Burden of Asthma in Europe from 1990 to 2021: A Sub-analysis of the Global Burden of Disease Study

Burden of Asthma in Europe from 1990 to 2021: A Sub-analysis of the Global Burden of Disease Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Burden of Asthma in Europe from 1990 to 2021: A Sub-analysis of the Global Burden of Disease Study Mohsen Farrokhpour, Fatemeh Momeni, Maryam Bakhtiari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6691765/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Asthma is a chronic respiratory condition affecting approximately 260 million people. Genetic, environmental, and socioeconomic factors influence the incidence, morbidity, and mortality rates due to asthma. While the global burden of asthma has been evaluated, the data on its burden in Europe is limited. This study investigates the asthma burden trend in Europe from 1990 to 2021. Methods: Data on incidence, prevalence, disability-adjusted life years (DALY), years of life lost (YLL), and mortality rates due to asthma in Europe between 1990 and 2021 were retrieved from the Global Burden of Disease (GBD) study. The data were analyzed using joinpoint regression using Python libraries. Results: The prevalence, incidence, YLL, DALY, and mortality decreased from 5568.25, 736.99, 217.17, 476.48, 9.46 per 100,000 population in 1990 to 3340.12, 516.70, 131.07, 264.62, 5.20 per 100,000 population in 2021. Western Europe had the highest asthma burden in 1990, but significantly narrowed the gap with Central Europe by 2021. Eastern Europe consistently maintained lower rates across all metrics. Eastern Europe experienced significant reductions in asthma mortality rates by 2021. Poland was the only country with an increase in asthma incidence rates. Conclusion: Asthma burden has significantly decreased across Europe, although disparities exist between countries. This downward trend could be attributed to improvements in environmental conditions and advancements in asthma treatment. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Asthma is a chronic respiratory disease characterized by hypersensitivity and inflammatory changes in small to medium-sized bronchioles. It typically presents in the first two decades of life with shortness of breath, cough, chest tightness, and wheezing[ 1 ]. Despite advancements in asthma treatment, it is still a significant global health concern as it is a potentially life-threatening condition that is associated with great morbidity and mortality. Furthermore, asthma imposes a great burden on the economy and healthcare system[ 2 – 5 ]. Asthma has become even more concerning since the COVID-19 pandemic. According to the most recent global epidemiologic studies, the number of people affected by this condition was 260 million in 2021[ 6 ]. Globally, the prevalence among children is estimated at 9.1%, adolescents at 11.0%, and adults at 6.6%[ 7 ]. The asthma incidence and mortality rates are influenced by multiple factors, including genetic predisposition, demographic variables, environmental exposures, socioeconomic status, and healthcare access[ 1 , 8 – 12 ]. Therefore, the prevalence of asthma significantly varies across regions and countries. Studies suggest that while asthma is more prevalent in people with higher socioeconomic backgrounds, the mortality rate is higher in the underprivileged population[ 8 , 9 ]. Another factor that plays an important role in prevalence and mortality rates is age. Although children are more commonly affected, the mortalities occur predominantly among the elderly[ 10 , 13 ]. In recent years, these risk factors have undergone notable shifts in Europe: the population is aging, lifestyles have changed, and COVID-19 emergence has had a great impact on public health. Moreover, European countries are different in terms of socioeconomic conditions and access to healthcare facilities, which leads to disparities in asthma burden. Hence, it's essential to explore how these changes have influenced asthma incidence and mortality trends in European countries. This study aims to investigate the temporal trends of asthma incidence and mortality, regional disparities, and disability-adjusted life years (DALY) in Europe from 1990 to 2021 using data from the Global Burden of Disease study. The findings of this study will hopefully lead to the development of more effective health strategies for the prevention and management of asthma. Methods The global burden of disease (GBD) study provides the most comprehensive data on the burden of diseases, risk factors, and injuries across the globe from 1990 to 2021[ 14 ]. The burden of diseases is estimated annually by measuring incidence, prevalence, years of life lost (YLL), years lived with disability (YLD), disability-adjusted life years (DALY), and deaths due to diseases. These data are collected through registration systems, census data, household surveys, disease registries, and published scientific literature. These raw data are then standardized and analyzed using sophisticated statistical modeling, namely Bayesian meta-regression models (DisMod-MR) and cause of death ensemble modeling (CODEm). The final estimates of the aforementioned metrics are then organized by country, region, age, sex, and year. GBD offers the socio-demographic Index (SDI) by which countries could be assessed and compared in terms of development level. All this information is available on the GBD website for researchers. In the present study, we retrieved data about incidence, prevalence, YLL, YLD, and DALY due to asthma in European countries from 1990 to 2021. We divided Europe into three regions: Eastern Europe, Central Europe, and Western Europe. We followed the asthma burden trends in these regions. Subsequently, we analyzed these trends in each country separately. Statistical Analysis The rates are reported per 100,000 population with a 95% uncertainty interval (UI), similar to the GBD study. We performed a detailed trend analysis using the joinpoint regression model. The study period timeline was divided into joinpoints and segments. The annual percentage change (APC) was calculated with a 95% confidence interval (CI) for each of the segments. The Grid Search Modeling Method was used to detect any trend deviations between joinpoints. The relationship between SDI and asthma was explored using LOESS regression. We used Python version 3.8, and its associated libraries, including NumPy, Pandas, Statsmodels, Matplotlib, and Folium for data preprocessing, data visualization, and statistical analysis. Results Overall asthma burden in Europe Eastern European countries showed a downward trend across all metrics. The age-standardized prevalence rates (ASPR) and age-standardized incidence rates (ASIR) dropped from 5415.99 [4626.85, 6287.36] and 736.30 [606.21, 913.90] in 1990 to 2622.05 [2124.97, 3234.01] and 460.11 [360.84, 601.68] in 2021. Similarly, age-standardized YLL rates (ASYR) and age-standardized DALY rates (ASDR) declined from 211.10 [134.00, 307.54] and 323.77 [247.10, 419.42] in 1990 to 104.02 [63.58, 156.95] and 116.52 [76.32, 169.50] in 2021. The age-standardized mortality rates (ASMR) also dropped from 4.09 [3.92, 4.20] to 0.46 [0.43, 0.50] over the study