Introduction

Asthma is a relatively common chronic disease affecting approximately 10% of

the population (1). Literature on the epidemiology of asthma focuses primarily
on prevalence, morbidity (usually measured by hospitalizations), and mortality.
It appears from this research that these measures may be showing an increase
throughout the world; however, there is debate over whether or not these
changes are real. In order to better understand the nature of the disease, its
burden on society, and what can be done to prevent the disease and its resultant
morbidity, we must have a solid understanding of its epidemiology.

The information included here is intended to provide an overview of the

epidemiology of asthma and the factors that may be contributing to its
development, morbidity, and mortality. Application of this epidemiologic
research in preventing avoidable morbidity and mortality will also be
presented.

What is Asthma?

What is asthma? Although this may seem like a fairly simple

question to answer, there has been much controversy surrounding the
definition of asthma. A large part of this stems from the fact that
although there are certain pathologic features that are found in many
asthmatics, there are none that apply solely to all patients diagnosed
with asthma. The National Asthma Education Expert Panel Report (2)
recommends the following clinical definition of asthma:

"Asthma is a lung disease with the following characteristics: 1) airway

obstruction that is reversible (but not completely so in some patients) either
spontaneously or with treatment; 2) airway inflammation; and 3) increase
airway responsiveness to a variety of stimuli."(2)

A clinical description of asthma is not the same as an epidemiologic definition

of the condition. Epidemiologic research of asthma often relies on self-
reporting of the asthma diagnosis and/or reporting of common symptoms such
as wheezing; however, there are problems associated with relying on this
diagnosis for such research. In general, asthma is underdiagnosed in the
population (3,4). Asthma and chronic bronchitis are overlapping diagnoses
among children. Wheezing tends to be the predominant symptom; however, if
it is mild, infrequent, or happens only with infection, the physician may not
make the diagnosis of asthma. Some asthmatics may only experience a cough
and no wheezing. In addition to possibly not being diagnosed as asthmatic,
such cases may also be excluded from studies focusing exclusively on the
report of wheezing. Another factor to consider is that parents may underreport
asthma or its symptoms in children (3,4).

Assessment of bronchial reactivity of the airways to exercise or pharmacologic

agents is another commonly used method of identifying cases of asthma.
However, this lacks specificity and sensitivity for asthma--up to 50% of those
with bronchial reactivity have neither symptoms nor diagnosed asthma, and up
to 50% of those with asthma do not have bronchial reactivity (3).

Epidemiology

• Incidence
• Prevalence
• Morbidity and Mortality
• Socioeconomic Status and Race

Incidence

Incidence rates, measures of the onset of a disease, provide information about

the probability of developing the disease. The incidence rate of asthma has
been estimated to be between 2.65 to 4/1000 per year. In childhood the onset of
asthma is more common among children less than five years of age and among
boys versus girls. In this age group, incidence rates have been estimated to vary
between 8.1 to 14/1000 per year for boys and between 4.3 to 9/1000 for girls.
Sex differences tend to disappear in adulthood. The incidence of asthma in
persons over 25 years of age has been estimated at 2.1/1000 per year (3)

Prevalence

When defining asthma in epidemiologic studies, the prevalence of asthma can

be described in a number of ways. It is important to be aware of this when
interpreting results of these studies. Point prevalence (asthma at the time of the
study survey), although the easiest measurement of prevalence to obtain, will
likely underestimate asthma's presence within the population. Lifetime
prevalence (asthma at any time in a person's life) presents the problem of recall
bias. In general, the most commonly accepted measurement used is period
prevalence, usually over the past 12 months (5).

Given differing definitions and methods of identifying cases, it is difficult to

interpret variations in asthma prevalence both over time and between
geographic areas. In looking at the review of studies presented by Cookson (6),
Gergen and Weiss (3) came to several conclusions about the international
prevalence of asthma:

"The point prevalence of current (or active) asthma for children in

'industrialized' countries ranges between 0.7% in Tokyo, Japan to 8.5% in
Tucson, Arizona, US and averages about 5% worldwide. Rates from
'nonindustrialized' countries vary from high levels in the Western Caroline
Islands, 49%, to 0.6% in South Fore, Papua New Guinea. However, rates for
'nonindustrialized' countries tend to be lower."

