Childhood asthma from a health equity perspective
2019; Elsevier BV; Volume: 122; Issue: 5 Linguagem: Inglês
10.1016/j.anai.2019.02.029
ISSN1534-4436
Autores Tópico(s)Chronic Obstructive Pulmonary Disease (COPD) Research
ResumoAsthma is the most frequent chronic noncommunicable disease of childhood in the world1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar and is particularly prevalent in urban settlements, where traffic-related pollution and household dampness—particularly common in slums—can lead to oxidative stress and airway inflammation.2WHOAir Pollution and Child Health: Prescribing Clean Air. World Health Organization, Geneva2018Google Scholar These occur more frequently among children, who are more susceptible to developing asthma because of their narrower airways, their faster breathing rates, and their more frequent breathing through the mouth than adults.2WHOAir Pollution and Child Health: Prescribing Clean Air. World Health Organization, Geneva2018Google Scholar In addition to the growth of urbanization around the world, increasing evidence of the role of early adverse experience1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar, 2WHOAir Pollution and Child Health: Prescribing Clean Air. World Health Organization, Geneva2018Google Scholar, 3Forno E. Gogna M. Cepeda A. et al.Asthma in Latin America.Thorax. 2015; 70: 898-905Crossref PubMed Scopus (61) Google Scholar—which is more frequent in contexts of poverty and inequality—in the onset of asthma is a significant reason for concern from a health equity perspective. The distribution of atopic and non-atopic asthma, phenotypes that present with similar clinical characteristics but have either overlapping or different causal mechanisms at different ages, varies throughout the world. A family history of asthma, rhinitis, or eczema, current or past dampness and mold in the household, and history of lower respiratory infections during childhood are among the most studied risk factors for non-atopic asthma, whereas exposure to road traffic is associated with both atopic and non-atopic asthma.1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar In 2018, the World Health Organization reported that exposure to ambient air pollution is 1 of the causes of the onset and severity of asthma in childhood and that household air pollution also may be a contributive risk.2WHOAir Pollution and Child Health: Prescribing Clean Air. World Health Organization, Geneva2018Google Scholar However, multiple other factors explain the differences in the distribution of asthma between and within countries. These include population density, altitude, malnutrition, exposure to tobacco smoke, gene-by-environment interactions, and epigenetic deregulation caused by early adverse experience—such as stress, exposure to violence, physical and sexual abuse, and depression and other mental health conditions among parents, as has been reported in Latin America and the Caribbean.1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar, 3Forno E. Gogna M. Cepeda A. et al.Asthma in Latin America.Thorax. 2015; 70: 898-905Crossref PubMed Scopus (61) Google Scholar Part of the geographical variation of asthma phenotypes may also be explained by underdiagnosis and misclassification of atopic asthma as nonatopic. Children with asthma who would test positive to atopy with an allergen-specific immunoglobulin E (IgE) test—less used in contexts of poverty because of its cost—may test negative to atopy with a skin prick test if they have chronic infections, which are more prevalent among the poor.1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar Therefore, the prevalence of atopic asthma in contexts of poverty may be higher than data reported to date because of misclassification. According to 2017 data from the Global Burden of Disease Study, shown in Figure 1, Latin America and the Caribbean—the most urbanized, unequal, and violent region in the world—had the highest prevalence among world regions of asthma in children.4Institute for Health Metrics and Evaluation (IHME)GBD Compare Data Visualization. IHME, University of Washington, Seattle, Washington2018http://vizhub.healthdata.org/gbd-compareGoogle Scholar Its prevalence of 11.7% among children aged 1 to 4, 11.2% among those aged 5 to 9, and 7.3% among those aged 10 to 14 has increased steadily since 2005.4Institute for Health Metrics and Evaluation (IHME)GBD Compare Data Visualization. IHME, University of Washington, Seattle, Washington2018http://vizhub.healthdata.org/gbd-compareGoogle Scholar Within the region, as shown in eFigure 1, the highest prevalence of asthma is found in the Caribbean, followed by South America, Central America, and Mexico. Because of different methodological approaches, these data are lower than the prevalence ranging between 9.3% and 33.1% found among 13- to 14-year-olds by The International Study of Asthma and Allergies in Childhood (ISAAC)—now the Global Asthma Network (GAN)—and other epidemiological surveillance studies.3Forno E. Gogna M. Cepeda A. et al.Asthma in Latin America.Thorax. 