Deaths from asthma in Italy (1974-1988): is there a relationship with changing pharmacological approaches?

Asthma mortality and long-acting beta2-agonists in five major European countries, 1994-2004

OBJECTIVES

Over the last few decades, important changes occurred in the pharmacological approach to asthma control. However, the possible link between pharmacologic treatment and asthma death remains controversial.

STUDY DESIGN AND SETTING

Age-standardized asthma mortality rates were computed over the 1994-2004 period for France, Germany, Spain, the UK, and Italy. Rates for children and young adults 5 to 34 years of age, middle age adults 35 to 64 years of age, and elderly adults > or = 65 years. Joinpoint regression was performed to identify years where significant changes in mortality trends occurred. Consumption of inhaled long-acting beta-2-agonists (LABA), including inhaled corticosteroids (ICS) when combined with LABAs in a single inhaler, derived from sales estimates.

RESULTS

In 1994, the highest asthma mortality rates were in Germany (4.7/100,000), and the lowest ones were in Italy and Spain (0.5/100,000). Steady downward trends were observed in all the countries considered. The largest decline was registered in Germany and the smallest one was in the UK. LABA sales increased steadily since 1994, particularly in France, Spain, and the UK, reaching values around 14 Defined Daily Doses (DDD)/1,000 inhabitants in 2004.

CONCLUSION

While the use of LABAs (with or without ICS) increased over the last decade, asthma mortality declined in major western European countries.

Asthma mortality in southern Brazil: is there a changing trend?

BACKGROUND

Mortality from asthma increased during the last decades but is now declining in some countries. Little is known about this trend in Brazil.

OBJECTIVE

The objective of the study was to determine the trends in asthma mortality in Southern Brazil.

METHODS

We reviewed death certificates of 566 people in the state of Rio Grande do Sul, Brazil, between 5 and 39 years of age in whom asthma was reported to be the underlying cause of death during the period of 1981-2003. Population data were available in 5-year age groups. Mortality rates were submitted to linear and quadratic regression procedures.

RESULTS

Among children and teenagers (5-19 years), there were 170 asthma deaths, ranging from 4 to 13 deaths each year with rates of 0.154/100,000 to 0.481/100,000. In young adults (20-39 years), 396 asthma deaths occurred, ranging from 9 to 32 each year, with rates from 0.276/100,000 to 1.034/100,000. There was an initial increase in rates, with later stabilization, and then the start of a decline beginning in the late 1990s and the early part of this decade. This trend occurred in both age subgroups examined but was more evident in males.

CONCLUSIONS

Asthma mortality in southern Brazil remains low and appears to be decreasing after reaching a peak in the mid-1990s. The reason for these trends remains unknown.

Asthma mortality, inhaled steroids, and changing asthma therapy in Argentina (1990-1999)

BACKGROUND

The asthma managing strategy has evolved and inhaled corticosteroids (ICS) are now the cornerstone of asthma treatment. Their effect on symptoms and exacerbations are well ascertained, whereas their effects on asthma mortality are still matter of debate. This ecological study evaluated asthma mortality rates and drug sales in the decade 1990-1999 in Argentina.

METHODS

Mortality (overall and adjusted for 5-34 years) was obtained from the Argentinean Epidemiological Institute, and data on the sales of antiasthma drugs were provided by the International Marketing Survey.

RESULTS

There was a significant change in drug sales in the spanned period: ICS +479%, inhaled beta2 agonists +32%, theophylline -63%. The crude and adjusted mortality rates were 3.38 and 0.72 in the 1980-1989 decade, and 2.58 (P<0.05) and 0.38 (P<0.01) in the subsequent one. There was inverse correlation between inhaled corticosteroid sale and age-adjusted (5-34) asthma mortality (r=-0.84; P=0.003), and the same with global mortality rates (r=-0.81; P=0.005). A positive correlation was also seen between theophylline sales and mortality.

CONCLUSION

The increased sale of ICS and possibly the decrease of theophylline use seem to be the more relevant factors associated with decreased asthma mortality in Argentina.