The prevalence of asthma has been reported to be increasing worldwide, but

this apparent trend continues to be debated. Changes in prevalence can be
confounded by factors such as: differing levels of awareness of the disease by
health care providers and/or families; changes in access to medical care; and
changes in medical diagnosis. Within the same population the prevalence of
asthma can vary to a significant degree based on the definition used and
questions asked of the study population. The following table shows the
variance in estimates of asthma prevalence from the National Health and
Nutrition Examination Survey (NHANES) and the National Health Interview
Survey (NHIS)--national surveys monitoring the health of the United States
population (3). Notice that within the same population the highest estimate of
prevalence is over three times that of the lowest depending on the question
asked.

Estimates of asthma prevalence: results from two national population-based

surveys.(From Evans et al(10))

Survey and questionnaire Rate per 100 population

NHANES 2
(persons 6 months-74 years, 1976-1980)
Did a doctor ever tell you that you had asthma? 06.2
Do you still have asthma? 03.0
During the past 12 months, not counting colds
06.5
or the flu, have you frequently had trouble with wheezing?
Has a doctor ever told you that you had asthma 10.5
and/or wheezing?
Do you still have asthma and/or wheezing? 07.7
NHIS
(all ages, 1979-1981)
During the past 12 months, did you have asthma? 03.1

The NHANES data can be used to examine trends in the reported cumulative
prevalence (ever having asthma and/or frequent wheezing within the year)
among six to 11-year-old children in the U.S. One should note, however, that
survey questions have changed, and NHANES 2 included questions about
allergy which may have resulted in an increased ascertainment of asthma cases.
From this data, there appears to be a significant increase (p&lt0.05) in asthma
prevalence in this age range from 4.8% in NHANES 1 (1971-1974) to 7.6% in
NHANES 2 (1976-1980) (7)

In Finland, Sweden, Australia , new Zealand, and England asthma prevalence

has been reported to be increasing. A retrospective analysis of the prevalence of
asthma in cohorts of 19-year-old Finnish candidates for military conscription
(representing 98% of the male Finnish population at this age) showed
prevalence increasing from 0.29% in 1966 to 1.79% in 1989. Asthma here was
defined as asthma recognized by a physician at call up examination, exemption
from military service because of disabling asthma, and discharge during the
year of required military service because of asthma (8). In 18-year-old Swedish
military conscripts, the prevalence of asthma increased from 1.9% in 1971 to
2.8% in 1981 (9).

Using a questionnaire, Robertson et al. (10) determined the prevalence of

reported asthma or wheezing in the past 12 months in Melbourne Australian
children aged 7, 12, and 15 years and then compared this to the prevalence of a
history of asthma as determined 26 years earlier in a 1964 survey of 7-year-old
Melbourne schoolchildren. Their analyses showed a 141% increase in asthma
prevalence among 7-year-olds, from 19.1% in 1964 to 46% in 1990. The
authors noted that part of this increase may have been due to increased
awareness of both asthma and the symptom of wheeze by health care providers
and the public. Peat et al. (11) conducted serial cross-sectional studies in 1982
and 1992 of 8-10 year old children in two Australian towns (Belmont and
Wagga Wagga). Using a self-administered questionnaire, they found significant
increases in both populations in the prevalence of doctor diagnosed asthma,
recent use of an asthma drug, and episode of wheeze. A histamine inhalation
test was included as an objective measurement of airway responsiveness, and
those children with both recent wheeze and airway hyperresponsiveness were
classified as cases of asthma. The prevalence of airway hyperresponsiveness
increased significantly in Belmont (10.7%, 95%CI 7.3-14.1, p&lt0.001) and in
Wagga Wagga (6.4%, 95%CI 2.9-9.9),p&lt0.05). Likewise, the prevalence of
current asthma increased in Belmont (7.5%, 95%CI 4.9-10.1, p&lt0.001) and in
Wagga Wagga (2.8%, 95%CI 0.1-5.5,p&lt0.05).

