Presented at Nestle standing alone: "RTD Allergy Prevention", Surabaya 15 Jube 2013

1. Allergic diseases:
epidemiology, cost of diseases
and quality of life.
Prof DR Dr Ariyanto Harsono SpA(K) 1

2. Introduction
• Epidemiological studies indicate a world-wide
and significant increase in atopic diseases over
the past decades, which has adopted alarming
dimensions within the industrialized world.
However, allergic asthma and pollinosis, in
particular, are on the increase in Third world
countries, in parallel to the industrialization and
westernization of their life-style. Since both
antigen exposure and the presence of additional
realization factors are required for the
manifestation of atopic diseases, this increase in
prevalence is not surprising.
2Prof DR Dr Ariyanto Harsono SpA(K)

3. In addition to increased indoor and outdoor
pollution, changes in the way of living--causing
increased allergen exposure--certainly play an
important role as cofactor in the increased incidence of
allergies. Accurate diagnostic procedures permit a
better understanding of the realization factors for
allergic diseases in epidemiological studies and
identification of the causative agent in the individual so
that effective therapeutic and prophylactic steps can be
taken.
Introduction…….
3Prof DR Dr Ariyanto Harsono SpA(K)

4. GENETIC
FACTOR
•ALLERGEN
•INFECTION
• POLUTANT
ENVIRONMENT
FACTOR
ALLERGIC DISEASES
Gern JE, Lemanske Jr RF. Immunol Allergy North Amer 1999; 19:233-52
4Prof DR Dr Ariyanto Harsono SpA(K)

5. Introduction…….
• Epidemiological information from Switzerland and
Japan shows that the prevalence of atopy is increasing
in children. In both these studies the increase in the
prevalence of atopy was due to an increase in
sensitisation to a variety of allergens and not
dominated by an increase in sensitisation to one
particular allergen. In Britain no evidence exists that
exposure to allergen has increased—in fact grass
pollen levels have steadily decreased over the past 20
years and pet ownership has probably not changed.
5Prof DR Dr Ariyanto Harsono SpA(K)

6. Epidemiology
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8. 8

9. 9Prof DR Dr Ariyanto Harsono SpA(K)

10. 10Prof DR Dr Ariyanto Harsono SpA(K)

11. 11Prof DR Dr Ariyanto Harsono SpA(K)

12. Prof DR Dr Ariyanto Harsono SpA(K) 12
Annual changes in prevalence of asthma in ISAAC
phase I and phase III in Europe

13. Prof DR Dr Ariyanto Harsono SpA(K) 13
Annual changes in prevalence of allergic
rhinoconjunctivitis in ISAAC phase I and phase III in
Europe

14. Food Allergy
Prof DR Dr Ariyanto Harsono SpA(K) 14
 Affect 200-250 million
globally
 CDC: 1998-2000 to 2007-
2009, food allergy increased
from 3.5% to 4.6% cases
 Food hypersensitivity is the
most cases found in the early
years of life, affecting about
6% of <3 years of age and
decreasing over the first
decade

15. Asthma Morbidity@Mortality
Braman SS: Chest 2006;130;4S-12S
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Prof DR Dr Ariyanto Harsono SpA(K)

16. Prevalence of food allergy
Food Self report Skin prick test/IgE
specific/food challenge
Milk 3.5%
(95%CI,2.9%-4.1%)
0.6% to 0.9%
Egg 1.3%
(95% CI, 1.0%-1.6%)
0.3% to 0.9%
Peanuts 0.75%
(95%CI, 0.6%-0.9%)
0.75%
Fish 0.6%
(95% CI, 0.5% 0.7%)
0.2%
Shellfish 1.1%
(95% CI, 1.0%-1.2%)
0.6%
Chafen JJS, et al. JAMA. 2010;303(18):1848-56.
16Prof DR Dr Ariyanto Harsono SpA(K)

17. Atopic dermatitis
• Atopic dermatitis affects 5-20% of children at
ages 6-7 months and 13-14 years
• AD increased lifetime prevalence in Africa,
Eastern Asia, Western and Nothern part of
Europe
• Female : Male = 1.3 : 1
Williams H, et al. J Allergy Clin Immunol, January 1999
Deckers IAG, et al. Investigating International Time Trends in the Incidence and Prevalence of Atopic
Eczema 1990–2010: A Systematic Review of Epidemiological Studies
17Prof DR Dr Ariyanto Harsono SpA(K)

18. Urticaria & Angioedema
Angioedema:
• Angioedema frequently associated with
urticaria but 10% occurs alone
• Prevalence angioedema in chillhood was 2-
5%
Urticaria :
• Prevalence of urticaria in the first 3 years of
life was 3.2% & 1% at 5 years of age
Cantani A. Pediatric Allergy, Asthma & Immunology. Springerlink. Berlin.2008. 380
18Prof DR Dr Ariyanto Harsono SpA(K)