Asthma deaths; persistent and preventable mortality

Bronchial asthma remains a significant cause of mortality at all ages, despite the increased understanding of its pathogenesis and the range of drugs available for its treatment. Changes in therapeutic management can influence death rates and constant surveillance, combined with high-quality post mortem investigations, is essential. Disease severity, poor disease management and adverse psychosocial circumstances are all risk factors for asthma mortality. Bronchial asthma causes characteristic histological changes in the mucosa of the airways which are present even before the clinical diagnosis of asthma can be made. These include fibrous thickening of the lamina reticularis of the epithelial basement membrane, smooth muscle hypertrophy and hyperplasia, increased mucosal vascularity and an eosinophil-rich inflammatory cell infiltrate. In addition, mucoid plugging of the airway lumen is frequently associated with fatal asthma. The recognition of these changes can allow the diagnosis of asthma to be made for the first time at autopsy, in those cases where asthma goes undiagnosed in life. Acute severe asthma may be accompanied by pneumothorax and surgical emphysema of the mediastinum. Disorders which may mimic asthma include pulmonary embolism, chronic obstructive pulmonary disease and anaphylaxis, but careful post mortem examination and appropriate investigations should reveal the true cause of death.

Mortality from asthma in children and young adults in Louisiana

BACKGROUND

Asthma mortality rates have been increasing despite our improved understanding of the pathophysiology of asthma and advanced methods of treatment. Although there are many national studies of asthma mortality rates, few studies have concentrated on subnational regions such as individual states.

OBJECTIVES

We sought to determine the trends in asthma mortality in children and young adults during the last 15 years in Louisiana.

METHODS

Asthma mortality data were acquired from the Louisiana State Center for Health Statistics for the years 1983 through 1997. All asthma deaths coded International Classification of Disease, Ninth Revision 493 were included in the data set along with year, sex, and rate characteristics. State population estimates obtained from the United States Bureau of Census for three 5-year periods (1983 to 1987, 1988 to 1992, and 1993 to 1997) were used to calculate crude and adjusted mortality rates. These time periods were compared with one another and with the period 1983 to 1987, which was used as a baseline.

RESULTS

For all residents, the mortality rate increased from 0.41 deaths per 100,000 persons during the 1983 to 1987 time period to 0.49 and 0.63 deaths per 100,000 persons during 1988 to 1992 and 1993 to 1997 time periods, respectively. Mortality rates have increased in both the white and non-white populations over the 15-year study period, with the most pronounced increases among the non-white population.

CONCLUSION

Asthma mortality rates in Louisiana have increased, particularly among the non-white population, over the last 15 years, although the results are not statistically significant. When compared with other states, asthma mortality in Louisiana is lower than in the northeast and central north states.

Fatal asthma from powdering shark cartilage and review of fatal occupational asthma literature

BACKGROUND

Work-related asthma (WRA) is the most common work-associated respiratory disease in developed countries.

METHOD

We report shark cartilage dust as a new potential cause of occupational asthma (OA) in the context of other fatal OA case reports.

RESULTS

A 38-year-old white male worked for 8 years in a facility which primarily granulated and powdered various plastics. Sixteen months prior to his death, the plant began grinding shark cartilage. After 10 months of exposure, he reported chest symptoms at work in association with exposure to shark cartilage dust and a physician diagnosed asthma. Six months later, he complained of shortness of breath at work and died from autopsy-confirmed asthma. The latency from onset of exposure to symptoms and from symptom onset to death was shorter than 10 previously reported OA fatalities.

CONCLUSION

Recognition of occupational causes and triggers of asthma and removal of affected individuals from these exposures is critical and can prevent progression to irreversible or even fatal asthma.

