Epidemiological measures of childhood asthma: cross-sectional and longitudinal consistency

Neonatal inflammation and its association with asthma and obesity in late childhood among individuals born extremely preterm

BACKGROUND

Asthma and obesity are frequent outcomes among individuals born extremely preterm and are associated with decreased lifespan. Neonatal inflammation is associated with chronic neurodevelopmental disorders; however, it is less studied in association with other later childhood chronic disorders in this population.

METHODS

Fourteen hospitals in 5 U.S. states enrolled 1506 infants born before 28 weeks of gestation in the Extremely Low Gestational Age Newborn cohort in 2004-2014. Neonatal blood spots were collected on postnatal days 1, 7, 14, 21, and 28, and used to measure 14 inflammation-related proteins. Associations were evaluated between high (top quartile) levels of proteins and two chronic health disorders at ages 10 and 15 years: physician-diagnosed asthma and obesity (body mass index ≥95th percentile).

RESULTS

Few associations were found between high levels of 14 inflammation-related proteins, either on a single day or on multiple days, and either asthma or obesity. Similarly, few associations were found in analyses stratified by sex or presence/absence of prenatal inflammation.

CONCLUSIONS

In extremely preterm newborns, systemic elevations of inflammation-related proteins during the neonatal period were not associated with childhood asthma and obesity outcomes at 10 or 15 years of age.

IMPACT

In the large multi-center Extremely Low Gestational Age Newborn (ELGAN) cohort, sustained elevation of neonatal levels of inflammation-related proteins was not consistently associated with asthma or obesity outcomes at 10 or 15 years of age. This finding contrasts with reported associations of perinatal inflammation with obesity at 2 years and neurodevelopmental disorders at 2-15 years in the ELGANs, suggesting that unlike neurodevelopment, peripubertal obesity and asthma may be driven by later childhood exposures. Future research on perinatal mechanisms of childhood asthma and obesity should account for both fetal and later exposures and pathways in addition to inflammation at birth.

Whispers of change in preschool asthma phenotypes: Findings in the French ELFE cohort

RATIONALE

Early life asthma phenotyping remains an unmet need in pediatric asthma. In France, severe pediatric asthma phenotyping has been done extensively; however, phenotypes in the general population remain underexplored. Based on the course and severity of respiratory/allergic symptoms, we aimed to identify and characterize early life wheeze profiles and asthma phenotypes in the general population.

METHODS

ELFE is a general population based birth cohort; which recruited 18,329 newborns in 2011, from 320 maternity units nationwide. Data was collected using parental responses to modified versions of ISAAC questionnaire on eczema, rhinitis, food allergy, cough, wheezing, dyspnoea and sleep disturbance due to wheezing at 3 time points: post-natal (2 months), infancy (age 1) and pre-school (age 5). We built a supervised trajectory for wheeze profiles and an unsupervised approach was used for asthma phenotypes. Chi squared (χ2) test or fisher's exact test was used as appropriate (p < 0.05).

RESULTS

Wheeze profiles and asthma phenotypes were ascertained at age 5. Supervised wheeze trajectory of 9161 children resulted in 4 wheeze profiles: Persistent (0.8%), Transient (12.1%), Incident wheezers at age 5 (13.3%) and Non wheezers (73.9%). While 9517 children in unsupervised clusters displayed 4 distinct asthma phenotypes: Mildly symptomatic (70%), Post-natal bronchiolitis with persistent rhinitis (10.2%), Severe early asthma (16.9%) and Early persistent atopy with late onset severe wheeze (2.9%).

CONCLUSION

We successfully determined early life wheeze profiles and asthma phenotypes in the general population of France.

The external validation of the asthma prediction tool in the French ELFE cohort

BACKGROUND

Existing predictive scores for early identification of children at high risk of developing asthma include invasive procedures, and hence have limited utility in a primary care setting. The Leicestershire respiratory cohort (LRC) has developed a noninvasive asthma prediction tool (APT) for children with promising results. We aimed to perform its external validation in the French general population Étude Longitudinale Française depuis l'Enfance (ELFE) cohort.

METHODS

Predictive scores were determined at Age 1 and the primary outcome of asthma was defined as parental reporting of "asthma ever or "wheezing in the past 12 months" at Age 5. Logistic regression was used to calculate the odds ratio (OR) and performance measures, and discriminative performance was reported using the receiver operating curve and area under curve (AUC). Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and visualized with a calibration plot. Overall performance was determined using Brier scores.

