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Asthma mortality in Colombia

Candelaria Vergara, MD and Luis Caraballo, MD

Background: Asthma mortality rates have increased in several industrialized


countries during the past two decades. In Latin America, there have been reported
only a few national studies of asthma mortality.
Objective: To detennine asthma mortality mtes in Colombia frm 1979 to 1994.
Methods: Death certificates fram the National Administrative Statistical Department of Colombia were collected and analyzed.
Results: For the entire population we found increasing rates of asthma mortality
from 2.15 in 1979 to 3.3 in 1985 followed by a decrease to 1.6 in 1994. Overall, the
trend has been to decrease, with a variation coefficient of 1.09% by year. Ageadjusted rates of death from asthma, bnsed on the population distribution of 1973,
showed the same decreasing trend. Deaths from asthma were more frequent in
subjects older than 35 years as compared with those younger than 5 years of age or
the age group ranging from 5 to 34 years. For the latter, rates of death increased
from 0.32 in 1980 to 0.37 in 1988, and fell to 0.20 in 1991. From 1992 to 1994 rates
for 5 to 34 years of age were higher than previously, increasing to 0.9 in 1992 and
decreasing to 0.6 in 1994. There was no significant variation in death rates between
men and women. Sixty-two percent of deaths from asthma occurred at home, 31%
at hospitals, and 6.7% in other places. Most asthma deaths were in urban areas.
Conclusions: In contrast to that observed in industrialized countries, we found a
decreasing trend in asthma mortality in Colombia. Rates of death fram asthma,
however, are still high in this country.
Ann AlIergy Asthma lmmunol 1998;80:55-60.

INTRODUCTION
Asthma is a chronic and worldwide
disease affecting people of all ages. Its
mortality remained relatively stable for
the 100 years preceding the 1960s
when "epidemics of death" began in
New Zealand, Australia, and the UK,I,2
and were associated in time with the
introduction of high dose isoprenaline
(isopraterenol) spray.3 Another peak of
asthma deaths occurred in the late
1970s, again in New Zealand, and simultaneous with the widespread usage
of another beta-agonist, fenotero1.4.5
Since 1977, reports fram the UK, Denmark, France, Canada, West Germany,
and the United States have shown increases in asthma mortality.6.7In contrast, in Japan, although rates of death
from asthma were higher than those in
From the Institute of Immunological Research. The Univc:rsity of Cartagena. Cartagena,
Colombia.
Received for publication December 2, 1996.
Accepted for publication in revised form May
9.1997.

the United States, they decreased fram


1979 to 1988.8 Asthma mortality in
Mexico also
. displayed a trend to dec1ine between 1960 and 1988.9
In the state of Rio Grande do Sul
(Brazil), a falling an!1ualrate of 1.53%
was observed when all ages were considered jn a study from the early 1960s
to 1991.10 lnvestigators have offered
multiple reasons for the rise in asthma
mortality, inc1uding the change in the
International Classification of Diseases
(lC;D) from version 8 to 9 in which
asthma is defined more broadly,1l yet
longitudinal studies7 confirm that such
increases are not due solely to a statistical artifact caused by changes in ICD
coding. Additional variables such as
poverty and access, availability and
utilization of health care, as well as air
pollution, have also been considered,12-14When a decreasing trend in
asthma mortality is found, several explanations arise. For example, the decreasing trend of asthma mortality in
Israel from 1976 to 1980 was probably

due to the general improvement in


medical care in that country during
these years.15 Changes in prevalence
and the impraved treatment of the disease can also explain that trend.
The first step for evaluating risk factors for asthmn deaths is to find out the
rates and trends of mortality in different regions and countries. In Latin
America, some studies hav dealt with
asthma mortality9,16-t9and most of
them report higher rates than those
found in some developed countries.
The present study was done to establish the rates of mortality due to
asthma in Colombia from 1979 to
1994.
METHODS
The National Administrative Statistical
Department supplied compressed files
of aIl death certificates. We extracted
those that identified asthma as the underlying cause of death (assigned by
lCD 3-digit code 493 according to
ICD-9) in the 33 geographic departments of Colombia, frol11 1979 to
1994. After transferring data to Microsoft Excel, we grouped and tabulated deaths by age, sex, zone (urban or
rural), month, and place of death. National population estimates were obtained directly fram the published census of 1985 and projections done by
the National Administrative Statistical
Department for the remaining years.
The analysis of death rates included al1
deaths ffOmasthma reported each year;
therefore, the observed differences ar~
real. In order to identify temporal variations in death rates, we applied a linear model. This method provides a
measure of a coefficient of variation in
rates during the time period considered. Age-adjusted death rates were
calculated using the direct method in
order to detennir!e whether the age distribution of the general population influenced the results. To obtain this information, we investigated the rate that

