The Global Asthma Network

The Global Asthma Network Innes Asher Department of Paediatrics: Child and Youth Health The University of Auckland, New Zealand Chair of the International Study of Asthma and Allergies in Childhood (ISAAC) and the Global Asthma Network 19 May 2014 http://www.globalasthmanetwork.org

Ehara tāku toa i te toa takitahi ēngari he toa takimano e My strength is not mine alone, but that of many

In this lecture Global burden of asthma ISAAC prevalence and severity ISAAC Environmental factors The Global Asthma Network Asthma in NZ

GBD - The global burden of asthma About 334 million people in the world have asthma Asthma is the 14th most important disorder in terms of global years lived with a disability (YLD) Deaths are less common from asthma than from other chronic diseases Vos T et al. Lancet 2012; 380: 2163 96

GBD - Disability adjusted life years (DALY s) from asthma in childhood Global rank compared with other causes Age (yrs) 2010 1-4 18 5-9 8 10-14 3 15-19 12 http://www.healthdata.org/data-visualization/gbd-arrow-diagram

85% of the world s 7.2 billion people live in low and middle income countries (LMICs) GNI per capita

Prevalence of asthma symptoms in children - until 1991 there were few studies

ISAAC*: 306 research centres in 105 countries *The International Study of Asthma and Allergies in Childhood

Prevalence ISAAC found that: asthma occurs everywhere in the world is more common than was thought there are large variations

Lai CKW et al. Thorax 2009; 64: 476-83.

Lai CKW et al. Thorax 2009; 64: 476-83.

Lai CKW et al. Thorax 2009; 64: 476-83.

Increase in Current Wheeze in School Children, 1973-1995 30 New Zealand 25 New Zealand Current Wheeze (%) 20 15 Australia Wales England England 10 Scotland & England 5 Scotland 0 1970 1975 1980 1985 1990 1995 2000 Year Magnus P, Jaakkola JJ. BMJ 1997; 14: 1795-9.

Prevalence changes over time ISAAC found that asthma overall is increasing increases are more common in LMICs

Severity Wheezing in the past 12 months and at least one of : >4 attacks of wheeze >1 night per week sleep disturbance from wheeze wheeze limiting speech Lai CKW et al. Thorax 2009; 64: 476-83.

ISAAC found that asthma is more commonly severe in low and middle income countries

ISAAC found that asthma is not strongly associated with allergy in non-affluent countries

Association of current wheeze & skin prick test reactivity Weinmayr G et al. Am J Respir Crit Care Med 2007; 176: 565-74.

Has ISAAC shed light on causation?

Professor Sir Geoffrey Rose, 1992 The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social.

Genetics could these explain differences in asthma rates? Unlikely based on Rose s premise ISAAC found small variations in allele frequency insufficient to explain large variations in prevalence* *Genuneit J et al. Clin & Exper Allergy, 2009 (39) 1875 1888.

ISAAC environmental factors ISAAC investigated the air we breathe: Outdoor air pollution Outdoor pollution Truck traffic Indoor air pollution Tobacco Open fire cooking

ISAAC environmental factors ISAAC investigated what we ingest: Diet Breastfeeding Fruit and vegetables Fastfood/burgers Medicines Paracetamol Antibiotics

ISAAC environmental factors ISAAC investigated lifestyle: Animals farm cats and dogs Housing Damp and mould Number of siblings Migration

ISAAC Outdoor air pollution - not assoc. with prevalence of symptoms of asthma PM 10 Satellite data PM 2.5 (also NO 2, O 3 ) Anderson HR, et al. Occup Environ Med 2010; 67:293-300. Anderson HR, et al. Environ Health Perspect 2012; 120:1333 1339. Ecological analyses

ISAAC Truck traffic in street of residence almost the whole day vs never +ve assoc. with current wheeze Odds Ratio 1.35 (1.22-1.48) Brunekreef B, et al. Environ Health Perspect 2009; 117: 1791-8.

ISAAC Maternal smoking +ve assoc. with asthma symptoms Age of children 6-7 yrs 13-14 yrs Fully adjusted OR (95%CI) 1.31 (1.22-1.41) 1.27 (1.19-1.36) Mitchell E, et al. Thorax 2012;67(11):941 949.

ISAAC Cooking with open fire only +ve assoc. with current wheeze Age of children 6-7 yrs 13-14 yrs Fully adjusted OR (95%CI) 2.17 (1.64-2.87) 1.35 (1.11-1.64) Wong GWK, et al. Lancet Resp 2013; 1(5):386-394.

Farm animal exposure Alpine Europe Farm animals and pasteurised milk in pregnancy and first year of life markedly protective against asthma Riedler J, Braun-Fahrländer C, von Mutius E et al. Lancet. 2001;358:1129-1133.

