Sunia Foliaki

Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC).

Background: Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) measured the global prevalence and severity of asthma symptoms in children. Methods: A cross-sectional questionnaire survey of 798 685 children aged 13–14 years from 233 centres in 97 countries, and 388 811 children aged 6–7 years from 144 centres in 61 countries, was conducted between 2000 and 2003 in >90% of the centres. Results: The prevalence of wheeze in the past 12 months (current wheeze) ranged from 0.8% in Tibet (China) to 32.6% in Wellington (New Zealand) in the 13–14 year olds, and from 2.4% in Jodhpur (India) to 37.6% in Costa Rica in the 6–7 year olds. The prevalence of symptoms of severe asthma, defined as ⩾4 attacks of wheeze or ⩾1 night per week sleep disturbance from wheeze or wheeze affecting speech in the past 12 months, ranged from 0.1% in Pune (India) to 16% in Costa Rica in the 13–14 year olds and from 0% to 20.3% in the same two centres, respectively, in the 6–7 year olds. Ecological economic analyses revealed a significant trend towards a higher prevalence of current wheeze in centres in higher income countries in both age groups, but this trend was reversed for the prevalence of severe symptoms among current wheezers, especially in the older age group. Conclusion: Wide variations exist in the symptom prevalence of childhood asthma worldwide. Although asthma symptoms tend to be more prevalent in more affluent countries, they appear to be more severe in less affluent countries.

Infections, medication use, and the prevalence of symptoms of asthma, rhinitis, and eczema in childhood

Background: The “hygiene hypothesis” postulates that infections during infancy may protect against asthma and atopy. There is also some evidence that antibiotic and/or paracetamol use may increase the risk of asthma. Methods: The study measured the association between infections, and medication use early in life and the risk of asthma at age 6–7 years. It involved 1584 children who had been notified to public health services with serious infections at age 0–4 years, and 2539 children sampled from the general population. For both groups, postal questionnaires were completed by parents. Results: There was little difference in the prevalence of current wheezing between the childhood infections group (prevalence  =  23.5%) and the general population group (prevalence  =  24.3%). There was also little difference whether the major site of infection was gastrointestinal (prevalence  =  24.1%), invasive (prevalence  =  24.6%) or respiratory (prevalence  =  21.1%). However, in both groups, there were associations with antibiotic (OR = 1.78, 95% CI 1.49 to 2.14) or paracetamol (OR = 1.38, 95% CI 1.04 to 1.83) use in the first year of life or recent paracetamol use (OR = 2.10, 95% CI 1.78 to 2.49) and current wheezing. There was a weak protective effect of childhood infections in children who had not used antibiotics in the first year of life (OR = 0.78, 95% CI 0.55 to 1.10). Conclusions: These findings are consistent with other evidence that antibiotic use early in life may increase the risk of asthma. They are also consistent with some preliminary evidence associating paracetamol use with an increased risk of asthma. Any protective effect of notifiable childhood infections was weak.

Antibiotic use in infancy and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old: International Study of Asthma and Allergies in Childhood Phase III.

BACKGROUND Phase III of the International Study of Asthma and Allergies in Childhood measured the global prevalence of symptoms of asthma, rhinoconjunctivitis, and eczema in children. OBJECTIVE To investigate the associations between the use of antibiotics in the first year of life and symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old. METHODS Parents or guardians of children 6 and 7 years old completed written questionnaires on current symptoms and possible risk factors. Prevalence odds ratios (ORs) were estimated by using logistic regression. RESULTS A total of 193,412 children from 71 centers in 29 countries participated. Reported use of antibiotics in the first year of life was associated with an increased risk of current asthma symptoms (wheezing in the previous 12 months) with an OR (adjusted for sex, region of the world, language, and per capita gross national income) of 1.96 (95% CI, 1.85-2.07); this fell to 1.70 (1.60-1.80) when adjusted for other risk factors for asthma. Similar associations were observed for severe asthma symptoms (OR, 1.82; 95% CI, 1.67-1.98), and asthma ever (OR, 1.94; 95% CI, 1.83-2.06). Use of antibiotics in the first year of life was also associated, but less strongly, with increased risks of current symptoms of rhinoconjunctivitis (OR, 1.56; 95% CI, 1.46-1.66) and eczema (OR, 1.58; 95% CI, 1.33-1.51). CONCLUSION There is an association between antibiotic use in the first year of life and current symptoms of asthma, rhinoconjunctivitis, and eczema in children 6 and 7 years old. Further research is required to determine whether the observed associations are causal or are a result of confounding by indication or reverse causation.