Trends in asthma mortality in Italy and Spain, 1980-1996

Asthma is a major public health problem, with variable trends in several countries. We analysed mortality trends from asthma in Italy and Spain between 1980 and 1996. Overall asthma-related mortality at all ages increased between 1980 and 1987 in both sexes in Italy, from 16.6 in 1980-1981 to 29.0 in 1986-1987 per million males, and from 8.0 in 1980-1981 to 13.8 in 1986-1987 per million females, but decreased thereafter to reach 14.6 per million in males and 8.7 in females in 1996. The downward trends after 1987 were consistent in middle age and elderly population, but asthma mortality tended to rise in children and young adults over the last few years. In Spain, overall age-standardized mortality rates from asthma declined in men from 37.8 in 1980-1981 to 10.1 in 1996, and from 19.5 in 1980-1981 to 13.2 per million females in 1996. In women, the fall in mortality rates was smaller, and overall mortality was higher than in males since early 1990s. Trends of asthma mortality in Italy and Spain were favourable over the last decade.

Rise and fall of asthma-related mortality in Italy and sales of beta2-agonists, 1980-1994

We performed this study with the aims of describing the trend of asthma-related mortality in Italy between 1980 and 1994, and to evaluate the relationship between sale estimates of beta2-agonists drugs and mortality from asthma. For asthma mortality we used data provided by National Institute of Statistics, for sale estimates of beta2-agonists we used data provided by IMS HEALTH. We calculated the gender specific age-standardized incidence rates of asthma-related deaths for all ages and for age classes. We found that estimates for asthma-related mortality steadily increased between 1980 and 1987 in both sexes, and thereafter decreased. In people, aged between 34 and 64 and over 64, death rates in males were significantly higher than in females while the rates in those aged less than 34, were mostly similar in both gender. The overall exposure to beta2-agonists (alone and in combination) increased from 1980 to 1990, remained stable between 1990 and 1993, and increased steeply in 1994. We conclude that asthma-related death rates have declined since the mid-1980's. This decline has been more pronounced in males and in the older ages, while the rates in younger patients of both genders have remained nearly unchanged. Our data do not substantiate the hypothesis of an increased risk of asthma-related mortality associated to the use of inhaled beta2-agonists in general nor fenoterol or salbutamol in particular.

Prescribing patterns for asthma by general practitioners in six European countries

To assess the level of concordance with international consensus on asthma management, we compared primary care prescribing patterns for asthma in different European countries. A prospective study of prescription items with an associated diagnostic label of asthma in patient consultations with a total of 235 general practitioners (GPs) from Belgium, England, Ireland, Italy, Northern Ireland, Portugal, Scotland and Spain was performed. A total of 101,544 consecutive consultations were recorded in autumns 1994 and 1995 of which 3595 (3.5%) were for patients with asthma and 3243 (3.2%) were for patients receiving a prescription for asthma. Overall, asthma consultations varied from 1.8% in Italy to 5.8% in Ireland (mean 3.4%, SD 1.6). Prescribed inhaled medications for children varied from 72% of the total asthma prescriptions in Ireland and Portugal to 82% in Northern Ireland (mean 79%, SD 8.1) and for adults 55% in Italy to 85% in Spain (mean 70%, SD 10). Inhaled corticosteroid usage for adults varied from 14% in Italy to 31% in Northern Ireland (mean 24%, SD 6.4). For children, beta2-agonist use varied from 24% in Italy to 67% in Spain (mean 45%, SD 13). Despite publication of international guidelines for the management of asthma, inter-country prescribing practices vary considerably and could be improved. The frequency of use of asthma as a diagnostic label also varies markedly.

Decrease in asthma mortality rate in Israel from 1991-1995: is it related to increased use of inhaled corticosteroids?

BACKGROUND

Asthma mortality rates (AMRs) during the last several decades increased in many countries with developed medical services, including Israel. The reasons for this trend were never established. Recent data suggested that this trend is changing.

OBJECTIVES

We sought to compare the AMR in Israel during 1991-1995 with that of the previous decade and to investigate a possible correlation between mortality rates and use of inhaled corticosteroids (ICSs) and beta(2)-agonists.

METHODS

Statistical data on the AMR in Israel during 1981-1995 were extracted. Data were analyzed for 5- and 10-year periods (1981-1990) and compared with a 5-year period (1991-1995). Data on ICS and beta(2)-agonist sales were extracted from the marketing companies' official reports.

