosis of asthma ismade on the basis of combined information from history, physicalexamination, and physiological tests, often over a period of time.

There is no single test or clinical feature which defines the presenceor absence of asthma, particularly from epidemiological studies oflarge populations. As a result, the prevalence of current asthmasymptoms is not equivalent to the prevalence of clinical asthma.

Another issue is that in both children and adults, wide variations inthe prevalence of current asthma symptoms are often observedbetween centres within the same country. This indicates that theasthma symptom prevalence rate reported for each country isdependent to some extent on the number of centres studied. Thepopulation sample chosen, on the basis of a defined geographicalarea, also influences the reported asthma symptom prevalence rates.In both ECRHS and ISAAC predominantly urban populations werestudied, but it is recognised that the prevalence of asthma symptomsis generally higher in urban than in rural areas.

Despite the use of standardised simple written questionnaires,validated study protocols (including those for translation ofquestionnaires), and stringent quality control measures in both ISAACand ECRHS, biases in the comparability of information wereunavoidable. This is evident from the simple observation that in thestudies data have been presented from standardised writtenquestionnaires which have been translated into over 50 languages,some of which have no colloquial term for wheezing. In an attemptto reduce the biases inherent in international comparisons of asthmasymptom prevalence data based on written questionnaires, a videoquestionnaire has been developed which shows rather than describesthe symptoms and signs of asthma, thereby allowing comparisonsbetween populations with different cultures and languages. Whilethe video questionnaire probably provides the most accuratecomparable estimates of asthma prevalence between populationsworldwide, its use has been confined to the ISAAC programme andinsufficient validation has been undertaken to date for it to be used asthe primary outcome variable in this report.

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B. Prevalence of "Clinical Asthma"

The true prevalence of asthma is difficult to determine due to the lackof a single objective diagnostic test, different methods of classificationof the condition, differing interpretation of symptoms in differentcountries, as well as the uncertain influence of increasing public andprofessional awareness of asthma. In this report an arbitrary figureof 50% of the prevalence of "current wheezing" in children (self-reported wheezing in the previous 12-month period in 13- to 14-year-old children) has been used as the prevalence of "clinical asthma." Insupport of this approach, in different populations from high- and low-income countries:

1. The prevalence of "clinically important" (severe) asthmasymptoms shows a similar degree of variation to mild wheezing,with a strong correlation at the national level. This indicates thatthe wide variation in prevalence of current wheezing is notexplained by a relative over-reporting of mild symptoms in high-prevalence countries, and that current wheezing can be used asthe 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 thatreporting current wheeze. This criteria of BHR plus currentwheeze has been proposed as the "gold standard" for identifyingclinical asthma in population-based studies, having been shownto identify a group with greater severity of clinical andphysiological measures and treatment requirements for asthma

than alternative criteria.

3. In children the prevalence rate determined by a positive responseto the video sequence of wheezing is about 50% of that ofcurrent 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 ECRHSasthma symptom prevalence data, with 74% of the variation inthe prevalence of current wheezing in adults at the centre levelexplained by the variation in the childhood data. The mean

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prevalence rate of current wheezing in children was 88% of thatrecorded in adults, in the countries which participated in bothstudies.

6. There is a close correlation between the ISAAC asthmaprevalence data for teenagers (13- to 14-year age group) andyoung children (6- to 7-year age group). In the countries whichstudied both age groups in the ISAAC programme, the meanprevalence rate of current wheezing in the 6- to 7-year age groupwas 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 inthe recognition and presentation to a doctor by an individual withrecurrent wheezing episodes, and the considerable differences indiagnostic labelling and treatment by doctors between populations.

As a result the prevalence rates for "clinical asthma" reported in thisreport represent a conservative estimate.

