dirceu solé - sap · dirceu solé full professor division of allergy, clinical immunology and...
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Dirceu SoléFull Professor Division of Allergy, Clinical Immunology and Rheumatology
Departament of Pediatrics – Federal University of São PauloPresident of SLAAI and ASBAI
20 Countries & 11 Territories
Total population = 569 million
Urban areas = 389 million(10% without potable water)
ColonizationPortuguese = Brazil
Spanish = All the others
*among current wheezers** without asthma among current wheezers
Severe wheeze**
Severe
wheeze*
Severe
wheeze
Asthma
ever
Wheezing
12 mo
N
18.941.111.293,851Latin America
16.538.59.4388,811Global total
Severe wheeze**
Severe
wheeze*
Severe
wheeze
Asthma
ever
Wheezing
12 mo
N
18.938.313.6165,917Latin America
20.043.312.6798,685Global total
6-7yr-old
13-14yr-old
Mallol, Solé and ISAAC Phase 3 colaborators – J Asthma, in press
Latin-America
Total
17.8
13.2
18.8
13.7
6.9
7.0
44,550
304,811
90.9
90.9
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Latin-America
Total
20.9
10.6
21.4
11.6
7.1
7.1
21,112
193,436
83.8
84.8
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Asher et al – Lancet 2006;368:733-43
Pearce et al – Thorax 2007;62:757-65
Mallol et al – J Asthma 2009, in press
Mexically ValeyMonterrey
HabanaMerida
Ciudad de Mexico 1
Ciudad de Mexico 4Toluca
Cuernavaca
San Pedro SulaSan Salvador
BarranquillaCaracas
David Panama
Ciudad Victoria
Ciudad de Mexico 3
Villahermosa
Managua
Costa Rica
Cali
Quito
ManausRecife
Maceio
LimaFeira de Santana
Vitoria da ConquistaBrasilia
Belo Horizonte
Bogota
Guayaquil
Caruaru
Aracaju
Salvador
Santa Cruz
Calama
Sao Paulo SulSao Paulo West
SaltaAssuncion
ItajaiPasso Fundo
Santa MariaPorto Alegre
PaysanduRosario city
Montevideo
Nova Iguaçu
Santo Andre
Curitiba
Santa Maria rural
Cordoba
Santiago South
Neuquen
ChiloeValdivia
Punta Arenas
0 5 10 15 20 25 30
Mallol, Solé, and LA ISAAC Phase 3 colaborators – J Asthma 2009 - in press
N Rhinitis Rhinolast yr conjunctivitis
Strachan et al – Pediatr Allergy Immunol 1997;
Aït-Khaled et al – Allergy 2009;64:123-48
Solé et al –Pediatr Allergy Immunol 2009 Sep 24. [Epub ahead of print]
Latin-America
Total
15.5
13.6
18.5
15.1
6.9
7.0
44,550
304,811
90.9
90.9
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Latin-America
Total
9.1
7.0
12.1
8.3
7.1
7.1
21,112
193,436
83.8
84.8
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Bjorksten et al –Pediatr Allergy Immunol 2008;19:110-24
Solé et al - Pediatr Allergy Immunol 2009 Sep 24. [Epub ahead of print]
0 10 20 30 40 50 60
Punta ArenasChiloé
ValdíviaNeuquen
MontevideoSantiago-S
RosarioPaysanduCordoba
Porto AlegreSanta Maria
Santa Maria-RPasso Fundo
ItajaíCuritiba
AsuncionSalta
S AndréSão Paulo-WSão Paulo-S
N IguaçuCalama
B HorizonteSta CruzBrasília
V ConquistaSalvador
F SantanaLima
AracajuMaceióCaruaru
RecifeManus
GuayaquilQuito
CaliBogotá
PanamáCosta Rica
CaracasBarranquilla
ManaguaS Salvador
S Pedro SulaV Hermosa
CuernavacaToluca
C Mexico 4C Mexico 3C mexico 1
MeridaLa HabanaC Victoria
MonterreyMexically
Solé et al -Pediatr Allergy Immunol. 2009 Sep 24. [Epub ahead of print]
Williams et al – J Allergy Clin Immunol 1999;103:125-38
Williams et al – J Allergy Clin Immunol 2008;121:947-54
Solé et al – Pediatr Allergy Immunol 2009, in press
N Flexural Severeeczema eczema
