The prevalence and determinants of asthma, asthma symptoms and rhinitis in a population-based study in Finland

Asthma and chronic rhinitis are global health problems that cause major burden and disability. The prevalence of asthma has increased in recent decades, which has also been reported in Finland. To address this increasing burden, The National Asthma Programme was conducted in Finland in 1994-2004 and the Allergy Programme in 2008-2018. Both programs were successful as asthma costs and hospital admissions, as well as allergy diets in children and adolescents, decreased significantly. However, asthma and rhinitis symptoms are still a major burden in Finland both for society and patients. Information on preventable risk factors is needed to decrease the symptoms of asthma and rhinitis. Although occupational exposures are known to cause both asthma and rhinitis symptoms, the effect of combined exposure to vapours, gases, dusts, and fumes (VGDF) with environmental tobacco smoke (ETS) or smoking on asthma and chronic rhinitis has not been fully explored. In addition to exposures, age at asthma diagnosis is known to affect disease progression. Asthma diagnosed in adulthood is related to a poorer prognosis, whereas asthma diagnosed in childhood may even remit. However, studies on the effect of age at asthma diagnosis on asthma symptoms in study cohorts (including asthmatics with asthma diagnosed at all ages) are still scarce. We assessed the prevalence and risk factors of asthma and symptoms of asthma and chronic rhinitis. In addition, we investigated whether combined exposure to VGDF with ETS or smoking would increase the prevalence of asthma and the symptoms of asthma and rhinitis. We also evaluated if asthma diagnosed in adulthood is associated with a more symptomatic disease. A cross-sectional postal survey was conducted in a random population sample as a part of the FinEsS-study in Helsinki in 1996, 2006, and 2016. The questionnaire was sent to 8000 adults in 1996, 4000 in 2006, and 8000 in 2016. In 2016, the questionnaire was sent additionally to a similar random population sample of 8000 participants in Western Finland. The response rate declined by study year; the rate was 75.9% in 1996, 61.7% in 2006, and 50.3% in 2016. There was a 52.3% response rate in Western Finland in 2016. All responders (n=3998) were included in the analysis of asthma and chronic rhinitis prevalence. To assess the risk factors for asthma and rhinitis symptoms, we included responders with reported asthma diagnosis (n=836) or chronic rhinitis (n=3488), respectively, who also reported their exposure history of tobacco smoke and VGDF. For the analysis of age at asthma diagnosis, we included responders with physician-diagnosed asthma and reported age at asthma diagnosis and smoking habits (n=842). The increase previously seen in asthma prevalence in Helsinki plateaued from 2006 to 2016. The results were similar in responders who were ever diagnosed with asthma (6.6% in 1996, 10.0% in 2006 and 10.9% in 2016) and in those with current asthma (5.8% in 1996, 8.5% in 2006 and 8.8% in 2016). In addition to asthma prevalence, a similar decrease was also seen in respiratory symptoms. The prevalence of respiratory symptoms decreased both in the general population and in responders with physician-diagnosed asthma from 2006 to 2016. Fewer asthmatics reported multiple symptoms in 2016 compared to 2006 (71.8% in 2006 vs 62.2% in 2016). Combined exposure to VGDF with ETS or smoking increased the prevalence of current asthma in responders who were ever diagnosed with asthma by a physician. The highest prevalence figures were in responders with combined exposure to VGDF and ETS (89.5% vs 77.9% in responders with no exposure history; p=0.027). Combined exposure to VGDF with ETS or smoking was also associated with a higher symptom burden both in asthma and chronic rhinitis. Responders with asthma diagnosed in adulthood had a higher symptom burden than those diagnosed in childhood, as all analysed asthma symptoms were more often reported by those diagnosed in adulthood. Our findings on asthma and asthma symptom prevalence complement previous positive results of the Finnish Asthma and Allergy Programmes. However, further actions are needed as both asthma and chronic rhinitis continue to present challenges both in everyday clinical practice and on a national level despite these positive trends observed in Finland. Exposure to tobacco smoke and VGDF is preventable; therefore, our results highlight the importance of active measures in the prevention of current asthma and in treatment of asthma and chronic rhinitis. In addition, targeted identification and treatment of asthma patients diagnosed in adulthood is important to optimize resource utilization and to achieve better disease control.Astma