To determine the number of persons with asthma in each country, themean prevalence of asthma calculated for each country wasmultiplied by the population of the country, which was derived fromthe WHO population statistics for 2001. For countries in which dataon asthma symptom prevalence were not available, the meanprevalence of clinical asthma in the specific region was used. Whilethe major limitations of this approach are evident, it does provide acrude estimate for the prevalence of clinical asthma in these

countries. This approach enabled the total number of asthmatics ineach region to be estimated and thereby the total number of personswith asthma worldwide.

C. Asthma Mortality

The asthma mortality comparison between countries has been madeusing the asthma mortality rates in the 5- to 34-year age group

because the diagnosis of asthma mortality is firmly established in thisgroup. It has been shown that in this age group false-positivereporting (i.e., deaths from other causes being falsely attributed toasthma) and false-negative reporting (i.e., asthma deaths being falselyassigned to other categories) are extremely low. However, theaccuracy of this approach declines with increasing age, with false-positive reporting rates of >30% in those aged 65 years or more.

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In this report, WHO country-specific mortality data for ICD codes490 to 493 have been used. These codes incorporate mortality datafrom asthma, emphysema, chronic bronchitis, and bronchitis notspecified as acute or chronic. In the 5- to 34-year age group, thesemortality figures are similar to the asthma mortality rates, due to therarity of mortality from chronic bronchitis or emphysema in this agegroup. This approach was supported by a validation study based ondata from 14 countries in 7 regions, in which the asthma mortalityrates in the 5- to 34-year age group as published by the nationalstatistics were compared with the WHO mortality rates for ICD codes490 to 493. This validation showed that the asthma mortality rates in

the 5- to 34-year age group were on average 89% of the WHO-derived figures.

For each country, the mean mortality rate from the two most recentyears in which it was available was presented. The mean period inwhich mortality data were available was 1996 to 1997; mortality datawere 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 thecountries being compared. In this way a more accuratedetermination of the case fatality rate can be achieved and with thistype of analysis a different perspective of the international differencesin asthma mortality rates is obtained. In this report, case fatality rateshave been derived for each country, in which the asthma mortalityrate in the 5 to 34 year age group has been determined as aproportion of the prevalence of clinical asthma, where data wereavailable. It is recognised that the case fatality rates represent a crudeestimate, dependent on many factors including the accuracy of themortality and prevalence statistics available in the different agegroups, diagnostic coding, and the recognition and management ofthe condition. It has not been possible to document overall asthmamortality rates or the number of deaths due to asthma in each countryas these data were not available from the WHO in a standardisedformat.

D. Disability-Adjusted Life Years

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

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of years of life lost to that of years of healthy life lost, representing ahealth gap measure which incorporates both loss of life and the lossof quality of life. This allows a composite measure of the burden ofboth fatal and non-fatal disease. As a result, the years lost todisability (YLD) is added to the years of life lost to prematuremortality (YLL) to yield an integrated unit of health - the "disability-adjusted life-year" (DALY), with one DALY representing the loss ofone year of healthy life. The DALYs lost due to asthma worldwide in2001 are presented, together with the 30 leading causes of DALYs.

These data were obtained from the recently published WHO WorldHealth Report 2002.

E. Populations with Regular Access to Essential Drugs

The world map documenting the percentage of the population ineach country with regular access to essential drugs was reproducedfrom the WHO World Health Report 1998.

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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 togeographical, political, historical, and racial considerations, and tosome extent according to the availability of asthma epidemiologicaldata within the study region. A broad overview of some, but by nomeans all, of the relevant issues and interesting features of the burdenof asthma within each region has been provided. Likewise, for manyregions the lists for further reading provide some, but not all, of thekey 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


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1. Scandinavia/

Baltic StatesDenmarkEstoniaFinlandIcelandLatviaLithuaniaNorwayPolandSweden

4. Balkans/Turkey/Caucasus/Mediterranean Islands

AlbaniaArmeniaAzerbaijanBosnia-HerzegovinaCroatiaCyprusGeorgiaGreeceFYR Macedonia

