aller-828; no.of pages10 article in press · 2017-02-03 · +model article in press aller-828;...

ARTICLE IN PRESS+ModelALLER-828; No. of Pages 10

Allergol Immunopathol (Madr). 2017;xxx(xx):xxx---xxx

www.elsevier.es/ai

Allergologia etimmunopathologia

Sociedad Espa nola de Inmunologıa Clınica,Alergologıa y Asma Pedi atrica

ORIGINAL ARTICLE

Global Asthma Network survey suggests more nationalasthma strategies could reduce burden of asthma

I. Ashera,∗, T. Haahtelab, O. Selroosc, P. Ellwooda, E. Ellwooda, the Global AsthmaNetwork Study Groupd

a Department of Paediatrics: Child and Youth Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealandb Skin and Allergy Hospital, Helsinki University Hospital, Finlandc Selroos Medical Consulting (Semeco AB), Angelholm, Swedend Listed in Appendix A.

Received 13 October 2016; accepted 31 October 2016

KEYWORDSAsthma;Global;Network;Strategies;National;Management;Burden

AbstractBackground: Several countries or regions within countries have an effective national asthmastrategy resulting in a reduction of the large burden of asthma to individuals and society. Therehas been no systematic appraisal of the extent of national asthma strategies in the world.Methods: The Global Asthma Network (GAN) undertook an email survey of 276 Principal Inves-tigators of GAN centres in 120 countries, in 2013---2014. One of the questions was: ‘‘Has anational asthma strategy been developed in your country for the next five years? For children?For adults?’’.Results: Investigators in 112 (93.3%) countries answered this question. Of these, 26 (23.2%)reported having a national asthma strategy for children and 24 (21.4%) for adults; 22 (19.6%)countries had a strategy for both children and adults; 28 (25%) had a strategy for at least oneage group. In countries with a high prevalence of current wheeze, strategies were significantlymore common than in low prevalence countries (11/13 (85%) and 7/31 (22.6%) respectively,p < 0.001).Interpretation: In 25% countries a national asthma strategy was reported. A large reduction inthe global burden of asthma could be potentially achieved if more countries had an effective
asthma strategy.© 2017 SEICAP. Published by Elsevier Espana, S.L.U. All rights reserved.
Please cite this article in press as: Asher I, et al. Global Asthmacould reduce burden of asthma. Allergol Immunopathol (Madr)

∗ Corresponding author.E-mail address: [email protected] (I. Asher).

http://dx.doi.org/10.1016/j.aller.2016.10.0130301-0546/© 2017 SEICAP. Published by Elsevier Espana, S.L.U. All rights

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dx.doi.org/10.1016/j.aller.2016.10.013

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ARTICLELLER-828; No. of Pages 10

ntroduction

sthma is a common chronic disease affecting an estimated41 million children and adults in the world according tohe estimates of the Global Burden of Disease 2013,1 whichlso estimated that asthma was the 15th highest rankedause of Years Lived with Disability.1 Many people withsthma are unnecessarily disabled, because they are noteceiving optimal asthma management.2 In 2013, it was esti-ated that about 22 million disability-adjusted life years are

ost because of asthma.3 The International Study of Asthmand Allergies in Childhood (ISAAC) found that the histori-al view of asthma being a disease of high-income countriesHICs) no longer holds: most people affected are in low- andiddle-income countries (LMICs), and asthma prevalence is

stimated to be increasing fastest in those countries,4 whereost of the world’s people live.To reduce the burden of asthma, several HICs and LMICs

ave developed an asthma strategy (or an asthma pro-ramme which is the terminology used by some countries)t a national or regional level which has resulted in rapideduction of the ill-effects of asthma.5 The strategies orrogrammes are formalised with political engagement andommitment. Implementation of such strategies includeselatively simple measures which are consistently appliedn the relevant population, to improve early detection ofsthma and provide access to effective anti-inflammatoryreatment. Extension of this approach to other countries oregions within countries could be of great potential benefito reducing the burden of asthma in the world.

The first comprehensive national asthma strategy waseveloped in Finland in 1994 and has served as a model forther countries. They developed and called it a compre-ensive nationwide Asthma Programme and over the nextecade this lessened the burden of asthma on individuals andociety and more than halved the total asthma costs (health-are, drugs, disability, and productivity loss)6,7 and theseenefits have continued.8 This model was followed sev-ral years later by several other national strategies withinhe European Union9 including France,10 Portugal,11 andpain.12 In other places, independent approaches have beensed with improved outcomes, including Australia,13 the cityf Salvador, Brazil,14 Canada,15 Costa Rica,16 Singapore,17

onga18 and Turkey.19

However, there are few reports of such strategies, sug-esting that in many countries there is no strategy or itas not been implemented. However there has been noystematic appraisal of the numbers of countries in theorld which have a national asthma strategy. The Globalsthma Network (GAN) was established in 2012, a collabo-ation between individuals from ISAAC and the Internationalnion Against Tuberculosis and Lung Disease (The Union).

ts goals are to improve asthma care globally, with a focusn LMICs,20 through enhanced surveillance, research col-aboration, capacity building and access to quality-assuredssential medicines. Given the large number of centres andountries involved with GAN, it was well placed to undertakeuch a survey.