ja pitkäkestoinen nuha, eli nenän limakalvojen tulehdustila (riniitti), ovat yleisiä kansansairauksia, jotka aiheuttavat huomattavan tautitaakan sekä sairastavuutta kaikkialla. Astman esiintyvyys on noussut kuluneina vuosikymmeninä, myös Suomessa. Kasvavan tautitaakan torjumiseksi Suomessa toteutettiin Kansallinen Astmaohjelma vv. 1994-2004 sekä Kansallinen Allergiaohjelma vv. 2008-2018. Nämä kansalliset ohjelmat saavuttivat tavoitteensa. Niiden seurauksena astman aiheuttamat kulut ja sairaalahoitojaksot, sekä lasten ja nuorten allergiaruokavaliot, vähenivät merkittävästi. Tästä huolimatta astman ja pitkäkestoisen nuhan aiheuttaman oireet ovat edelleen merkittävä ongelma Suomessa sekä yhteiskunnalle että potilaille. Astma- ja nuhaoireiden vähentämiseksi on tehokas ennaltaehkäisy tarpeen. Se puolestaan edellyttää tautien syntyä edistävien riskitekijöiden tuntemista. Työhön liittyvien savujen, kaasujen, huurujen ja pölyjen sekä tupakansavun tiedetään aiheuttavan astma- ja nuhaoireita. Vielä ei kuitenkaan tiedetä, millaisia vaikutuksia syntyy, jos astmaa tai pitkäkestoista nuhaa sairastava henkilö tupakoi tai altistuu toisten tupakoinnille ja työelämän altisteille samanaikaisesti. Altisteiden lisäksi henkilön ikä astmadiagnoosin hetkellä vaikuttaa sairauden kulkuun. Aikuisiällä todettuun astmaan liittyy huonompi ennuste, kun taas lapsena todettu astma saattaa jopa parantua oireettomaksi. Tutkimuksia, joissa samalla kertaa olisi tutkittu sekä aikuisena että lapsena astmaan sairastuneita, on kuitenkin varsin vähän. Tässä tutkimuksessa selvitettiin astman esiintyvyyttä sekä riskitekijöitä, sekä astman ja nuhan oireisiin vaikuttavia tekijöitä. Tarkastelimme myös, onko samanaikainen altistuminen sekä työperäisille altisteille että tupakansavulle yhteydessä astman sekä astma- ja nuhaoireiden esiintyvyyteen. Kolmas tavoite oli arvioida, ovatko aikuisena astmaan sairastuneet oireisempia lapsena sairastuneisiin verrattuna.  Osana FinEsS-tutkimusta lähetettiin satunnaisesti valituille helsinkiläisille postitse kyselykaavake 1996 (8000 henkilöä), 2006 (4000 henkilöä) sekä 2016 (8000 henkilöä). Vuonna 2016 kyselykaavake lähetettiin lisäksi 8000 osallistujalle Länsi-Suomessa. Vastaajien osuus laski tutkimuksen edetessä ollen vuonna 1996 75,9%, vuonna 2006 61,7% ja vuonna 2016 50,3%. 52,3% vastasi Länsi-Suomessa. Kaikki vastanneet (n=3998) olivat mukana astman ja pitkäkestoisen nuhan esiintyvyyden analyyseissä. Astma- ja nuhaoireiden riskitekijöiden arvioimiseksi tehdyissä analyyseissä olivat mukana ne, joilla oli lääkärin toteama astma (n=836) tai nuha (n=3488), ja jotka olivat vastanneet myös altistumista ja tupakointitapoja koskeviin kysymyksiin. Astman alkamisiän vaikutusta koskeviin analyyseihin sisällytimme ne vastaajat, jotka raportoivat lääkärin toteaman astman, ikänsä diagnoosihetkellä sekä tupakointitapansa (n=842). Aiemmin Helsingissä todettu astman lisääntyminen oli tasaantunut vv. 2006-2016. Vastaava löydös nähtiin sekä niiden vastaajien joukossa, joilla lääkäri oli joskus todennut astman (6.6% vuonna 1996, 10.0% vuonna 2006 ja 10.9% vuonna 2016) , että niillä, joilla astmadiagnoosin lisäksi oli kyselyhetkellä astmaoireita tai käytössään astmalääkkeitä (5.8% vuonna 1996, 8.5% vuonna 2006 ja 8.8% vuonna 2016). Astman esiintyvyyttä vastaava lasku nähtiin myös hengitystieoireissa. Ne vähenivät selvästi vv. 2006-2016 sekä koko tutkimusotoksessa että astmaatikoilla.  Harvemmat astmaatikot raportoivat lukuisia oireita vuonna 2016 verrattuna vuoteen 2006 (71.8% vuonna 2006 vs. 62.2% vuonna 2016). Samanaikainen altistuminen sekä työperäisille altisteille että tupakansavulle lisäsi kyselyhetkellä oireisten ja astmalääkkeitä käyttävien astmaatikkojen osuutta sekä astma- ja nuhaoireiden määrää. Korkein esiintyvyys nähtiin astmaatikoilla, jotka altistuivat sekä ympäristön tupakansavulle että työperäisille altisteille (89.5% vs. 77.9% astmaatikoilla ilman altistushistoriaa; p=0.027) Altistuminen sekä työperäisille altisteille että tupakansavulle lisäsi oireilua sekä astmassa että nuhassa. Aikuisiällä astmaan sairastuneet raportoivat kaikkia kysyttyjä astmaoireita useammin kuin lapsena astmaan sairastuneet.  Löydöksemme astman, pitkäkestoisen nuhan sekä astma- ja nuhaoireiden vähenemisestä täydentävät aiemmin raportoituja positiivisia tuloksia Kansallisista Astma- ja Allergiaohjelmista. Hyvästä kehityksestä huolimatta sekä astma että nuha ovat yhä terveydenhuollon haasteita, joten lisätoimet ovat tarpeen. Altistuminen työperäisille altisteille sekä tupakansavulle on ehkäistävissä. Löydöksemme korostavat aktiivisen ennaltaehkäisyn merkitystä astmaoireiden ennaltaehkäisyssä sekä astman ja nuhan hoidossa. Tämän lisäksi aikuisiällä astmaan sairastuneiden kohdistettu tunnistaminen ja hoito on tärkeää resurssien optimoinnin sekä hoitotavoitteiden saavuttamisen kannalta