MaltaSerbiaSloveniaTurkey

7. Central Asia & Pakistan

Afghanistan

KazakhstanKyrgyzstanPakistanTajikistanTurkmenistanUzbekistan

10. Northeast Asia

JapanNorth KoreaSouth Korea

2. United Kingdom/

Republic of IrelandEnglandGuernseyIsle of ManJerseyNorthern IrelandRepublic of IrelandScotlandWales

5. Russia & FormerSocialist Republics ofE. Europe

BelarusBulgariaCzech RepublicHungaryMoldaviaRomaniaRussian FederationSlovakiaUkraine

8. Southern Asia

Bangladesh

BhutanIndiaNepalSeychellesSri Lanka

11. Southeast Asia

BruneiCambodiaIndonesiaLaosMalaysiaMyanmarPhilippinesSingaporeThailandVietnam

3. Western Europe

AustriaBelgiumFranceGermanyItalyLuxembourgNetherlandsPortugalSpainSwitzerland

6. Middle East

BahrainIranIraqIsraelJordanKingdom of SaudiArabia

KuwaitLebanon

Occupied Territory ofPalestineOmanQatarSyriaUnited Arab EmiratesYemen

9. China/Taiwan/Mongolia

China

Hong KongMacauMongoliaTaiwan

12. Oceania

AustraliaFijiNew ZealandPapua New Guinea

SamoaTahitiOther Pacific Islands

22

Regions


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13. North America

CanadaUnited States of America

16. South America

ArgentinaBoliviaBrazilChileColombiaEcuadorFrench GuianaGuyanaParaguayPeruSurinameUruguayVenezuela

19. East Africa

BurundiDjiboutiEritrea

EthiopiaKenyaMadagascarMalawiMauritiusMozambiqueRwandaSomaliaTanzaniaUganda

14. Central America

BelizeCosta RicaEl SalvadorGuatemalaHondurasMexicoNicaraguaPanama

17. North Africa

AlgeriaChadEgyptLibyaMoroccoNigerSudanTunisia

20. Southern Africa

AngolaBotswanaCongo

NamibiaSouth AfricaSwazilandZaireZambiaZimbabwe

15. Caribbean

BarbadosCubaDominican RepublicHaitiJamaicaPuerto RicoTrinidad & TobagoOther Caribbean Islands

18. West Africa

BeninBurkina FasoCameroonCape VerdeCentral African RepublicEquatorial GuineaGabonGambiaGhanaGuineaGuinea-BissauIvory CoastLiberiaMali

MauritaniaNigeriaSenegalSierra LeoneTogoWestern Sahara

23

Regions


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24

Scandinavia/Baltic States

Key Points:

1. The prevalence of asthma symptoms is similar throughout theregion, with generally higher rates in Scandinavian countries, andsomewhat lower rates in the former socialist countries in theBaltic region.

2. The prevalence of asthma has increased throughout the regionover recent decades. The data reporting the increased prevalenceof asthma in young army recruits in a number of countries withinthe Scandinavian region provide some of the most convincing

data worldwide of the increase in asthma prevalence that hasoccurred over recent decades. The increase in asthma prevalencebegan in the 1960s/70s and has increased steadily since this time.

3. The prevalence of asthma is greater in urban communitiescompared with rural communities throughout the region. Thereasons for these differences are uncertain.

4. The trend of increasing asthma prevalence has been associatedwith 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 theformer socialist countries of the Baltics as these communitiesincreasingly adopt the Western lifestyle.

6. There is considerable underdiagnosis of asthma within the formersocialist countries in the Baltic region compared withScandinavia. This is illustrated by the considerably lower

percentage of individuals with asthma symptoms who receive adiagnosis of asthma in these countries.

7. The cost of asthma medications is a major barrier to the deliveryof health care to asthmatics within the former socialist countriesin the Baltic region. In these countries a considerably lowerpercentage of individuals with asthma symptoms receives asthmamedication.

