turma3.0910@gmail

1. turma3.0910@gmail.com 24.05.2010

2. INTRODUCTION: BACKGROUNG AND JUSTIFICATION Asthma is one of the most common chronic conditions…. Asthma’s possible etiology (adapted from Early life origins of asthma, J. Clin. Invest. James E. Gern, et al. 104:837)

3. INTRODUCTION: BACKGROUNG AND JUSTIFICATION (adapted from http://www.european-lung-foundation.org/index.php?id=46)

4. INTRODUCTION: BACKGROUNG AND JUSTIFICATION Costofcare for asthmainEurope… The total annual costs of asthma care in Europe amount to approximately €17.7 billion (adapted from http://www.european-lung-foundation.org/index.php?id=46)

5. The prevalence of asthma in young adults (20-44 years) in different parts of the Europe (adapted from www.medsci.uu.se) The recent substantial increase in the reported prevalence of asthma worldwide has led to numerous studies of the prevalence and characteristics of this condition. 

6. RESEARCH QUESTION AND AIMS The central question that motivates the development of this study is: “What methods exist to assess the prevalence of asthma in Europe?” And from this main question we can infer three important aims: - Review the methods used to assess the prevalence of asthma in Europe, that fit our established inclusion/exclusion criteria; - Debate the main differences between them and consider advantages and disadvantages; - Explore and characterize the 2 major European methods used to assess the prevalence of asthma, ISAAC and ECRHS.

7. Participants and methods

8. STUDY PARTICIPANTS Our study consisted in a systematic review, therefore we used other articles as unit of analysis in its development. Inclusion criteria: • Describe methods to assess the prevalence of asthma; • Having European population as the assessment target; • An identifiable description of the methods indicating the sources must have been present; • Population-based response rate must have been statistically significant. Exclusion criteria: • Articles that have been written before 1990; • Articles that used a language other than English.

9. STUDY DESIGN

10. DATA COLLECTION METHODS - SEARCHING We searched the MEDLINE with a specific query: User Query: asthma AND prevalence AND Europe AND methods AND (Humans[Mesh] AND English[lang]) Query Translation: ("asthma"[MeSH Terms] OR "asthma"[All Fields]) AND ("epidemiology"[Subheading] OR "epidemiology"[All Fields] OR "prevalence"[All Fields] OR "prevalence"[MeSH Terms]) AND ("europe"[MeSH Terms] OR "europe"[All Fields]) AND ("methods"[Subheading] OR "methods"[All Fields] OR "methods"[MeSH Terms]) AND ("humans"[MeSH Terms] AND English[lang]) Results: 1474 KEY-WORDS: Asthma, prevalence, methods, Europe, assessment, ECRHS, ISAAC

11. DATA COLLECTION METHODS - SELECTING First selective phase: Titles and abstracts of the retrieved studies were screened for relevance each by two reviewers - concordant in excluding the article would be removed - concordant in including the article would pass to next phase If they had not the same opinion it would be necessary a third reviewer… Second phase: The full-texts of the articles were analyzed and identified as potentially relevant through the same review method as the first phase

12. DATA COLLECTION METHODS - EXTRACTING Scanning and extracting were conducted on the 28th and 29th of March, 2010. N=1474 title and abstract scanning N=1368articleswereexcluded N=106 articleswereincluded full text scanning N=24articleswereexcluded N=82 articleswereincluded

13. DATA COLLECTION METHODS - SYNTHESIZING • After selected articles were obtained a resume was made based on • these pre-established points: • method name; • target population; • year; • design and structure of the method; • results obtained; • possible advantages and disadvantages; • observations.

14. VARIABLES DESCRIPTION We considered two types of variables in our work: - qualitative - quantitative represented by the numerical values obtained in the assessment of the prevalence of asthma by a certain method. Quantitative values represented by the nominal values obtained from the characteristics of the methods following the application of the pre-established points. Qualitative values With all of this we intend to standardize the interpretation of the asthma methods and to better assess their characteristics.

15. PLANNED STATISTICAL ANALYSIS Our statistical analysis will consist in: • Descriptive part - describes the general characteristics of a given method, according to the above mentioned pre-established points. we will compare extensively all the methods included in the selected articles according to the pre-established points….

16. GLOBAL ASSESSMENT ITEMS Therefore, it is our intention not only to extensively compare the previously mentioned characteristics of the different methods found, but also to consider and reflect on the values obtained by them. Special attention will be given to the two major European studies to assess the prevalence of asthma: ISAAC and ECRHS.

17. Results

18. Author(s) Country Method Year Sample Prevalence

19. METHODS USED TO ASSESS THE PREVALENCE OF ASTHMA Articles: 82

20. - Parental questionnaires: 25 • - Only questionnaires: 46 • - Questionnaires + Clinic Tests: 8 • Video: 2 • E-mail: 2 • Postal: 44 • Telephone: 5 • In Hospitals: 3 Types of questionnaire - Delivery modes

21. Discussion/Conclusion

22. METHODS USED TO ASSESS THE PREVALENCE OF ASTHMA Parental questionnaires: 25 Children may not be able to answer the questionnaires, due to their immaturity, so parental questionnaires are probably a better way to assess asthma in children. Even though the parents are present, they may not be aware of certain episodes that happen at school or in other occasions in which they were not present. There may also be lack of communication between the children and the parents.

