Pinot de Moira Angela, Custovic Adnan
National Heart and Lung Institute, Imperial College London, London, United Kingdom.
World Allergy Organ J. 2024 Dec 3;17(12):101010. doi: 10.1016/j.waojou.2024.101010. eCollection 2024 Dec.
Asthma is a complex, heterogeneous condition, broadly characterized by chronic airway inflammation with variable expiratory airflow limitation, but with several subtypes underpinned by different (although likely overlapping) pathological mechanisms. It is one of the most common chronic diseases of childhood and represents a significant cost for healthcare systems and affected families. Evidence suggests that a disproportionate proportion of this burden falls on families from disadvantaged socioeconomic circumstances (SECs). In this review, we describe the extent to which growing up in disadvantaged SECs is associated with an increased risk of childhood asthma diagnosis and asthma outcomes, including how this differs geographically and across different asthma subtypes. We also discuss the complex and interdependent mediating pathways that may link disadvantaged SECs with childhood asthma and asthma-related outcomes. In high-income countries (HICs), there is a fairly consistent association between growing up in disadvantaged SECs and increased prevalence of childhood asthma. However, evidence suggests that this social patterning differs across different asthma subtypes, with asthma phenotypes associated with disadvantaged SECs being less likely to be associated with atopy and more likely to begin in infancy and persist into adolescence. Disadvantaged SECs are also associated with worse asthma outcomes, which may contribute to the persistence of symptoms among disadvantaged children. In low- and middle-income countries (LMICs), the patterns are more variable and data more limited, but there is some evidence that disadvantaged SECs and atopic asthma are similarly negatively associated. There are also clear disparities in asthma outcomes, with LMICs having disproportionately high asthma-related morbidity and mortality, despite having lower asthma prevalence. A lack of accessibility to essential medication and appropriate care no doubt contributes to these disparities. The pathways leading to social inequalities in asthma are complex and interdependent, and as yet not fully understood. There is a clear need for further research into the relative importance of potential mediating pathways, including how these vary across the life course and across asthma subtypes. A stronger understanding of these pathways will help identify the most effective policy entry points for intervention, ultimately reducing inequalities across the life course.
哮喘是一种复杂的异质性疾病，其主要特征为慢性气道炎症伴可变的呼气气流受限，但有几种亚型由不同（尽管可能重叠）的病理机制支撑。它是儿童期最常见的慢性病之一，给医疗保健系统和受影响家庭带来了巨大成本。有证据表明，这一负担中不成比例的部分落在了社会经济状况不利的家庭身上。在本综述中，我们描述了在社会经济状况不利的环境中成长与儿童哮喘诊断风险增加及哮喘结局之间的关联程度，包括这种关联在地理上以及不同哮喘亚型之间的差异。我们还讨论了可能将社会经济状况不利与儿童哮喘及哮喘相关结局联系起来的复杂且相互依存的中介途径。在高收入国家，在社会经济状况不利的环境中成长与儿童哮喘患病率增加之间存在相当一致的关联。然而，有证据表明这种社会模式在不同哮喘亚型中存在差异，与社会经济状况不利相关的哮喘表型与特应性的关联可能性较小，且更有可能在婴儿期发病并持续到青春期。社会经济状况不利还与更差的哮喘结局相关，这可能导致弱势儿童症状持续存在。在低收入和中等收入国家，情况更具变化性且数据更有限，但有一些证据表明社会经济状况不利与特应性哮喘同样呈负相关。哮喘结局方面也存在明显差异，尽管低收入和中等收入国家的哮喘患病率较低，但与哮喘相关的发病率和死亡率却高得不成比例。无法获得基本药物和适当护理无疑是造成这些差异的原因之一。导致哮喘社会不平等的途径复杂且相互依存，目前尚未完全了解。显然需要进一步研究潜在中介途径的相对重要性，包括这些途径在生命历程和不同哮喘亚型中的变化情况。对这些途径有更深入的了解将有助于确定最有效的政策干预切入点，最终减少生命历程中的不平等现象。