period. Overall, the average annual change percentage (AACP) for ASPR, ASIR, ASYR, ASDR, and ASMR were -2.32 [-2.37, -2.27], -1.52 [-1.54, -1.49], -2.26 [-2.31, -2.21], -3.23 [-3.33, -3.12], -6.72 [-7.38, -6.05] respectively. Central European countries experienced a decline in all asthma-related burden indicators. The ASPR and ASIR decreased from 7490.23 [6523.42, 8535.56] and 892.00 [758.55, 1067.59] in 1990 to 5642.95 [4722.71, 6691.58] and 898.73 [725.29, 1136.93] in 2021. Likewise, ASYR and ASDR declined from 289.66 [181.92, 425.17] and 389.92 [285.68, 526.68] in 1990 to 223.37 [140.43, 334.67] and 239.11 [156.47, 350.46] in 2021, respectively. ASMR experienced a downward trend with 4.77 [4.47, 5.18] in 1990, reaching 0.79 [0.72, 0.86] in 2021. These decreasing trends corresponded to AAPC of -0.88 [-0.94, -0.82], 0.03 [-0.06, 0.13], -0.81 [-0.86, -0.76], -1.57 [-1.68, -1.46], -5.67 [-6.19, -5.14] for ASPR, ASIR, ASYR, ASDR, and ASMR. Western European countries showed a similar pattern. ASPR and ASIR decreased from 9751.88 [8517.41, 11246.13] and 650.20 [552.53, 774.66] in 1990 to 5886.78 [4943.98, 6943.63] and 498.80 [404.70, 632.59] in 2021. There was a significant drop in ASYR and ASDR from 380.70 [243.28, 560.20] and 460.16 [323.02, 637.33] in 1990 to 498.80 [404.70, 632.59] and 231.84 [144.77, 342.97] in 2021. Likewise, ASMR showed a decrease from 3.16 [2.94, 3.36] to 0.67 [0.59, 0.71]. These decreasing trends resulted in the AAPC of -1.62 [-1.69, -1.55], -0.84 [-0.89, -0.79], -1.59 [-1.66, -1.52], -1.97 [-2.06, -1.89], and -4.89 [-5.25, -4.54] for ASPR, ASIR, ASYR, ASDR, and ASMR. Prevalence (ASPR) In 1990, the ASPR ranged from 16628.61 [14434.36, 19048.33] in the United Kingdom to 3469.35 [2899.92, 4148.80] in Slovakia. The United Kingdom, Portugal, and Sweden had the highest prevalence of asthma with 16628.61 [14434.36, 19048.33], 14563.01 [11431.60, 17765.14], and 13432.23 [11212.64, 15791.00] per 100,000 population, respectively. In contrast, Slovakia, Lithuania, and Montenegro had the lowest ASPR with a prevalence of 3469.35 [2899.92, 4148.80], 3664.53 [3149.98, 4314.64], and 3785.45 [3070.70, 4661.40] per 100,000 population. In 2021, the ASPR range was between 10029.77 [8450.19, 11747.37] in the United Kingdom and 2418.87 [1960.76, 2967.85] in the Russian Federation. The United Kingdom, Poland, and Portugal had the highest ASPR in 2021, with the prevalence of 10029.77 [8450.19, 11747.37], 9329.08 [7839.39, 11200.28], and 9465.39 [7816.92, 11402.82] per 100,000 population. The three countries with the lowest ASPR in 2021 were the Russian Federation, Ukraine, and Belarus, with ASPR of 5569.65 [4776.22, 6413.96], 4929.84 [4094.65, 5926.65], and 7415.20 [6312.37, 8648.35], respectively. The Russian Federation experienced the steepest decline in prevalence with AAPC of -2.67 [-2.73, -2.61]. Incidence (ASIR) For ASIR, the highest values in 1990 were found in Poland (ASIR = 1355.72 [1164.15, 1570.95]), the United Kingdom (ASIR = 1049.62 [864.14, 1276.74]), and Macedonia (ASIR = 1022.60 [877.01, 1217.23]). The ASIR ranged between 1355.72 [1164.15, 1570.95] in Poland and 405.66 [337.69, 495.31] in the Netherlands. In 2021, Poland (ASIR = 1467.91 [1163.39, 1879.79]), the United Kingdom (ASIR = 793.69 [643.07, 998.97]), and Macedonia (ASIR = 796.35 [663.83, 986.17]) still had the highest incidence rates. The ASIR range was between 1467.91 [1163.39, 1879.79] in Poland and 339.04 [280.69, 419.64] in the Netherlands. The most significant decline was observed in the Russian Federation (AAPC = -1.77 [-1.81, -1.73]). YLL (ASYR) In 1990, the United Kingdom (ASYR = 652.79 [423.81, 941.37]), Portugal (ASYR = 567.33 [346.53, 862.45]), and Sweden (ASYR = 523.75 [329.16, 765.10]) had the highest ASYR in Europe. The Czech Republic had the lowest YLL rates (ASYR = 141.50 [87.66, 207.80]) in Europe in 1990. In 2021, the highest ASYR values were observed in the United Kingdom (ASYR = 394.56 [249.32, 586.99]), Portugal (ASYR = 371.01 [230.30, 556.67]), and Poland (ASYR = 369.05 [235.51, 551.09]). The lowest ASYR was reported in the Russian Federation (ASYR = 95.88 [59.09, 145.43]) in 2021. The Russian Federation had the steepest decrease in YLD from asthma (AAPC = -2.60 [-2.66, -2.55]) DALY (ASDR) In terms of ASDR, the United Kingdom (ASDR = 736.19 [507.62, 1025.31]) had the highest rate among European countries, followed by Poland (ASDR = 653.24 [471.51, 883.71]) and Norway (ASDR = 614.77 [429.98, 836.92]), in 1990. The lowest ASDR was reported in Montenegro (ASDR = 161.22 [104.83, 240.00]) in 1990. In 2021, the highest ASDRs were reported in the United Kingdom (ASDR = 427.66 [282.71, 620.14]), Poland (ASDR = 384.91 [251.39, 567.25]), and Portugal (ASDR = 386.79 [246.16, 572.89]). The lowest DALY was observed in Hungary (ASDR = 140.13 [89.28, 205.88]). The Russian Federation demonstrated the most substantial reduction in DALY rates (AAPC = -3.70 [-3.89, -3.51]) Mortality (ASMR) In 1990, the mortality rates ranged between 8.08 [5.72, 12.44] in Cyprus to 0.22 [0.16, 0.30] in Monaco. The three countries with the highest mortality rates were Cyprus with 8.08 [5.72, 12.44] deaths, Macedonia with 7.95 [6.49, 10.82] deaths, and Serbia with 6.93 [5.03, 10.25]. In 2021, the ASMR range was between 2.35 [1.77, 3.38] in Macedonia and 0.15 [0.12, 0.20] in Monaco. Macedonia, with 2.35 [1.77, 3.38] deaths, Cyprus, with 2.03 [1.66, 2.45], and Serbia with 1.88 [1.53, 2.29] deaths, still had the highest mortality rates in Europe. Belarus, with an AAPC of -7.89 [-8.43, -7.35] experienced the most significant decrease in mortality. Discussion The findings of this study indicated that the burden of asthma showed a decreasing pattern over the past three decades across Europe. A similar trend has been observed globally since 1990 [ 7 ]. Overall, the ASPR, ASIR, ASYR, ASDR, and ASMR have declined dramatically, although there has been a considerable difference between European countries. The ASPR declined substantially across all European countries from 1990 to 2021. Western Europe had significantly higher asthma prevalence rates in 1990, approximately 30% higher than Central Europe and 80% higher than Eastern Europe. By 2021, the gap between Western and Central Europe had narrowed considerably, while Eastern Europe continued to have lower prevalence rates. Eastern Europe had the most dramatic reduction in prevalence, while Central Europe had the slowest decline. The United Kingdom, which had the highest prevalence in both 1990 (16628.61 [14434.36, 19048.33]) and 2021 (10029.77 [8450.19, 11747.37]), experienced a 39.7% reduction. Similarly, other high-burden countries in 1990, including Portugal (14563.01 to 9465.39 per 100,000) and Sweden (13432.23 to 7522.65 per 100,000) showed improvements in terms of prevalence. Central Europe had the highest incidence of new asthma cases in 1990, approximately 37% higher than Western Europe. It was the only region that showed a slight increase in incidence rates. In contrast, Western and Eastern Europe showed substantial reductions in terms of incidence. Poland maintained its position as the country with the highest asthma incidence rate between 1990 and 2021. It's the only country that experienced an increase in the incidence of asthma (from 1355.72 to 1467.91 per 100,000 population). This positive AAPC (0.28%) for Poland was in contrast with the negative incidence trends in other European countries. The United Kingdom and Macedonia remained in the top three countries for asthma incidence in both 1990 and 2021, though their incidence rates dropped substantially. Western Europe had a substantially higher disability burden from asthma in 1990, approximately 31% and 80% higher than Central Europe and Eastern Europe, respectively. However, the difference in asthma YLL between Western and Central Europe diminished by 2021. Eastern Europe had a significantly lower burden in 2021. The United Kingdom and Portugal had the highest ASYR in both 1990 and 2021, despite a substantial decrease in rates. Western Europe had the highest ASDR in 1990, approximately 18% higher than Central Europe and 42% higher than Eastern Europe. By 2021, Western and Central Europe had similar mortality rates, while Eastern Europe had a mortality rate of less than half of the other regions. Eastern Europe showed the most significant improvement in mortality rates. Countries that had the highest ASDR (the United Kingdom and Poland) remained the same in 1990 and 2021, although the absolute values of ASDR had decreased. There was a dramatic reduction in asthma mortality rates between 1990 and 2021, with Eastern Europe showing the greatest improvement. Even countries with the highest mortality rates in 2021 had lower mortality rates compared to those in 1990. Macedonia, Cyprus, and Serbia had the highest mortality rates in both 1990 and 2021; however, there have been significant improvements. All three regions showed marked improvements, particularly in mortality rates. This could be due to advancements in asthma medications, management protocols, and improved emergency care for asthma exacerbations. While Western Europe had higher prevalence and burden rates in 1990, it had largely caught up to Central Europe by 2021. Eastern Europe, particularly the Russian Federation, showed the steepest decline across all metrics from 1990 to 2021, suggesting effective prevention, management, and treatment strategies in this region. The disparities between countries in the asthma burden trend could be attributed to socioeconomic differences, genetic predispositions, and healthcare facilities. The results suggested that countries with higher SDI experienced the most substantial decrease in asthma burden. Here, we briefly discuss the factors that have contributed to asthma burden reduction and their differences between countries. The association between exposure to environmental pollutants, particularly nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter (PM), and asthma burden has been thoroughly investigated. Multiple studies suggested that long-term exposure to these air pollutants has a strong association with increased asthma incidence, exacerbation attacks, and mortality rates[ 15 – 19 ]. Some studies have revealed that even prenatal exposure to these pollutants is associated with increased childhood asthma incidence rates[ 20 , 21 ]. Implementation of clean air policies in some countries has led to a significant decline in asthma development and exacerbations[ 22 ]. A study in 2023 indicated that the concentration of these pollutants in Europe and North America has decreased over the past three decades[ 23 ]. This could partly explain the downward trend of asthma incidence and mortality rates in European countries. Tobacco smoking is another risk factor for asthma development and exacerbation attacks. Tobacco smoking and exposure to secondhand smoke have been shown to increase asthma development, attacks, and mortality rates. Anti-smoking initiatives and legislations like cigarette tax increases have led to a significant decrease in tobacco consumption. Studies have reported that the overall prevalence of tobacco smoking has declined in Europe and North America after the introduction of tobacco control policies[ 24 – 26 ]. One study showed that smoking initiation rates have dropped during late adolescence in most European countries, while they increased during early adolescence[ 27 ]. Smoking cessation rates have improved, especially in Northern Europe. Data from 17 European countries between 1980 and 2010 showed that cessation rates among individuals under 40 years old increased across all regions, with Northern Europe exhibiting the highest rates[ 28 , 29 ]. Despite improvements in tobacco consumption in Europe, considerable disparities are evident across European countries. A 2017 cross-sectional analysis reported current smoking rates ranging from 7.2% in Sweden to 36.6% in Greece. Additionally, the prevalence of ever smoking varied, with France at 57.4% and Ireland at 37.5%[ 30 ]. These overall improvements in smoking rates could have contributed to the asthma burden decrease across Europe. Disparities in smoking rates could explain the disparities in asthma burden between countries. The association between occupational pollutants and asthma development has been firmly established[ 31 , 32 ]. Enhancement of workplace safety has played a key role in reducing the asthma burden in Europe[ 33 ]. Numerous European countries have implemented national and regional asthma management programs with the aim of reducing asthma-related morbidity, mortality, and healthcare costs. These initiatives mainly focused on the early diagnosis, patient education, guideline-based treatment, and collaboration between primary care physicians and specialists. The Finnish National Asthma Program (1994–2004) is a pivotal example. This 10-year program was initiated to reduce the asthma burden in Finland. The results were remarkable. Between 1993 and 2003, the number of hospitalization days due to asthma dropped by 54%, going from 110,000 to 51,000 cases. Similarly, the number of working-age individuals with asthma receiving disability pensions decreased by 76%. During the same period, total healthcare costs due to asthma decreased slightly. Although these programs led to a significant decline in asthma burden, the rates of decline varied across countries[ 34 , 35 ]. Our increasing knowledge of asthma pathophysiology has led to the development of asthma medications, particularly inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and short-acting beta-agonists (SABA). Early asthma treatment with ICS has been proven to significantly reduce asthma morbidity and mortality[ 36 – 38 ]. Additionally, the development of monoclonal antibodies has revolutionized asthma management. Introduction of biologic monoclonal antibodies has extended the survival of asthmatic patients and reduced asthma exacerbations[ 39 , 40 ]. Moreover, monoclonal antibodies have reduced patients' reliance on oral glucocorticoids for managing severe asthma, which has helped further decrease asthma-related morbidity and mortality[ 41 ]. Patient education is another noteworthy contributor to improved patients' quality of life and decreased use of healthcare resources. Adopting a patient-centered approach has been highly recommended in asthma management guidelines. This self-management approach involves educating patients about asthma disease and its triggers, symptoms