RESULTS

Of the 10,689 children analyzed: 84.9% were at low, 13.1% medium, and 2% at high risk of developing asthma at Age 5. Children in the medium-risk category were three times more likely to develop asthma (OR = 3.3, 95% confidence interval [CI] = 2.97-3.78) whereas 13 times more likely in the high-risk category (OR = 13.8, 95% CI = 10.2-18.8). The tool's AUC was comparable: LRC 0.74 versus ELFE 0.68; as were the Brier scores LRC 0.16 versus ELFE 0.14. The tool's performance was robust to changes in inclusion criteria and outcome definitions.

CONCLUSIONS AND RELEVANCE

Results of the present study and previous validation studies performed in high-risk populations provide a comprehensive measure of the effectiveness of the APT, providing encouragement for its application by general practitioners.

Gestational hypertension and childhood atopy: a Millennium Cohort Study analysis

Gestational hypertension may confer risk of atopic disease in offspring through a direct biological mechanism, but another possibility is that risk is mediated through complications of pregnancy. To explore these associations, we conducted an analysis of a nationally representative birth cohort based in the UK involving children born 2000-2002. We included 12,450 mother-child pairs. We used logistic regression to estimate the association between hypertensive disease and asthma, hay fever, or eczema by age 5, and parentally reported early wheeze and severe wheeze. Mediation by gestation at delivery and caesarean delivery was explored using causal mediation analysis. Odds ratios (95% CI) for gestational hypertension and childhood asthma, hay fever, and eczema were 1.32 (1.09, 1.59), 1.22 (0.97, 1.55), and 1.12 (0.96, 1.32) respectively, adjusted for confounding. The population attributable fractions were 2.4% (1.0-3.8%), 0.9% (-0.3% to 2.1%), and 1.8% (0.0-3.7%), respectively. Accounting for mediation by gestational age and caesarean delivery, odds ratios (95% CI) for the potential direct effects of gestational hypertension were 1.21 (0.97, 1.50), 1.17 (0.91, 1.49), and 1.11 (0.94, 1.31) for the same.Conclusion: Gestational hypertension was weakly positively associated with asthma and this was partly mediated by earlier delivery. Only a small proportion of early childhood asthma was attributable to gestational hypertensive disease in this representative UK-based birth cohort. What is known: • Gestational hypertension has been shown to be an inconsistent risk factor for the atopic diseases. • The in utero immune environment may modify the risk of atopy in offspring; alternatively, complications of pregnancy including caesarean delivery and prematurity may explain an association between hypertensive disease and atopy. What is new: • Self-reported gestational hypertension was a weak risk factor for asthma and wheeze in the Millennium Cohort Study. • Part of the association between gestational hypertensive disease and asthma was explained by earlier delivery.

Defining asthma in children: how well do parents, doctors and spirometry agree?

Background

Because diagnosing asthma in school-aged children is challenging, a variety of proxies for asthma are used in clinical practice and research settings as indicators of this disease. We aimed to provide insight into the agreement between various asthma indicators based on parental report, medical diagnosis and spirometry.

Methods

Children from the WHISTLER birth cohort performed spirometry and were followed up with parental ISAAC (International Study of Asthma and Allergies in Childhood) questionnaires about asthma at 5 and 8 years of age. Medical data were extracted from primary care records. We compared 15 asthma indicators based on parental report, medical diagnosis and spirometry using positive agreement, κ statistics and latent class cluster analysis.

Results

At 5 years of age, 1007 children completed a study visit, while 803 children visited at 8 years of age. Depending on the indicator, the responder and child's age, the asthma prevalence ranged from 0.2% to 26.6%. Cluster analysis revealed classes related to the presence of recent symptoms and a decreased lung function. Agreement between parents and doctors was generally low with κ coefficients ranging from 0.07 (recent wheeze) to 0.52 (recent asthma medication). Additionally, parental report showed to be sensitive to recall bias over time.

Conclusions

Dependent on the asthma indicator, the responder and the age of the child, substantial differences in agreement were observed between commonly used indicators associated with asthmatic disease in school-aged children. Most agreement between parents and doctors was seen for objective and recent indicators such as the recent use of asthma medication. We advocate caution when literature with different asthma indicators is compared.