55

VOLUME 80. JANUARY, 1998

RESULTS
Trend of Asthma Mortality in
Colombia
Asthma was the cause in 10,938 deaths
in the time period studied. Five hundred and nine occurred in 1979 with
successive increases until 942 were
reached in 1985. In 1986, 781 deaths
occurred, 806 in 1987. and 764 in
1988. Values vaned during the subsequent years uudl t 994. when 568
deaths were reported.
Death rates had a similar pttern. In
1979 the rate of death was 2.06 per
100,000 which rose to 3.15 in 1985
and decreased to 1.6 in 1994 (Fig 1).
When asthma death rates of aIl ages
were considered, a decreasing trend
with a variation coefficient of 1.09%
per year was observed. An average of
c::
'...
.:::,
!::
.::;

3,5 r--T--T

Distribution by Age and Sex


Deaths from asthma were more frequent among peple older than 35
yeara than those )'ounscr than S yean
of age and than the group between 5
and 34 years of age (FiS 2). The age
group older than 35 years aecounts for
72.9% of deaths, suggesting that this
group is driving the trend.
Overall, rates of death from asthma
in the group of 5 to 34 years showed no
great variations until 1992, when it increased to a value of 0.9 and Iater

'

T--T

3jH~ --J -JJ-

:::
~
'...

declined to 0.6 in 1994. Asthma mortatity in this group aecounts for 1t % of


total deaths. with a mean of 75.2
deaths per year. When the group was
divided into six 5-year subgroups, the
highest number of deaths (21.8%) occurred in the subgroup of 30 to 34
years. The percentage of deaths for the
other subgroups ranged between
13.5% and 16.8%. Although deaths
from asthma in this group were more
frequent among men, the difference
was not significant. Places of death
were the same as observed for all age
groups. An increase of the rates of
death frQmasthmn In 1992 to 1994 W\S
observed in this group, but the general
trend is not to increase. An inerease of
34.4% in the frequency of deaths from
asthma from 1979 to 1980 was observed. Although that increase occurred 1 year later, implementation of
the ICD-9 in 1979 could have infIuenced this increase. Unfortunately, we
could not obtain information about

deaths and standard deviation (SD)


were calculated to show that the peak
mortality rate observed in 1985 was
not in the range covered by the average :!: 2 SD. Age-adjusted rates of
death from asthma, based on the population distribution of 1973, were 2.75
in 1980, 2.78 in 1985, 2.30 in 1986,
and 1.2 in 1994. These figures show
the same decreasing trend as crude
rates.

would have preval1ed if the age-specific rates for each year had occurred
in a population with the same age distribution as that of Colombia in 1973.

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year
Figure 1. Asthma death rates per 100,000 genera] population

56

in Colombia,

]979 to ]994.

ANNALS

OF ALLERGY.

ASTHMA.

& IMMUNOLOGY

1000
'"
900

.!;!
"'"

::
.s

/ \

800
700

,/

13

.S

600

500

..
;

...

.:;

..,
'S

400

/ \

./'

'-

1/

'::::.:

1\

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'"

-------,

-- 1---

1/

'"

\\

100
O
m
~
m
~

--- /

......

300
200

"-

--

'--

/1
//

om
m

'"
m

'"
m

M
m

"m
m

'"
m

<D

~
m

'"

'"

m
m

'"

'"

'"

om
m

m
m

N
m
m

M
m
m
~

"
m
m
~

year
-+-

5-34years

-.- al!ages

..