RESULTS

The mean AMR per 100,000 population per year during 1981-1990 in the 5- to 34-year-old group was 0.393 +/- 0.055 and decreased to 0.202 +/- 0. 046 during the 1991-1995 period (P =.03). There was no significant difference between changes in mean AMR in the 35- to 64-year-old or in the 5- to 64-year-old group during the same periods (4.568 vs 4. 063 and 2.480 vs 2.133). The mean ICS unit sales rates (per 100,000 population per year) between 1982-1990 and 1991-1995 were 21.70 and 190.45, respectively (P <.05). The correlation between ICS sales and AMR was -0.631 (P =.016). Sales of beta(2)-agonists did not change significantly during the study period.

CONCLUSIONS

We identified a trend of decreased AMRs in Israel during 1991-1995. The decline in AMRs paralleled the increase in ICS sales, whereas the sales of inhaled beta(2)-agonists did not change significantly. One may speculate that the decrease in AMR may be the result of better anti-inflammatory treatment, as reflected by the increased use of ICSs. The feasibility of reducing AMRs in a country such as Israel, with low AMRs to start with, by improving medical treatment is encouraging.

Temporal trends and ethnic variations in asthma mortality in Singapore, 1976-1995

BACKGROUND

A study was undertaken to examine temporal trends and ethnic differences in the asthma mortality rate in Singapore.

METHODS

Asthma mortality rates in Singapore were estimated from vital data for the years from 1976 to 1995. Trends in sex and age specific (5-14, 15-34, 35-59, 60+ years) rates were obtained for four periods (1976-80, 1981-85, 1986-90, 1991-95) and for Chinese, Malay, and Indian subjects for the years when these data were available (1989-95).

RESULTS

An increase in asthma mortality was observed in children aged 5-14 years from 0.21 per 100,000 person years in 1976-80 to 0.72 per 100,000 person years in 1991-95. No increases were noted in the other age groups but a small decrease was observed in the 1991-95 period for the 35-59 year age group. Marked ethnic differences in mortality rates were observed. In the group aged 5-34 years the asthma mortality rates were 0.5 per 100,000 in Chinese subjects, 1.3 per 100,000 in Indians, and 2.5 per 100,000 in Malay subjects. Similar 2-4 fold differences were observed in all other age groups.

CONCLUSIONS

Apart from genetic factors, environmental exposures and medical care factors which influence asthma prevalence and severity are most likely to be the causes of the observed temporal trends and ethnic differences in the asthma mortality rate in Singapore, but further studies are needed to elucidate these more fully.

Trends in asthma mortality in young people in southern Brazil

BACKGROUND

Mortality from asthma increased and is now declining in some countries, but little is known about these trends in South America.

OBJECTIVE

We aimed to assess trends in mortality from asthma in southern Brazil in children and young adults.

METHODS

Death certificates of 425 people in the state of Rio Grande do Sul aged between 5 and 39 years in whom asthma was reported to be the underlying cause of death during the period 1970 to 1992 were reviewed. Population data were available in 10-year age groups. Testing for trends in mortality rates was conducted using linear and log-linear regression procedures.

RESULTS

Asthma mortality rates in the age groups 5 to 19 and 20 to 39 years ranged between 0.04 and 0.39/100,000 and 0.28 to 0.75/100,000, respectively, and were nonuniformly distributed over the study period. The mean annual increase in rate in 5- to 19-year olds was +0.01 (95% CI 0.003 to 0.016), an average annual percentage increase of +6.8% (95% CI 3% to 11%), with a total increase of 352% between 1970 and 1992. This increase was not due to a shift in labeling from bronchitis to asthma. In the 20 to 39-year age group, asthma and bronchitis mortality rates showed no trend to increase or decrease.

CONCLUSIONS

Asthma mortality in southern Brazil is low, but rose significantly between 1970 and 1992 in the 5 to 19-year age group. This trend differs from that found in other states of Brazil and several other Latin American countries. Reasons for this difference remain unclear.