Monday, August 7, 2017

1960s: Spike in asthma death rate earns worldwide attention

A gradual rise in asthma deaths began during the 1940, although it gained little attention from the medical community, let along the general public.  However, a rising tide of asthma deaths in the 1960s not only gained the attention of the medical community, it resulted in an increase in research and studies into our disease.  This would have a significant impact on the millions of asthmatics around the world, and for the better.

The asthma death started to rise sharply in 1961.  Then, according to Beasly, Pearce and Crane:
In the mid-1960s, asthma mortality increased dramatically in at least six Western countries: England and Wales, Scotland, Ireland, New Zealand, Australia, and Norway.  In these countries, the mortality rates increased 2-10 fold within a 2-5 year period.  Other countries such as the United States, Denmark, Canada, and Germany did not experience epidemics, although in some countries such as Japan, significant increases in asthma mortality were noted within more narrowly defined age groups. (1, page 15)
It was the goal of researchers to discover the likely cause.  A variety of theories were postulated and investigated by the experts.

A.  Accuracy of physicians certifying the cause of death:  This was investigated and pretty much ruled out as a probable cause (7, page 337

B.   Changes in the way asthma was diagnosed:  While it was determined that asthma might be misdiagnosed or under diagnosed, this was ultimately ruled out as a likely cause in an increase in asthma fatalities (7, page 335)

C.  Increase in the number of cases of asthma:  This was actually considered as a likely cause noted by Speizer, Doll and Heaf in 1968.  They said, "In the absence of evidence t the contrary, it would seem that an increase in the case fatality rateis the most likely explanation of the increased mortality rate, and we have accepted this as a working hypothesis." ( 7, page 338),

D.  Environmental factors:  As noted by Speizer, Doll and Heaf in 1968:
"Certainly the increase could not be due to smoke pollution, which has decreased in English towns over the last decade, nor could it be attributed to pollution with sulphur gases, which has remained approximately constant (Ministry of Techology, 1967).  Motor traffic has increased considerably, and one of the constituents of motor fumes could perhaps have had a harmful effect.  If this were the case, however, a substantial difference in mortality would be expected between urban and rural areas, and we have failed to find any evidence of this in the national mortality data for 1966.  The death rate as 2.0 per 100,000 persons aged 5 to 34 in conurbations, 3.0 in urban areas of more than 100000 population, 2.2 in urban areas under 50,000 population, and 1.9 in rural districts. (7, page 338)
Similarly, Lawrence K. Altman said:
We often yearn for the "good old days." For instance, it is often said that there is more pollution today than before, but that statement i snot necessarily correct. Think back to those earlier eras.  Think of the stench from humans who found it dificult to keep clean when bathtubs were scarce. Imagine what it was like when horse manure constantly filled the streets.  It is said that in the 1920s asthma from horses was a common affliction. Dr. Sheffer told me about how a horse trotting along the street could trigger an asthma attack inDr. Robert Cook of Roosevelt Hospital in New York City.
Think also of the dust in the environment and pollution from wood-burning and coal-burning stoves.  Recall the inversions that caused so much sickness and death in Pennsylvania and London, England, a few decades ago. 
Many ofthe offending environmental hazards have been removed. Public health campaigns and legislation have reduced the amount of tobacco smoke and dangerous chemicals in the air.  Those changes have created a widespread impression that we live at a time when we breathe cleaner air (8, pages 5-6)
So, needless to say, environmental causes were ruled out as a factor. This is not to say that environmental factors are not likely factors in asthma morbidity in mortality.  It merely rules these out as likely culprits or the spike in morbidity and mortality during the 1940s and 1960s.

