Editorial
Zero tolerance for asthma deaths in children
Tolerância zero para mortes por asma em crianças
Alessandro Fiocchi
, Rocco Valluzzi, Lamia Dahdah
Corresponding author
Bambino Gesù Childrens’ Hospital IRCCS, Rome, Italy
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class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Rocco" "apellidos" => "Valluzzi" ] 2 => array:2 [ "nombre" => "Lamia" "apellidos" => "Dahdah" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Bambino Gesù Childrens’ Hospital IRCCS, Rome, Italy" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tolerância zero para mortes por asma em crianças" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 1496 "Tamanyo" => 114380 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decrease of asthma mortality in Finland following the implementation of the National Asthma Programme from 1994 to 2004.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The first time I heard someone talk about zero tolerance toward death from asthma was at the World Allergy Organization (WAO) International Scientific Conference in Dubai in 2010. I was impressed by the vigor with which Professor Tari Haahtela presented the results obtained with the use of health education plans in the prevention of asthma mortality in Finland. Gary Wong had just affirmed the same concept in a different context.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Under all the heavens then, including that of Latin America,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> there is no greater cost than the preventable death of a patient, in particular among children.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After its rise from a rate of 0.45/100,000 in 1974/5 to a peak rate of 0.62/100,000 in 1985/6, the mortality from asthma across the world has declined. In 2004/5, the mortality in developed countries – including the United States, Canada, New Zealand, Australia, Western Europe, Hong Kong, and Japan – was reduced to a rate of 0.23/100,000. This reduction was associated to the increasing use of inhaled corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The drop in mortality has coincided with the introduction of increasingly precise guidelines for the management of asthma internationally and in specific countries, with the development of educational plans for practitioners, pharmacists, and other health professions, and with their implementation by the health authorities of each country.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The prototype for models of disease management remains the Finnish asthma management program, which produced a huge effect in reducing asthma mortality and morbidity over the period 1994–2004. It was centered on early diagnosis, active anti-inflammatory treatment immediately after the diagnosis, information on the disease and its treatment, self-management, and effective networking among specialists, primary care physicians, and pharmacists. This program resulted in a reduction in asthma deaths from 100 to less than 20 per year in the Finnish population of 5 million, which could be largely attributed to early and more effective use of anti-inflammatory medication, especially inhaled corticosteroids (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Other countries (Australia, Ireland, Canada, Poland, Tonga, South Africa, New Zealand) followed the Finnish example, developing their own national asthma reduction strategies with good success.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,6</span></a> In Europe, the integrated plan ‘European Asthma Research and Innovation Partnership’ (EARIP) has been also put in place to harmonize asthma education activities across the continent, in order to develop a comprehensive approach focused on asthma control, to reduce asthma-related mortality and morbidity.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> Its ambition is to reduce asthma mortality in Europe by 25% within ten years and by 50% within 20 years.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite all the progress made with early therapeutic intervention, an incompressible mortality rate remains, even when the possibilities offered by conventional anti-inflammatory drugs have been saturated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In developed countries, we are now experiencing signals of upward rebound in mortality,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> together with an increase in corticosteroid-induced adverse events in severe asthma patients,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> while the mortality from asthma has not been eliminated anywhere.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This scenario is applicable to some parts of Brazil, but not to the whole country. The data published in this issue of the <span class="elsevierStyleItalic">Jornal</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> are of particular interest as they arise from a solid reporting system in a young age range, where asthma mortality can be very accurately tracked due to absence of confounding diagnoses.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> In Brazil, the reduction in asthma mortality over 20 years is conspicuous, testifying to the great progress in pediatric pulmonology care in that country. The most important reduction was achieved in the group of children under the age of 4 years, which, however, remains the group that most contributes to asthma mortality in 2015. Indeed, the mortality for asthma in Brazilian children has not reached an optimal low level countrywide. Some areas of higher mortality still persist, in particular among children under 10 years of age and in some geographical areas, such as the North and the Northeast.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The study calls for two areas of possible intervention: adolescents and preschoolers.