Prevalence studies from England are not consistent in their results. In reviewing
asthma prevalence studies conducted in the United Kingdom between 1964 and
1986, Anderson (4) concluded that there is "little evidence" of a trend in
estimates of prevalence of wheezing (described as 'current' or 'recent').
Prevalence of diagnosed asthma did show a tendency to increase in recent
years. In a longitudinal study of English children 4 to 12 years of age, Burney
et al. (12) found significant increases over a 13-year period (1973-1986) in
reported asthma (p&lt0.001) and persistant wheeze (p&lt0.001) in both boys
and girls.

Geographic comparisons can provide clues about factors possibly contributing

to the development and/or promotion of asthma. However, as was stated earlier,
comparisons of studies can be limited by differences in research
methodologies. A few studies have employed standardized methodologies in
order to provide a comparative analysis of prevalence in different countries.
The prevalence of asthma in children in New Zealand and Australia has been
reported to be higher than that found in other countries (3). One study
compared the prevalence of asthma in 12-year-olds in New Zealand and South
Wales. Using the same questionnaire and an exercise provocation test in both
countries, this study found New Zealand children to have a higher prevalence
of reported history of asthma or wheeze and were more likely to have a positive
exercise provocation test (12). Burr et al. (13) also used a similar questionnaire
and exercise challenge test in their comparative survey of childhood asthma in
New Zealand, Wales, South Africa, and Sweden. Their data showed that
children in New Zealand had the highest prevalence of asthma ever, current
asthma, and wheeze without a cold. Swedish children had the lowest
prevalence of asthma and asthma-like symptoms (14).

Morbidity and Mortality

A comparison of reported asthma mortality rates in 20 countries during the

period of 1985-1987 showed a variation from over 9/100,000 in West Germany
to less than 2/100,000 in the Netherlands, the U.S., and Hong Kong (14).
Throughout the world asthma morbidity and mortality appear to be increasing
(4,15,16), and as with prevalence, the reasons for these trends are not clear.
Defining and identifying the disease again are obstacles in understanding
trends. Various factors hypothesized to be contributing to increasing mortality
trends include: 1) changes in 1979 in the ninth revision of the World Health
Organization International Classification of Diseases that resulted in "asthma
with bronchitis" being coded to "asthma" in ICD9 versus "bronchitis" in ICD8;
2) changes in physician diagnostic patterns, such as over-reporting asthma
deaths over age 50 and under-reporting in younger ages; 3) increased diagnosis
of asthma; 4) increased prevalence and/or severity of the disease; and 5)
adverse drug effects (4)

With the change from ICD8 to ICD9 came an increase in asthma mortality rates
in 1979. The effect of this change was evaluated in the UK where it was
determined that the expected increase in coding of asthma deaths in those under
45 years would be only 6% (16). The effect was similarly evaluated in New
Zealand 5-34 year olds, and an expected increase of just 2.4% in coded asthma
deaths was calculated (17). Additionally, trends from 1980 to 1987, after the
coding change, show a continued increase in many countries, such as Italy,
Denmark, Israel, Australia, France, and the United States. New Zealand,
Sweden, and Japan experienced decreased mortality during this time period
(15).

In the United States an analysis by the Centers for Disease Control and
Prevention (CDC) shows the overall annual age-adjusted death rate for asthma
increased 40%, from 13.4/1 million in 1982 to 18.8/1 million in 1991 (mortality
data was not available for 1992). In 5-34 year olds, this rate increased from 3.4
to 4.9 deaths per 1 million population (18).

Trends in hospitalization among children (0-17 years of age) in the U.S. from
1979 to 1987 were reported by Gergen and Weiss (19). Using the National
Hospital Discharge Survey, they found a 4.5% per year increase in asthma
hospitalizations (95%CI, 2% to 7.1%), with the largest increase being 5.0% per
year among 0- to 4-year-olds (95%CI, 3.4% to 6.7%). African American
children 0 to 4 years old had about 1.8 times greater increase than Caucasian
children of the same age. Their analyses of data regarding admissions for lower
respiratory tract disease and bronchitis showed decreases that suggested
diagnostic transfer may have contributed in part to increased hospitalizations.

