Dirceu Solé Full Professor Division of Allergy, Clinical Immunology and Rheumatology Departament of Pediatrics Federal University of São Paulo

Transcrição

1 Dirceu Solé Full Professor Division of Allergy, Clinical Immunology and Rheumatology Departament of Pediatrics Federal University of São Paulo President of SLAAI and ASBAI

2 Asher et al Lancet 2006;368:733-43

3 20 Countries & 11 Territories Total population = 569 million Urban areas = 389 million (10% without potable water) Colonization Portuguese = Brazil Spanish = All the others

4 Mallol & Solé, 2009

5 6-7yr-old N Wheezing 12 mo Asthma ever Severe wheeze Severe wheeze* Severe wheeze** Latin America 93, Global total 388, yr-old N Wheezing 12 mo Asthma ever Severe wheeze Severe wheeze* Severe wheeze** Latin America 165, Global total 798, *among current wheezers ** without asthma among current wheezers Mallol, Solé and ISAAC Phase 3 colaborators J Asthma, in press

6 Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 21, , Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 44, , Asher et al Lancet 2006;368: Pearce et al Thorax 2007;62: Mallol et al J Asthma 2009, in press

7 Pearce et al Thorax 2007;62:758-66

8 Mexically Valey Monterrey Ciudad Victoria Habana Merida Ciudad de Mexico 1 Ciudad de Mexico 3 Ciudad de Mexico 4 Toluca Cuernavaca Villahermosa San Pedro Sula San Salvador Managua Barranquilla Caracas Costa Rica David Panama Bogota Cali Quito Guayaquil Manaus Recife Caruaru Maceio Aracaju Lima Feira de Santana Salvador Vitoria da Conquista Brasilia Santa Cruz Belo Horizonte Calama Nova Iguaçu Sao Paulo Sul Sao Paulo West Santo Andre Salta Assuncion Curitiba Itajai Passo Fundo Santa Maria rural Santa Maria Porto Alegre Cordoba Paysandu Rosario city Santiago South Montevideo Neuquen Valdivia Chiloe Punta Arenas Mallol, Solé, and LA ISAAC Phase 3 colaborators J Asthma in press

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10 N Rhinitis Rhino last yr conjunctivitis Strachan et al Pediatr Allergy Immunol 1997; Aït-Khaled et al Allergy 2009;64: Solé et al Pediatr Allergy Immunol 2009 Sep 24. [Epub ahead of print]

11 Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 21, , Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 44, , Bjorksten et al Pediatr Allergy Immunol 2008;19: Solé et al - Pediatr Allergy Immunol 2009 Sep 24. [Epub ahead of print]

12 Bjorksten et al Pediatr Allergy Immunol 2008;19:110-24

13 Mexically Monterrey C Victoria La Habana Merida C mexico 1 C Mexico 3 C Mexico 4 Toluca Cuernavaca V Hermosa S Pedro Sula S Salvador Managua Barranquilla Caracas Costa Rica Panamá Bogotá Cali Quito Guayaquil Manus Recife Caruaru Maceió Aracaju Lima F Santana Salvador V Conquista Brasília Sta Cruz B Horizonte Calama N Iguaçu São Paulo-S São Paulo-W S André Salta Asuncion Curitiba Itajaí Passo Fundo Santa Maria-R Santa Maria Porto Alegre Cordoba Paysandu Rosario Santiago-S Montevideo Neuquen Valdívia Chiloé Punta Arenas Solé et al -Pediatr Allergy Immunol Sep 24. [Epub ahead of print]

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15 N Flexural Severe eczema eczema Williams et al J Allergy Clin Immunol 1999;103: Williams et al J Allergy Clin Immunol 2008;121: Solé et al Pediatr Allergy Immunol 2009, in press

16 Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 21, , Latin-America Total Centre N Year between P1 P3 Change/ Response phases year rate (%) 44, , Asher et al Lancet 2006;368: Bjorksten et al Pediatr Allergy Immunol 2008;19: Solé et al Pediatr Allergy Immunol 2009, in press