of asthma exacerbation, personalized action plans, and monitoring with peak expiratory flow. Studies have shown that asthma self-management has been associated with decreased hospital visits, exacerbation attacks, and healthcare costs[ 42 , 43 ]. Despite the progress made, obesity has become an increasing concern. High BMI has increased asthma-related DALY rates by 4.3% from 1990 to 2021. Therefore, structured and global initiatives to handle this issue are essential to reverse this trend[ 6 ]. Conclusion European countries have experienced a downward trend in prevalence, incidence, DALY, and mortality rate due to asthma. However, there have been significant disparities between countries, which could be explained by differences in socioeconomic index, genetic predispositions, and healthcare facilities across countries. Declarations Ethics approval and consent to participate Not applicable. This study used publicly available, de-identified data from the Global Burden of Disease (GBD) database, and did not involve human participants or the collection of any identifiable personal data. Availability of data and materials The data used in this study are publicly available through the Global Health Data Exchange (GHDx) website maintained by the Institute for Health Metrics and Evaluation (IHME). Competing interests The authors declare that they have no competing interests. Funding Sources This study was not supported by any sponsor or funder. References Dijk, F.N., et al., Genetics of onset of asthma. Curr Opin Allergy Clin Immunol, 2013. 13 (2): p. 193-202. Bhattacharya, A., G. Syamlal, and K.E. Dodd, Medical costs and incremental medical costs of asthma among workers in the United States. Am J Ind Med, 2024. 67 (9): p. 834-843. 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Kearns, N., et al., Inhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis. J Allergy Clin Immunol Pract, 2020. 8 (2): p. 605-617.e6. Charles, D., et al., Real-world efficacy of treatment with benralizumab, dupilumab, mepolizumab and reslizumab for severe asthma: A systematic review and meta-analysis. Clin Exp Allergy, 2022. 52 (5): p. 616-627. Agache, I., et al., Efficacy and safety of treatment with biologicals (benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab) for severe eosinophilic asthma. A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma. Allergy, 2020. 75 (5): p. 1023-1042. Chen, W., et al., Impact of biologics initiation on oral corticosteroid use in the International Severe Asthma Registry and the Optimum Patient Care Research Database: a pooled analysis of real-world data. J Allergy Clin Immunol Pract, 2025. Hodkinson, A., et al., Self-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis. Bmj, 2020. 370 : p. m2521. Pinnock, H., et al., Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Med, 2017. 15 (1): p. 64. Additional Declarations No competing interests reported. Supplementary Files supplementary.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 11 Jul, 2025 Reviewers agreed at journal 04 Jul, 2025 Reviewers invited by journal 24 Jun, 2025 Editor invited by journal 28 May, 2025 Editor assigned by journal 28 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 18 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6691765","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475802017,"identity":"131cbef2-afe9-4055-a3c3-a361f9c59fd0","order_by":0,"name":"Mohsen Farrokhpour","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACHhAhxyAhwXwAyJCQIVaLMVALWwJICw8pWngM4Fy8QLe99/CHjzsM8iVn93x+daPGgoeB/fDRDfi0mJ05lyY584yB5WyZs9usc44BHcaTlnYDr5YbOWbMvG1/DOQkcrcZ57ABtUjwmBHSYvz5b5sBUEvOM+Ocf8RpMZBmBGqRlshhfpzbRoyWM2fMJHuBWiRnpJkx5/ZJ8LAR9MvxHuMPP4FaJG4kP/6c861Ojp/98DG8WpABmwSYJFY5CDB/IEX1KBgFo2AUjBwAAJS7Q/3m8p9cAAAAAElFTkSuQmCC","orcid":"","institution":"Firoozgar Clinical Research Development Center, Department of Internal Medicine, School of medicine, Iran University of Medical Sciences, Tehran","correspondingAuthor":true,"prefix":"","firstName":"Mohsen","middleName":"","lastName":"Farrokhpour","suffix":""},{"id":475802018,"identity":"980a1ed7-84fc-49b0-afca-5c9a3dfb323d","order_by":1,"name":"Fatemeh Momeni","email":"","orcid":"","institution":"School of Medicine, Tehran University of Medical Sciences, 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image in the Result section.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6691765/v1/ecceeb49fa07a9906b8ab13b.png"},{"id":85495079,"identity":"a2124669-5fe9-4675-ad3a-512bd2c84d54","added_by":"auto","created_at":"2025-06-26 13:39:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":173470,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Result section.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6691765/v1/12e3496c6bb67a96c420296f.png"},{"id":85495081,"identity":"e8272524-ceb5-4eb6-9fe2-21e431116618","added_by":"auto","created_at":"2025-06-26 13:39:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":179350,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Result 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13:55:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1846054,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6691765/v1/cd2b0d84-0f69-4db8-92f2-3a70d16d6d34.pdf"},{"id":85495094,"identity":"9ef54527-5c89-465b-a46b-33c8077cfaee","added_by":"auto","created_at":"2025-06-26 13:39:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":7916407,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-6691765/v1/cb40357dcb9c0f9ffc1a4888.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Burden of Asthma in Europe from 1990 to 2021: A Sub-analysis of the Global Burden of Disease Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAsthma is a chronic respiratory disease characterized by hypersensitivity and inflammatory changes in small to medium-sized bronchioles. It typically presents in the first two decades of life with shortness of breath, cough, chest tightness, and wheezing[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite advancements in asthma treatment, it is still a significant global health concern as it is a potentially life-threatening condition that is associated with great morbidity and mortality. Furthermore, asthma imposes a great burden on the economy and healthcare system[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Asthma has become even more concerning since the COVID-19 pandemic. According to the most recent global epidemiologic studies, the number of people affected by this condition was 260\u0026nbsp;million in 2021[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Globally, the prevalence among children is estimated at 9.1%, adolescents at 11.0%, and adults at 6.6%[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe asthma incidence and mortality rates are influenced by multiple factors, including genetic predisposition, demographic variables, environmental exposures, socioeconomic status, and healthcare access[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the prevalence of asthma significantly varies across regions and countries. Studies suggest that while asthma is more prevalent in people with higher socioeconomic backgrounds, the mortality rate is higher in the underprivileged population[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another factor that plays an important role in prevalence and mortality rates is age. Although children are more commonly affected, the mortalities occur predominantly among the elderly[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In recent years, these risk factors have undergone notable shifts in Europe: the population is aging, lifestyles have changed, and COVID-19 emergence has had a great impact on public health. Moreover, European countries are different in terms of socioeconomic conditions and access to healthcare facilities, which leads to disparities in asthma burden. Hence, it's essential to explore how these changes have influenced asthma incidence and mortality trends in European countries.