Latin-America
Total
7.2
7.0
9.0
7.6
6.9
7.0
44,550
304,811
90.9
90.9
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Latin-America
Total
8.7
6.9
10.5
8.6
7.1
7.1
21,112
193,436
83.8
84.8
Centre N Year between P1 P3 Change/ Responsephases year rate (%)
Asher et al – Lancet 2006;368:733-43
Bjorksten et al –Pediatr Allergy Immunol 2008;19:110-24
Solé et al – Pediatr Allergy Immunol 2009, in press
Mexically ValeyMonterrey
Ciudad VictoriaHabanaMerida
Ciudad de Mexico 1Ciudad de Mexico 3Ciudad de Mexico 4
TolucaCuernavaca
VillahermosaSan Pedro Sula
San SalvadorManagua
BarranquillaCaracas
Costa RicaDavid Panama
BogotaCali
QuitoGuayaquil
ManausRecife
CaruaruMaceioAracaju
LimaFeira de Santana
SalvadorVitoria da Conquista
BrasiliaSanta Cruz
Belo HorizonteCalama
Nova IguaçuSao Paulo Sul
Sao Paulo WestSanto Andre
SaltaAssuncion
CuritibaItajai
Passo FundoSanta Maria rural
Santa MariaPorto Alegre
CordobaPaysandu
Rosario citySantiago South
MontevideoNeuquen
ValdiviaChiloe
Punta Arenas
0 5 10 15 20 25 30
Solé et al – J Investig Allergol Immunol 2009, in press
Min (%) Max (%) Mean (%) Variation
Asthma6-7yr13-14 yr
Severe asthma6-7 y13-14 yr
Rhinoconjunctivitis6-7 yr13-14 yr
Severe rhinitis6-7 yr13-14yr
Flexural eczema6-7 yr13-14 yr
Severe eczema6-713-14 yr
3.63.9
0.90.6
5.57.2
0.30.3
3.22.9
0.30.1
37.630.8
11.85.9
21.245.1
4.04.9
25.030.2
2.74.2
17.315.5
3.92.6
13.518.9
1.81.5
11.39.5
1.51.3
10.08.0
13.010.0
4.06.0
13.016.0
8.010.0
9.042.0
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
http://www.studentsoftheworld.info/infopays/rank/PNB2.html; http://hdr.undp.org/en/reports/global/hdr2007-2008
http://en.wikipedia.org/wiki/Water_and_sanitation_in_Latin_America; http://www.paho.org/English/SHA/coredata/
tabulator/newTabulator.htm; http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate_(2005)
Anderson et al – Occup Environ Med published online 5 Nov 2009
Prevalence of symptoms (ISAAC Ph 1):asthma, rhinoconjunctivitis, eczema
Particulate matter <10mm (PM10) – city-level
Associations evaluated by binomial regression
Adjusted for Gross National Product per capita
Results compared with a meta-analysis ofpublished multi-centre studies
0 50 100 150PM10
-1
-2
-3
-4
-5
Lo
g o
f se
ve
re w
he
eze
Spearman r =0.36p<0.001
-1
-2
-3
-4
-5
Lo
g o
f se
ve
re w
he
eze
0 50 100 150PM10
Spearman r =0.39p<0.001
Anderson et al – Occup Environ Med published online 5 Nov 2009
Anderson et al – Occup Environ Med published online 5 Nov 2009
European countries
Non-European higher income countries
Non-European lower income countries
Subtotal
Overall
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 isassociated 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 PM10.
The results suggest that community levels of ambient PM are unlikely to explain
international variations in prevalence.
Fututre studies of differences in prevalence between communities will benefit fromimproved exposure assessment and control for confounding factors at individual level.
Anderson et al – Occup Environ Med published online 5 Nov 2009
In a study of over a million children from 105 cities in 51countries, we found little or no evidence of associationswith modelled urban background PM10.
The results suggest that community levels of ambient PM
are unlikely to explain international variations in prevalence.
