How going to CRECHE can lower your child’s risk of asthma...

and growing up on a FARM can help too, according to fascinating new research

WE KNOW what triggers it but we don’t know what causes it, and shocking statistics show that around one person in Ireland dies from asthma every week.

Like cystic fibrosis, we have one of the highest rates of asthma in the world and scientists have yet to discover the reason for this.

However, a leading physician has said that there is a continuing body of evidence emerging that suggests rigid hygiene may be causing children to develop asthma at an early age in what is known as the ‘hygiene hypothesis’.

‘Ireland is a hot spot on the planet for asthma, so in that sense the condition is something people need to be aware of,’ says Dr Marcus Butler, a consultant respiratory physician at St Vincent’s Hospital in Dublin and director of the Asthma Society of Ireland.

‘We have one of the highest rates of asthma in the world — the latest data shows we are one of four or five countries with the highest rates of

asthma per capita, alongside the United Kingdom, Australia, New Zealand and Brazil.

‘We don’t know the reason for this, but there is certainly research data that suggests the Western way of living and cleaner standards of hygiene have an impact.

‘This theory has been around for a long time, but there is an increasing body of evidence to suggest this is the case.

‘There is a greater awareness of asthma and so perhaps a higher rate of diagnosis in Western countries, but we don’t really fully understand why asthma is so prevalent and why it varies regionally in the world,’ said Dr Butler.

Around 475,000 people in Ireland have asthma, including one in five children. It can develop at any stage of life and Dr Butler says there are genetic influences in some cases.

‘There are different types of asthma too,’ he explains. ‘Broadly speaking, there are people who have quite an allergic partner to asthma, which in childhood is the most dominant form of asthma.

‘It is a less dominant form in adults — many adults can develop asthma for the first time in adulthood and not have had it at all in childhood. In those cases it is 50/50 as to whether there is an allergy basis or no allergic reaction as a trigger for the disease.

‘Beyond that there are other subtypes that are increasingly recognised such as severe asthma, which requires higher levels of maintenance and treatment to help the patient maintain an acceptable quality of life or still might not have an acceptable quality of life despite using regular high-dose medications.’

IT IS believed that modern living is one cause and statistics show you are more likely to have some form of asthma if you live in a city.

‘There are certain risk factors,’ Dr Butler says. ‘Those who are exposed to slightly more unclean environments seems to have a lower rate of asthma development in childhood. There is compelling data that children who are exposed to daycare and creche at an earlier age have lower rates of asthma than when children are introduced to daycare at an older age.’

A new large-scale meta-analysis led by researchers at the University of California San Francisco and UCSF Benioff Children’s Hospital San Francisco found that rather than increasing the risk of asthma in children, attending a creche actually meant children between the ages of three and five were 34% less likely to develop the condition.

Children who grow up on farms have lower rates of asthma than those who live in urban areas, although there are exceptions. But at a population level, we are seeing these patterns emerging.’

There is still no cure for asthma as the cause of the disease is not yet known.

‘We do have very effective treatments that can remove the symptoms and inconvenience, and restore an excellent quality of life, but when the treatments are stopped, the asthma will re-emerge when triggered,’ Dr Butler explains.

‘We know what triggers asthma to develop but we don’t know what actually causes it. Asthma can be set off by certain exposures in the environment,’ says Dr Butler, adding that an asthma patient who develops a head cold may find it affects their chest, whereby a person without asthma may not develop these more serious symptoms.

And pollen might be a factor in some cases, but by far the biggest trigger for allergic asthma is actually lurking in our homes.

‘Other triggers include a variety of inhaled allergens and the chief trigger for asthma here is the house dust mite, a microscopic organism that is found everywhere in a temperate climate,’ Dr Butler says.

‘These dust mites feed off human skin cells that we shed continuously so there are very high proportions of these organisms living in bedrooms, for example.

‘They can actually make a mattress heavier over many years — which is a scary thought. It’s not visible dust that is the allergen, it is proteins that are shed from the body of these microscopic organisms that cause the problem — they are very tiny molecules.