17 Williams et al J Allergy Clin Immunol 2008;121: LA centers English speaking center

18 Mexically Valey Monterrey Ciudad Victoria Habana Merida Ciudad de Mexico 1 Ciudad de Mexico 3 Ciudad de Mexico 4 Toluca Cuernavaca Villahermosa San Pedro Sula San Salvador Managua Barranquilla Caracas Costa Rica David Panama Bogota Cali Quito Guayaquil Manaus Recife Caruaru Maceio Aracaju Lima Feira de Santana Salvador Vitoria da Conquista Brasilia Santa Cruz Belo Horizonte Calama Nova Iguaçu Sao Paulo Sul Sao Paulo West Santo Andre Salta Assuncion Curitiba Itajai Passo Fundo Santa Maria rural Santa Maria Porto Alegre Cordoba Paysandu Rosario city Santiago South Montevideo Neuquen Valdivia Chiloe Punta Arenas Solé et al J Investig Allergol Immunol 2009, in press

19 Asthma 6-7yr yr Severe asthma 6-7 y yr Rhinoconjunctivitis 6-7 yr yr Severe rhinitis 6-7 yr 13-14yr Flexural eczema 6-7 yr yr Severe eczema yr Min (%) Max (%) Mean (%) Variation

20 Gross National Product Infant mortality rate % population with potable water service % population with sewage disposal services Annual deaths kids under 5 yrs of age due to intestinal infectious diseases Annual incidence of tuberculosis tabulator/newtabulator.htm;

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22 Prevalence of symptoms (ISAAC Ph 1): asthma, rhinoconjunctivitis, eczema Particulate matter <10mm (PM 10 ) city-level Associations evaluated by binomial regression Adjusted for Gross National Product per capita Results compared with a meta-analysis of published multi-centre studies Anderson et al Occup Environ Med published online 5 Nov 2009

23 Log of severe wheeze Log of severe wheeze Spearman r =0.39 p< Spearman r =0.36 p< PM PM10 Anderson et al Occup Environ Med published online 5 Nov 2009

24 European countries Non-European higher income countries Non-European lower income countries Subtotal Overall Anderson et al Occup Environ Med published online 5 Nov 2009

25 The reasons for the wide international variations in the prevalence of childhood asthma, rhinoconjunctivitis and eczema are not understood. One factor might be exposure to ambient particulate matter (PM) since this is associated with a range of respiratory outcomes and associations have been observed with proximity to traffic pollution. In a study of over a million children from 105 cities in 51 countries, we found little or no evidence of associations with modelled urban background PM 10. In a study of over a million children from 105 cities in 51 countries, we found little or no evidence of associations with modelled urban background PM 10. The results suggest that community levels of ambient PM The are results unlikely suggest to that explain community international levels of ambient PM variations are unlikely to in explain international variations in prevalence. prevalence. Fututre studies of differences in prevalence between communities will benefit from improved exposure assessment and control for confounding factors at individual level. Anderson et al Occup Environ Med published online 5 Nov 2009

26 Mexically Valey Monterrey Ciudad Victoria Habana Merida Ciudad de Mexico 1 Ciudad de Mexico 3 Ciudad de Mexico 4 Toluca Cuernavaca Villahermosa San Pedro Sula San Salvador Managua Barranquilla Caracas Costa Rica David Panama Bogota Cali Quito Guayaquil Manaus Recife Caruaru Maceio Aracaju Lima Feira de Santana Salvador Vitoria da Conquista Brasilia Santa Cruz Belo Horizonte Calama Nova Iguaçu Sao Paulo Sul Sao Paulo West Santo Andre Salta Assuncion Curitiba Itajai Passo Fundo Santa Maria rural Santa Maria Porto Alegre Cordoba Paysandu Rosario city Santiago South Montevideo Neuquen Valdivia Chiloe Punta Arenas Mallol, Solé, and LA ISAAC Phase 3 colaborators J Asthma in press

27 Mexically Monterrey C Victoria La Habana Merida C mexico 1 C Mexico 3 C Mexico 4 Toluca Cuernavaca V Hermosa S Pedro Sula S Salvador Managua Barranquilla Caracas Costa Rica Panamá Bogotá Cali Quito Guayaquil Manus Recife Caruaru Maceió Aracaju Lima F Santana Salvador V Conquista Brasília Sta Cruz B Horizonte Calama N Iguaçu São Paulo-S São Paulo-W S André Salta Asuncion Curitiba Itajaí Passo Fundo Santa Maria-R Santa Maria Porto Alegre Cordoba Paysandu Rosario Santiago-S Montevideo Neuquen Valdívia Chiloé Punta Arenas Solé et al -Pediatr Allergy Immunol Sep 24. [Epub ahead of print]