Based on the low number of national asthma strategieseported in the literature, our hypothesis was that mostountries in the world do not have a national asthma strat-gy. GAN has collaborators in more than half of the world’s

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PRESSI. Asher et al.

ountries, which enabled a simple survey to be undertakeno answer a question about whether a country had a nationalsthma strategy for children and adults.

aterials and methods

cross-sectional survey of GAN centres was carried outetween April 2013 and July 2014. A GAN centre was onehere an Expression of Interest form had been submitted

o the GAN Global Centre (Auckland). The survey was senty email to each centre’s principal investigator by the GANesearch Manager (PE). The survey was sent to GAN Princi-al Investigators in 276 centres in 120 countries; 46 wereICs and 74 LMICs, defined by the criteria used by the Worldank for the period 1 July 2013---30 June 2014.21

The survey form had eight questions, the last one ofhich was ‘‘Has a national asthma strategy been devel-ped in your country for the next five years? For children?Yes/No/Don’t Know), For adults? (Yes/No/Don’t Know)’’.he former seven questions were about national asthmaanagement guidelines in their country (not included in

hese analyses).Where conflicting answers were given by two or more

nvestigators from different centres within a country, theAN Global Centre staff entered into a discussion via emailith the centre investigators until agreement between themas reached.

Country findings were compared with the prevalence ofsthma symptoms in 13---14 year olds in countries wherehis had been estimated in ISAAC Phase Three.22 Countriesere categorised as high prevalence if the prevalence ofurrent wheeze was >20%, and low prevalence if the preva-ence of current wheeze was <10%. The relationship ofational asthma strategies to changes in country prevalencef asthma symptoms in 13---14 year olds in countries wherehis had been estimated in ISAAC Phase Three4 was alsoxamined.

The data were entered into an Excel spreadsheet andhecked for apparent inconsistencies which were reconciledf appropriate. Simple descriptive analyses were under-aken. The Chi-Squared test was used to compare responsesbout strategies between LMICs and HICs, and high and lowrevalence countries with those answering ‘Yes’ comparedith those not answering Yes (‘No’ or ‘Don’t know’).23

esults

f the 276 centre principal investigators in 120 countries,13 (77.2%) investigators in 112 (93.3%) countries com-leted the national asthma strategy question. There wereo responses from any investigators in eight countries whoere approached: three HICs and five LMICs.

Conflicting answers were obtained from two or moreentres in 16 countries, and agreement was subsequentlyeached. Of the 112 countries, 43 (38.4%) were HICs includ-ng 48.3% of the world’s 89 HICs; 69 (61.6%) were LMICsncluding 48.2% of the world’s 143 LMICs (Table 1).


Of those 112 countries where the national asthma strat-gy questions were answered for children, 12 reportedDon’t Know’, seven in HICs and five in LMICs. For adults,6 reported ‘Don’t Know’, 11 in HICs and five in LMICs.

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dx.doi.org/10.1016/j.aller.2016.10.013

Please cite this article in press as: Asher I, et al. Global Asthma Network survey suggests more national asthma strategiescould reduce burden of asthma. Allergol Immunopathol (Madr). 2017. http://dx.doi.org/10.1016/j.aller.2016.10.013


Global Asthma Network Survey Suggests National Asthma Strategies Needed 3

Table 1 Responses to national asthma strategy questions by country, age group and country income.

Country name National Strategy Child National Strategy Adult World Bank

Albania No No LMICa

Algeria No No LMICArgentina No No LMICArmenia No No LMICAustralia Yes Yes HICb

Austria No No HICBelarus No No LMICBelgium Don’t know Don’t know HICBenin No No LMICBolivia No No LMICBosnia and Herzegovina No Don’t know LMICBrazil No No LMICBulgaria No No LMICBurkina Faso No No LMICCameroon No No LMICCanada Yes Yes HICChannel Islands No Don’t know HICChile Don’t know Don’t know HICChina Don’t know No LMICColombia No No LMICCongo Dem Rep No No LMICCosta Rica Yes Yes LMICCroatia Don’t know Don’t know HICCyprus No No HICDenmark Don’t know Don’t know HICEcuador No No LMICEgypt No No LMICEl Salvador Yes Yes LMICEthiopia Don’t know Don’t know LMICFaroe Islands No No HICFiji No No LMICFinland Yes Yes HICFrance Yes Yes HICFrench Polynesia No No HICGambia No No LMICGeorgia Yes Yes LMICGermany No No HICGhana No No LMICGreece No No HICGrenada No No LMICHong Kong Don’t know Don’t know HICHungary No No HICIndia Yes No LMICIndonesia No No LMICIran Yes Yes LMICIreland Yes Yes HICIsrael No No HICItaly No No HICJamaica Don’t know Don’t know LMICJapan Yes Yes HICJordan No No LMICKenya No No LMICKorea, South Yes Yes HICKosovo No No LMICKuwait Yes Don’t know HICLatvia No No HICLibya No No LMIC

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4 I. Asher et al.