In the UK, hospitalizations due to asthma in children were increasing until the
mid-1980s. A study using data from the Hospital In-Patient Enquiry (which
provides hospital admission data for England and Wales), described trends in
admission rates in England and Wales (1976 to 1985), the East Anglian region
(1976 to 1991-2), and Wales (1980-1990). The rates for England and Wales
combined increased through 1985. In East Anglia, rates rose until 1985 when
they peaked and then appeared to decline. Rates in Wales increased until a peak
in 1988 and a subsequent decline. A change in the information system used to
collect hospital admission data may have confounded these trends, but the
observation that some of the downwards trends were started before the system
change suggests that this change may have only partly contributed to the
observed trends. Other possible factors included changes in medical care
delivery, treatment, hospital admission and readmission policies, and severity
or prevalence of asthma. The researchers also noted that recent asthma
mortality data supports a possible true change in asthma morbidity (20).

Of special note are the two "epidemics" of asthma mortality in New Zealand,
the first in the 1960s and another in the 1970s. In Chapter 6 of the text "Asthma
and Rhinitis", Neil Pearce et al. provide a review of these mortality epidemics.
I will just mention a few key points. In the 1960s large increases in asthma
mortality were also seen in England and Wales, Scotland, Ireland, Australia,
and Norway; however, mortality rates remained relatively stable in the U.S. and
Germany. Various possible reasons for these trends were investigated including
changes in medical diagnosis, disease classification, death certification, asthma
prevalence, and treatment methods. Ecologic data correlating asthma mortality
with sales of beta-agonist bronchodilators appeared to show some support for
the possible association between use of these asthma treatment drugs and
increasing asthma mortality. However, there are limitations to this type of data,
and formal case-control studies were not done (21).

There continues to be debate about the possible dangers of beta-agonist

bronchodilators. It has been hypothesized that underuse of corticosteroids and
overuse of beta-agonists have contributed to increases in asthma deaths.
Fenoterol, a selective B2-agonist, was hypothesized to play a large role in the
second asthma mortality epidemic, this time experienced only in New Zealand.
Sales of fenoterol appeared to correlate with trends in asthma deaths. This
along with additional observations as well as laboratory studies of its possible
physiologic effects, prompted researchers to carry out several case-control
studies. These studies supported the association between fenoterol use and
increasing asthma mortality, even when controlling for asthma severity. Last of
all, additional ecologic data showed that mortality rates dropped significantly
after warnings about the use of fenoterol were announced and sales of the drug
decreased (21).

Socioeconomic Status and Race

Asthma prevalence appears to differ between certain races and by
socioeconomic status. In NHANES 2 (1976-1980), the cumulative prevalence
of asthma for all age groups was estimated to be 10.6% This prevalence was
greater in males than in females (11.4% vs 9.7%, p&lt0.05). The prevalence in
African Americans was greater than in Caucasians (12.2% and 10.4%,
respectively, but this difference was not significant. Those living below poverty
level appeared to experience significantly more asthma than those living at or
above poverty level (13.1% vs 10.3%, p&lt0.05) (7).

In the U.S., asthma mortality is more common among nonwhites, those living
in urban areas, and the poor (22). The CDC analysis, mentioned in the
"Morbidity and Mortality" section, found that African Americans more so than
Caucasians experienced a higher annual death rate and a higher age-adjusted
hospital discharge rate for asthma as a primary diagnosis (18). Lang et al. (23)
analyzed asthma mortality rates in Philadelphia, Pennsylvania (a large urban
area from 1969-1991 in order to identify trends in rates and possible
associations with changes in air population. Mortality rates were found to
increase during this time and were highest in census tracts with the highest
percentages of low income and minority residents, especially African
Americans. Concentrations of major air pollutants declined during this time,
suggesting that other factors in this urban area contributed to this trend.

Poverty is also associated with increases in asthma morbidity and mortality in

New Zealand. Maoris and Pacific island Polynesians experience higher
mortality rates and hospitalization rates than other New Zealanders (3)

Understanding the distribution of asthma over time and between populations

can help to identify risk factors, develop effective interventions, and identify
and target persons at risk so that we may decrease the unnecessary burden of
asthma morbidity and mortality. Possible risk factors for the development of
asthma as well as for morbidity and mortality resulting from asthma are
addressed in "Risk Factors".