A variety of clinical definitions are used as indicators of asthma. There are substantial differences in agreement between parents, doctors and lung function. Caution is needed when literature with different asthma indicators is compared.https://bit.ly/2VxDH8p

Accuracy of Maternal Reports of Young Children's Dental Disease Status: Avon Longitudinal Study of Parents and Children

Background: Parental reports of their children's health status is integral to pediatric medical and dental care. Therefore, understanding the accuracy of such reports is vital. Our objectives were to (1) assess the correlation between maternal reports of their children's indicators of caries experience (subjective assessment) and actual caries status determined by oral examination (objective assessment), and (2) identify potential modifiers of this correlation. Methods: Longitudinal data from the Avon longitudinal study of parents and children (n = 1429) was used to assess the correlation between maternal reports of the number of missing and filled teeth of children aged 38 months, 54 months, and 5.5 years and clinical oral examinations of decayed, missing and filled teeth conducted when the same children were 31, 43 months, and five years of age. Homogeneity chi-square tests assessed differences in correlations according to sociodemographic factors. Results: Overall, we found a statistically significant correlation that was weak to moderate in magnitude. Maternal reports of missing teeth at 38 months was significantly correlated with decayed teeth, 0.27 (p < 0.001); missing teeth, 0.23 (p < 0.001), and the decayed, missing and filled (dmft) index, 0.35 (p < 0.001) based on oral examination at 31 months. A maternal report of filled teeth at 54 months was significantly correlated with decayed teeth, 0.30 (p < 0.001); filled teeth 0.30 (p < 0.001), and dmft 0.40 (p < 0.001) at 43 months. Mothers tended to underestimate the extent of missing and filled teeth in their children irrespective of the child's age, but the extent of underestimation was greater among younger children. Maternal age, education level, and whether the child had ever visited a dentist were significant modifiers of subjective and objective caries assessments. Conclusions: From a clinical and dental public health perspective, our findings of a weak to moderate correlation of maternal assessments of their children's caries experience may be concerning when reporting the burden of dental diseases in large population studies or for surveillance purposes that rely on self-reported measures and must therefore be utilized with caution because of the potential to result in underestimated disease burden.

Pre-pregnancy Maternal Weight and Gestational Weight Gain Increase the Risk for Childhood Asthma and Wheeze: An Updated Meta-Analysis

Background: Mounting evidence suggests that childhood asthma is closely associated with maternal weight before pregnancy and gestational weight gain (GWG), yet the results are not often reproducible. Objectives: We conducted a comprehensive meta-analysis, aiming to evaluate the association of pre-pregnancy maternal obesity or overweight and high GWG with the risk for childhood asthma and wheeze. Methods: Literature search, quality assessment, and data extraction were completed independently and in duplicate. Effect-size estimates are expressed as odds ratio (OR) with 95% confidence interval (CI). Results: Twenty-two observational studies involving 145,574 mother-child pairs were meta-analyzed. In overall analyses, maternal obesity or overweight in pre-pregnancy significantly increased the risk of both childhood asthma and wheeze (adjusted OR: 1.41 and 1.13, 95% CI: 1.26-1.59 and 1.07-1.20, both p < 0.001). Per 1 kg/m² increment in maternal body mass index was associated with a significantly increased risk of childhood asthma and wheeze (adjusted OR: 1.03, 95% CI: 1.02-1.03, p < 0.001). Compared with normal GWG, very high GWG (adjusted OR: 1.24, 95% CI: 1.04-1.47, p: 0.018), moderate high GWG (adjusted OR: 1.12, 95% CI: 1.04-1.21, p: 0.004), and very low GWG (adjusted OR: 1.26, 95% CI: 1.08-1.47, p: 0.004) increased the risk of childhood asthma and wheeze. There was a low probability of publication bias. Conclusions: Our findings indicate that both pre-pregnancy maternal obesity or overweight and very to moderate high or low GWG render their offspring susceptible to a significantly increased risk of having childhood asthma and wheeze.

Prevalence of chronic rhinosinusitis in the general population based on sinus radiology and symptomatology

BACKGROUND

The prevalence of chronic rhinosinusitis (CRS) measured in epidemiologic studies is 5% to 12%. This might be an overestimation because of overlap with other diseases, such as allergic rhinitis.