Table 1 (Continued)

Country name National Strategy Child National Strategy Adult World Bank

Macedonia No No LMICMalawi Yes Yes LMICMalaysia No No LMICMali No No LMICMalta No No HICMexico No No LMICNetherlands Don’t know Don’t know HICNew Caledonia No No HICNew Zealand No No HICNicaragua No No LMICNigeria No No LMICNiue Don’t know Don’t know LMICNorway No No HICOman No No HICPakistan No No LMICPalau No No LMICPalestine No No LMICPanama Yes Yes LMICPeru Yes Yes LMICPhilippines No No LMICPoland Don’t know Don’t know HICPortugal Yes Yes HICReunion Island No No HICRomania No No LMICRussia Yes No HICSamoa No No LMICSaudi Arabia Yes Yes HICSenegal No No LMICSerbia Yes Yes LMICSierra Leone No No LMICSingapore No Don’t know HICSouth Africa No No LMICSpain No No HICSri Lanka No No LMICSudan No Yes LMICSyrian Arab Republic No No LMICTaiwan Yes Don’t know HICThailand No No LMICTogo Don’t know No LMICTokelau No No LMICTonga No Don’t know LMICTrinidad and Tobago No No HICTunisia No No LMICTurkey Yes Yes LMICTuvalu No No LMICUganda No No LMICUkraine No Yes LMICUnited Arab Emirates Yes Yes HICUnited Kingdom Yes Yes HICUnited States Yes Yes HICUruguay No No HICVanuatu No No LMICVietnam Yes Yes LMICZambia No No LMICZimbabwe No No LMIC

a LMIC = low or medium income country (by World Bank assessment).b HIC = high income country (by World Bank assessment).

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dx.doi.org/10.1016/j.aller.2016.10.013


Global Asthma Network Survey Suggests National Asthma Strategies Needed 5

ries

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Of the 112 countries, 26 (23.2%) reported a nationalasthma strategy for children, 24 (21.4%) reported a nationalasthma strategy for adults, and 22 (19.6%) countries hadstrategies for both children and adults. Twenty-eight (25%)had a national asthma strategy for at least one age group.These are illustrated in Fig. 1.

Of the 28 countries who reported a national asthma strat-egy for at least one age group 15 (53.6%) were HICs and 13(46.4%) LMICs. Strategies were reported in 15/43 (34.9%)HICs and 13/69 (18.8%) LMICs; these differences were notsignificant p = 0.057.

In 81/112 (72%) countries the prevalence of asthma symp-toms had been estimated in ISAAC. Any national asthmastrategy was significantly more common in countries withhigh prevalence of current wheeze (>20%) than low preva-lence (<10%): 11/13 (85%) and 7/31 (22.6%) respectively,p < 0.001, with the remaining 37 countries having preva-lence 10---20%. Of the 49 countries in whom time-trends inthe prevalence of asthma symptoms had been estimated inISAAC, any national asthma strategy was equally common inthose whose prevalence rose (11/30) and in those in whichit fell (6/19) p = 0.72.

Discussion

In this email survey of about half the world’s countries GANwas able to confirm our hypothesis that most countries in theworld do not have a national asthma strategy; only about one


in four countries reported that they had a national asthmastrategy. Of potential concern was that the proportion ofLMICs with a strategy was lower than HICs, although thiswas not statistically significant.

acbi


asthma strategy.

About three in four countries surveyed by GAN had therevalence of asthma symptoms measured in ISAAC, and ofhese, having a national asthma strategy was significantlyore common in countries with high prevalence comparedith low prevalence of current wheeze. While on the facef it this seems logical --- more asthma symptoms, more con-ern to take action to address the issue --- there are threeaveats. Firstly, many of the countries with a low preva-ence of asthma symptoms and no national asthma strategyave very large populations; e.g. Brazil, China, Indonesia,exico, Philippines, each of which has >100 million peo-le and is among the top 12 most populous countries inhe world in 2015.24 Small improvements in the manage-ent and outcomes for people with asthma in each of these

ountries would have a relatively big impact on the globalumbers of people burdened by asthma. Secondly, in thisurvey one in four countries had not measured their asthmarevalence, which illustrates either their lack of interest insthma or perhaps they had experienced difficulties engag-ng in world-wide epidemiological studies. Thirdly, the ISAACata is already 13 years old (2002---3) and thus not coincidentith this survey, so the interpretation needs caution.

This is a very large study, a high response rate of 93%as achieved, data was reported from 112 countries, and

he countries which responded were about half the world’sICs and LMICs. The response rate was high because of thelose relationship between the GAN Global Centre and GANrincipal Investigators.