2015; 70: 898-905Crossref PubMed Scopus (61) Google Scholar Although asthma prevalence is higher among males than among females in most Latin American and Caribbean countries, asthma in the region causes greater disability among females than among males aged 10 and older,4Institute for Health Metrics and Evaluation (IHME)GBD Compare Data Visualization. IHME, University of Washington, Seattle, Washington2018http://vizhub.healthdata.org/gbd-compareGoogle Scholar as shown in eFigure 2. The GBD data, however, do not allow for disaggregation by socioeconomic stratifiers or between urban and rural settings. As the population living in urban settings continues to grow and street and household violence increase unabatedly, particularly in Latin America and the Caribbean, we should expect an increase in asthma in children, in both incidence and prevalence. Children living in slums of large cities experience the highest prevalence of asthma and, because of their continued exposure to ambient and household pollution, and their limited access to quality health care and health information—which may delay diagnosis and treatment and may preclude adherence—they are at higher risk of uncontrolled asthma episodes. These can generate sleep disorders, hospitalizations, and absenteeism from school, as well as absenteeism from work for their caregivers and out-of-pocket expenditures, which can lead to fewer learning opportunities for children and reduced household income, thus exacerbating their situations of poverty. History of asthma has been associated with chronic obstructive pulmonary disease later in life among urban dwellers in Peru,5Jaganath D. Miranda J.J. Gilman R.H. et al.Prevalence of chronic obstructive pulmonary disease and variation in risk factors across four geographically diverse resource-limited settings in Peru.Respir Res. 2015; 16: 40Crossref PubMed Scopus (52) Google Scholar a finding that points to the potential long-term consequences of uncontrolled asthma. In addition to developing and enforcing policies to control air quality, systematic asthma risk screening in children, which could be conducted in primary health care settings and schools, should be promoted in urban settings, particularly in slums. Educational campaigns to increase awareness about asthma and the benefits of screening and treatment adherence, and timely and continuous access to subsidized treatment to improve adherence and to prevent uncontrolled asthma, should be prioritized in contexts of poverty to achieve health equity. Along these public health interventions, to reduce the incidence of asthma more research should be conducted on the causal mechanisms associated with the onset of atopic and nonatopic asthma—which will also require better use of diagnostic tools—on the differences in prevalence between age groups and sexes, and on strategies that improve treatment adherence. To monitor progress, better definitions of asthma are needed,1Strina A. Barreto M.L. Cooper P.J. Rodrigues L.C. Risk factors for non-atopic asthma/wheeze in children and adolescents: a systematic review.Emerg Themes Epidemiol. 2014; 11: 1-11PubMed Google Scholar as well as data disaggregated by socioeconomic position and type of urban residence, rendering slum health more visible. Finally, birth cohort studies may elucidate the association between environmental exposures, early adverse experience, and the onset of asthma. eFigure 2DALYs caused by asthma in Latin America and the Caribbean, by sex and age group, 2017.Source: Institute for Health Metrics and Evaluation (IHME).4Institute for Health Metrics and Evaluation (IHME)GBD Compare Data Visualization. IHME, University of Washington, Seattle, Washington2018http://vizhub.healthdata.org/gbd-compareGoogle ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) Race and allergy: Are we that different?Annals of Allergy, Asthma & ImmunologyVol. 122Issue 5PreviewOn November 24, 1974, an Australopithecus afarensis specimen "Lucy," was discovered in Hadar, Ethiopia by paleoanthropologists Donald Johanson and Maurice Taieb, nicknamed after the Beatles song "Lucy in the Sky with Diamonds," which was playing at the time she was found.1 Lucy, about 3.2 million years old, was 3.5 feet tall, had powerful arms and long, curved toes, could climb trees as well as walk upright, and she decided to walk across the desert and take off from Ethiopia, initiating the population of the rest of the world. Full-Text PDF
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