Smoking, environmental tobacco smoke and occupational irritants increase the risk of chronic rhinitis

Background: Allergic and non-allergic rhinitis cause a lot of symptoms in everyday life. To decrease the burden more information of the preventable risk factors is needed. We assessed prevalence and risk factors for chronic nasal symptoms, exploring the effects of smoking, environmental tobacco smoke, exposure to occupational irritants, and their combinations. Methods: In 2016, a postal survey was conducted among a random population sample of 8000 adults in Helsinki, Finland with a 50.5% response rate. Results: Smoking was associated with a significant increase in occurrence of chronic rhinitis (longstanding nasal congestion or runny nose), but not with self-reported or physician diagnosed allergic rhinitis. The highest prevalence estimates of nasal symptoms, 55.1% for chronic rhinitis, 49.1% for nasal congestion, and 40.7% for runny nose, were found among smokers with occupational exposure to gases, fumes or dusts. Besides active smoking, also exposure to environmental tobacco smoke combined with occupational exposure increased the risk of nasal symptoms. Conclusions: Smoking, environmental tobacco smoke, and occupational irritants are significant risk factors for nasal symptoms with an additive pattern. The findings suggest that these factors should be systematically inquired in patients with nasal symptoms for appropriate preventive measures. (192 words).Peer reviewe

The increase of asthma prevalence has levelled off and symptoms decreased in adults during 20 years from 1996 to 2016 in Helsinki, Finland