The recommended components of a successful national


sthma strategy include: government commitment, poli-ies and legislation (e.g. tobacco reduction), managementy the health ministry, funding and capacity building, reg-stry of outcome data before and after implementation


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prevalence, severity, asthma control, hospitalisations, mor-ality), asthma management guidelines adjusted for theountry, access to medical care and quality-assured, afford-ble, essential asthma medicines available for everyoneith asthma, education of the public, continued educa-

ion of health professionals, economic analyses, process andutcome evaluation, follow-up programmes, and continuedsthma research.5,9

There may be different interpretations of the termnational asthma strategy’ which is also synonymous withhe term ‘national asthma programme’. National asthmaanagement guidelines alone should not be considered a

ational asthma strategy or programme, although they formn essential part. In this particular survey, national asthmaanagement guidelines alone were unlikely to be confusedith strategy, because they were asked about in the pre-eding seven questions in the survey. However, the surveys likely to have missed asthma strategies which were notountry-wide; these would be more likely in a very largeountry like Brazil or China. Additionally, some nationalsthma ‘programmes’ may not have been interpreted asstrategies’ for the purpose of this survey.

In the review of national and regional asthma strategiesn Europe,9 a systematic search of the English literaturen 2014 found only eight published national and regionalsthma strategies in European Union countries: Finland,7

rance, Ireland, Italy, The Netherlands, Lodz area of Poland,hole of Poland and Portugal,11 with only three strategiesaving been evaluated (Finland, Poland, Portugal). Outsidehe European Union, asthma strategies have been identifiedrom only eight other countries.13---19,25

There are likely to be many reasons for the low levelf publication of national asthma strategies where theyxist, including poor preparation with insufficient documen-ation, dissemination, implementation or evaluation, lackf appropriate training of primary health care professionalsn diagnosis and treatment, poor access to quality-assured,ssential asthma medicines, poor outcomes, unable torepare an article for publication in English, and publicationias. The absence of a national asthma strategy may reflecthat asthma is not recognised as a serious public health prob-em, a lack of asthma prevalence, severity and mortalityata, a lack of government prioritisation of asthma amongther non-communicable diseases, lack of national healthoordination, and/or a lack of government commitment tomproving national health issues.

Not all national asthma strategies have been successful.elroos and others have suggested that good results can alsoe achieved without a formal national asthma strategy, asong as evidence-based management guidelines are imple-ented and widely used.9 This is happening, for example,

n Sweden, where recommendations (in Swedish) for diag-osis and treatment have been issued and updated by theational Board of Health and Welfare.26 The Swedish Asthmand Allergy Foundation has recently issued a comprehen-ive national strategy document. It has been estimated thatlobal asthma deaths (all ages) reduced from 504,300 in990 to 489,000 in 2013,27 but many countries do not report


sthma deaths separately.28 In Europe, asthma mortalityecreased from 6441 to 1164 cases (82%) from 1990---2012.29

In 2009, a group of experts in asthma care, the Advanc-ng Asthma Care Network, reviewed asthma projects and

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trategies in Argentina, Australia, Brazil, China, Japan,exico, Philippines, Russia, South Africa, and Turkey.30

ll successful asthma strategies improved early diag-osis and the introduction of first-line treatment withnti-inflammatory medication, improved long-term diseaseontrol nationally, introduced simple means for guided self-anagement to proactively prevent exacerbations/attacks,

nd had effective education and networking with gen-ral practitioners, nurses and pharmacists. A systematicpproach was recommended, aiming to motivate and organ-se, and with improvements that could be achieved withelatively simple means. When multidisciplinary actions areeing planned, all the main stakeholders should be repre-ented.

A more limited approach to improving asthma outcomesas been used successfully in pilot projects in LMICs, usingstandard case management’, a term which ‘‘encompassesiagnosis of asthma, standardisation of treatment accord-ng to severity based on asthma guidelines, and patientducation, coupled with a simple system for monitor-ng patient outcomes. Appropriate training of health careorkers and availability of essential asthma medicines areey to the effectiveness of standard case management.’’.31

ilot studies in 2007---2008 of the feasibility and effects oftandard case management were applied in Benin,32 Haiyuanounty, Anhui Province, China,33 and Sudan34 reduced hos-italisations in those completing the study. In El Salvador005---2010,35 by using Practical Approach to Lung Healthnd essential asthma medicines free of charge, the num-er of patients being referred from primary to secondary orertiary level dropped by 60%, with greater convenience foratients, and savings for health services.

Political engagement, leadership and commitment areey components for developing an effective national asthmatrategy, and these are challenging and may not be easilychieved. The literature supports the view that programmesstrategies) are more likely to be successful where thisas occurred. The political organisation and health leader-hip in a country would undoubtedly influence the chancef success, as would co-ordinated access to affordable,uality-assured, essential asthma medicines. Identifying aolitical champion is a critical factor, and may be easier inome localities than others. In 2010 the Global Initiative forsthma (GINA) launched a challenge to countries to reduceospitalisations by 50% over five years36 but the results haveeen modest. The motivation to tackle the asthma burden isot always self-evident, e.g. in places where private health-are dominates and hospitals compete.

In this survey, we asked only about national asthmatrategies, not local or regional strategies. We know thathere have been successful strategies in cities such asalvador, Brazil14; although these would not have been iden-ified in our survey. Strategies at a sub-national level may behe only feasible approach in some very large and populousountries such as Brazil and China; in such cases, coveragef the whole nation by harmonised sub-national strategiesould be sought.