23. METHODS USED TO ASSESS THE PREVALENCE OF ASTHMA Only questionnaires: 46 Questionnaires + Clinic Tests: 8 Written questionnaires are probably the method of choice for comparing prevalence in large epidemiological studies, although objective measures may improve the outcome. Clinic tests may provide more exact results. "In a study conducted in 4 different countries only 50 % of the subjects who according to their doctor suffered from asthma reported it in the questionnaire"

24. TYPES OF QUESTIONNAIRE Postal questionnaires are the most likely to have a higher response rate than the other means of communication. E-mails require that the target population have Internet at home Telephone questionnaires require that the target population are at home when the call is made. They are, however, much faster. Telephone questionnaires are answered especially by the retired population and housewives. Hospital questionnaires have an extremely high response rate, but it is only used when the target population is hospitalized. • E-mail: 2 • Postal: 44 • Telephone: 5 • Video: 2 • In Hospitals: 3

25. ISAAC – INTERNATIONAL STUDY OF ASTHMA AND ALLERGIES IN CHILDHOOD There are 3 main methods that allow to calculate the prevalence of asthma, using the ISAAC questionnaire: - written asthma questionnaire - video questionnaire - phone interview Which are the main differences? Advantages and Disadvantages?

26. VIDEO QUESTIONNAIRE: - Video questionnaire was developed to try to circumvent the discrepancies of language. WRITTEN/POSTAL QUESTIONNAIRE: The questionnaire were mailed with a pre-paid return envelop. Those subjects who did not respond within 2 weeks received one reminder letter. After one reminder the overall response rate increased and no further reminders were mailed. PHONE QUESTIONNAIRE: - Generally used when no answer is obtained throught written questionnaire. It is not used as a single method, because it takes to much time.

27. ISAAC – WRITTEN QUESTIONNAIRE Differences between questionnaires completed by parents and questionnaires completed by children/adolescents: Parents may report more serious symptoms and they might be less aware of occasional symptoms occurring following exercise. On the other hand, teenagers may have difficulties in differentiating exercise induced wheezing from other poor conditioning forms of breathlessness that may result in over-reporting.

28. ISAAC – WRITTEN QUESTIONNAIRE Women always have greater tendency to answer more easily to this type of questionnaire, just like older people, because they are usually retired and/or more available. On the other hand, males and younger people are lesse available. The latter were, in fact, those who showed a smaller response rate, probably due to the fact that had no time or patience for this type of study, eventually find them unnecessary. Disadvantages: - phone and mailed questionnaires are not objective measurements.

29. VIDEO QUESTIONNAIRE …participating countries found video prevalence estimates lower than written estimates for comparable questions. Why ? Some advantages/disadvantages… - A possible explanation is that the video scenes are likely to represent more severe symptoms (wheezing at rest) than the written questionnaire, which covers mild to severe symptoms (any wheezing). - The other possible explanation is not understanding the meaning of the term “wheezing”. … but there is good agreement between two methods!

30. GNT-HIS: GermanNationalTelephoneHealthInterviewSurvey 2003 Objectives: Estimate of asthma prevalence in German adults based on a recent nationwide sample and investigate differences according to age, sex, and region of residence (East vs. West) as well as other variables associated with asthma. Target Population: Non institutionalized adult population 18 years of age and older in Germany who could be contacted via conventional landline telephone. Method: First, households were selected with a modified random digit dialing to reach those with and without a telephone number listed in telephone directories. Second, the interviewer asked to talk to the household member 18 years of age or older whose birthday was next (next-birthday method).

31. GNT-HIS: GermanNationalTelephoneHealthInterviewSurvey 2003 Some limitations… - The questionnaire included only one question on asthma that estimates lifetime prevalence. - The elderly may not remember an asthma diagnosis in younger years or in childhood. This may lead to an underestimation of their lifetime prevalence. - Subjects who participated may differ from non-responders. People who only answered the short questionnaire were significantly older, had a lower educational level, and had better physical health compared to subjects who completed the survey. Households’ access to landline telephone is not likely to be a significant problem. According to the Federal Office of Statistics about 98.7% of all German households had a telephone at their disposal in 2004. But…

32. SIDRIA - ItalianStudiesofRespiratoryDiseasesinChildhoodandtheEnvironment SIDRIA contributed to the ISAAC study with a large sample of children, and widely extended the objective of ISAAC, since it was aimed at evaluating the effects of several potential environmental risk factors, including outdoor air pollution, on children’s respiratory health.

33. ISAAC(International Study of Asthma and Allergies in Childhood) • AIMS: • Describe the prevalence and severity of asthma, rhinitis and eczema in children living in different centres, and to make comparisons within and between countries; • Obtain baseline measures for assessment of future trends in the prevalence and severity of these diseases; • Provide a framework for further etiological research into genetic, lifestyle, environmental and medical care factors affecting these diseases.

