The Challenge of Asthma

Guy B. Marks
UNSW, Australia
Woolcock Institute of Medical Research
The Union
Global Asthma Network
(views expressed are my own!)

Overview
What is asthma?
Can asthma be cured or prevented?
Can asthma be treated so that its impact is
lessened?
What is the burden of asthma?
Global Asthma Report

WHAT IS ASTHMA?

Symptoms
Wheeze, chest tightness, shortness of
breath, cough (usually dry)
Episodic
Triggered
Reversible

Davies F. (2004). Spotting the Sick Child. London, Department of Health, UK

Slide
courtesy of Professor Innes Asher

GAN

Davies F. (2004). Spotting the Sick Child. London, Department of Health, UK

Slide
courtesy of Professor Innes Asher

GAN

What is asthma?

Slide courtesy of Professor Innes Asher

GAN

Typical features
Symptoms as described
Episodic and triggered symptoms
Airflow obstruction (breathing tests)
Variable, reversible, inducible

Airway inflammation
Special type of airway inflammation

Major impact of asthma for

individuals
Distress due to symptoms
Exacerbations
Hospitalisation
Death (rare)

Disability
Impaired quality of life
Adverse effects of treatment

Life course of asthma

May start at any age
Typically, in childhood

Childhood asthma may remit

Typically, if mild and not associated with allergy

Asthma persisting into adulthood rarely remits

May wax and wane during life
Some cases progress to chronic airflow
obstruction

Associated illnesses
Atopy (allergy)
This, in turn, associated with eczema and
allergic rhinitis (hayfever)

Nasal polyps

Causes of asthma
Generally not known
Occupational sensitisers cause occupational
asthma
Maternal smoking during pregnancy
increases risk of childhood wheezing

Triggers and exacerbating factors

Viral respiratory tract infections
Most commonly, the common cold
Also influenza, RSV, others

Allergens, if sensitised
HDM, grasses, animal danders, moulds
Occupational sensitisers

Exercise, laughter, rapid breathing (anxiety)

Irritants
Insect sprays, perfumes, cigarette smoke

CAN ASTHMA BE PREVENTED

OR CURED?

Can it be prevented?
In general, the answer is no with some
exceptions:
Occupational asthma can be prevented by
avoiding exposure to sensitisers in workplaces
The risk of asthma or asthma-like symptoms in
children can be reduced in mothers do not
smoke during pregnancy

Can it be cured?
In general the answer is no, with some
qualifications:
Some children, do grow out of asthma but we
do not know any way to make this more likely
Asthma can be controlled, so that it is not a
problem for the person, by treatment, but the
treatment needs to be continued

CAN ASTHMA BE TREATED SO

THAT IT IS CONTROLLED?

Can asthma be controlled?

In general, the answer is yes but with
some caveats
It requires the right treatment used regularly
(daily or twice daily)
It requires effective use of inhaled therapy
Control stops soon after treatment stops
It comes at cost (financial and adverse effects)

What do we mean by controlled?

No or few symptoms:
Including with exercise and at night/early
morning

No exacerbations
No urgent medical care or treatment
No hospital visits

Normal lung function and no risk of decline

in lung function
No disability

Under ideal
circumstances
asthma can be
wellcontrolled
with treatment in
most people

Bateman ED et al. Can Guideline-defined Asthma Control Be Achieved?: The Gaining Optimal Asthma ControL
Study. Am J Respir Crit Care Med. 2004; 170:836-44.

What is required?
In most people with asthma, inhaled
corticosteroid therapy
Taken once or twice daily
Inhaled correctly
Taken regularly

Rescue therapy
Taken as required for symptoms or
exacerbations

Inhaled correctly?

How well are we actually doing?

NOT VERY WELL.
Why?
Appropriate medicines are not:

Prescribed
Available
Affordable
Quality-assured
Purchased
Taken at all
Taken regularly
Taken consistently
Taken correctly

What is the consequence?

Avoidable and
unnecessary
suffering,
disability,
hospitalisations
and deaths!

WHAT IS THE BURDEN OF

ASTHMA?

Prevalence of current wheeze, age 13-14 years, 2000-03

< 5%

5% - 10%

798,685 participants
233 centres
97 countries
Self-completed Q

10% - 20%
>20%

Global average: 14.1%

Lai CKW, Beasley R, Crane J, Foliaki S, Shah J, Weiland S, et al. Global variation in the prevalence and
severity of asthma symptoms: Phase Three of the International Study of Asthma and Allergies in
Childhood (ISAAC). Thorax. 2009; 64(6):476-83.

Prevalence of severe asthma, age 13-14 years, 2000-03

< 2.5%
2.5% - 5%
5% - 7.5%
>7.5%

In last year
4 attacks of wheeze
1 night/week sleep disturbance due to wheeze
episode of wheeze affecting speech

Global average: 6.9%

Lai CKW, Beasley R, Crane J, Foliaki S, Shah J, Weiland S et al. Global variation in the prevalence and
severity of asthma symptoms: Phase Three of the International Study of Asthma and Allergies in
Childhood (ISAAC). Thorax. 2009; 64(6):476-83.

Prevalence of current wheeze, age 6-7 years, 2000-03

< 5%

5% - 10%

388,811 participants
144 centres
61 countries
parent-completed Q

10% - 20%
>20%

Global average: 11.5%

Lai CKW, Beasley R, Crane J, Foliaki S, Shah J, Weiland S, et al. Global variation in the prevalence and
severity of asthma symptoms: Phase Three of the International Study of Asthma and Allergies in
Childhood (ISAAC). Thorax. 2009; 64(6):476-83.