\u003c/p\u003e \u003cp\u003eThis study aims to investigate the temporal trends of asthma incidence and mortality, regional disparities, and disability-adjusted life years (DALY) in Europe from 1990 to 2021 using data from the Global Burden of Disease study. The findings of this study will hopefully lead to the development of more effective health strategies for the prevention and management of asthma.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe global burden of disease (GBD) study provides the most comprehensive data on the burden of diseases, risk factors, and injuries across the globe from 1990 to 2021[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The burden of diseases is estimated annually by measuring incidence, prevalence, years of life lost (YLL), years lived with disability (YLD), disability-adjusted life years (DALY), and deaths due to diseases. These data are collected through registration systems, census data, household surveys, disease registries, and published scientific literature. These raw data are then standardized and analyzed using sophisticated statistical modeling, namely Bayesian meta-regression models (DisMod-MR) and cause of death ensemble modeling (CODEm). The final estimates of the aforementioned metrics are then organized by country, region, age, sex, and year. GBD offers the socio-demographic Index (SDI) by which countries could be assessed and compared in terms of development level. All this information is available on the GBD website for researchers.\u003c/p\u003e \u003cp\u003eIn the present study, we retrieved data about incidence, prevalence, YLL, YLD, and DALY due to asthma in European countries from 1990 to 2021. We divided Europe into three regions: Eastern Europe, Central Europe, and Western Europe. We followed the asthma burden trends in these regions. Subsequently, we analyzed these trends in each country separately.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe rates are reported per 100,000 population with a 95% uncertainty interval (UI), similar to the GBD study. We performed a detailed trend analysis using the joinpoint regression model. The study period timeline was divided into joinpoints and segments. The annual percentage change (APC) was calculated with a 95% confidence interval (CI) for each of the segments. The Grid Search Modeling Method was used to detect any trend deviations between joinpoints. The relationship between SDI and asthma was explored using LOESS regression. We used Python version 3.8, and its associated libraries, including NumPy, Pandas, Statsmodels, Matplotlib, and Folium for data preprocessing, data visualization, and statistical analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eOverall asthma burden in Europe\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEastern European countries showed a downward trend across all metrics. The age-standardized prevalence rates (ASPR) and age-standardized incidence rates (ASIR) dropped from 5415.99 [4626.85, 6287.36] and 736.30 [606.21, 913.90] in 1990 to 2622.05 [2124.97, 3234.01] and 460.11 [360.84, 601.68] in 2021. Similarly, age-standardized YLL rates (ASYR) and age-standardized DALY rates (ASDR) declined from 211.10 [134.00, 307.54] and 323.77 [247.10, 419.42] in 1990 to 104.02 [63.58, 156.95] and 116.52 [76.32, 169.50] in 2021. The age-standardized mortality rates (ASMR) also dropped from 4.09 [3.92, 4.20] to 0.46 [0.43, 0.50] over the study period. Overall, the average annual change percentage (AACP) for ASPR, ASIR, ASYR, ASDR, and ASMR were -2.32 [-2.37, -2.27], -1.52 [-1.54, -1.49], -2.26 [-2.31, -2.21], -3.23 [-3.33, -3.12],\u0026nbsp;-6.72 [-7.38, -6.05] respectively.\u003c/p\u003e\n\u003cp\u003eCentral European countries experienced a decline in all asthma-related burden indicators. The ASPR and ASIR decreased from 7490.23 [6523.42, 8535.56] and 892.00 [758.55, 1067.59] in 1990 to 5642.95 [4722.71, 6691.58] and 898.73 [725.29, 1136.93] in 2021. Likewise, ASYR and ASDR declined from 289.66 [181.92, 425.17] and 389.92 [285.68, 526.68] in 1990 to 223.37 [140.43, 334.67] and 239.11 [156.47, 350.46] in 2021, respectively. ASMR experienced a downward trend with 4.77 [4.47, 5.18] in 1990, reaching 0.79 [0.72, 0.86] in 2021. These decreasing trends corresponded to AAPC of -0.88 [-0.94, -0.82], 0.03 [-0.06, 0.13], -0.81 [-0.86, -0.76], -1.57 [-1.68, -1.46], -5.67 [-6.19, -5.14] for ASPR, ASIR, ASYR, ASDR, and ASMR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWestern European countries showed a similar pattern. ASPR and ASIR decreased from 9751.88 [8517.41, 11246.13] and 650.20 [552.53, 774.66] in 1990 to 5886.78 [4943.98, 6943.63] and 498.80 [404.70, 632.59] in 2021. There was a significant drop in ASYR and ASDR from 380.70 [243.28, 560.20] and 460.16 [323.02, 637.33] in 1990 to 498.80 [404.70, 632.59] and 231.84 [144.77, 342.97] in 2021. Likewise, ASMR showed a decrease from 3.16 [2.94, 3.36] to 0.67 [0.59, 0.71]. These decreasing trends resulted in the AAPC of -1.62 [-1.69, -1.55], -0.84 [-0.89, -0.79], -1.59 [-1.66, -1.52], -1.97 [-2.06, -1.89], and -4.89 [-5.25, -4.54] for ASPR, ASIR, ASYR, ASDR, and ASMR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevalence (ASPR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 1990, the ASPR ranged from 16628.61 [14434.36, 19048.33] in the United Kingdom to 3469.35 [2899.92, 4148.80] in Slovakia. The United Kingdom, Portugal, and Sweden had the highest prevalence of asthma with 16628.61 [14434.36, 19048.33], 14563.01 [11431.60, 17765.14], and 13432.23 [11212.64, 15791.00] per 100,000 population, respectively. In contrast, Slovakia, Lithuania, and Montenegro had the lowest ASPR with a prevalence of 3469.35 [2899.92, 4148.80], 3664.53 [3149.98, 4314.64], and 3785.45 [3070.70, 4661.40] per 100,000 population.\u003c/p\u003e\n\u003cp\u003eIn 2021, the ASPR range was between 10029.77 [8450.19, 11747.37] in the United Kingdom and 2418.87 [1960.76, 2967.85] in the Russian Federation. The United Kingdom, Poland, and Portugal had the highest ASPR in 2021, with the prevalence of 10029.77 [8450.19, 11747.37], 9329.08 [7839.39, 11200.28], and 9465.39 [7816.92, 11402.82] per 100,000 population. The three countries with the lowest ASPR in 2021 were the Russian Federation, Ukraine, and Belarus, with ASPR of 5569.65 [4776.22, 6413.96], 4929.84 [4094.65, 5926.65], and 7415.20 [6312.37, 8648.35], respectively. The Russian Federation experienced the steepest decline in prevalence with AAPC of\u0026nbsp;-2.67 [-2.73, -2.61].