34. ECRHS(European Community Respiratory Health Survey) • AIMS: • Assess the variation in the prevalence of asthma, asthma-like symptoms and bronchial responsiveness in Europe; • Estimate the variation in exposure to known or suspected risk factors for asthma, to measure their association with asthma and to further assess the extent to which they explain variations in prevalence across Europe; • Estimate the variation in treatment practice for asthma in the European Community.

37. REFERENCES [1] Subbarao, P; Mandhane, P. J; Sears, M. R (2009).  Asthma: epidemiology, etiology and risk factors. DOI:10.1503/cmaj.080612. [2] Björkstén, B; Dumitrascu, D; Foucard, T; Khetsuriani, N; Khaitov, R; Leja, M; Lis, G; Pekkanen, J; Priftanji, A; Riikjärv, M.A. (1998). Prevalence of childhood asthma, rhinitis and eczema in Scandinavia and Eastern Europe. Eur Respir J; 12: 432–437. [3] Liebhart, J; Malolepszy, J; Wojtyniak, B; Pisiewicz, K; Plusa, T; Gladysz, U. (2007). Prevalence and Risk Factors for Asthma in Poland: Results From the PMSEAD Study. J Investig Allergol Clin Immunol; Vol. 17 (6): 367-374. [4] Burney, P; Chinn, S; Jarvis, D; Luczynska, C; Lai, E. (1996). Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 9, 687–695. [5] Urrutia, I; Aguirre, U; Sunyer, J; Plana, E; Muniozguren, N; Martínez-Moratalla, J; Payo, F; Maldonado, J; Anto, J.(2007). Changes in the Prevalence of Asthma in the Spanish Cohort of the European Community Respiratory Health Survey (ECRHS-II). Arch Bronconeumol ;43(8):425-30. [6] Caldeira, R. D; Bettiol, H; Bardieri, M A; Terra-Filho, J; Garcia, C A; Vianna, E O (2006). Prevalence and risk factors for work related asthma in young adults. 63: 694-699.

38. REFERENCES [7] Pearce, N; Sunyer, J; Cheng, S; Chinn, S; Bjorksten (2000). Comparison of asthma prevalence in the ISAAC and the ECRHS. 16: 420-426. [8] Borrego, M; César, M; Leiria-Pinto, P; Rosado-Pinto, J E. (2005). Prevalence of asthma in a Portuguese countryside town: repercussions on absenterism and self-concept. 33(2): 93-9. [9] Priftis, K N; Paragiotakos, D B; Anthracopoulos, M B; Papadimitriou, A; Nicolaidou, P (2007). Aims, methods and preliminary findings of the Physical Activity, Nutricion and Allergies in children examined in Athens (PANACEA) epidemiological study. 7:140. [10] Chatenoud, L; Malvezzi, M; Pitrelli, A; La Vecchia, C; Banfi, F (2009). Asthma mortality and long-acting Beta2-agonists in five major europeans countries, 1994-2004. 46: 546-551. [11] Bjerg, A; Standstrom, T; Lundback, B; Ronmark, E (2009). Time trends in asthma and wheeze in Swedish children 1996-2006: prevalence and risk factors by sex.

39. ABSTRACT BACKGROUND: Asthma is one of the most common chronic conditions affecting both children and adults, yet much remains to be learned of its etiology. The recent substantial increase in the reported prevalence of asthma worldwide has led to numerous studies of the prevalence and characteristics of this condition. METHODS: We searched the MEDLINE for studies published from 1990 to 2009 which assess the prevalence of asthma in Europe. Using pre-established inclusion and exclusion criteria, we examined as many articles as we could that used European methods to assess the prevalence of asthma, particularly attending to the target population, design and structure of the method, results obtained, as well as possible advantages and disadvantages. RESULTS: 84articles describing different studies satisfied our inclusion criteria. 54 of all analyzed studies used the two main European methods, ISAAC (The International Study of Asthma and Allergies in Childhood) – 48 articles - and ECRHS (European Community Respiratory Health Survey) – 6 articles. The remaining 30 were not based in the previous mentioned methods.  CONCLUSIONS: Few well-designed methods have been conducted to assess the prevalence of asthma in European countries. Most European studies are based in ECRHS or ISAAC questionnaires or in their general structure, so that they can overcome their disadvantages. The differences in prevalences are, probably, due to the different existent methods.

40. Areal, Maria Clara (mimed09089@med.up.pt); Ferro, Ana (mimed09195@med.up.pt); Horta, Pedro (mimed09129@med.up.pt); Mendes, Maria José (xt09035@med.up.pt); Mota, Ricardo (mimed09154@med.up.pt); Pinto, Pedro David (mimed09130@med.up.pt); Reis, Ana Clara (mimed09189@med.up.pt); Santos, Henrique (mimed09287@med.up.pt); Shekhovtsova, Maria (mimed09106@med.up.pt); Silva, Rómulo (mimed09149@med.up.pt); Teixeira, Tânia (mimed09184@med.up.pt); Vinha, José (mimed09204@med.up.pt)