Figure 2. Asthma dealhs in Colombia

deaths due lo asthma in 1978 and earlier to evaluate this possibility. Overall, rates of death from asthma were
similar in both sexes. We did not anaIyze death from aslhma by race or poverty because these data were not registered in the death certificates.
Places 01 Death
Asthma mortality at home was more
frequent (62.2%) than in hospitals
(31.0%); 3.4% of deaths occurred in
other places and in 3.3% the place of
death was not specified. Overall,
deaths at home were twice to three
times more frequent than those occurring at hospitals. Furtherrnore, deaths
at home dropped from 73.6% in 1979
to 44% in 1994, when a simultaneous
increase in deaths occurred in hospitals
(25.2% 1050.3%). In this lime periodo
certificates that did not register the

VOLUME 80, JANUARY. 1998

-->34 years
---*-< 5years

by age groups.

1919 10 1994.

place of death increased. This could


partially account for the decrease in
frequency of deaths reported 10 have
occurred at home.
Geographic Distribution
As!hma deaths were more frequent in
urban (77.3%) than in rural zones (Table 1). The higher rates of death from
asthma were found in the areas of Antioquia and Valle and in the cily of
Santa F de Bogot. These three geographic areas account for 41.6% of
asthroa mortalilY in the country. The
lowest values were found in the departments of Vichada. Vaups, Guaina,
and Amazonas.
Time 01 Year
Asthma morta1ity did not show a significant varialion by month in the period studied. Percentages of death from

aSlhma throughout Ihe year ranged


from 7.5% in January to 10.3% in
May. Deaths from asthma were more
frequenl in January in seven of the 16
years sludied (1981, 1984, 1986, 1987.
and 198910 1991).
DISCUSSION
Asthma mortality in Colombia is lower
than thal reported in other countrles
such as Cosla Rica. Argentina, Cuba,
Uruguay and Venezuela, where, according to a collaborative study supported by the Latin American Association of Allergy, Asthma and
Immunology,'O mean rates were 3.76,
3.38,4.09,5.63, and 3.1, respectively,
for the time period between the early
1980s and 1992. In Brazi1 death rates
due to asthma in the 1980s was
6/100,000 general population" and in

51

Table 1. Deaths from asthma by geographic

New Zealand rates ranged fram 5.0 in


1960 to 6.8 in 1985.21 In contrast,
asthma mortality rates in Colombia
were higher that those reported in
countries such as Canada, Sweden,
USA, West Germany, England, and
Wales between 1970 and 1985.1 According to the Latin American collaborative study,20 Chile also showed a
lower mortality rate fram asthma than
that found in Colombia, with a mean of
1.80 from 1980 to 1990. Rates of death
fram asthma, similar to those we found
in this study, have been described in
Rio Grande do Sul (Brazil) and Philadelphia, USA.IO.'2
The origins of the above disparities
in the rates of death fram asthma are
not clear; some studies have shown
inaccuracies in the certification of
cause of death. particulaily in older
subjects,22but differences in the socioeconomic level and health conditions
are more likely to explain them. Figure
3 shows changes of rates of death fram

distribution, 1979 to 1994


Rural

Urban

Non-specified

Year
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Total
ilsthma

No

No

No

372
482
530
519
601
595
708
578
603
606
452
480
448
462
526
498
8460

73.5
71.5
73.4
74.5
78.9
76.8
74.7
74.0
74.9
79.3
76.5
76.7
80.1
86.8
83.4
87.6
77.3

135
192
192
178
161
175
227
194
200
156
134
136
104
69
98
65
2416

26.5
28.5
26.6
25.5
21.1
25.6
23.9
24.9
24.8
20.4
22.6
21.7
18.6
12.9
15.5
11.4
22.1

O
O
O
O
O
5
7
9
3
2
5
10
7
1
6
5
60

0.0
0.0
0.0
0.0
0.0
0.6
0.7
1.2
0.3
0.3
0.8
1.6
1.3
0.2
0.9
0.8
0.5

in Colombia

and

three

other

countries.
Although in many countries an increase in asthma deaths has been re-

ported. mortality rates due to asthma in


Colombia showed a decreasing trend,
similar to that described in Mexlco and
Rio Grande do Sul. We also found a

....

..

---

BRAZIL

-fr-

USA

--New

Zealand

--Colombia

6
c::::,
c::::,
c::::,

c::;
c::::,
.....

ti
t::I

!S

!S
c:.