Background: Mortality and hospitalization due to asthma have decreased in many European countries, but asthma symptoms still cause a lot of morbidity and costs. Objectives: We evaluated prevalence trends of asthma, asthma symptoms and allergic rhinoconjunctivitis in adults aged 20-69 years during a 20-year period from 1996 to 2016 in the city of Helsinki, the capital of Finland. Methods: Three cross-sectional postal surveys were conducted in random population samples 10 years apart. In 1996, 2006 and 2016, a total of 6062 (response rate 75.9%), 2449 (61.9%) and 4026 subjects (50.3%) took part, respectively. Results: In all responders, the prevalence of physician-diagnosed asthma was 6.6% in 1996, 10% in 2006 and 10.9% in 2016. The prevalence increased from 1996 to 2006, but stabilized from 2006 to 2016, both in men and women and in smokers and non-smokers. The prevalence of current asthma (8.5% in 2006 and 8.8% in 2016) and of asthma with rhinoconjunctivitis (7.6% in 2006 and 7.5% in 2016) remained also at the same level. Allergic rhinoconjunctivitis decreased significantly from 2006 (42.7%) to 2016 (39.0%, p=0.004). Those with physician diagnosed asthma reported significantly less symptoms in 2016 compared to 2006 and 1996, although there was no change in smoking habits or medication use. Young asthmatics (20-29 years) without rhinoconjunctivitis reported least symptoms. Conclusion: Previously observed increase of physician-diagnosed asthma prevalence in adults seems to be levelling off in Helsinki, and patients have fewer symptoms than 20 years ago. In addition, allergic rhinoconjunctivitis is less frequent than 10 years earlier. (247 words).Peer reviewe

The combined effect of exposures to vapours, gases, dusts, fumes and tobacco smoke on current asthma

Smoking, exposure to environmental tobacco smoke (ETS) and occupational exposure to vapours, gases, dusts or fumes (VGDF) increase asthma symptoms. The impact of combined exposure is less well established. We aimed to evaluate the risk of combined exposure to smoking, ETS and VGDF on the prevalence of current asthma and asthma-related symptoms with a postal survey among a random population of 16,000 adults, aged 20-69 years (response rate 51.5%). The 836 responders with physician-diagnosed asthma were included in the analysis. Of them, 81.9% had current asthma defined as physician-diagnosed asthma with current asthma medication use or reported symptoms. There was a consistently increasing trend in the prevalence of current asthma by increased exposure. The highest prevalence of multiple symptoms was in smokers with VGDF exposure (92.1%) compared to the unexposed (73.9%, p = 0.001). In logistic regression analysis, combined exposure to several exposures increased the risk in all analysed symptoms (p = 0.002-0.007). In conclusion, smoking and exposure to ETS or VGDF increased the prevalence of current asthma and multiple symptoms. The combined exposure carried the highest risk. Preventive strategies are called for to mitigate exposure to tobacco smoke and VGDF.Peer reviewe

Age at asthma diagnosis is related to prevalence and characteristics of asthma symptoms

Background: Although asthma may begin at any age, knowledge about relationship between asthma age of onset and the prevalence and character of different symptoms is scarce. Objectives: The aim of this study was to investigate if adult-diagnosed asthma is associated with more symptoms and different symptom profiles than child-diagnosed asthma.Methods: A FinEsS postal survey was conducted in a random sample of 16 000 20-69-year-old Finnish adults in 2016. Those reporting physician-diagnosed asthma and age at asthma diagnosis were included. Age 18 years was chosen to delineate child-and adult-diagnosed asthma.Results: Of responders (N = 8199, 51.5%), 842 (10.3%) reported asthma diagnosis. Adult -diagnosed asthma was reported by 499 (59.3%) and child-diagnosed by 343 (40.7%). Of re-sponders with adult-diagnosed and child-diagnosed asthma, 81.8% versus 60.6% used asthma medication (p < 0.001), respectively. Current asthma was also more prevalent in adult-diagnosed asthma (89.2% versus 72.0%, p < 0.001). Risk factors of attacks of breathlessness during the last 12 months were adult-diagnosis (OR = 2.41, 95% CI 1.64-3.54, p < 0.001), female gender (OR = 1.49, 1.07-2.08, p = 0.018), family history of asthma (OR = 1.48, 1.07-2.04, p = 0.018) and allergic rhinitis (OR = 1.49, 1.07-2.09, p = 0.019). All the analysed asthma symptoms, except dyspnea in exercise, were more prevalent in adult-diagnosed asthma in age-and gender-adjusted analyses (p = 0.032-Peer reviewe