OBJECTIVE

We aimed to calculate the prevalence of CRS using a combination of epidemiologically based CRS according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) together with sinonasal opacification on imaging.

METHODS

Subjects who underwent a computed tomographic or magnetic resonance imaging scan of the head for any nonrhinologic indication were asked to fill in the Global Allergy and Asthma European Network survey containing EPOS symptom criteria. The scans were evaluated according to the Lund-Mackay (LM) scoring system. Epidemiologically based CRS is based on nasal symptoms according to EPOS; clinically based CRS also encompasses endoscopy and/or CT scanning.

RESULTS

Eight hundred thirty-four subjects were included. One hundred seven (12.8%) had epidemiologically based CRS according to EPOS. Of these subjects, 50% had an LM score of 0, 26% had an LM score of 1 to 3, and 23% had an LM score of 4 or greater. Twenty-five (3.0%) subjects had clinically based CRS (based on LM score ≥4), and 53 (6.4%) subjects had clinically based CRS (based on LM score >0). Allergic rhinitis was reported by 167 (20%) subjects. In subjects who did not report upper airway symptoms, 57% had an LM score of 0, 30% had an LM score of 1 to 3, and 12% had an LM score of 4 or greater.

CONCLUSION

We found a prevalence of 3.0% to 6.4% of clinically based CRS (depending on an LM cutoff point; ie, LM ≥ 4 or LM > 0, respectively) in a relatively randomly selected group of subjects.

Early life vitamin D status and asthma and wheeze: a systematic review and meta-analysis

BACKGROUND

Vitamin D deficiency has been linked to an increased risk of asthma. This study aimed to quantify the effect of early life vitamin D status on asthma and wheeze later in life.

METHODS

PubMed, Embase, CINAHL, and CNKI databases, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to July 2017. We included randomized controlled trials (RCTs) and cohort studies with vitamin D level in blood (maternal or cord or infant) or intake (maternal intake during pregnancy or infant intake) and asthma and/or wheeze. Two reviewers independently extracted data. Fixed- and random-effects models were used to summarize the risk estimates of comparisons between highest vs. lowest vitamin D categories.

RESULTS

Of the 1485 studies identified, three RCTs and 33 cohort studies were included. We did not include the RCTs (1619 participants) in the meta-analysis as the comparators and outcome definitions were heterogenous. Three RCTs reported a non-statistically significant effect of vitamin D supplementation during pregnancy on offspring wheeze/asthma at 3 years of age. Pooled estimates of cohort studies suggest no association between antenatal blood vitamin D levels or vitamin D intake and offspring asthma assessed either > 5 years or ≤ 5 years. The estimate for blood vitamin D remained unchanged when two studies assessing asthma in adulthood were excluded, but a significant inverse association emerged between vitamin D intake and childhood asthma. We found no association between antenatal vitamin D level and wheeze. On the other hand, vitamin D intake during pregnancy may have a protective effect against wheeze.

CONCLUSIONS

The pooled estimates from cohort studies show no association between antenatal blood vitamin D level and asthma/wheeze in later life. Whereas, the pooled estimates from cohort studies suggest that antenatal vitamin D intake may have an effect on childhood asthma > 5 years or childhood wheeze. The inconsistent results from studies assessing vitamin D either in blood or intake may be explained by previously reported non-linear association between blood vitamin D3 and childhood asthma. Further trials with enough power and longer follow-up time should be conducted to confirm the results.

Childhood asthma prevalence: cross-sectional record linkage study comparing parent-reported wheeze with general practitioner-recorded asthma diagnoses from primary care electronic health records in Wales

Introduction

Electronic health records (EHRs) are increasingly used to estimate the prevalence of childhood asthma. The relation of these estimates to those obtained from parent-reported wheezing suggestive of asthma is unclear. We hypothesised that parent-reported wheezing would be more prevalent than general practitioner (GP)-recorded asthma diagnoses in preschool-aged children.

Methods

1529 of 1840 (83%) Millennium Cohort Study children registered with GPs in the Welsh Secure Anonymised Information Linkage databank were linked. Prevalences of parent-reported wheezing and GP-recorded asthma diagnoses in the previous 12 months were estimated, respectively, from parent report at ages 3, 5, 7 and 11 years, and from Read codes for asthma diagnoses and prescriptions based on GP EHRs over the same time period. Prevalences were weighted to account for clustered survey design and non-response. Cohen’s kappa statistics were used to assess agreement.