;:

...

o.
1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

year
Figure 3. Asthma mortalily

""

in the general population

of four countries during 196010

ANNALS

1994.10.21.31

OF ALLERGY.

ASTHMA.

& IMMUNOLOGY

.
descending trend when rates were estlmated in the ase sroup of 5 10 34
years, for whom eertifieation of
aSlhma as a cause of dealh can be more
reliable than in people older than 35

years."
Asthma mortality depends on the
global management of the disease.
During the last 10 years ehanges in
publie health policies lo improve Ihe
delivery of heallh eare have been made
in Colombia. This could be eausing the
deereasing trehd of asthma mortality,
but we do not have data from the evaluation of the health eare stratesies to
confirm its effeets on this particular
disease. Desilninl .tudies to anal)'ze
this and other eonditlons that can affeet
the mortalily from asthma in this eountry is neeessary.
For example, it seems that melered
dose inhaler beta-2-agonists are not
widely used in Colombia. mainly because of their priee. In eontrast, oral
corticosteroids,
especially
prednisolone, are eommonly used, even
wilhout medieal preseription. AIthough these two aspeets of aSlhma
treatmenl can inlluenee the Irend of
monality. Ihey are nol seienlifically
documented in Ihis eounlry.
In addilion. Ihe effeet of ehanges in
aslhma prevalenee in Colombia on our
results eannot be evalualed beeause
sludies of aSlhma prevalenee and ils
lrend al a national level are not available. Aeeording lo one investigalion
from a Caribbean city of Colombia.
asthma prevalenee in 1990 was higher
than in other Latin American cities,24
but several climale and racial differenees exisl within the eountry Ihal
make it diffieult to extrapolate these
data to other cities.
We found that Ihe higher rates of
deaths from asthma were in subjeets
older than 35 years of age. As mentioned earlier. it appears thal this age
group drives the trend, possibly affeeting the reliabilily of the dala. Age adjustment of deaths from aSlhma was
done to eorreet for faelors inllueneing
age distribulion of Ihe population, for
inslanee. aging, and the resuits also
showed a deereasing trend. So, it
seems thal the higher asthma mortality

VOLUME 80. JANUARY. 1998

rales in the group older than 35 years


result from the hiSh number of deaths
together with a low number of people
in that group, a eharaeteristic of the
population distribution in Colombia.
Several faetors have becn associated
with higher dealh rales in people older
than 35 years: the inereased possibility
of eonfusion when diagnosing asthma
as cause of dealh in Ihis age group due
lo the presenee of eoneomitant eardiorespiralory diseases; the higher risk of
loxicily when using beta 2-agonist administered by metered dose inhaler,"
and the laek of aeeess to medieal
eare.'. Unfortunately, wilh the data
avallable in Colombia we eannol anaIyze Ihe real effeet of these faetors on
our results.
Although some authors found differenees in sex distribution of asthma
mortality in Ihe US." in Ihis and other
studies""'" a remarkable differenee in
sex distribulion of deaths from asthma
was not observed. In Ihe USA. nearly
50% of deaths oceurred at hospilals or
emergeney rooms.'." This differs from
our findings and Ihose from New Zealand" and Latin American developing
eountries'" where most of Ihe deaths
from asthma oceurred al home. It is
nOlewonhy Ihat in Colombia. between
1979 ~nd 1994, deaths at home deereased signifieantly while deaths at
hospitals inereased; this shift eould reIleel an improvement in aeeess to
health eare, whieh can probably exert
some inlluenee on the overall trend of
a decreasing asthma mortalily rateoAs
deseribed in other reports,"" our study
shows Ihal mosl deaths from asthma
occur in urban areas. It has been suggesled that the effeet of air and indoor
pollution can aeeount for higher
asthma mortality".14.3";however, data
abouI air pollution in urban areas of
Colombia is not available.
In summary, our results show thal
aSlhma mortality in Colombia. a tropical and developing Latin American
eountry. is high bUI has a favorable
deseending trend. Tlte causes of this
Irend are not known and their analysis
is impeded by poor registering of
health data in this eountry. More epi-

demiologie sludies are being designed


to evaluale Ihis issue.
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Luis Carabal/o
Apartado Areo 445
Cartagena
Colombia

/'

60

ANNALS OF ALLERGY, ASTHMA. & IMMUNOL