Age-specific incidence of allergic and non-allergic asthma

Background Onset of allergic asthma has a strong association with childhood but only a few studies have analyzed incidence of asthma from childhood to late adulthood in relation to allergy. The purpose of the study was to assess age-specific incidence of allergic and non-allergic asthma. Methods Questionnaires were sent to 8000 randomly selected recipients aged 20-69 years in Finland in 2016. The response rate was 52.3% (n = 4173). The questionnaire included questions on e.g. atopic status, asthma and age at asthma diagnosis. Asthma was classified allergic if also a physician-diagnosed allergic rhinitis was reported. Results The prevalence of physician-diagnosed asthma and allergic rhinitis were 11.2 and 17.8%, respectively. Of the 445 responders with physician-diagnosed asthma, 52% were classified as allergic and 48% as non-allergic. Median ages at diagnosis of allergic and non-allergic asthma were 19 and 35 years, respectively. Among subjects with asthma diagnosis at ages 0-9, 10-19, 20-29, 30-39, 40-49, 50-59 and 60-69 years, 70, 62, 58, 53, 38, 19 and 33%, respectively, were allergic. For non-allergic asthma, the incidence rate was lowest in children and young adults (0.7/1000/year). It increased after middle age and was highest in older age groups (2.4/1000/year in 50-59 years old). Conclusions The incidence of allergic asthma is highest in early childhood and steadily decreases with advancing age, while the incidence of non-allergic asthma is low until it peaks in late adulthood. After approximately 40 years of age, most of the new cases of asthma are non-allergic.Peer reviewe

Age- and gender-specific incidence of new asthma diagnosis from childhood to late adulthood

Background: Asthma is currently divided into different phenotypes, with age at onset as a relevant differentiating factor. In addition, asthma with onset in adulthood seems to have a poorer prognosis, but studies investigating age-specific incidence of asthma with a wide age span are scarce. Objective: To evaluate incidence of asthma diagnosis at different ages and differences between child- and adult-diagnosed asthma in a large population-based study, with gender-specific analyzes included. Methods: In 2016, a respiratory questionnaire was sent to 8000 randomly selected subjects aged 20-69 years in western Finland. After two reminders, 4173 (52.3%) subjects responded. Incidence rate of asthma was retrospectively estimated based on the reported age of asthma onset. Adult-diagnosed asthma was defined as a physician-diagnosis of asthma made at >= 18 years of age. Results: Among those with physician-diagnosed asthma, altogether, 63.7% of subjects, 58.4% of men and 67.8% of women, reported adult-diagnosed asthma. Incidence of asthma diagnosis was calculated in 10-year age groups and it peaked in young boys (0-9 years) and middle-aged women (40-49 years) and the average incidence rate during the examined period between 1946 and 2015 was 2.2/1000/year. Adult-diagnosed asthma became the dominant phenotype among those with physician-diagnosed asthma by age of 50 years and 38 years in men and women, respectively. Conclusions: Asthma is mainly diagnosed during adulthood and the incidence of asthma diagnosis peaks in middle-aged women. Asthma diagnosed in adulthood should be considered more in clinical practice and management guidelines.Peer reviewe

Asthma Remission by Age at Diagnosis and Gender in a Population-Based Study

BACKGROUND: Child-onset asthma is known to remit with high probability, but remission in adult-onset asthma is seem-ingly less frequent. Reports of the association between remission and asthma age of onset up to late adulthood are scarce. OBJECTIVE: To evaluate the association between asthma remission, age at diagnosis and gender, and assess risk factors of nonremission. METHODS: In 2016, a random sample of 16,000 subjects aged 20 to 69 years from Helsinki and Western Finland were sent a FinEsS questionnaire. Physician-diagnosed asthma was catego-rized by age at diagnosis to early-(0-11 years), intermediate-(12-39 years), and late-diagnosed (40-69 years) asthma. Asthma remission was defined by not having had asthma symptoms and not having used asthma medication in the past 12 months. RESULTS: Totally, 8199 (51.5%) responded, and 879 reported physician-diagnosed asthma. Remission was most common in early-diagnosed (30.2%), followed by intermediate-diagnosed (17.9%), and least common in late-diagnosed asthma (5.0%) (P < .001), and the median times from diagnosis were 27, 18.5, and 10 years, respectively. In males, the corresponding remission rates were 36.7%, 20.0%, and 3.4%, and in females, 20.4%, 16.6%, and 5.9% (gender difference P < .001). In multivariable binary logistic regression analysis, signifi-cant risk factors of asthma nonremission were intermediate (odds ratio [OR] = 2.15, 95% confidence interval: 1.373.36) and late diagnosis (OR = 11.06, 4.82-25.37) compared with early diagnosis, chronic obstructive pulmonary disease (COPD) (OR = 5.56, 1.26-24.49), allergic rhinitis (OR = 2.28, 1.50-3.46), and family history of asthma (OR = 1.86, 1.22-2.85). Results were similar after excluding COPD. CONCLUSION: Remission was rare in adults diagnosed with asthma after age 40 years in both genders. Late-diagnosed asthma was the most significant independent risk factor for nonremission. (C) 2020 American Academy of Allergy, Asthma & ImmunologyPeer reviewe

