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Backgrounder: Asthma Control

The theme of World Asthma Day 2013, an awareness-raising event organized by the Global Initiative for Asthma (GINA), is You Can Control Your Asthma. The GINA Board of Directors has chosen this theme to emphasize that effective asthma treatments exist and, with proper diagnosis, education, and treatment, the great majority of asthma patients can achieve and maintain good control of their disease. When asthma is under control, patients can live full and active lives and can prevent visits to the emergency department and hospital. According to the GINA Global Strategy for Asthma Management and Prevention (2012), asthma control means that a person with asthma has: No (or minimal) asthma symptoms. No waking at night due to asthma. No (or minimal) need to use reliever medication. The ability to do normal physical activity and exercise. Normal (or near-normal) lung function test results (PEF and FEV 1). No (or very infrequent) asthma attacks. More than 300 million people around the world have asthma 1, and the disease imposes a heavy burden on individuals, families, and societies. The Global Burden of Asthma Report, a compilation of published data on the prevalence and impact of asthma around the world that was launched on World Asthma Day 2004, indicates that asthma control often falls short and there are many barriers to asthma control around the world. Lack of Asthma Control Proper long-term management of asthma will permit most patients to achieve good control of their disease. Yet the Global Burden of Asthma Report documents ample evidence that, in many regions around the world, this goal is
Unless otherwise noted, all information in this backgrounder comes from the Global Burden of Asthma Report. The Report was commissioned by GINA and written by Richard Beasley, Matthew Masoli, Denise Fabian, and Shaun Holt, of the Medical Research Institute of New Zealand and the University of Southampton in the UK. For more information about the unmet needs of asthma, and an explanation of the regions mentioned in this backgrounder, download the full Report from www.ginasthma.org.
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often not met: Hospitalizations, emergency room visits, and other urgent care occur when a persons asthma is not under control. Although the rates of these medical visits generally increase as the prevalence of asthma rises, the very high proportions of people with asthma who require such care in many countries is an indication that lack of control is widespread. o In Western Europe, for example, one in four people with asthma required an emergency room visit or unscheduled urgent care in the previous year. o One in five Israeli children with asthma visits the emergency room per year, and one in ten requires hospitalization. o In the China/Taiwan/Mongolia region, one-third of people with asthma require urgent care, emergency room visits, or hospital admission for asthma. o In North America, 40 percent of people with asthma required such care in the previous year. The above facts indicate that there is a major opportunity to reduce hospitalizations by improving asthma control, and on World Asthma Day 2010 GINA launched an initiative encouraging governments and health departments around the world to improve asthma control and reduce asthma hospitalization 50% over 5 years. On World Asthma Day 2011, GINA began the next phase of the Asthma Control Challenge with an online data collection system for countries around the world to track their progress in reducing hospitalizations. Poor asthma control is also seen in the lifestyle limitations experienced by some people with asthma. In Egypt, for example, up to one in four children with asthma is unable to attend school regularly because of poor asthma control. Asthma deaths are the ultimate, tragic evidence of uncontrolled asthma. According to the Global Burden of Asthma Report, the majority of asthma deaths in some regions of the world are preventable.

What are the Barriers to Asthma Control? Although the barriers to asthma control vary from country to country and from region to region around the world, the Global Burden of Asthma Report identifies several patterns: Diagnosis. Some people with asthma symptoms may never receive a diagnosis of asthma, and thus do not have the opportunity for good asthma treatment and control. Various factors such as poor access to medical care, underrecognition by health professionals, lack of awareness among patients, and overlap of asthma symptoms with those of other diseases contribute to underdiagnosis of asthma in regions including the

Baltic states, the Middle East, Southern Asia, China/Taiwan/Mongolia, and East, West, and Southern Africa. Treatment. Barriers relating to treatment are the most commonly cited in the Global Burden of Asthma Report, occurring in one form or another in almost all regions around the world: o The high cost of medicines means that many people with asthma in the Baltic states, the Balkans/Turkey/Caucasus/Mediterranean Islands region, the Middle East, Central and South America, East and West Africa, and other areas may not receive sufficient medication to control their disease. In Turkey, the cost of a year of treatment for a person with moderate persistent asthma is about half the monthly salary of a nurse; in Syria, it is greater than a nurses monthly salary. o Asthma medications are not available in some areas, such as parts of the Middle East, Southern Asia, Central America, and North, West, and East Africa. o Treatment that is not consistent with evidence-based guidelines may hamper asthma control in, for example, the UK/Republic of Ireland, Western Europe, China/Taiwan/Mongolia, Central America, the Caribbean, and West and East Africa. There are wide variations in prescribing practices in different areas of the world, and even when cost is not a barrier undertreatment may still occur. o The underuse of inhaled corticosteroids for long-term management of asthma is a particular problem in many regions, including the Middle East, the Caribbean, and West Africa. These medications diminish chronic inflammation in the lungs of asthma patients, and are a key to controlling the disease. o A general lack of access to medical care limits asthma treatment and control in areas such as the Balkans/Turkey/Caucasus/Mediterranean Islands region, Eastern Europe, Russia, Central Asia and Pakistan, Southern Asia, Southern Africa, and China. This lack of access may arise from socioeconomic factors, or may be a matter of scarce infrastructure and poor transport, especially in rural areas. Education. People with asthma may not understand how to use their medications properly, or may not understand concepts such as asthma control and when to seek help for worsening asthma that would help them manage their disease effectively. Misconceptions about asthma and its treatment represent are widespread in regions including Southeast Asia, Central Asia and Pakistan, Eastern Europe, the UK/Republic of Ireland, Northeast Asia, and Russia. Environmental Health. Avoiding risk factors that cause asthma symptoms is an important strategy for improving control. However, in many regions of the world, people with asthma may be exposed to conditions such as outdoor or indoor air pollution, cigarette smoke, or chemicals on the job that make their asthma worse.

Improving Control The Global Burden of Asthma Report also details a number of instances where improving asthma control has reduced the burden of this disease. For example: Declining asthma mortality rates over the last 10 years have been attributed to the increased use of inhaled corticosteroid therapy in areas including Scandinavia, the UK/Republic of Ireland, Western Europe, and Argentina. In Northeast Asia, increased use of inhaled glucocorticosteroids has led to a reduction in asthma severity. National asthma campaigns in Finland and other Scandinavian countries, the UK, Australia, New Zealand, and elsewhere have reduced asthma morbidity and mortality. These programs often include educational components for both health professionals and the general public.

A strategy for achieving and maintaining asthma control is set out in the GINA Global Strategy for Asthma Management and Prevention . The strategy requires four interrelated components of therapy: Develop patient/doctor partnership. Identify and reduce exposure to risk factors. Assess, treat, and monitor asthma. Manage asthma exacerbations.

Under this strategy, asthma is treated in a stepwise manner to achieve and maintain control of the disease. Medication is increasedstepped upwhen asthma is not controlled, and gradually stepped down once good control is achieved and maintained for a period of time.