The survey asked about national asthma strategies for


hildren separately from adults. Most who reported strate-ies had them for both age groups. The reasons whyhere would be separate strategies may include differentpproaches between children and adults, as often happens


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ARTICLEALLER-828; No. of Pages 10

Global Asthma Network Survey Suggests National Asthma Str

with national asthma management guidelines. Or there mayhave been ascertainment bias, with child-health profes-sionals not being aware that an asthma strategy had beendeveloped for adults and vice versa.

A successful strategy is not expected to affect prevalenceand incidence as we do not have effective interventionsfor these.20 However, reduction in disease severity andimproved control may be impressive. In Finland in early1990s, 20% of patients were estimated to have uncontrolled(severe) asthma compared to 10% in 2001 and 4% in 2010.7,37

If the gains of the Finnish study were replicated by havingeffective national asthma strategies throughout the world,then the number of emergency visits would be estimated tofall by 24% in adults and 61% in children, hospital days wouldfall by about 54%, significant disability would decrease byabout 76%, costs per patient per year would fall by 36%, anddeaths by 31%. Even if half these gains were achieved, therewould be a large reduction of the burden of asthma in theworld. Implementation of a national strategy is an appropri-ate way to address asthma, where the disability numbers andcosts are disproportionately high, in contrast with the rel-atively high mortality found with other non-communicablediseases.20

We recommend that health authorities along with gov-ernments in all countries should develop national asthmastrategies with associated national action plans to improveearly detection of asthma and subsequently improve asthmamanagement and reduce costs.5 Such strategies should beevaluated, reported, and published. The problems to beaddressed may be different in HICs compared to LMICs,and the solutions need to be tailored according to an indi-vidual country’s local needs, resources and organisation.Knowledge of asthma prevalence and severity and changesover time is fundamental to understanding the burden ofasthma within each country and thus leading to the devel-opment of a national asthma strategy. This can be achievedusing the methodology developed by ISAAC38,39 and contin-ued (expanded to include adults) under GAN.40

Ethical disclosures

Confidentiality of data. The authors declare that no patientdata appears in this article.

Right to privacy and informed consent. The authorsdeclare that no patient data appears in this article.

Protection of human subjects and animals in research.The authors declare that the procedures followed were inaccordance with the regulations of the responsible ClinicalResearch Ethics Committee and in accordance with those ofthe World Medical Association and the Helsinki Declaration.

Conflict of interest


The authors declare no conflicts of interest. The correspond-ing author confirms that she had full access to all the datain the study and had final responsibility for the decision tosubmit for publication.

sSd-


PRESSies Needed 7

cknowledgements

he authors wish to acknowledge the funder, The Inter-ational Union against Tuberculosis and Lung Disease, forrants to the Global Asthma Network 2013---2015.

ppendix A. The Global Asthma Networktudy Group

he Global Asthma Network Steering Group

Asher --- University of Auckland, Auckland, New Zealand;E Billo, Joensuu, Finland; K Bissell --- International Uniongainst Tuberculosis and Lung Disease (The Union), Paris,rance; C-Y Chiang --- International Union Against Tubercu-osis and Lung Disease (The Union), Taipei City, Taiwan; Al Sony --- The Epidemiological Laboratory for Public Healthnd Research, Khartoum, Sudan; P Ellwood --- University ofuckland, Auckland, New Zealand; L García-Marcos --- ‘Vir-en de la Arrixaca’ University Children’s Hospital, Murcia,pain; J Mallol --- University of Santiago de Chile (USACH),antiago, Chile; GB Marks --- University of New South Wales,ydney, Australia; N Pearce --- London School of Hygiene andropical Medicine, London, United Kingdom; D Strachan --- Steorge’s, University of London, London, United Kingdom.

he Global Asthma Network Study Group

lbania: A Priftanji --- Mother Theresa University Hospitalf Tirana (Tiranë); Algeria: B Benhabylès --- CHU MustaphaWilaya of Algiers), R Boukari --- Saad Dahlab UniversityBlida); Argentina: FA Castracane --- Programa Provincialsma Infantil de Mendoza (Mendoza), M Gómez --- Hospi-al San Bernardo (Salta), N Salmun --- Asthma and Allergyoundation (Buenos Aires); Armenia: A Baghdasaryan ---‘Arabkir’’ Joint Medical Centre (Yerevan); Australia: Surgess --- Mater Children’s Hospital (Brisbane), GB Marks ---niversity of New South Wales (Sydney), J Mattes --- Hunteredical Research Institute and Newcastle Children’s Hos-ital (Newcastle), A Tai --- Adelaide University (Adelaide);ustria: G Haidinger --- Medical University Vienna (Urfahr-mgebung), J Riedler --- Children’s Hospital SchwarzachSalzburg); Belarus: A Shpakou --- Yanka Kupala State Uni-ersity of Grodno (Grodno); Belgium: J Weyler --- Universityf Antwerp (Antwerp); Benin: M Gninafon --- Université’Abomey-Calavi (Cotonou); Bolivia: J Aguirre de Abruzzese