ISAAC Farm animals in the first year of life +ve assoc. with current wheeze L Smit. IJE 2012:41:761 Fully adjusted OR (95%CI) Countries In pregnancy In 1 st year of life Non-affluent 1.38 (1.21-1.58) 1.27 (1.12-1.44) Affluent 0.95 (0.84-1.08) 0.96 (0.86-1.08) Brunekreef B, et al. Int J Epidemiol 2012; 41: 753-61.

Cat and dog exposure +ve assoc. with current wheeze Fully adjusted Odds Ratio (95%CI) Cat in the 1 st year of life Cat (13-14 years) Dog (13-14 years) 1.17 (1.09-1.26) 1.09 (1.02-1.15) 1.10 (1.04-1.16) Brunekreef B, et al. Epidemiology 2012; 23: 742-50.

ISAAC Breastfeeding ve assoc. with current wheeze Countries Current wheezers Non-atopic Atopic Non-affluent 0.69 (0.53-0.90) 0.86 (0.55-1.35) Affluent 0.87 (0.72-1.06) 0.85 (0.67-1.08) Nagel G, et al. Eur Respir J 2009; 33: 993-1002.

ISAAC Burgers and fast food +ve assoc. with current wheeze Fully adjusted Odds Ratio (95%CI) Consumption of burgers Consumption of fast food/burgers 1.42 (1.08-1.87) 1.39 (1.30-1.49) Nagel G et al. Thorax 2010; 65: 516-22. Ellwood P et al. Thorax 2013: 68(4):351-360.

ISAAC Fruit and vegetables ve assoc. with current wheeze Fully adjusted Odds Ratio (95%CI) Consumption of vegetables Consumption of fruit 0.86 (0.74-0.98) 0.86 (0.76-0.97) Nagel G et al. Thorax 2010; 65: 516-22. Ellwood P et al. Thorax 2013: 68(4):351-360.

ISAAC Obesity +ve assoc. with current wheeze Age of children 6-7 yrs 13-14 yrs Fully adjusted OR (95%CI) 1.27 (1.12-1.44) 1.29 (1.14-1.46) Mitchell E, et al. Clin Exp Allergy 2012; 43: 73-84

ISAAC Medicines in the first year of life +ve assoc with current wheeze Fully adjusted Odds Ratio (95%CI) Antibiotic use in the 1 st year of life Paracetamol use in the 1 st year of life 1.70 (1.60-1.80) 1.46 (1.36-1.56) Foliaki S et al. J Allergy Clin Immunol 2009; 124: 982-9. Beasley R et al. Lancet 2008; 372: 1039-48.

These relationships may be potentially causal or may be due to reverse causation paracetamol/antibiotics given because of respiratory symptoms confounding by indication paracetamol/antibiotics given for chest infections, which were in turn associated with subsequent respiratory disease

Damp and mould in housing +ve assoc. with current wheeze and cough with phlegm Symptom Fully adjusted Odds Ratio (95%CI) Current wheeze 1.58 (1.40 1.79) Cough with phlegm 1.71 (1.47;1.99 Frequent cough with phlegm 1.91 (1.51;2.41) Weinmayr G et al. Clin Exp Allergy 2013, 43, 762 774

ISAAC higher total number of siblings not assoc. with current wheeze Age of children 6-7 yrs 13-14 yrs Fully adjusted Odds Ratio (95%CI) 0.99 (0.92,1.05) 0.97 (0.91,1.04) Strachan D et al. Clin Exp Allergy 2014 epub doi.org/10.1111/cea.12349

ISAAC higher total number of siblings +ve assoc. with severe wheeze Age of children 6-7 yrs 13-14 yrs Fully adjusted Odds Ratio (95%CI) 1.19 (1.09,1.30) 1.14 (1.05,1.24) Strachan D et al. Clin Exp Allergy 2014 epub doi: 10.1111/cea.12349

ISAAC migration -ve assoc. with current wheeze Age of children 6-7 yrs 13-14 yrs Fully adjusted Odds Ratio (95%CI) 0.87 (0.77 0.98) 0.88 (0.79 0.99) Garcia-Marcos L et al. Int J Epidem 2014 epub doi: 10.1093/ije/dyu145

Has ISAAC shed light on causation? Many potentially preventative strategies for further exploration The process of urbanisation needs further exploration

http://www.globalasthmanetwork.org o Established 2012 o Builds on the work of ISAAC and the International Union of Tuberculosis and Lung Disease (The Union) o Current funding - The Union (More needed)