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncidence (ASIR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor ASIR, the highest values in 1990 were found in Poland (ASIR =\u0026nbsp;1355.72 [1164.15, 1570.95]), the United Kingdom (ASIR = 1049.62 [864.14, 1276.74]), and Macedonia (ASIR = 1022.60 [877.01, 1217.23]). The ASIR ranged between 1355.72 [1164.15, 1570.95] in Poland and 405.66 [337.69, 495.31] in the Netherlands.\u003c/p\u003e\n\u003cp\u003eIn 2021, Poland (ASIR = 1467.91 [1163.39, 1879.79]), the United Kingdom (ASIR = 793.69 [643.07, 998.97]), and Macedonia (ASIR = 796.35 [663.83, 986.17]) still had the highest incidence rates. The ASIR range was between 1467.91 [1163.39, 1879.79] in Poland and 339.04 [280.69, 419.64] in the Netherlands.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most significant decline was observed in the Russian Federation (AAPC = -1.77 [-1.81, -1.73]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYLL (ASYR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 1990, the United Kingdom (ASYR = 652.79 [423.81, 941.37]), Portugal (ASYR = 567.33 [346.53, 862.45]), and Sweden (ASYR = 523.75 [329.16, 765.10]) had the highest ASYR in Europe. The Czech Republic had the lowest YLL rates (ASYR = 141.50 [87.66, 207.80]) in Europe in 1990.\u003c/p\u003e\n\u003cp\u003eIn 2021, the highest ASYR values were observed in the United Kingdom (ASYR = 394.56 [249.32, 586.99]), Portugal (ASYR = 371.01 [230.30, 556.67]), and Poland (ASYR = 369.05 [235.51, 551.09]). The lowest ASYR was reported in the Russian Federation (ASYR = 95.88 [59.09, 145.43]) in 2021.\u003c/p\u003e\n\u003cp\u003eThe Russian Federation had the steepest decrease in YLD from asthma (AAPC = -2.60 [-2.66, -2.55])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDALY (ASDR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn terms of ASDR, the United Kingdom (ASDR =\u0026nbsp;736.19 [507.62, 1025.31])\u0026nbsp;had the highest rate\u0026nbsp;among European countries, followed by Poland (ASDR = 653.24 [471.51, 883.71]) and Norway (ASDR = 614.77 [429.98, 836.92]), in 1990. The lowest ASDR was reported in Montenegro (ASDR = 161.22 [104.83, 240.00]) in 1990.\u003c/p\u003e\n\u003cp\u003eIn 2021, the highest ASDRs were reported in the United Kingdom (ASDR = 427.66 [282.71, 620.14]), Poland (ASDR = 384.91 [251.39, 567.25]), and Portugal (ASDR = 386.79 [246.16, 572.89]). The lowest DALY was observed in Hungary (ASDR = 140.13 [89.28, 205.88]).\u003c/p\u003e\n\u003cp\u003eThe Russian Federation demonstrated the most substantial reduction in DALY rates (AAPC = -3.70 [-3.89, -3.51])\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMortality (ASMR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 1990, the mortality rates ranged between\u0026nbsp;8.08 [5.72, 12.44]\u0026nbsp;in Cyprus to\u0026nbsp;0.22 [0.16, 0.30] in Monaco. The three countries with the highest mortality rates were\u0026nbsp;Cyprus with\u0026nbsp;8.08 [5.72, 12.44]\u0026nbsp;deaths, Macedonia with\u0026nbsp;7.95 [6.49, 10.82] deaths, and Serbia with\u0026nbsp;6.93 [5.03, 10.25].\u003c/p\u003e\n\u003cp\u003eIn 2021, the ASMR range was between 2.35 [1.77, 3.38] in Macedonia and 0.15 [0.12, 0.20] in Monaco. Macedonia, with 2.35 [1.77, 3.38] deaths, Cyprus, with 2.03 [1.66, 2.45], and Serbia with 1.88 [1.53, 2.29] deaths, still had the highest mortality rates in Europe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBelarus, with an AAPC of -7.89 [-8.43, -7.35] experienced the most significant decrease in mortality.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study indicated that the burden of asthma showed a decreasing pattern over the past three decades across Europe. A similar trend has been observed globally since 1990 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Overall, the ASPR, ASIR, ASYR, ASDR, and ASMR have declined dramatically, although there has been a considerable difference between European countries.\u003c/p\u003e \u003cp\u003eThe ASPR declined substantially across all European countries from 1990 to 2021. Western Europe had significantly higher asthma prevalence rates in 1990, approximately 30% higher than Central Europe and 80% higher than Eastern Europe. By 2021, the gap between Western and Central Europe had narrowed considerably, while Eastern Europe continued to have lower prevalence rates. Eastern Europe had the most dramatic reduction in prevalence, while Central Europe had the slowest decline. The United Kingdom, which had the highest prevalence in both 1990 (16628.61 [14434.36, 19048.33]) and 2021 (10029.77 [8450.19, 11747.37]), experienced a 39.7% reduction. Similarly, other high-burden countries in 1990, including Portugal (14563.01 to 9465.39 per 100,000) and Sweden (13432.23 to 7522.65 per 100,000) showed improvements in terms of prevalence.\u003c/p\u003e \u003cp\u003eCentral Europe had the highest incidence of new asthma cases in 1990, approximately 37% higher than Western Europe. It was the only region that showed a slight increase in incidence rates. In contrast, Western and Eastern Europe showed substantial reductions in terms of incidence. Poland maintained its position as the country with the highest asthma incidence rate between 1990 and 2021. It's the only country that experienced an increase in the incidence of asthma (from 1355.72 to 1467.91 per 100,000 population). This positive AAPC (0.28%) for Poland was in contrast with the negative incidence trends in other European countries. The United Kingdom and Macedonia remained in the top three countries for asthma incidence in both 1990 and 2021, though their incidence rates dropped substantially.\u003c/p\u003e \u003cp\u003eWestern Europe had a substantially higher disability burden from asthma in 1990, approximately 31% and 80% higher than Central Europe and Eastern Europe, respectively. However, the difference in asthma YLL between Western and Central Europe diminished by 2021. Eastern Europe had a significantly lower burden in 2021. The United Kingdom and Portugal had the highest ASYR in both 1990 and 2021, despite a substantial decrease in rates.\u003c/p\u003e \u003cp\u003eWestern Europe had the highest ASDR in 1990, approximately 18% higher than Central Europe and 42% higher than Eastern Europe. By 2021, Western and Central Europe had similar mortality rates, while Eastern Europe had a mortality rate of less than half of the other regions. Eastern Europe showed the most significant improvement in mortality rates. Countries that had the highest ASDR (the United Kingdom and Poland) remained the same in 1990 and 2021, although the absolute values of ASDR had decreased.\u003c/p\u003e \u003cp\u003eThere was a dramatic reduction in asthma mortality rates between 1990 and 2021, with Eastern Europe showing the greatest improvement. Even countries with the highest mortality rates in 2021 had lower mortality rates compared to those in 1990. Macedonia, Cyprus, and Serbia had the highest mortality rates in both 1990 and 2021; however, there have been significant improvements.