Results

Parent-reported wheezing was more prevalent than GP-recorded asthma diagnoses at 3 and 5 years. Both diminished with age: by age 11, prevalences of parent-reported wheezing and GP-recorded asthma diagnosis were 12.9% (95% CI 10.6 to 15.4) and 10.9% (8.8 to 13.3), respectively (difference: 2% (−0.5 to 4.5)). Other GP-recorded respiratory diagnoses accounted for 45.7% (95% CI 37.7 to 53.9) and 44.8% (33.9 to 56.2) of the excess in parent-reported wheezing at ages 3 and 5 years, respectively.

Conclusion

Parent-reported wheezing is more prevalent than GP-recorded asthma diagnoses in the preschool years, and this difference diminishes in primary school-aged children. Further research is needed to evaluate the implications of these differences for the characterisation of longitudinal childhood asthma phenotypes from EHRs.

Asthma and dietary intake: an overview of systematic reviews

Epidemiological research on the relationship between diet and asthma has increased in the last decade. Several components found in foods have been proposed to have a series of antioxidant, anti-allergic and anti-inflammatory properties, which can have a protective effect against asthma risk. Several literature reviews and critical appraisals have been published to summarize the existing evidence in this field. In the context of this EAACI Lifestyle and asthma Task Force, we summarize the evidence from existing systematic reviews on dietary intake and asthma, using the PRISMA guidelines. We therefore report the quality of eligible systematic reviews and summarize the results of those with an AMSTAR score ≥32. The GRADE approach is used to assess the overall quality of the existing evidence. This overview is centred on systematic reviews of nutritional components provided in the diet only, as a way to establish what type of advice can be given in clinical practice and to the general population on dietary habits and asthma.

Risk factors for the development of pleural empyema in children

Pediatric pleural empyema has increased substantially over the past 20 years and reasons for this rise remain not fully explained. We investigated potential risk factors for the development of empyema in children by examining a cohort of patients with community-acquired pneumonia. Demographic, clinical, and socioeconomic characteristics, use of Ibuprofen prior to presentation and selected potential epidemiological risk factors were analyzed. Data were collected from a prospective etiological study of radiologically confirmed pneumonia in hospitalized children aged ≤16 years. One hundred sixty children were enrolled; 56% were male and 69% aged <5 years. Empyema complication developed in 40 (25%) children. Children with empyema were more frequently prescribed Ibuprofen prior to admission to hospital than those without (82% vs. 46.2%; OR 1.94, 97.5% credible interval 0.80-3.18). Bacterial infection was strongly associated with the development of empyema (OR 3.34, 97.5% credible interval 1.70-5.14). In contrast age, sex, maternal age, parental smoking, level of socioeconomic status, nursery attendance, asthma, household characteristics (bedrooms and number of occupants) were not significantly different between groups. In conclusion, children with pneumonia who developed empyema had more often received Ibuprofen prior to hospitalization and confirmed bacterial infection. We suggest a population-based study involving both primary and secondary care settings would help to investigate the role of Ibuprofen use in modulating the course of disease in children with pneumonia.

Validation of a questionnaire against clinical assessment in the diagnosis of asthma in school children

AIM

A questionnaire has been used repeatedly in cross-sectional studies to determine the prevalence of asthma, allergic rhinoconjunctivitis (AR) and eczema among schoolchildren in Nordland County, Norway. The current study was designed to validate the questionnaire against clinical assessment as the diagnostic gold standard and to investigate the extent of possible misclassification.

METHODS

A subsample of 801 schoolchildren of 4150, whose parents had answered a questionnaire covering asthma and atopic diseases, underwent a detailed clinical evaluation including a standardized interview, a clinical examination, skin prick tests (SPT), blood samples, spirometry an exercise treadmill test (EIB test) and measurement of exhaled nitrogen oxide (FeNO).

RESULTS

The questionnaire had a sensitivity of 0.96 and a specificity of 0.87 for the diagnosis of asthma ever compared to clinical assessment. The overall agreement (kappa) was 0.80. After clinical assessment the prevalence of asthma ever was adjusted from 17.6 % to 16.9 % (95% CI: 15.8-18.0). The most sensitive and specific questions in identifying asthmatic children by the questionnaire were questions asking about diagnosis ('Has the child ever had asthma?') rather than those covering asthma symptoms such as wheeze, shortness of breath and/or cough. A positive exercise test increased the post-test probability for the asthma diagnosis only to a minimal degree.