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Brazilian adolescents with asthma incur the risk of under-hospitalization during attacks,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> perhaps as part of their denial of the disease, noncompliant therapeutic behaviors, smoking, and psychosocial issues. Some of these conditions are ameliorable with specific educational interventions, targeted toward the reasons for poor control of asthmatic symptoms: underestimation by patients and physicians, under-treatment – especially with anti-inflammatory drugs, overuse of bronchodilators in case of attacks, low compliance to medications, and poor skills in the use of prescribed devices.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> An important part could be the use of the now-available Portuguese version of the Test for Respiratory and Asthma Control in Kids (TRACK).<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> A substantial part of the causes (for instance, low-income households<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14,15</span></a>) would require complex interventions.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Of note, 68% of reported deaths happened in children under 4 years of age.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> In this age range, uncertainties remain about the possibility of labeling a child as asthmatic.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> We fully agree with the authors’ opinion that in preschool age asthma must be considered as such, beyond the difficulties of definition. Under its multifaceted phenotypes,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> preschoolers experience severe wheezing episodes resulting in emergency room visits, hospitalization, and oral steroid courses. Preschoolers merit asthma treatment, as an early intervention may decrease the number of exacerbations and promote lung growth. As part of this intervention, educational plans must not be spared.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A considerable obstacle for the realization of educational plans could be the territorial vastness and the socioeconomic heterogeneity of Brazil. This nation has one of the highest rates of inequality in the world, and the Gini index, measuring economic inequality within countries, has been associated with a high prevalence of allergies and asthma.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> It is also a country with high prevalence of sensitization to perennial allergens, associated with asthma mortality.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> However, Brazil offers opportunities for educational plans. It is the fifth country in smart phone usage in the world: as 54% of Brazilian adults own a smart phone, and families often share one device, it can be estimated that 120 million Brazilians have access to the internet.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> This could offer the infrastructural opportunities for modern, digital health-based interventions.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> An additional effort will be necessary on the part of the Brazilian medical community and health authorities to address, together with the health problems, the social issues that can be glimpsed under the data of the present study. After all, it is a question of facing one of the many aspects of the fragility of children in the preschool age and in adolescence, which recalls the need for recognition, care, and education.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Every asthma death is one too many. The interest of their <span class="elsevierStyleItalic">Jornal</span> shows that Brazilian pediatricians are ready to take up this challenge.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fiocchi A, Valluzzi R, Dahdah L. Zero tolerance for asthma deaths in children. J Pediatr (Rio J). 2020;96:403–5.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Pitchon in pages 432–8.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 1496 "Tamanyo" => 114380 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decrease of asthma mortality in Finland following the implementation of the National Asthma Programme from 1994 to 2004.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Zero tolerance to asthma death" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.W. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 5 | 13 |
| 2024 October | 46 | 36 | 82 |
| 2024 September | 26 | 26 | 52 |
| 2024 August | 32 | 31 | 63 |
| 2024 July | 36 | 46 | 82 |
| 2024 June | 20 | 37 | 57 |
| 2024 May | 19 | 6 | 25 |
| 2024 April | 29 | 26 | 55 |
| 2024 March | 21 | 21 | 42 |
| 2024 February | 20 | 32 | 52 |
| 2024 January | 25 | 26 | 51 |
| 2023 December | 12 | 25 | 37 |
| 2023 November | 34 | 38 | 72 |
| 2023 October | 24 | 35 | 59 |
| 2023 September | 20 | 31 | 51 |
| 2023 August | 25 | 20 | 45 |
| 2023 July | 29 | 14 | 43 |
| 2023 June | 17 | 12 | 29 |
| 2023 May | 22 | 13 | 35 |
| 2023 April | 19 | 13 | 32 |
| 2023 March | 34 | 14 | 48 |
| 2023 February | 33 | 16 | 49 |
| 2023 January | 16 | 16 | 32 |
| 2022 December | 35 | 23 | 58 |
| 2022 November | 28 | 22 | 50 |
| 2022 October | 41 | 32 | 73 |
| 2022 September | 28 | 35 | 63 |
| 2022 August | 28 | 29 | 57 |
| 2022 July | 29 | 32 | 61 |
| 2022 June | 21 | 34 | 55 |
| 2022 May | 21 | 30 | 51 |
| 2022 April | 61 | 32 | 93 |
| 2022 March | 29 | 36 | 65 |
| 2022 February | 15 | 20 | 35 |
| 2022 January | 10 | 24 | 34 |
| 2021 December | 9 | 17 | 26 |
| 2021 November | 9 | 17 | 26 |
| 2021 October | 10 | 7 | 17 |
| 2021 September | 13 | 10 | 23 |
| 2021 August | 8 | 14 | 22 |
| 2021 July | 9 | 2 | 11 |
| 2021 June | 6 | 8 | 14 |
| 2021 May | 15 | 8 | 23 |
| 2021 April | 20 | 6 | 26 |
| 2021 March | 23 | 13 | 36 |
| 2021 February | 10 | 3 | 13 |
| 2021 January | 17 | 11 | 28 |
| 2020 December | 14 | 6 | 20 |
| 2020 November | 10 | 16 | 26 |
| 2020 October | 26 | 22 | 48 |
| 2020 September | 34 | 26 | 60 |
| 2020 August | 58 | 17 | 75 |
| 2020 July | 7 | 4 | 11 |
| 2020 June | 1 | 5 | 6 |
| 2020 May | 12 | 10 | 22 |
| 2020 April | 5 | 8 | 13 |
| 2020 March | 6 | 10 | 16 |
| 2020 February | 9 | 28 | 37 |
| 2020 January | 15 | 23 | 38 |
| 2019 December | 9 | 3 | 12 |
| 2019 November | 8 | 10 | 18 |
| 2019 October | 11 | 12 | 23 |
| 2019 September | 10 | 16 | 26 |
| 2019 August | 7 | 12 | 19 |
Show all