Cancer disparities in indigenous Polynesian populations: Māori, Native Hawaiians, and Pacific people

Polynesia consists of several islands that are scattered across a vast triangle in the Pacific, and include New Zealand, Hawaii, and the Pacific islands. There are reported differences in the types of cancer and epidemiologies seen among communities in these islands, the reasons for which are diverse and complex. In this Review, we describe patterns of cancer incidence, mortality, and survival in indigenous populations compared with populations of European origin in Polynesia, and highlight the limited available data for Pacific populations. Additionally, we document the current knowledge of the underlying biology of cancers in these populations, and report risk factors that differ between ethnicities, including smoking, viral infections, and obesity. Disparities in measures of health are highlighted, as are evident differences in knowledge of tumour biology and cancer management between majority and minority populations.

Siblings, asthma, rhinoconjunctivitis and eczema: a worldwide perspective from the International Study of Asthma and Allergies in Childhood

Associations of larger families with lower prevalences of hay fever, eczema and objective markers of allergic sensitization have been found fairly consistently in affluent countries, but little is known about these relationships in less affluent countries.

Exposure to Cats and Dogs, and Symptoms of Asthma, Rhinoconjunctivitis, and Eczema

Background: Associations between exposure to cats and dogs and respiratory and allergic outcomes in children have been reported in affluent countries, but little is known about such associations in less-affluent countries. Methods: The International Study of Asthma and Allergies in Childhood, phase 3 was carried out in children aged 6–7 years and adolescents aged 13–14 years across the world. Questions about cats and dogs in the home were included in an additional questionnaire. Using logistic regression, we investigated the association between such exposures and symptoms of asthma, rhinoconjunctivitis, and eczema. Adjustments were made for sex, region of the world, language, gross national income per capita, and 10 other covariates. Results: Among children (6–7 years of age), cat exposure in the first year of life was associated with current symptoms of asthma, wheeze, rhinoconjunctivitis, and eczema, especially in less-affluent countries. Among adolescents (13–14 years of age), we found a positive association between exposure to cats or dogs and symptom prevalence in more-affluent and less-affluent countries. The global multivariate odds ratios for children with complete covariate data were 1.17 (95% confidence interval = 1.08–1.29) for current symptoms of asthma, 1.13 (1.05–1.23) for rhinoconjunctivitis, and 1.38 (1.26–1.52) for eczema. Smaller odds ratios were found for exposure to only dogs. Exposure to only cats was associated with eczema. Conclusion: Early-life exposure to cats is a risk factor for symptoms of asthma, rhinoconjunctivitis, and eczema in 6- to 7-year-old children, especially in less-affluent countries. Current exposure to cats and dogs combined, and only to dogs, is a risk factor for symptom reporting by 13- to 14-year-old adolescents worldwide.

Prevalence of symptoms of childhood asthma, allergic rhinoconjunctivitis and eczema in the Pacific: The International Study of Asthma and Allergies in Childhood (ISAAC)

The International Study of Asthma and Allergies in Childhood (ISAAC) has provided valuable information regarding international prevalence patterns and potential risk factors for asthma, allergic rhinoconjunctivitis and eczema. However, the only Pacific countries that participated in ISAAC Phase I were Australia and New Zealand, and these included only a small number of Pacific children. Phase III has involved not only repeating the Phase I survey to examine time trends, but also to include centres and countries which are of interest but did not participate in Phase I. The ISAAC Phase III study was therefore conducted in the Pacific (in French Polynesia, New Caledonia, Tonga, Fiji Islands, Samoa, Cook Islands, Tokelau Islands and Niue). The overall prevalence rates of current symptoms (in the last 12 months) were 9.9% for asthma, 16.4% for allergic rhinoconjunctivitis and 10.7% for atopic eczema. The prevalence of current wheezing (9.9%) was generally much lower than that has been observed in Pacific children in New Zealand (31%), but there was considerable variation between the various Pacific centres: Tokelau Islands (19.7%), Tonga (16.2%), Niue (12.7%), French Polynesia (11.3%), Cook Islands (10.6%), Fiji Islands (10.4%), New Caledonia (8.2%) and Samoa (5.8%). The reasons for these differences in prevalence across the Pacific are unclear and require further research. The finding that prevalence levels are generally considerably lower than those in Pacific children in New Zealand adds to previous evidence that children who migrate experience an altered risk of asthma as a result of exposure to a new environment during childhood.