28 Mexically Valey Monterrey Ciudad Victoria Habana Merida Ciudad de Mexico 1 Ciudad de Mexico 3 Ciudad de Mexico 4 Toluca Cuernavaca Villahermosa San Pedro Sula San Salvador Managua Barranquilla Caracas Costa Rica David Panama Bogota Cali Quito Guayaquil Manaus Recife Caruaru Maceio Aracaju Lima Feira de Santana Salvador Vitoria da Conquista Brasilia Santa Cruz Belo Horizonte Calama Nova Iguaçu Sao Paulo Sul Sao Paulo West Santo Andre Salta Assuncion Curitiba Itajai Passo Fundo Santa Maria rural Santa Maria Porto Alegre Cordoba Paysandu Rosario city Santiago South Montevideo Neuquen Valdivia Chiloe Punta Arenas Solé et al J Investig Allergol Immunol 2009, in press

29 Total Calories/capita/day Protein/capita/day (g) Fat/capita/day (g) Vegetal Calories/capita/day Protein/capita/day (g) Fat/capita/day (g) Animal Calories/capita/day Protein/capita/day (g) Fat/capita/day (g)

30 Antibiotic use early in life may increase risk of asthma and allergic diseases? Ecologic analysis: antibiotics sales vs prevalence of symptoms (asthma, allergic rhinoconjunctivitis, and atopic eczema - ISAAC Ph3) 99 centres from 28 countries Data obtained from: Institute for Medical Statistics (IMS), Health Global Services, UK Analysis adjusted for gross national product (GNP) Foliaki et al J Allergy Clin Immunol 2009;124:982-9

31 Thailand (76%) Syrian Arabic Republic (70%) Panama (69%) New Zealand (63%) Nigeria (62%) Chile (62%) Mexico (61%) Iran (60%) Canada (59%) Portugal (58%) Colombia (57%) Hungary (56%) Spain (54%) Belgium (53%) Barbados (53%) Lithuania (49%) Brazil (48%) India (48%) Estonia (36%) Taiwan (23%) LA country ( ) % children use antibiotics Foliaki et al J Allergy Clin Immunol 2009;124:982-9

32 Africa ( ) 2.06 ( ) 1.25 ( ) Asia-Pacific hypothesis 4that 10,092 antibiotic 1.79( ) use increases 1.94 ( ) the 1.42 risk ( ) of Eastern Mediterranean 4 8, ( ) 1.52 ( ) 1.22 ( ) Indian Subcontinent Latin America North America ,020 12,703 2, ( ) 1.96 ( ) 1.75 ( ) OR (CI95%)* These findings are consistent with the Region Centers Children Asthma (wheeze) Rhinoconjunctivitis Eczema asthma, rhinitis, or eczema. If there is a causal 1.34 ( ) 1.62 ( ) 1.22 ( ) 1.33 ( ) 1.65 ( ) association of antibiotic use with asthma risk, it does 1.56 ( ) N/Eastern Europe 3 6, ( ) 1.87 ( ) 1.47 ( ) not appear to explain the international differences in Oceania 4 9, ( ) 1.64 ( ) 1.43 ( ) Western Europe 12 26,309 asthma 1.57 ( ) prevalence ( ) 1.34 ( ) * Multiple regression analysis including centers with at least 70% data available for all covariates. All children who had a missing value of any of the covariates have been removed. Adjusted for sex, region of the world, language, GNI, maternal education, breast-feeding, current paternal smoking, consumption of vegetables, consumption of pulses, consumpption of fruits, paracetamol use in the first year of life, current paracetamol use, older siblings, and younger siblings Foliaki et al J Allergy Clin Immunol 2009;124:982-9

33 205,487 children (6-7 yrs old) 73 centers in 31 countries Association of: Paracetamol for fever (first year of life and nowadays) with increased risk of asthma and allergic diseases Beasley et al Lancet 2008;372:

34 Beasley et al Lancet 2008;372:

35 Use of paracetamol in the first year of life and later childhood, is associated with risk of asthma, rhinoconjunctivitis, and eczema at age 6 to 7 years. We suggest that exposure to paracetamol might be a risk for the development of these diseases in childhood Beasley et al Lancet 2008;372:

36 Higher variability on prevalence of these diseases between countries and in centers from the same country of Latin America Significant increase among both age groups during a 7-year interval (Phase I and III) in several centers Mean increase of Asthma prevalence rates doubled those from developed countries

37 Confirms Phase I results: probably the Hygiene Hypothesis is not applicable to Latin America Asthma is a heterogeneous disease and local studies are mandatory Asthma and allergic diseases in schoolchildren continue to be a major health problem in Latin America

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