Mexically ValeyMonterrey
HabanaMerida
Ciudad de Mexico 1
Ciudad de Mexico 4Toluca
Cuernavaca
San Pedro SulaSan Salvador
BarranquillaCaracas
David Panama
Ciudad Victoria
Ciudad de Mexico 3
Villahermosa
Managua
Costa Rica
Cali
Quito
ManausRecife
Maceio
LimaFeira de Santana
Vitoria da ConquistaBrasilia
Belo Horizonte
Bogota
Guayaquil
Caruaru
Aracaju
Salvador
Santa Cruz
Calama
Sao Paulo SulSao Paulo West
SaltaAssuncion
ItajaiPasso Fundo
Santa MariaPorto Alegre
PaysanduRosario city
Montevideo
Nova Iguaçu
Santo Andre
Curitiba
Santa Maria rural
Cordoba
Santiago South
Neuquen
ChiloeValdivia
Punta Arenas
0 5 10 15 20 25 300 1 2 3 4 5 6
Mallol, Solé, and LA ISAAC Phase 3 colaborators – J Asthma 2009 - in press
Solé et al -Pediatr Allergy Immunol. 2009 Sep 24. [Epub ahead of print]0 10 20 30 40 50 60
Punta ArenasChiloé
ValdíviaNeuquen
MontevideoSantiago-S
RosarioPaysanduCordoba
Porto AlegreSanta Maria
Santa Maria-RPasso Fundo
ItajaíCuritiba
AsuncionSalta
S AndréSão Paulo-WSão Paulo-S
N IguaçuCalama
B HorizonteSta CruzBrasília
V ConquistaSalvador
F SantanaLima
AracajuMaceióCaruaru
RecifeManus
GuayaquilQuito
CaliBogotá
PanamáCosta Rica
CaracasBarranquilla
ManaguaS Salvador
S Pedro SulaV Hermosa
CuernavacaToluca
C Mexico 4C Mexico 3C mexico 1
MeridaLa HabanaC Victoria
MonterreyMexically
0 10 20 30 40 50
Mexically ValeyMonterrey
Ciudad VictoriaHabanaMerida
Ciudad de Mexico 1Ciudad de Mexico 3Ciudad de Mexico 4
TolucaCuernavaca
VillahermosaSan Pedro Sula
San SalvadorManagua
BarranquillaCaracas
Costa RicaDavid Panama
BogotaCali
QuitoGuayaquil
ManausRecife
CaruaruMaceioAracaju
LimaFeira de Santana
SalvadorVitoria da Conquista
BrasiliaSanta Cruz
Belo HorizonteCalama
Nova IguaçuSao Paulo Sul
Sao Paulo WestSanto Andre
SaltaAssuncion
CuritibaItajai
Passo FundoSanta Maria rural
Santa MariaPorto Alegre
CordobaPaysandu
Rosario citySantiago South
MontevideoNeuquen
ValdiviaChiloe
Punta Arenas
0 5 10 15 20 25 300 5 10 15 20 25 30
Solé et al – J Investig Allergol Immunol 2009, in press
http://faostat.fao.org/site/502/DesktopDefault.aspx?PageID=502
TotalCalories/capita/day
Protein/capita/day (g)Fat/capita/day (g)
AnimalCalories/capita/day
Protein/capita/day (g)Fat/capita/day (g)
VegetalCalories/capita/day
Protein/capita/day (g)Fat/capita/day (g)
Foliaki et al – J Allergy Clin Immunol 2009;124:982-9
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)
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%)
Foliaki et al – J Allergy Clin Immunol 2009;124:982-9
LA country( ) % children useantibiotics
Africa
Asia-Pacific
Eastern Mediterranean
Indian Subcontinent
Latin America
North America
N/Eastern Europe
Oceania
Western Europe
1
4
4
11
6
2
3
4
12
890
10,092
8,237
27,020
12,703
2,656
6,540
9,206
26,309
0.81 (0.02-3.20)
1.79(1.42-2.26)
1.54(1.24-1.90)
1.52 (1.23-1.88)
1.96 (1.67-2.30)
1.75 (1.42-2.17)
1.72 (1.40-2.12)
1.81 (1.58-2.07)
1.57 (1.42-1.74)
2.06 (0.26-16.61)
1.94 (1.60-2.34)
1.52 (1.06-2.18)
1.34 (1.11-1.62)
1.62 (1.37-1.92)
1.22 (0.92-1.63)
1.87 (1.41-2.48)
1.64 (1.39-1.94)
1.47 (1.31-1.65)
1.25 (0.45-3.44)
1.42 (1.20-1.69)
1.22 (0.80-1.84)
1.33 (1.06-1.66)
1.65 (1.40-1.95)
1.56 (1.18-2.04)
1.47 (1.17-1.85)
1.43 (1.24-1.65)
1.34 (1.21-1.49)
Region Centers Children Asthma (wheeze) Rhinoconjunctivitis Eczema
OR (CI95%)*
Foliaki et al – J Allergy Clin Immunol 2009;124:982-9
* 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
These findings are consistent with the
hypothesis that antibiotic use increases the risk of
asthma, rhinitis, or eczema. If there is a causal
association of antibiotic use with asthma risk, it does
not appear to explain the international differences in
asthma prevalence.
Beasley et al – Lancet 2008;372:1039-48
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;372:1039-48
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
Higher variability on prevalence of these diseases between countries and in centersfrom 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
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