Changing pattern of ill health for indigenous people.

Control of lifestyle is beyond individuals and depends on social and political factors Industrialising societies are said to have undergone various epidemiological transition stages, in which the transition from stage two to stage three involves a change from receding pandemics to lifestyle diseases.1 The dynamics of this transition, which took thousands of years in Western countries, have been unprecedented and greatly compacted in time in most indigenous populations. Rather than a transition we see the rise of lifestyle non-communicable diseases at a time when the receding pandemics have not yet receded.2 The pattern seems to be similar in indigenous people in their traditional lands, such as the Pacific, and in newly adopted metropolitan centres, such as New Zealand. We consider here the different dynamics of the epidemiological transition in indigenous people and argue that these are linked to socioeconomic transitions beyond their power and their borders. Thus individual lifestyle interventions cannot be naively transferred to indigenous populations. Rather, what is required is appropriate national and international social and political commitment to health protection, …

Global prevention and control of NCDs: Limitations of the standard approach.

The five-target ‘25 × 25’ strategy for tackling the emerging global epidemic of non-communicable diseases (NCDs) focuses on four diseases (CVD, diabetes, cancer, and chronic respiratory disease), four risk factors (tobacco, diet and physical activity, dietary salt, and alcohol), and one cardiovascular preventive drug treatment. The goal is to decrease mortality from NCDs by 25 per cent by the year 2025. The ‘standard approach’ to the ‘25 × 25’ strategy has the benefit of simplicity, but also has major weaknesses. These include lack of recognition of: (i) the fundamental drivers of the NCD epidemic; (ii) the ‘missing NCDs’, which are major causes of morbidity; (iii) the ‘missing causes’ and the ‘causes of the causes’; and (iv) the role of health care and the need for integration of interventions.

Prevention and control of diabetes in Pacific people

Diabetes is a major problem worldwide. Among Pacific people, prevention and control of diabetes lies in counteracting rapid changes in lifestyle and must take account of political and economic factors and social structure Early studies clearly showed that while diabetes was virtually non-existent in populations indigenous to the Pacific maintaining a traditional lifestyle, the reverse was true for the urbanised Pacific populations.1 In recent decades diabetes prevalence has increased rapidly over time in the indigenous people in the Pacific region (Polynesian, Melanesian, Micronesian), both in the Pacific islands and in countries such as New Zealand.2 Epidemiological evidence indicates that prevalence is generally lowest in traditional Pacific environments, and is higher in both urban Pacific and adopted metropolitan environments; in the latter environments, prevalence is markedly higher in Pacific people than in white people. Prevalence has been increasing rapidly in all three environments, and Pacific people experience greater morbidity and more complications than white people with diabetes. Genetic factors alone cannot explain these patterns, which are due to rapid changes in lifestyle and risk factors such as obesity, unhealthy diets, and physical inactivity that have become widespread throughout the region.2 Although the risk factors associated with diabetes are now reasonably well understood, the prevention and control of the condition in the Pacific, and in Pacific people in Western countries, is not straightforward. We here consider the individual level and population level approaches to diabetes prevention and control in Pacific people. Vigorous pharmacological interventions have a clear role in the management of existing diabetes. Nevertheless, in some Pacific countries a large proportion of resources is spent on identifying people with diabetes and on a variety of non-standardised drug treatment regimens. Modification of individual behaviour is undertaken in less than 5% of the population.3 Given the high cost of …