-- Department of Health (Santa Cruz); Bosnia and Her-egovina: S Domuz --- School of Applied Health SciencesPrijedor); Brazil: HV Brandão --- Universidade Estadual deeira de Santana (Feira de Santana), PAM Camargos --- Fed-ral University of Minas Gerais (Belo Horizonte), M de Britto

-- Instituto de Medicina Integral (Recife), GB Fischer --- Uni-ersidad Federal (Porto Alegre), FC Kuschnir --- Rio de Janeirotate University (UERJ) (Rio de Janeiro), AM Menezes ---ederal University of Pelotas (Pelotas), AC Porto Neto ---asso Fundo University (Passo Fundo), N Rosário --- Univer-


ity of Parana (Curitiba), D Solé --- Universidade Federal deão Paulo (São Paulo South), NF Wandalsen --- Faculdadee Medicina do ABC (Santo André); Bulgaria: TB Mustakov

-- University Hospital ‘Alexandrovska’, Medical University


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(-hY-s-GCX(BSdv--l&oMFUdJH--UMDsI(&LYCC(l(osM(((bRIAIBcPMmAMMs

ZMfCAaHpvNSA(E(SoHp(MM(((M(tHHjLdrUMNSBh-pCUNAAHtNWTK(oGIWChiarella --- Universidad Peruana de Ciencias Aplicadas, UPC


Sofia); Burkina Faso: E Birba --- Université Poly Technique-- BOBO (Bobo-Dioulasso); Cameroon: BH Mbatchou Nga-ane --- University of Douala (Douala), EW Pefura Yone ---aounde Jamot Hospital (Bafoussam); Canada: DC Rennie

-- University of Saskatchewan (Saskatoon), T To --- Univer-ity of Toronto, (Ontario); Channel Islands: P Standring

-- Princess Elizabeth Hospital (Guernsey); Chile: MA Calvoil --- Universidad Austral de Chile (Valdivia); China: Y-Zhen --- Training Hospital for Peking University (Beijing),

Kan --- Anhui Chest Hospital (Hefei), Y Lin --- The UnionTayuan); Colombia: E Garcia --- Fundación Santa Fe deogotá (Bogotá), J Niederbacher --- Universidad Industrial deantander (Bucaramanga), GA Ordonez --- Universidad Libree Cali (Cali); Congo, Dem. Rep.: B Kabengele Obel --- Uni-ersity of Kinshasa (Kinshasa); Costa Rica: ME Soto-Quirós

-- University of Costa Rica (Costa Rica); Croatia: S Banac-- Rijeka Clinical Hospital Centre (Rijeka); Cyprus: P Yial-ouros --- Cyprus International Institute for Environmental

Public Health (Nicosia); Denmark: L Lochte --- Universityf Copenhagen (Copenhagen); Ecuador: S Barba --- AXXIS-edical Centre SEAICA (Quito), P Cooper --- Universidad Sanrancisco de Quito (Esmeraldas); Egypt: M El Falaki --- Caironiversity (Cairo), A Mokhtar --- Ministry of Health (Alexan-ria); El Salvador: M Figueroa Colorado --- Universidad Drose Matias Delgado (San Salvador); Ethiopia: A Berihu ---ealth Consultancy Centre (Mekelle); Faroe Islands: P Weihe

-- The Faroese Hospital System (Faroe Islands); Fiji: VA Lal-- Ministry of Health (Suva); Finland: M Mäkelä --- Helsinkiniversity Hospital (Helsinki); France: I Annesi-Maesano ---edical School Saint-Antoine, France (West Marne, Créteil),

Charpin --- Aix Marseille University (Marseille), C Raheri-on --- University of Bordeaux (Bordeaux); French Polynesia:

Annesi-Maesano --- Medical School Saint-Antoine, FrancePolynésie francaise); Georgia: M Gotua --- Center of Allergy

Immunology (Tbilisi, Kutaisi); Germany: E von Mutius ---udwig Maximilians University (Munich); Ghana: EO Addo-obo --- Komfo Anokye Teaching Hospital (KATH) (Kumasi), NFlement --- FHI 360 Ghana Country Office (Accra); Greece:h Gratziou --- National Kapodistrian University of AthensAthens), J Tsanakas --- University of Thessaloniki (Thessa-oniki); Grenada: M Akpinar-Elci --- Old Dominion UniversityGrenada); Hong Kong: CKW Lai --- The Chinese Universityf Hong Kong (Hong Kong); Hungary: Z Novák --- Univer-ity of Szeged (Szeged); India: S Awasthi --- King George’sedical University (Lucknow), R Ilangho --- Apollo Hospitals