\u003c/p\u003e \u003cp\u003eAll three regions showed marked improvements, particularly in mortality rates. This could be due to advancements in asthma medications, management protocols, and improved emergency care for asthma exacerbations. While Western Europe had higher prevalence and burden rates in 1990, it had largely caught up to Central Europe by 2021. Eastern Europe, particularly the Russian Federation, showed the steepest decline across all metrics from 1990 to 2021, suggesting effective prevention, management, and treatment strategies in this region.\u003c/p\u003e \u003cp\u003eThe disparities between countries in the asthma burden trend could be attributed to socioeconomic differences, genetic predispositions, and healthcare facilities. The results suggested that countries with higher SDI experienced the most substantial decrease in asthma burden. Here, we briefly discuss the factors that have contributed to asthma burden reduction and their differences between countries.\u003c/p\u003e \u003cp\u003eThe association between exposure to environmental pollutants, particularly nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and particulate matter (PM), and asthma burden has been thoroughly investigated. Multiple studies suggested that long-term exposure to these air pollutants has a strong association with increased asthma incidence, exacerbation attacks, and mortality rates[\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Some studies have revealed that even prenatal exposure to these pollutants is associated with increased childhood asthma incidence rates[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Implementation of clean air policies in some countries has led to a significant decline in asthma development and exacerbations[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A study in 2023 indicated that the concentration of these pollutants in Europe and North America has decreased over the past three decades[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This could partly explain the downward trend of asthma incidence and mortality rates in European countries.\u003c/p\u003e \u003cp\u003eTobacco smoking is another risk factor for asthma development and exacerbation attacks. Tobacco smoking and exposure to secondhand smoke have been shown to increase asthma development, attacks, and mortality rates. Anti-smoking initiatives and legislations like cigarette tax increases have led to a significant decrease in tobacco consumption. Studies have reported that the overall prevalence of tobacco smoking has declined in Europe and North America after the introduction of tobacco control policies[\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. One study showed that smoking initiation rates have dropped during late adolescence in most European countries, while they increased during early adolescence[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Smoking cessation rates have improved, especially in Northern Europe. Data from 17 European countries between 1980 and 2010 showed that cessation rates among individuals under 40 years old increased across all regions, with Northern Europe exhibiting the highest rates[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Despite improvements in tobacco consumption in Europe, considerable disparities are evident across European countries. A 2017 cross-sectional analysis reported current smoking rates ranging from 7.2% in Sweden to 36.6% in Greece. Additionally, the prevalence of ever smoking varied, with France at 57.4% and Ireland at 37.5%[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These overall improvements in smoking rates could have contributed to the asthma burden decrease across Europe. Disparities in smoking rates could explain the disparities in asthma burden between countries.\u003c/p\u003e \u003cp\u003eThe association between occupational pollutants and asthma development has been firmly established[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Enhancement of workplace safety has played a key role in reducing the asthma burden in Europe[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNumerous European countries have implemented national and regional asthma management programs with the aim of reducing asthma-related morbidity, mortality, and healthcare costs. These initiatives mainly focused on the early diagnosis, patient education, guideline-based treatment, and collaboration between primary care physicians and specialists. The Finnish National Asthma Program (1994\u0026ndash;2004) is a pivotal example. This 10-year program was initiated to reduce the asthma burden in Finland. The results were remarkable. Between 1993 and 2003, the number of hospitalization days due to asthma dropped by 54%, going from 110,000 to 51,000 cases. Similarly, the number of working-age individuals with asthma receiving disability pensions decreased by 76%. During the same period, total healthcare costs due to asthma decreased slightly. Although these programs led to a significant decline in asthma burden, the rates of decline varied across countries[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur increasing knowledge of asthma pathophysiology has led to the development of asthma medications, particularly inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and short-acting beta-agonists (SABA). Early asthma treatment with ICS has been proven to significantly reduce asthma morbidity and mortality[\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Additionally, the development of monoclonal antibodies has revolutionized asthma management. Introduction of biologic monoclonal antibodies has extended the survival of asthmatic patients and reduced asthma exacerbations[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Moreover, monoclonal antibodies have reduced patients' reliance on oral glucocorticoids for managing severe asthma, which has helped further decrease asthma-related morbidity and mortality[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient education is another noteworthy contributor to improved patients' quality of life and decreased use of healthcare resources. Adopting a patient-centered approach has been highly recommended in asthma management guidelines. This self-management approach involves educating patients about asthma disease and its triggers, symptoms of asthma exacerbation, personalized action plans, and monitoring with peak expiratory flow. Studies have shown that asthma self-management has been associated with decreased hospital visits, exacerbation attacks, and healthcare costs[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the progress made, obesity has become an increasing concern. High BMI has increased asthma-related DALY rates by 4.3% from 1990 to 2021. Therefore, structured and global initiatives to handle this issue are essential to reverse this trend[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEuropean countries have experienced a downward trend in prevalence, incidence, DALY, and mortality rate due to asthma. However, there have been significant disparities between countries, which could be explained by differences in socioeconomic index, genetic predispositions, and healthcare facilities across countries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study used publicly available, de-identified data from the Global Burden of Disease (GBD) database, and did not involve human participants or the collection of any identifiable personal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are publicly available through the Global Health Data Exchange (GHDx) website maintained by the Institute for Health Metrics and Evaluation (IHME).