Differences in diagnostic patterns of obstructive airway disease between areas and sex in Sweden and Finland-the Nordic EpiLung study

Objective:To investigate the current prevalence of physician-diagnosed obstructive airway diseases by respiratory symptoms and by sex in Sweden and Finland. Method:In 2016, a postal questionnaire was answered by 34,072 randomly selected adults in four study areas: Vastra Gotaland and Norrbotten in Sweden, and Seinajoki-Vaasa and Helsinki in Finland. Results:The prevalence of asthma symptoms was higher in Norrbotten (13.2%), Seinajoki-Vaasa (14.8%) and Helsinki (14.4%) than in Vastra Gotaland (10.7%), and physician-diagnosed asthma was highest in Norrbotten (13.0%) and least in Vastra Gotaland (10.1%). Chronic productive cough was most common in the Finnish areas (7.7-8.2% versus 6.3-6.7%) while the prevalence of physician-diagnosed chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD) varied between 1.7 and 2.7% in the four areas. Among individuals with respiratory symptoms, the prevalence of asthma was most common in Norrbotten, while a diagnosis of COPD or CB was most common in Vastra Gotaland and Seinajoki-Vaasa. More women than men with respiratory symptoms reported a diagnosis of asthma in Sweden and Seinajoki-Vaasa but there were no sex differences in Helsinki. In Sweden, more women than men with symptoms of cough or phlegm reported a diagnosis of CB or COPD, while in Finland the opposite was found. Conclusion:The prevalence of respiratory symptoms and corresponding diagnoses varied between and within the countries. The proportion reporting a diagnosis of obstructive airway disease among individuals with respiratory symptoms varied, indicating differences in diagnostic patterns both between areas and by sex.Peer reviewe

Influence of Childhood Exposure to a Farming Environment on Age at Asthma Diagnosis in a Population-Based Study

Purpose: Asthma is a heterogeneous disease, and factors associated with different asthma phenotypes are poorly understood. Given the higher prevalence of farming exposure and late diagnosis of asthma in more rural Western Finland as compared with the capital of Helsinki, we investigated the relationship between childhood farming environment and age at asthma diagnosis. Methods: A cross-sectional population-based study was carried out with subjects aged 2069 years in Western Finland. The response rate was 52.5%. We included 3864 participants, 416 of whom had physician-diagnosed asthma at a known age and with data on the childhood environment. The main finding was confirmed in a similar sample from Helsinki. Participants were classified as follows with respect to asthma diagnosis: early diagnosis (011 years), intermediate diagnosis (12-39 years), and late diagnosis (40-69 years). Results: The prevalence of asthma was similar both without and with childhood exposure to a farming environment (11.7% vs 11.3%). Allergic rhinitis, family history of asthma, exsmoker, occupational exposure, and BMI >= 30 kg/m(2) were associated with a higher likelihood of asthma. Childhood exposure to a farming environment did not increase the odds of having asthma (aOR, 1.10; 95% CI, 0.87-1.40). It did increase the odds of late diagnosis (aOR, 2.30; 95% CI, 1.12-4.69), but the odds were lower for early (aOR, 0.49; 95% CI, 0.30-0.80) and intermediate diagnosis of asthma (aOR, 0.75; 95% CI, 0.47-1.18). Conclusion: Odds were lower for early diagnosis of asthma and higher for late diagnosis of asthma in a childhood farming environment. This suggests a new hypothesis concerning the etiology of asthma when it is diagnosed late.Peer reviewe