Chennai), A Maitra --- Institute of Child Health (Kolkata10)), M Mukherjee --- KPC Medical College and HospitalKolkata (14)), UA Pai --- Consultant Pediatrician (Mum-ai (7)), AV Pherwani --- P.D. Hinduja Hospital and Medicalesearch Centre (Mumbai (11)), BK Reddy --- Indira Gandhinstitute of Child Health (Bangalore), M Sabir --- Maharajagrasen Medical College (Bikaner), SK Sharma --- All India

nstitute of Medical Sciences (New Delhi), V Singh --- Asthmahawan (Jaipur), M Singh --- Postgraduate Institute of Medi-al Education and Research (Chandigarh), TU Sukumaran ---ushpagiri Medical College (Kottayam), S Varkki --- Christianedical College Hospital (Vellore); Indonesia: CB Kartasas-ita --- Padjajaran University (Bandung); Iran: M Cheraghi ---hvaz Jundishapur University of Medical Sciences (Ahvaz),


Karimi --- Shahid Sadoughi Medical University (Yazd),-R Masjedi --- National Research Institute of Tuberculo-

is and Lung Diseases (Birjand, Bushehr, Rasht, Tehran,

(CU



anjan); Ireland: P Manning --- Royal College of Surgeonsedical School (Ireland); Israel: T Shohat --- Israel Center

or Disease Control (Israel); Italy: S Bonini --- Via Ugo dearolis 59 (Ascoli Piceno), F Forastiere --- Rome E Healthuthority (Roma), S La Grutta --- Institute of Biomedicinend Molecular Immunology (Palermo), MG Petronio --- Localealth Authority (Empoli), S Piffer --- Azienda Provincialeer I Servizi Sanitari (Trento); Jamaica: E Kahwa --- Uni-ersity of the West Indies (Kingston); Japan: H Odajima ---ational Hospital Organization Fukuoka Hospital (Fukuoka),

Yoshihara --- Dokkyo Medical University (Tochigi); Jordan: Fbu-Ekteish --- Jordon University of Science and TechnologyAmman), O Al Omari --- Jerash University (Jerash); Kenya:I Amukoye --- Kenya Medical Research Institute (KEMRI)Nairobi), FO Esamai --- Moi University College of Healthciences (Eldoret); Korea, South: S-J Hong --- Universityf Ulsan (Seoul); Kosovo: L Neziri-Ahmetaj --- Universityospital (Prishtina); Kuwait: JA al-Momen --- Al-Amiri Hos-ital (Kuwait); Latvia: V Svabe --- Riga Stradins UniversityRiga); Libya: M Shenkada --- Ministry of Health (Tripoli);acedonia: E Vlaski --- University Children’s Clinic (Skopje);alawi: K Mortimer --- Liverpool School of Tropical Medicine

Blantyre); Malaysia: J de Bruyne --- University of MalayaKlang Valley); Mali: Y Toloba --- Université de BamakoBamako); Malta: S Montefort --- University of Malta (Malta);exico: BE Del-Río-Navarro --- Hospital Infantil de México

Mexico City North), R García-Almaráz --- Hospital Infan-il de Tamaulipas (Ciudad Victoria), SN González-Díaz ---ospital Universitario (Monterrey), DD Hernández-Colín ---ospital Civil De Guadalajara Juan I Menchaca (Guadala-

ara), CA Jiménez González --- Universidad Autonoma of Sanuis Potosí (San Luis Potosí), JV Mérida-Palacio --- Centroe Investigacion de Enfermedades Alergicas y Respirato-ias (Mexicali); Netherlands: B Brunekreef --- Universiteittrecht (Utrecht); New Caledonia: I Annesi-Maesano ---edical School Saint-Antoine, France (Nouvelle-Calédonie);ew Zealand: I Asher --- University of Auckland (Auckland),

Currie --- Hawke’s Bay District Health Board (Hawke’say), J Douwes --- Massey University (Wellington), D Gra-am --- Waikato District Health Board (Waikato), R Hancox

-- University of Otago (Otago), C Moyes --- Whakatane Hos-ital (Bay of Plenty), P Pattemore --- University of Otago,hristchurch (Christchurch); Nicaragua: MZ Cordero Rizo ---niversity National Autonomous of Nicaragua (Matagalpa);igeria: GE Erhabor --- Obafemi Awolowo University (Ife),

Falade --- University of Ibadan (Ibadan), B Garba Ilah ---hmad Sani Yariman Bakura Specialist Hospital (Gusau), Aammangabdo --- University of Maiduguri Teaching Hospi-al (Maiduguri), N Onyia --- Paelon Memorial Clinic (Lagos);iue: M Pulu --- Niue Foou Hosptial (Niue Island); Norway:

Nystad --- Norwegian Institute of Public Health (Oslo,romsø); Oman: O Al-Rawas --- Sultan Qaboos University (Al-hod); Pakistan: MO Yusuf --- The Allergy & Asthma InstituteIslamabad); Palau: BM Watson --- Ministry of Health (Republicf Palau); Palestine: N El Sharif --- Al Quds University (Northaza, Ramallah); Panama: G Cukier --- Hospital Materno

nfantil Jose Domingo de Obaldia (David-Panamá); Peru: Checkley --- Johns Hopkins University (Tumbes, Puno), P


Lima); Philippines: R Pagcatipunan --- Adventist Medicalenter Manila (Metro Manila); Poland: G Lis --- Jagiellonianniversity (Kraków); Portugal: M Morais-Almeida --- Hospital