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDijk, F.N., et al., \u003cem\u003eGenetics of onset of asthma.\u003c/em\u003e Curr Opin Allergy Clin Immunol, 2013. \u003cstrong\u003e13\u003c/strong\u003e(2): p. 193-202.\u003c/li\u003e\n\u003cli\u003eBhattacharya, A., G. 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Filippidis, \u003cem\u003eBurden of current and past smoking across 28 European countries in 2017: A cross-sectional analysis.\u003c/em\u003e Tob Induc Dis, 2022. \u003cstrong\u003e20\u003c/strong\u003e: p. 56.\u003c/li\u003e\n\u003cli\u003eWah, W., et al., \u003cem\u003eSystematic review of impacts of occupational exposure to wildfire smoke on respiratory function, symptoms, measures and diseases.\u003c/em\u003e Int J Hyg Environ Health, 2025. \u003cstrong\u003e263\u003c/strong\u003e: p. 114463.\u003c/li\u003e\n\u003cli\u003eZivadinovic, N., et al., \u003cem\u003eOccupational risk factors for asthma exacerbation in adults: a five-year follow-up of the Norwegian Telemark study cohort.\u003c/em\u003e J Asthma, 2025: p. 1-13.\u003c/li\u003e\n\u003cli\u003eHenneberger, P.K., et al., \u003cem\u003eThe effectiveness of removal from exposure and reduction of exposure for managing occupational asthma: Summary of an updated Cochrane systematic review.\u003c/em\u003e Am J Ind Med, 2021. \u003cstrong\u003e64\u003c/strong\u003e(3): p. 165-169.\u003c/li\u003e\n\u003cli\u003eSelroos, O., et al., \u003cem\u003eNational and regional asthma programmes in Europe.\u003c/em\u003e Eur Respir Rev, 2015. \u003cstrong\u003e24\u003c/strong\u003e(137): p. 474-83.\u003c/li\u003e\n\u003cli\u003eHaahtela, T., et al., \u003cem\u003eThe Finnish Allergy Program 2008-2018: Society-wide proactive program for change of management to mitigate allergy burden.\u003c/em\u003e J Allergy Clin Immunol, 2021. \u003cstrong\u003e148\u003c/strong\u003e(2): p. 319-326.e4.\u003c/li\u003e\n\u003cli\u003ePapi, A., et al., \u003cem\u003eAlbuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma.\u003c/em\u003e N Engl J Med, 2022. \u003cstrong\u003e386\u003c/strong\u003e(22): p. 2071-2083.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Byrne, P., et al., \u003cem\u003eAsthma progression and mortality: the role of inhaled corticosteroids.\u003c/em\u003e Eur Respir J, 2019. \u003cstrong\u003e54\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eKearns, N., et al., \u003cem\u003eInhaled Corticosteroids in Acute Asthma: A Systemic Review and Meta-Analysis.\u003c/em\u003e J Allergy Clin Immunol Pract, 2020. \u003cstrong\u003e8\u003c/strong\u003e(2): p. 605-617.e6.\u003c/li\u003e\n\u003cli\u003eCharles, D., et al., \u003cem\u003eReal-world efficacy of treatment with benralizumab, dupilumab, mepolizumab and reslizumab for severe asthma: A systematic review and meta-analysis.\u003c/em\u003e Clin Exp Allergy, 2022. \u003cstrong\u003e52\u003c/strong\u003e(5): p. 616-627.\u003c/li\u003e\n\u003cli\u003eAgache, I., et al., \u003cem\u003eEfficacy and safety of treatment with biologicals (benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab) for severe eosinophilic asthma. A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma.\u003c/em\u003e Allergy, 2020. \u003cstrong\u003e75\u003c/strong\u003e(5): p. 1023-1042.\u003c/li\u003e\n\u003cli\u003eChen, W., et al., \u003cem\u003eImpact of biologics initiation on oral corticosteroid use in the International Severe Asthma Registry and the Optimum Patient Care Research Database: a pooled analysis of real-world data.\u003c/em\u003e J Allergy Clin Immunol Pract, 2025.\u003c/li\u003e\n\u003cli\u003eHodkinson, A., et al., \u003cem\u003eSelf-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis.\u003c/em\u003e Bmj, 2020. \u003cstrong\u003e370\u003c/strong\u003e: p. m2521.\u003c/li\u003e\n\u003cli\u003ePinnock, H., et al., \u003cem\u003eSystematic meta-review of supported self-management for asthma: a healthcare perspective.\u003c/em\u003e BMC Med, 2017. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 64.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6691765/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6691765/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAsthma is a chronic respiratory condition affecting approximately 260 million people. Genetic, environmental, and socioeconomic factors influence the incidence, morbidity, and mortality rates due to asthma. While the global burden of asthma has been evaluated, the data on its burden in Europe is limited. This study investigates the asthma burden trend in Europe from 1990 to 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Data on incidence, prevalence, disability-adjusted life years (DALY), years of life lost (YLL), and mortality rates due to asthma in Europe between 1990 and 2021 were retrieved from the Global Burden of Disease (GBD) study. The data were analyzed using joinpoint regression using Python libraries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The prevalence, incidence, YLL, DALY, and mortality decreased from 5568.25, 736.99, 217.17, 476.48, 9.46 per 100,000 population in 1990 to 3340.12, 516.70, 131.07, 264.62, 5.20 per 100,000 population in 2021. Western Europe had the highest asthma burden in 1990, but significantly narrowed the gap with Central Europe by 2021. Eastern Europe consistently maintained lower rates across all metrics. Eastern Europe experienced significant reductions in asthma mortality rates by 2021. Poland was the only country with an increase in asthma incidence rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Asthma burden has significantly decreased across Europe, although disparities exist between countries. This downward trend could be attributed to improvements in environmental conditions and advancements in asthma treatment.\u003c/p\u003e","manuscriptTitle":"Burden of Asthma in Europe from 1990 to 2021: A Sub-analysis of the Global Burden of Disease Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-26 13:39:11","doi":"10.21203/rs.3.rs-6691765/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-11T13:56:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109775266191655600163773982059900159485","date":"2025-07-04T08:28:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T11:40:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-28T15:51:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-28T11:05:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T11:05:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-05-18T12:39:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73c9710d-d9f1-41dd-b5d7-680f89460c02","owner":[],"postedDate":"June 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-26T13:39:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-26 13:39:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6691765","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6691765","identity":"rs-6691765","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}