19. Prevalence of allergy in children (cross sectional)
6.9%
9.0%
4.9%
8.9%
14.2%
3.9%
13.9%
12.3%
24.6%
0%
5%
10%
15%
20%
25%
Jakarta Pusat (1990) ISAAC Jakarta Timur
(2001)
EAAEL Jakarta (2006)
Asma Rinitis alergi Dermatitis atopi
Asthma Allergic Rhinitis Atopic
Dermatitis
Munasir Z, et al
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Prof DR Dr Ariyanto Harsono SpA(K)

20. Asthma Fatality Rate
Chest 2006;130;4S-12S
20Prof DR Dr Ariyanto Harsono SpA(K)

21. Burden of Allergic Diseases
• The World Allergy Organization presented
data this week on the marked global increase
of allergic diseases, highlighting that allergies
are becoming more severe and complex and
that the heaviest burden is on children and
young adults. Allergy interacts with many
other environmental factors such as
pollutants, infections, lifestyle, and diet that
increase the impact on chronic disease.
21Prof DR Dr Ariyanto Harsono SpA(K)

22. • WAO addressed the need for increased
disease awareness, improved patient care,
better healthcare delivery and a focus on
preventative strategies during international
press conference.
22Prof DR Dr Ariyanto Harsono SpA(K)

23. …burden of allergic disease
Economic burden:
• Drug prescription
• Consultation to
physician
• Hospital admission
• Indirect costs
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24. …burden of allergic disease
Parental reports of the most bothersome nasal
allergy symptoms.
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25. Component of financial burden of allergic diseases
DIRECT COST INDIRECT COST
Physician office visits
Laboratory tests
Medication
Immunotherapy
Treatment of co-
morbidities
Absenteeism
Decreased productivity at
work/school
Sleeping disorders
Impaired quality of life for patients and parents/family
Pawankar R, et al. WAO White Book on Allergy 2011
25Prof DR Dr Ariyanto Harsono SpA(K)

26. Approximately 30 to 40 percent of the world’s
population suffers from allergic diseases, and the
prevalence is escalating to epidemic proportions.
According to the World Health Organization (WHO):
o An estimated 300 million individuals have asthma
worldwide, a figure that could increase to 400 million
by 2025 if trends continue.
o Allergic rhinitis, which is a risk factor for asthma,
affects 400 million people annually, and
o Food allergies affect about 200 to 250 million.
o An estimated 250,000 avoidable deaths from asthma
occur each year. Chest 2006;130;4S-12S
26Prof DR Dr Ariyanto Harsono SpA(K)

27. Asthma is a significant expense for society and
healthcare systems
As prevalence increases, so do costs.
 The total costs of asthma in the US are estimated to have increased
between the mid 1980s and the mid 1990s from approximately
US$4.5 billion to over US$10 billion.
 Weiss and colleagues estimated the total asthma costs for
Australia, the UK and the US (adjusted to 1991 US dollars for
comparison purposes) at US$457 million, US$1.79 billion and
US$6.40 billion, respectively.
 Updating these figures to 2003 dollars using the Consumer Price
Index (CPI) yields approximately US$617 million, US$2.42 billion and
US$8.64 billion, respectively.
 Total cost of asthma in the US in 1998 was estimated at US$12.67
billion (based on 1994 actual costs adjusted to 1998 dollars using
the CPI); the adjusted cost (using the CPI) projected to 2003 would
be US$13.34 billion. 27Prof DR Dr Ariyanto Harsono SpA(K)

28. Globally, the economic costs associated with asthma
exceed those of tuberculosis and HIV/AIDS combined.
Developed economies can expect to spend 1 to 2% of their health-care
budget on asthma.
 Investigations have shown22 that the financial burden on patients
with asthma in different Western countries ranges from $300 to
$1,300 per patient per year.
 In the United States, the total direct medical and indirect economic
costs (ie, loss of school or work days, lost productivity, premature
retirement) of asthma were approximately $12 billion in 1994,
representing an increase of 50% from just 10 years before, mainly
because of an increase in indirect economic costs.
 The indirect costs represent not just costs relating to the patient
but, if the patient is a child, also to their family; in England, 69% of
parents or partners of parents of asthmatic children reported
having to take time off work because of their child’s asthma, and
13% had lost their jobs.
28Prof DR Dr Ariyanto Harsono SpA(K)

29. Barriers to Reducing the Burden of
Asthma
 Poverty; inadequate resources
 Low public health priority
 Poor health-care infrastructure
 Difficulties in implementing guidelines developed in
wealthier countries
 Limited availability of and access to medication
 Lack of patient education
 Environmental factors
 Tobacco
 Pollution
 Occupational exposure
 Poor patient compliance
Chest 2006;130;4S-12S
29Prof DR Dr Ariyanto Harsono SpA(K)