CONCLUSION

Based on the good agreement between the questionnaire responses and the clinical assessments, it is concluded that the questionnaire had good validity and served as a useful epidemiological tool. Detailed clinical testing added little additional information.

Validating childhood asthma in an epidemiological study using linked electronic patient records

OBJECTIVE

To investigate the performance of parent-reported data in identifying physician-confirmed asthma.

DESIGN AND SETTING

Validation study using linkage between the Avon Longitudinal Study of Parents and Children (ALSPAC) and electronic patient records held within the General Practice Research Database (GPRD).

PARTICIPANTS

Participants were those eligible to participate in ALSPAC who also had a record in the GPRD; this included 765 individuals, just under 4% of ALSPAC-eligible participants. The analysis was based on 141 participants with complete parent-reported asthma data.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main GPRD outcome measure was whether a child had a diagnosis of asthma before they were nine. Parent-reported measures were doctor diagnosis of asthma (before mean age 7.5 years), various outcomes based on wheezing and breathlessness recorded longitudinally between 6 months and 8.5 years. Secondary outcomes were bronchial hyper-responsiveness (BHR), forced expiratory volume in 1 s/forced vital capacity ratio and skin prick test responses.

RESULTS

Among the 141 participants with complete parent-reported data, 26 (18%) had an asthma diagnosis before age nine. Using general practitioner (GP)-recorded asthma as the gold standard, the question 'Has a doctor ever diagnosed your child with asthma?' was both sensitive (88.5%) and specific (95.7%). 'Ever wheezed' had the highest sensitivity (100%) but low specificity (60%). More specific definitions were obtained by restricting to those who had wheezed on more than one occasion, experienced frequent wheeze and/or wheezed after the age of 3, but these measures had low sensitivities. BHR only identified 50% of those with a GP-recorded diagnosis.

CONCLUSIONS

Parental reports of a doctor's diagnosis agree well with a GP-recorded diagnosis. High specificity for asthma can be achieved by using detailed wheezing questions, although these definitions are likely to exclude mild cases of asthma. Our study shows that linkage between observational studies and electronic patient records has the potential to enhance epidemiological research.

Home/social environment and asthma profiles in a vulnerable community from Caracas: lessons for urban Venezuela?

BACKGROUND

Asthma is a significant public health problem in Venezuela affecting the predominantly urban and poor majority of the population. Information regarding home and the social environment, key elements in asthma, is found to be deficient in these deprived socioeconomic sectors. This study was carried out to depict a life with asthma in this context which has been served over the years by a National Asthma Control Program.

METHODS

A survey of families residing in a socioeconomically deprived community of Caracas was carried out with the assumption that this community reflects the image of a life with asthma emanating from our deprived urban areas. Home physical settings were inspected for the following items: moldy walls, floors, ceilings, windows, sewage, garbage disposal, running water, plumbing, electricity, telephone, construction debris, furniture, bathrooms, food storage, and home appliances. In addition, we also gathered information regarding smoking habits, fumes exposure, pets and/or animals, and sighting of roaches and/or rodents. The presence of people with asthma was observed and their status of control was assessed through the asthma control test (ACT). Comparisons were made between families with asthmatics and those without asthmatics.

RESULTS

Randomly, 242 of 750 families (32.26%) were surveyed, with "head of family" providing information (75.6%) on most occasions. No significant association was found with respect to the previously explored items in those families with or without the presence of asthmatics. Medically diagnosed asthma was found in 14.91%, with ACT scores of <19 points in two-thirds of these adults and asthmatic children. Asthmatics reported symptoms occurring mostly during the night and an almost exclusive use of rescue medications. Families provided most treatments and children preferred to use the oral route for control medications. Significant work and school absenteeism were detected in more than 50% of these asthmatics.

CONCLUSIONS

No physical home environmental/risk factors turned out to be significantly associated with families reporting the presence of asthmatics. The high impact of asthma found in this Caracas slum underscores the realities of Venezuela's impoverished urban majority. To properly address this important challenge, our National Asthma Control Program needs to be reassessed.