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Benefits of early use of inhaled corticosteroids (ICS)
2
Tubercle and Lung Disease: Supplement 2
situation, especially in risk groups with initial resistance and low compliance with treatment. This analysis and its conclusions will be discussed. 1. Lambregts-van Weezenbeek CSB, Veen J. Control of drug resistant tuberculosis. Tubercle and Lung Disease 1995: 76: in press 2. Data will be finalised and submitted for publication
Asthma among farmers Pham, Q.T., Chau, N., Megherbi, S.E., Darnel, M., Drouinneaud, V., Bourgkard, E., Teculescu, D. Unit( 420 I.N.S.E.R.M., France
In a five year follow-up study, asthma was looked at among farmers, the most important and homogeneous subgroup in a cohort of 755 agricultural workers affiliated to the agricultural health insurance of Meuse country (N-E France). At the first examination, a self completed questionnaire on symptoms, smoking habits and occupational hazards was completed and lung function and allergen prick tests were performed. Five year later, a self completed questionnaire was addressed to each participant. The farmers studied (309 men and 175 women) experienced a similar prevalence of asthma in 1988 and 1993 (8,3% and 9,8% for men and 3,6% and 5,8% for women). An increase in asthma prevalence was noted at the second examination among those with multiple occupational hazards (still active or retired) compared with those few exposed (8,2% and 41,7% vs 6,8% and 12%). "Persistent" asthma (asthma in 1988 and 1993) was mostly observed among those exposed t o multiple hazards, those with Dermatophagoides and/or pollen positive skin tests and/or those with an airflow obstruction at the first examination. The subjects with asthma in 1988 and 1993 and those who declared asthma in 1993 had FEV1. 0 and FEV1/VC in 1988 significantly lower than, those without asthma.
The wheezy child - is it pneumonia? MulhoIland, K. CDR Programme, WHO, Geneva
The lung represents the main site of communication between the human body and environmental air. The various protective mechanisms in the lung of a young child must face a constant barrage of assaults from the environment. In developing countries viruses and smoke, mainly from biomass fuels used for cooking, constantly challenge children's lungs against the background of a respiratory tract which is usually colonized with potentially pathogenic bacteria. In this environment, bacterial pneumonia is common and wheezing occurs mainly in young infants in the context of, probably viral, acute respiratory infections, while true atopic asthma seems to be .relatively uncommon. In industrialized countries children's lungs are challenged by viruses, atmospheric pollution, particularly tobacco smoke, and various aller-
gens in the context of a relatively sterile respiratory tract. In contrast to developing countries, and in contrast to industrialized countries 100 years ago, bacterial pneumonia is rare, while asthma is increasingly common. The defence mechanisms in the lung evolved in the context of colonization with encapsulated bacteria. Over the past century in industrialized countries this colonization has become much less while young children have been exposed to a wide variety of 'new' antigens. Examination of this problem may help us understand how we can avoid a growing asthma problem in developing countries and perhaps how to reduce asthma levels in industrialized countries. It may also help us decide which wheezing children in developing countries need antibiotics.
Benefits of early use of inhaled corticosteroids (ICS) Woolcock, A.J. Institute of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown NSW, Australia
Traditionally there has been a great reluctance to use inhaled steroids in small children because of fears about the systemic effects, difficultly with administration and cost. However, there is evidence that children with persistent asthma who are treated with ICS soon after diagnosis have a better response than children who commence ICS 1-2 years after diagnosis. This is also well described for adults. Apart from cost, the main problem associated with using ICS is in deciding which children require them. In general terms, if the airways are not functioning normally between acute attacks, then ICS are indicated. In a sophisticated setting, and in children greater than 4 years, airway function can be assessed by measuring peak flow in the mornings and the frequency of wheezing attacks. In less sophisticated circumstances, clinical judgement is needed, based on frequency and severity of wheezing episodes. It is clear that steroids are the most effective way of controlling persistent asthma in all age groups and the inhaled route gives an opportunity to use doses which are without side-effects in the long term. ICS can be used intermittently, but protocols to determine dose and frequency are still being assessed. Issues of cost and delivery methods for infants can be overcome once the benefits of ICS are widely recognised.