E.   Aging population:  This was not considered an adequate reason because a majority of the data collected by the experts is generally collected for asthmatics between the ages of 5 and 35 years of age, or some similar range.  The reason for this is because the older a person gets the greater the chance asthma will be complicated, or confused with, other medical conditions people normally get as they get older.  Asthma under the age of 5 is difficult to diagnose.  (1, page 13)

F.  Improved ability to recognize and diagnose asthma: This may result in an increase in the number of people diagnosed, but it would not explain the increase in morbidity and mortality.   (1, page 18)

G.  Change in mode of treatment.  There were actually two new modes of treatment on the market during the 1960.  They were:
  1. Systemic Corticosteroids
  2. Metered Dose Inhaler (MDI).  This was often referred to as pressurized aerosol (asthma rescue inhaler)
Systemic corticosteroids were never ruled out as a culprit.  However, Speizer, Doll and Heaf note the following: 
Corticosteroids were introduced into the management of the disease in 1952, but the increase in mortality did not begin until nine years later.  This discrepancy, however, is not sufficient to exculpate them entirely.  The frequent and prolonged use of corticosteroids spread slowly, and the risk of harmful effects may be at a maximum only after patients have been under treatment for several years.  
If patients were on a high dose of steroids and the patient suddenly stopped taking the medicine, this would result in adrenal gland suppression, which may result in death.

The asthma rescue inhaler was introduced between 1957 and 1960:  According to Speizer, Doll and Heaf:
These were introduced in England and Wales in 1960 and began to gain wide acceptance in 1961; and in the next five years their consumption is estimated to have increased more than fourfold (Ministry of Health, unpublished data).  The closeness of the correlation justifies inquiry into the possible harmful effect of the preparations, but a temporal correlatoin of this sort, taken by itself, is a poor basis for drawing conclusions about cause and effect." (7, page 335)
Ultimately, while there were many likely causes for the spike in asthma deaths during the 1940s and 1960s, the finger was pointing at beta adrenergic medicine as the likely culprit.  Whether this was the actual cause was never fully determined.

References.
  1. Beasley, Charles Richard William Beasley, Neil Edward Pearce, Julian Crane, authors of chapter two in the book "Fatal Asthma" edited by Albert L. Sheffer, 1998, New York, Hong Kong, Marcel Dekker, Inc. Chapter two is titled "Worldwide trends in asthma mortality during the twentieth century."
  2. Woolcock, Ann Janet, author of chapter 14 of the book, "Fatal Asthma," edited by Albert L. Sheffer, 1998, New York and Hong Kong, Marcel Dekker, Inc. Chapter 14 is titled "Natural Histor of Fatal Asthma."
  3. Sears, Malcolm R., "author of chapter 29 in the book "Fatal Asthma," edited by Albert L. Sheffer, 1998, New York and Hong Kong, Marcel Dekker, Inc.  Chapter 29 is titled "Role of B-Agonists in Asthma Fatalities."
  4. Jackson, Mark, "Asthma: The Biography," 2009, New York, Oxford University Press
  5. Bisgaard, Hans, Chris O'Callaghan, Gerald S. Smaldone, editors, "Drug Delivery to the Lung," 2001, New York, Marcel Dekker, Inc
  6. Mittman, Gregg, "Breathing Space," 
  7. Speizer, F.E., R. Doll, P. Heaf, "Observations on Recent Increase in Mortality from Asthma," British Medical Journal, February 10, 1968, 1, pages 335-339
  8. Altman, Lawrence K., "The Public Perception of Asthma," Chapter one of the book "Fatal Asthma," edited by Albert L. Sheffer, New York, Marcel Dekker, Inc, pages 3 and 11
  9. Speizer, F.E., R. Doll, P. Heaf, and B. Strang, "Investigation into use of drugs preceding death from asthma," British Medical Journal, 1968, 1, 339-343Sheffer, Albert L, "Partner Asthma Center's Grand Rounds," asthma.partners.org, http://www.asthma.partners.org/newfiles/ShefferFatalAsthma.html, accessed 10/5/13
  10. Bendy, Christine J., E.L-Fellah, R. Schneider, "Tolerance to sympathomimetic bronchodilators in guinea-pig isolated lungs following chronic administration in vivo," 1975, British Journal of Pharmacology, 55, pages 547-554
  11. Yarbrough, J.,  L.E. Lansfield, and S. Ting, "Metered dose inhaler induced bronchospasm in asthma patients," , Annals of Allergy, Asthma and Immunology," July, 1985, (55)1, pages 25-27
  12. Grant, Evalyn N., Kevin B. Weiss, "Socioeconomic risk factors for asthma mortality," chapter 17 of the book, Fatal Asthma," edited by Albert L. Sheffer, 1998, New York, Hong Kong, Marcel Dekker, Inc.

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