Number of persons with asthma: 3.4 m

Total population: 70.2 m

Mean prevalence of clinical asthma: 4.9%

DenmarkEstonia

Finland

IcelandLatvia

Lithuania

NorwayPoland

Sweden


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8. Asthma mortality rates have declined markedly over the last 10years in Scandinavian countries, a trend which has beenattributed to improvements in asthma management, including theincreased use of inhaled corticosteroid therapy. These countrieshave amongst the lowest case fatality rates worldwide andindicate the potential that exists to reduce asthma mortality inother countries.

9. The national asthma public health programmes developed in anumber of Scandinavian countries can be used by other countriesas models of programmes which have been shown to markedlyreduce morbidity and mortality from asthma. The nationalprogramme developed in Finland represents a particularlysuccessful multidisciplinary programme in which the strategicplanning, principles, implementation, and evaluation have beenclearly outlined.

10.Work is an important cause for the development of asthma inboth men and women within the region. The risk is particularlyhigh for agricultural, forestry, fishing, and manufacturing workers.The potential for prevention is considerably greater and morewidely spread than generally assumed.

25

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Asher MI, Keil U, Anderson HR et al. International study of asthma andallergies in childhood (ISAAC): rationale and methods. Eur Respir J1995; 8: 483-91.

Asthma Programme in Finland 1994-2004: Report of a Working Group.Clin Exper Allergy1996; 26(Suppl 1): 1-24.

Backer V, Dirksen A, Bach-Mortensen N, Hansen KK, Laursen EM,Wendelboe D. The distribution of bronchial responsiveness to histamineand exercise in 527 children and adolescents. J Allergy Clin Immunol1991; 88: 68-76.

Backer V, Ulrik CS. Bronchial responsiveness to exercise in a randomsample of 494 children and adolescents from Copenhagen. Clin Exper

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Bjrnsson E, Plaschke P, Norrman E, Janson C, Lundbck B, Rosenhall A,Lindholm N, Rosenhall L, Berglund E, Boman G. Symptoms related toasthma and chronic bronchitis in three areas of Sweden. Eur Respir J1994; 7: 2146-53.

Brbck L, Breborowicz A, Dreborg S, Knutsson A, Pieklik H, Bjrkstn B.Atopic sensitization and respiratory symptoms among Polish and Swedishschoolchildren. Clin Exper Allergy1994; 24: 826-35.

Breborowicz A, Burchardt B, Pieklik H. Asthma, allergic rhinitis and atopic

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Breborowicz A, Swiatly A, Alkiewicz J, Moczko J. Use of a videoquestionnaire for assessment of asthma prevalence in schoolchildren aspart of the ISAAC epidemiology study. Pneumonologia i AlergologiaPolska 1998; 66: 368-72.

Brogger J, Bakke P, Eide GE, Johansen B, Andersen A, Gulsvik A. Long-termchanges in adult asthma prevalence. Eur Respir J 2003; 21: 468-72.

Burney P. The changing prevalence of asthma? Thorax2002; 57(Suppl II):ii36-ii39.

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Chinn S, Burney P, Jarvis D, Luczynska C on behalf of the EuropeanCommunity Respiratory Health Survey (ECRHS). Variation in bronchialresponsiveness in the European Community Respiratory Health Survey(ECRHS). Eur Respir J 1997; 10: 2495-501.

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31

United Kingdom/Republic of Ireland

Key Points:

1. This region has amongst the highest prevalence rates of asthma inthe world.2. There has been a marked increase in the incidence of asthma

attacks diagnosed by general practitioners over the last fewdecades, such that it is now about five times higher than it was25 years ago. About 20,000 first or new episodes of asthmapresent each week to general practitioners in the region.