‘The pollens that set off hay fever can also set off asthma. Stress is another frequent trigger, air pollution can trigger asthma and doing vigorous exercise can exacerbate the condition, but this is not usual and generally doesn’t occur when people are managing their asthma properly. We very much encourage exercise which is managed by pre-medicating with a Ventolin inhaler.’

The Asthma Society of Ireland is keen to get the message out there that taking daily medication is vital for sufferers.

‘It is a very treatable condition and the unfortunate thing is many patients don’t enjoy the benefits of this,’ Dr Butler says. ‘The reasons for this are becoming increasingly clear. There are various barriers that get in the way of the medicine doing their jobs.’

Fears of long-term steroid use is one of these barriers which can lead to bad outcomes as the medicines taken for asthma have remarkably good outcomes in terms of safety and patients should be reassured the daily controller medication to keep the asthma at bay is very safe when taken in the long term.

‘Asthma is a condition where there is thickening and swelling of the airways that can come and go. Mucus can be secreted in the airways and these airways are engorged with cells that are very active and cause the muscle to tighten at times,’ says Dr Butler.

‘The controller drugs take away the abnormal inflammation and swelling, clearing the mucus so it makes it more difficult for patients with asthma to be triggered. Patients taking these drugs won’t get triggered compared to a patient who is not taking their controller.’

AND as we still don’t understand what causes asthma, keeping it at bay is essential. ‘One person a week dies from asthma in Ireland,’ Dr Butler says. ‘In recent years data has confirmed approximately 50 deaths a year from asthma here. It is a very similar death rate in Britain and this is a scary number. The factors behind this are imperfectly understood.’

The majority of these deaths may be predictable or preventable because there is a worsening of the condition in the weeks before patients succumb to the disease.

However, in the minority, 10% to 15% of patient fatalities, symptoms come on and result in death in a period of two to six hours during a rapid onset life-threatening asthma attack. This is not very common,

assures Dr Butler, but the fact that it does happen is very concerning.

‘This is more likely to happen to someone who is not on a controller drug or not taking their controller drug, especially if the asthma is troublesome and the patient has frequent flare-ups,’ says Dr Butler. But all too often when people are relieved of their symptoms, they don’t continue with their medication regime.

‘When the symptoms go away it doesn’t mean the asthma has gone away,’ Dr Butler explains. ‘The symptoms are actually just dormant and will flare up again when there is another trigger.

When the symptoms have gone the patient loses the stimulus to take the medication or the lack of desire to take it. After a sufficiently long period of time you can, in a careful way, wean the strength of the medicines down to a very low level, but it has to be done in a much slower and more cautious manner than common sense would dictate.’

The latest research shows many people don’t actually know the correct procedure to deal with asthma attacks. Very few asthmatics, let alone members of the general public, know the symptoms of an asthma attack and how to treat one. Given that 90% of these asthma deaths are preventable, this is a major health concern.

In Ireland, one person every 26 minutes attends an emergency department with uncontrolled asthma. But in a survey by the Asthma Society Of Ireland, only 7% of asthmatics actually knew all the symptoms.

Around 43% of those with asthma don’t know when an attack can occur and almost half would not see a health professional after having an attack.

“Managing asthma becomes more difficult over the summer as the nice weather brings along a sharp increase in pollen count,’ Dr Butler says. ‘Research suggests that up to 80% of people with asthma notice a worsening of asthma symptoms due to allergies such as pollen, as an allergic reaction is triggered.

‘I see a drop in asthma control among my allergic asthma patients during hay-fever season, which leaves them at risk of a more serious asthma attack.

‘It is vital that all asthma patients with pollen or grass allergy have an asthma action plan and prepare for the hayfever season to limit its effects.”

The Asthma Society Of Ireland has just teamed up with Dyson and GSK to launch its annual pollen tracker so sufferers can keep an eye on the daily count and be prepared. They are also urging people to learn the Five Step Rule in case anyone they know has an asthma attack.