30. As the prevalence of allergic disease rises in countries
around the world regardless of their economic status, so
do the socioeconomic costs both direct:
interference with breathing during day or night,
emergency department visits,
hospitalizations
and indirect
reduced quality of life,
reduced work productivity and
absenteeism.
30Prof DR Dr Ariyanto Harsono SpA(K)

31. WAO recommends
 (1) increased, availability and accessibility to allergy
diagnosis and therapies
 (2) increased resources dedicated to advanced research
toward preventive strategies to increase tolerance to
allergens and slow disease progression and
 (3) global partnerships of multi-disciplinary teams, involving
clinicians, academia, patient representatives, and industry.
The common goal is to reduce the burden of allergic diseases
and develop cost-effective, innovative preventive strategies
and a more integrated, holistic approach to treatment.
These efforts can thereby prevent premature and
unwanted deaths and improve quality of life.
31Prof DR Dr Ariyanto Harsono SpA(K)

32. Health-Related Quality of Life
 An important predictor of low Health Related Quality of Life (HRQL)
was allergic disease (i.e. asthma, eczema, rhino conjunctivitis) in
addition to food hypersensitivity.
 The higher the number of allergic diseases, the lower the physical
HRQL for the child, the lower the parental HRQL and the more
disruption in family activities.
 Male gender predicted lower physical HRQL than female gender. If
the child had sibling(s) with food hypersensitivity this predicted
lower psychosocial HRQL for the child and lower parental HRQL.
 Food-induced gastro-intestinal symptoms predicted lower parental
HRQL
 food-induced breathing difficulties predicted higher psychosocial
HRQL for the child and enhanced HRQL with regards to the family's
ability to get along.
32Prof DR Dr Ariyanto Harsono SpA(K)

33. • The variance in the child's physical HRQL was to a
considerable extent explained by the presence of
allergic disease. However, food hypersensitivity
by itself was associated with deterioration of
child's psychosocial HRQL, regardless of
additional allergic disease. The results suggest
that it is rather the risk of food reactions and
measures to avoid them that are associated with
lower HRQL than the clinical reactivity induced by
food intake. Therefore, food hypersensitivity
must be considered to have a strong psychosocial
impact.
33Prof DR Dr Ariyanto Harsono SpA(K)

34. Asthma is a chronic disorder that can significantly
impact the quality of life of the affected patients and
their families. Uncontrolled or poorly controlled
asthma can:
• disturb sleep;
• increase fatigue and decrease energy;
• produce difficulty concentrating;
• restrict physical activity and exercise;
• cause absences from work and/or school; and
• reduce participation in normal daily activities
34Prof DR Dr Ariyanto Harsono SpA(K)

35. A total of 232 patients with allergic rhinitis, 40 with asthma, and
44 with both diseases were enrolled. The mean (SD) age was 32
(13) years and 65% were females.
HRQL was significantly lower in patients with
asthma, with or without rhinitis, than in those
with allergic rhinitis alone.
• Female sex,
• Older age,
• Increased BMI and
• Less educational status
were found to be the major determinants of
impaired quality of life in patients with allergic
rhinitis or asthma.
Internat. Arch. Allergy Immunol. (2003);130: pp. 2–9.
35Prof DR Dr Ariyanto Harsono SpA(K)

36. 36

37. Figure. Mean (SD) physical component summary (PCS) and mental
component summary (MCS) health related quality of life scores in the
3 study groups.
J Investig Allergol Clin Immunol 2008; Vol. 18(3): 168-173
Rinitis Alergika
asma
Asma+rinitis
PCS MCS
37

38. quality of life was significantly impaired in patients with
asthma with or without rhinitis than in those with allergic
rhinitis only. However the results of our study suggest that
the impairment in HRQOL seen in asthmatic patients may
be similar to or not greater than that experienced by the
patients with “one airway disease.” The major
determinants of impaired HRQOL are
 female sex,
 higher BMI, and
 older age as a reflection of the duration of the disease.
Further investigation with larger populations is needed in
order to determine the extent to which asthma and rhinitis
comorbidities are associated in HRQOL.
J Investig Allergol Clin Immunol 2008; Vol. 18(3): 168-173
38Prof DR Dr Ariyanto Harsono SpA(K)

39. Conclusions
• Prevalence of allergic diseases are
increasing
• Burden of the diseases includes symptom
burden, impaired quality of life and
productivity, co-
morbidities, complications, and disease
management (economic burden)
• Allergy prevention is highly needed
39Prof DR Dr Ariyanto Harsono SpA(K)

40. Thank You
40Prof DR Dr Ariyanto Harsono SpA(K)