The case against early steroid use Weinberg, E. Red Cross Children's Hospital, Cape Town, South Africa
Asthma is now regarded as an inflammatory disease especially in adults. As a result there has been a sustained campaign for the use of inhaled steroids in asthma. This has progressed to the stage where the early use of inhaled steroids in childhood asthma is being advised. The diagnosis of asthma is difficult in infancy. We
Tubercle and Lung Disease: Supplement 2
situation, especially in risk groups with initial resistance and low compliance with treatment. This analysis and its conclusions will be discussed. 1. Lambregts-van Weezenbeek CSB, Veen J. Control of drug resistant tuberculosis. Tubercle and Lung Disease 1995: 76: in press 2. Data will be finalised and submitted for publication
Asthma among farmers Pham, Q.T., Chau, N., Megherbi, S.E., Darnel, M., Drouinneaud, V., Bourgkard, E., Teculescu, D. Unit( 420 I.N.S.E.R.M., France
In a five year follow-up study, asthma was looked at among farmers, the most important and homogeneous subgroup in a cohort of 755 agricultural workers affiliated to the agricultural health insurance of Meuse country (N-E France). At the first examination, a self completed questionnaire on symptoms, smoking habits and occupational hazards was completed and lung function and allergen prick tests were performed. Five year later, a self completed questionnaire was addressed to each participant. The farmers studied (309 men and 175 women) experienced a similar prevalence of asthma in 1988 and 1993 (8,3% and 9,8% for men and 3,6% and 5,8% for women). An increase in asthma prevalence was noted at the second examination among those with multiple occupational hazards (still active or retired) compared with those few exposed (8,2% and 41,7% vs 6,8% and 12%). "Persistent" asthma (asthma in 1988 and 1993) was mostly observed among those exposed t o multiple hazards, those with Dermatophagoides and/or pollen positive skin tests and/or those with an airflow obstruction at the first examination. The subjects with asthma in 1988 and 1993 and those who declared asthma in 1993 had FEV1. 0 and FEV1/VC in 1988 significantly lower than, those without asthma.
The wheezy child - is it pneumonia? MulhoIland, K. CDR Programme, WHO, Geneva
The lung represents the main site of communication between the human body and environmental air. The various protective mechanisms in the lung of a young child must face a constant barrage of assaults from the environment. In developing countries viruses and smoke, mainly from biomass fuels used for cooking, constantly challenge children's lungs against the background of a respiratory tract which is usually colonized with potentially pathogenic bacteria. In this environment, bacterial pneumonia is common and wheezing occurs mainly in young infants in the context of, probably viral, acute respiratory infections, while true atopic asthma seems to be .relatively uncommon. In industrialized countries children's lungs are challenged by viruses, atmospheric pollution, particularly tobacco smoke, and various aller-
gens in the context of a relatively sterile respiratory tract. In contrast to developing countries, and in contrast to industrialized countries 100 years ago, bacterial pneumonia is rare, while asthma is increasingly common. The defence mechanisms in the lung evolved in the context of colonization with encapsulated bacteria. Over the past century in industrialized countries this colonization has become much less while young children have been exposed to a wide variety of 'new' antigens. Examination of this problem may help us understand how we can avoid a growing asthma problem in developing countries and perhaps how to reduce asthma levels in industrialized countries. It may also help us decide which wheezing children in developing countries need antibiotics.
Benefits of early use of inhaled corticosteroids (ICS) Woolcock, A.J. Institute of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown NSW, Australia
Traditionally there has been a great reluctance to use inhaled steroids in small children because of fears about the systemic effects, difficultly with administration and cost. However, there is evidence that children with persistent asthma who are treated with ICS soon after diagnosis have a better response than children who commence ICS 1-2 years after diagnosis. This is also well described for adults. Apart from cost, the main problem associated with using ICS is in deciding which children require them. In general terms, if the airways are not functioning normally between acute attacks, then ICS are indicated. In a sophisticated setting, and in children greater than 4 years, airway function can be assessed by measuring peak flow in the mornings and the frequency of wheezing attacks. In less sophisticated circumstances, clinical judgement is needed, based on frequency and severity of wheezing episodes. It is clear that steroids are the most effective way of controlling persistent asthma in all age groups and the inhaled route gives an opportunity to use doses which are without side-effects in the long term. ICS can be used intermittently, but protocols to determine dose and frequency are still being assessed. Issues of cost and delivery methods for infants can be overcome once the benefits of ICS are widely recognised.
The case against early steroid use Weinberg, E. Red Cross Children's Hospital, Cape Town, South Africa
Asthma is now regarded as an inflammatory disease especially in adults. As a result there has been a sustained campaign for the use of inhaled steroids in asthma. This has progressed to the stage where the early use of inhaled steroids in childhood asthma is being advised. The diagnosis of asthma is difficult in infancy. We