Prevalence of severe asthma, age 6-7 years, 2000-03

< 2.5%
2.5% - 5%
5% - 7.5%
>7.5%

In last year
4 attacks of wheeze
1 night/week sleep disturbance due to wheeze
episode of wheeze affecting speech

Global average: 4.9%

Lai CKW, Beasley R, Crane J, Foliaki S, Shah J, Weiland S et al. Global variation in the prevalence and
severity of asthma symptoms: Phase Three of the International Study of Asthma and Allergies in
Childhood (ISAAC). Thorax. 2009; 64(6):476-83.

World Health Survey

68 countries
308,218 participants aged 18 years
Mean age 43 years

Sembajwe G, Cifuentes M, Tak SW, Kriebel D, Gore R, Punnett

L. National income, self-reported wheezing and asthma diagnosis
from the World Health Survey. European Respiratory Journal.
2010 Feb;35(2):279-86

Prevalence of current wheeze in low

income countries

Prevalence of current wheeze in

middle income countries

Prevalence of current wheeze in high income countries

Prevalence of asthma in adults, by GNI

World Health Survey, 2002-3

Burden
Mortality outcomes (YLL)
+
Non-fatal health outcomes (YLD)
=
Disability-adjusted life years (DALYs)

Burden = DALYs

Years of life in good health lost

A common currency for measuring the overall
burden attributable to disease.
Can be compared:
Between diseases
Between regions
Over time

Burden attributed to asthma, by age, global

Institute of Health Metrics and Evaluation (IHME)

DALYs attributed to asthma, by location, all

ages

Institute of Health Metrics and Evaluation (IHME)

Death due to
asthma is rare
in most high
income
countries but
not rare low
and middle
income
countries

Asthma Burden

Affects people of all ages

Global distribution
Common chronic disease
Much of the regional variation is
unexplained
No recent global data on time trends

GLOBAL ASTHMA REPORT

2014
To be launched at this meeting,
Thursday 30th October @ 1300 in Room 128
Available at Global Asthma Network booth

Global Asthma Report 2014: Key Recommendations

The World Health Organization

(WHO) should
add essential asthma medicines to their
Prequalification Programme, promote the
standardisation of the dosages of active ingredients
in combined inhalers and the harmonisation of

quality requirements for inhalers across

international reference documents such as the
pharmacopoeias.

Global Asthma Report 2014: Key Recommendations

Governments should
commit to research, intervention, and monitoring to
reduce the burden of asthma in the world. Global
surveillance of asthma requires standardised
measures of asthma implemented in large scale

surveys of both children and adults in diverse

settings worldwide;

Global Asthma Report 2014: Key Recommendations

Governments should
include asthma in all their actions arising from the
WHO Global Action Plan for the Prevention and
Control of Non-communicable Diseases (NCDs)
2013-2020, and the WHO NCD Global Monitoring

Framework;

Global Asthma Report 2014: Key Recommendations

Governments should
ensure that they have a list of essential medicines
for asthma which includes both inhaled
corticosteroids and bronchodilator in dosages
recommended by WHO, and that these are

available, quality-assured, and affordable for

everyone in their countries;

Global Asthma Report 2014: Key Recommendations

Governments should
ensure all asthma inhalers procured, distributed and
sold in their countries meet international quality
standards;

Global Asthma Report 2014: Key Recommendations

Governments should
particularly in low-income countries, make
commitments to ensure that the supply of quality
assured, affordable essential asthma medicines is
uninterrupted, health professionals are appropriately

trained, and health services are organised to

manage asthma;

Global Asthma Report 2014: Key Recommendations

Governments should
particularly in low- and middle-income countries
make asthma a health priority, in order to more
quickly invest in asthma research relevant to their
populations, integrate care at community and

primary health care levels with appropriate referral

procedures, and develop capacity in standard case
management of asthma;

Global Asthma Report 2014: Key Recommendations

Governments should
strengthen policies to reduce tobacco consumption,
encourage healthy eating and reduce exposure to
potentially harmful chemicals, smoke and dust.
Funders need to support further research to identify

causes of asthma;

Global Asthma Report 2014: Key Recommendations

Governments should
measure and monitor the economic costs of asthma
in their countries, including health care costs and
productivity losses.

Global Asthma Report 2014: Key Recommendations

Health authorities in all countries should

develop national strategies and action plans to
improve asthma management and reduce costs;

Global Asthma Report 2014: Key Recommendations

Health authorities in all countries should

ensure the availability of nationally approriate
asthma management guidelines and provide access
for everyone to the quality-assured, affordable
essential asthma medicines those guidelines

recommend;

Global Asthma Report 2014: Key Recommendations

Health authorities in all countries should

encourage their health professionals to attend short
courses relevant to asthma research and policy;

Global Asthma Report 2014: Key Recommendations

Health authorities in all countries should

collect counts of hospital admissions in children and
adults, from defined catchment populations, to
monitor trends in asthma over time;

Global Asthma Report 2014: Key Recommendations

Health authorities in all countries should

report rates of asthma deaths in children and adults
to monitor progress in asthma care and as an early
warning of epidemics of fatal asthma.

Global Asthma Report 2014: Key Recommendations

Health professionals in all countries

should
regard frequent or severe recurrent wheezing in
infancy as part of the spectrum of asthma

Global Asthma Report 2014: Key Recommendations

Health professionals in all countries

should
ensure that their country is represented in the
Global Asthma Network (GAN).