3. Asthma disproportionately affects certain ethnic minority groups

and low socioeconomic groups, which represent a priority formanagement initiatives.4. Asthma is one of the leading causes of hospital admission in

children. There are over 75,000 emergency hospital admissionsdue to asthma each year, a quarter of which are in childrenbelow 4 years of age. The number of hospital admissions hasgradually 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. Anaverage primary care organisation in the United Kingdom of330,000 people can expect to treat 25,000 people with asthma,with over 400 patients with asthma admitted to hospital and 8asthma deaths each year.

6. It has been estimated that one in four people have severe ormoderately severe asthma that might be relieved if treatmentwere reviewed and made more appropriate. However, one in 10

people living with asthma has severe or moderately severeasthma that is inadequately controlled despite the best clinicaland preventive management.




EnglandGuernsey

Isle of Man

JerseyNorthern Ireland

Republic of Ireland

ScotlandWales


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7. Currently over 1,500 people die from asthma each year withinthe region. Confidential inquiries have shown that suboptimalroutine care, delay in obtaining help during the final attack, andpoor 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 themanagement of asthma, particularly the increased use of inhaledcorticosteroid therapy.

9. The total cost of asthma in the region has been estimated to beabout 2.5 billion. This includes the cost of about 900 millionto the public health service. It is estimated that 50% of all annualhealthcare costs for asthma come from the most severe 20% ofthe asthmatic population. About 20 million working days are lostdue to asthma each year.

10.The United Kingdom National Asthma Campaign is a successfulmodel of a national education, management, and research-basedprogramme which has contributed to reducing the burden ofasthma in the region. It could be used as a basis for similarpublic health programmes in other countries, as well as a

resource for educational material and management programmes.

32

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37

Western Europe

Key Points:

1. The prevalence of asthma is generally high within WesternEurope. The prevalence of other atopic diseases such as allergicrhinitis and eczema are amongst the highest in the world.

2. The prevalence of asthma is generally higher in urban areascompared with suburban areas, and lower in communities livingat high altitude. The lowest levels are in individuals who havelived on a farm in childhood.

3. The available evidence indicates that the prevalence of asthmahas increased markedly in both children and adults over recentdecades within the region. The increase has been particularlymarked in the former East Germany, which now has prevalencerates which are similar to those in former West Germany.

4. There are wide variations in the treatment of asthma withinWestern Europe; however, in general asthma is often undertreatedand management generally falls short of that recommended in

international guidelines.5. The burden of asthma is considerable within the region, withover one in four children and adults with asthma requiring anunscheduled urgent care visit in the previous twelve-month period.

6. Asthma remains an important cause of hospital admissions. Forexample, in Switzerland there are over 40,000 asthma-relatedhospitalizations annually, representing the largest category ofdirect medical expenditures for asthma.

7. The experience with the soybean epidemic asthma in Barcelonademonstrates the potential impact of exposure to a workplacesensitizing agent within the general community. It also suggeststhat episodes of severe asthma in the community which areconsidered idiopathic may be due to the inhalation of airborneoccupational agents and illustrates the importance of vigilance withrespect to the patterns of asthma exacerbations in communities.




AustriaBelgium

FranceGermany

ItalyLuxembourg

NetherlandsPortugal

SpainSwitzerland


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8. Asthma is a major health-care cost in countries within this regionwith both significant direct medical and indirect costs for asthma-related morbidity. For example, in the Netherlands it has beenestimated that the annual direct medical cost per person withasthma is about US $500.

9. There has been a general trend of declining asthma mortality inmost countries within Western Europe. This pattern has beenprimarily attributed to changes in management, in particular theincreasing use of inhaled corticosteroids. For example, inGermany, in the 1990s there was a strong and significantnegative correlation between asthma mortality and prescribedinhaled corticosteroid use.

10.There are a number of countries within Western Europe, such asFrance, in which the asthma mortality rate has not fallen over thelast decade to the degree observed in other countries. One of thepriorities within these countries is public health strategies toreduce the number of deaths from asthma.

38

FURTHER READING

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