Global Asthma Network 276 centres in 119 countries

GAN Target: Decrease severe asthma by 50% by 2025 DECREASE: severity of asthma proportion of symptomatic people with asthma not on ICS time off work/school because of asthma unplanned visits for asthma hospital admissions for asthma mortality from asthma

GAN Target: Increase access to quality-assured essential asthma medicines On the WHO prequalification list On all National Essential Medicines Lists Available in all countries Affordable in all countries

GAN Survey of Asthma Guidelines and National Asthma Strategies 2013 Asthma guidelines used: only 89% countries National asthma strategies: only 23% countries

Next GAN research 2015 - GAN is doing the ONLY world surveys of asthma in children and adults ISAAC protocol 6-7 yrs and 13-14 yrs Adults - parents of children Measurements questionnaires: Prevalence, severity Asthma management and control Risk factors

Asthma in NZ

Symptoms of Asthma Among Children and Adults in New Zealand Wheeze in the past year 6-7 Year Age Group ISAAC Phase Three 2002-3 13-14 Year Age Group ISAAC Phase Three 2002-3 Adults 20 44 Years ECRHS 22.2% 1 26.7% 1 25.9% 2 Asthma ever 30.2% 1 32.4% 1 1 Asher MI, et al. N Z Med J 2008; 121: 52-63. 2 ECRHS. Eur Respir J 1996; 9, 687-95. 3 Lai CKW, et al. Thorax 2009; 64: 476-83.

ISAAC Phase Three: Symptoms of Asthma by Ethnicity Among 6-7 Year Old Children in New Zealand Maori Pacific European Wheeze in the past year 28.5% 25.2% 20.7% 1 night waking/week from wheeze in the past year 17.1% 16.4% 12.1% Asthma ever 38.8% 26.4% 29.0% Ellison-Loschmann L, et al. Int J Tuberc Lung Dis 2009; 13: 775-82.

ISAAC Phase Three: Symptoms of Asthma by Ethnicity Among 13-14 Year Old Adolescents in New Zealand Maori Pacific European Wheeze in the past year 29.9% 20.8% 28.6% 1 night waking from wheeze in the past year 15.9% 12.9% 9.9% Asthma ever 37.6% 24.7% 34.2% Ellison-Loschmann L, et al. Int J Tuberc Lung Dis 2009; 13: 775-82.

Asthma and wheeze are the top of the list of hospital admissions in NZ for conditions with a social gradient 0-14 yrs 2008-2012 Craig E, et al. Child Poverty Monitor technical report NZCYES 2013

Hospital Admissions and Deaths due to Asthma in Children and Young People 0-24 Years, New Zealand 1990-2006 Craig E, et al. New Zealand Child and Youth Epidemiology Service; 2011.

Hospital Admissions and Deaths due to Asthma in Children and Young People 0-24 Years by Age, New Zealand 2006-2010 Craig E, et al New Zealand Child and Youth Epidemiology Service; 2011.

Hospital Admissions due to Asthma in Children and Young People 0-24 Years by Ethnicity, New Zealand 2000-2010 Increasing gaps Craig E, et al. New Zealand Child and Youth Epidemiology Service; 2011.

Rates for Hospital Admissions due to Asthma in Children 0-24 Years by NZDep Index Decile, New Zealand 2006-2010 9.0 8.0 7.0 6.0 Rate 5.0 4.0 3.0 2.0 1.0 0.0 1 2 3 4 5 6 7 8 9 10 NZDep Index Decile Craig E, et al. New Zealand Child and Youth Epidemiology Service; 2011.

Addressing the inequalities The root disparities in the determinants of health need to be addressed by government policy changes poverty inadequate basic health care: barriers to primary health care including cost variable prescription of inhaled steroids cost of medicines low health literacy unhealthy housing

In NZ improved housing quality helps asthma Improved: self-reported wheezing days off school and work fewer visits to GPs fewer hospital admissions for respiratory conditions children with asthma significantly reduced their symptoms, days off school and healthcare visits Howden Chapman P, et al 2007 and 2009 Jackson G. J Epidem Comm Health 2011; 65:588-593.

Addressing the inequalities Asthma Foundation of NZ: Update asthma guidelines: BPAC (Best Practice Advocacy Centre) NICE guidelines (National Institute for Health Care and Excellence, UK) National respiratory strategy (including asthma) being prepared Respiratory disease impact report (including asthma) due September 2014 (review of published work)

Ongoing monitoring of asthma in NZ NZCYES 0-24 years admissions, deaths NZ Health Survey all ages two questions asthma ever any asthma treatment GAN 6-7 yr, 13-14 yr, adults prevalence, severity asthma management and control risk factors

Ma tōu rourou, ma tōku rourou, Ka ora ai ngā tamariki With your small basket and my small basket we can keep the children well