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Global Asthma Network Survey Suggests National Asthma Str

CUR Descobertas (Lisboa); Reunion Island: I Annesi-Maesano--- Medical School Saint-Antoine, France (Reunion Island);Romania: D Deleanu --- University of Medicine & PharmacyIULIU Hatieganu (Cluj-Napoca); Russia: E Kamaltynova --- TheSiberian State Medical University (Tomsk), EG Kondiurina ---Novosibirsk State Medical University (Novosibirsk); Samoa: LEsera-Tulifau --- Moto’otua Hospital/National Health Services(Apia); Saudi Arabia: BR Al-Ghamdi --- King Khaled Univer-sity (Abha), A Yousef --- University of Dammam/King FahdHospital of the University (Alkhobar); Senegal: NO Toure--- Université Cheikh Anta DIOP, (Dakar); Serbia: M Hadnad-jev --- Primary Health Care (Novi Sad), D Visnjevac --- TheHealth Centre of Indjija (Indjija), Z Zivkovic --- Children’sHospital for Lung Diseases and Tuberculosis (Belgrade);Sierra Leone: G Fadlu-Deen --- Connaught Teaching Hospi-tal (Freetown); Singapore: DYT Goh --- National Universityof Singapore (Singapore); South Africa: R Masekala --- Uni-versity of Pretoria (Pretoria), K Voyi --- University of Pretoria(Polokwane, Ekurhuleni), HJ Zar --- University of Cape Town(Cape Town); Spain: A Arnedo-Pena --- Center Public HealthCastellon (Castellón), RM Busquets --- Universidad Autonomade Barcelona (Barcelona), I Carvajal-Uruena --- Centro deSalud de La Ería (Asturias), L García-Marcos --- ‘Virgen dela Arrixaca’ University Children’s Hospital (Cartagena), CGonzález Díaz --- Universidad del País Vasco UPV/EHU (Bil-bao), J Korta Murua --- Donostia Hospital (San Sebastián),A López-Silvarrey Varela --- Fundacion Maria Jose Jove (LaCoruna), C Luna-Paredes --- Sección de Neumología y Aler-gia Infantil (Madrid), M Morales-Suárez-Varela --- ValenciaUniversity-CIBERESP (Valencia), M Praena-Crespo --- ServicioAndaluz de Salud (Sevilla), A Rabadán-Asensio --- Delegationat Cadiz of Andalusian Regional Health Ministry (Cádiz), JWärnberg --- University of Málaga (Málaga); Sri Lanka: KDGunasekera --- Central Chest Clinic Colombo (Colombo), STKudagammana --- Teaching Hospital Peradeniya (Peradeniya);Sudan: A El Sony --- The Epidemiological Laboratory for Pub-lic Health and Research (Khartoum), S Hassanain --- Ministryof Health (Gadarif); Syrian Arab Republic: Y Mohammad--- National Center for Research and Training in ChronicRespiratory Diseases --- Tishreen University (Lattakia); Tai-wan: YL Guo --- National Taiwan University (Tainan), J-LHuang --- Chang Gung University (Taipei); Thailand: M Lao-araya --- Chiang Mai University (Chiang Mai), S Phumethum--- Prapokklao Hospital (Chantaburi), J Teeratakulpisarn ---Khon Kaen University (Khon Kaen), P Vichyanond --- Mahi-dol University (Bangkok); The Gambia: S Anderson --- MedicalResearch Council Unit (Fajara); Togo: O Tidjani --- CHU Tokoin(Lome); Tokelau: T Iosefa --- Ministry of Health (Tokelau);Tonga: G Aho --- Vaiola Hospital (Nuku’alofa); Trinidad andTobago: D Dookeeram --- Sangre Grande Hospital (Trinidadand Tobago); Tunisia: A Hamzaoui --- Abderrahmen MamiHospital (Ariana); Turkey: A Yorgancioglu --- Celal BayarUniversity School of Medicine (Ankara); Tuvalu: N Ituaso-Conway --- Princess Margaret Hospital (Funafuti); Uganda: WWorodria --- Mulago Hospital & Complex (Kampala); Ukraine:O Fedortsiv --- Ivan Horbachevsky Ternopil State MedicalUniversity (Ternopil); United Arab Emirates: B Mahboub ---University of Sharjah (Sharjah); United Kingdom: AH Mansur


--- University of Birmingham and Heartlands Hospital (Bir-mingham); United States: M Akpinar-Elci --- Old DominionUniversity (Virginia), RP Doshi --- Parkview Hospital (FortWayne), GJ Redding --- Seattle Children’s Hospital (Seattle),

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PRESSies Needed 9

Yeatts --- University of North Carolina at Chapel Hill (Northarolina); Uruguay: M Valentin-Rostan --- Hospital Pereiraossell (Montevideo); Vanuatu: G Harrison --- Vila Centralospital (Port Vila); Vietnam: LTT Le --- University Medicalentre (Ho Chi Minh); Zambia: S Wa Somwe --- Universityeaching Hospital (Lusaka); Zimbabwe: P Manangazira ---inistry of Health and Child Care (Zimbabwe).

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