Electronic cigarette use and respiratory symptoms in the French population-based Constances cohort.

BACKGROUND: Knowledge about the consequences of electronic cigarette (EC) use on respiratory health is still limited. We aimed to assess whether EC use is associated with the occurrence of asthma symptoms and chronic bronchitis among the French adult population, with a specific focus on never combustible cigarettes (CC) smokers. We further investigated whether the association differed in men and women. METHODS: Constances is a population-based cohort of adults aged 18-69 years at inception. We analyzed baseline data collected in 136,276 participants recruited in 2015-2019. Associations of current and former EC use with respiratory symptoms (asthma symptom score and chronic bronchitis) were assessed, controlling for CC smoking, cannabis use, demographics, education and body mass index (BMI). RESULTS: Increased frequencies of respiratory symptoms were observed in both current and former EC users (for the asthma symptom score, adjusted mean score ratio (aMSR): 1.34 [95 % confidence interval: 1.28-1.41] and 1.39 [1.33-1.45], respectively; for chronic bronchitis, adjusted prevalence ratio (aPR): 1.27 [1.19-1.36] and 1.40 [1.32-1.48], respectively). Among never CC smokers, ever EC use was associated with an increased asthma symptom score in both men and women (aMSR = 1.44 [1.09-1.90] and 1.36 [1.01-1.83], respectively), and with a higher prevalence of chronic bronchitis only in women (aPR = 1.97 [1.27-3.05]). CONCLUSION: EC use is associated with symptoms of asthma and chronic bronchitis, independently of CC smoking and cannabis use. The fact that these associations are observed among individuals who have never smoked tobacco adds further evidence of the deleterious effects of EC on respiratory health.

Impact of asthma on working life: an analysis of the French CONSTANCES cohort.

OBJECTIVES: Asthma has significant occupational consequences. The objective of our study was to investigate the links between asthma and the career path, taking into account gender and age at asthma onset. METHODS: Using cross-sectional data collected at inclusion in the French CONSTANCES cohort in 2013-2014, we studied the links between each career path indicator (number of job periods, total duration of employment, numbers of part-time jobs and work interruptions due to unemployment or health issues, employment status at inclusion) on the one hand, and current asthma and asthma symptom score in the last 12 months on the other hand, as reported by the participants. Multivariate analyses were performed separately for men and women using logistic and negative binomial regression models adjusted for age, smoking status, body mass index and educational level. RESULTS: When the asthma symptom score was used, significant associations were observed with all of the career path indicators studied: a high symptom score was associated with a shorter total duration of employment as well as a greater number of job periods, part-time jobs and work interruptions due to unemployment or health issues. These associations were of similar magnitude in men and women. When current asthma was used, the associations were more pronounced in women for some career path indicators. CONCLUSION: The career path of asthmatic adults is more often unfavourable than that of those without asthma. Efforts should be made to support people with asthma in the workplace, in order to maintain employment and facilitate the return to work.

Effect of Interfacial Schemes on the Optical and Structural Properties of InAs/GaSb Type-II Superlattices.

Incorporating an intentional strain compensating InSb interface (IF) layer in InAs/GaSb type-II superlattices (T2SLs) enhances device performance. But there is a lack of studies that correlate this approach's optical and structural quality, so the mechanisms by which this improvement is achieved remain unclear. One critical issue in increasing the performance of InAs/GaSb T2SLs arises from the lattice mismatch between InAs and GaSb, leading to interfacial strain in the structure. Not only that but also, since each side of the InAs/GaSb heterosystem does not have common atoms, there is a possibility of atomic intermixing at the IFs. To address such issues, an intentional InSb interfacial layer is commonly introduced at the InAs-on-GaSb and GaSb-on-InAs IFs to compensate for the strain and the chemical mismatches. In this report, we investigate InAs/GaSb T2SLs with (Sample A) and without (Sample B) InSb IF layers emitting in the mid-wavelength infrared (MWIR) through photoluminescence (PL) and band structure simulations. The PL studies indicate that the maximum PL intensity of Sample A is 1.6 times stronger than that of Sample B. This could be attributed to the effect of migration-enhanced epitaxy (MEE) growth mode. Band structure simulations understand the impact of atomic intermixing and segregation at T2SL IFs on the bandgap energy and PL intensity. It is observed that atomic intermixing at the IFs changes the bandgap energy and significantly affects the wave function overlap and the optical property of the samples. Transmission electron microscopy (TEM) measurements reveal that the T2SL IFs in Sample A are very rough compared to sharp IFs in Sample B, indicating a high possibility of atomic intermixing and segregation. Based on these results, it is believed that high-quality heterostructure could be achieved by controlling the IFs to enhance its structural and compositional homogeneities and the optical properties of the T2SLs.

Underdiagnosis of obstructive lung disease: findings from the French CONSTANCES cohort.

BACKGROUND: The burden of undiagnosed obstructive lung disease (OLD) (mainly asthma and chronic obstructive pulmonary disease) is not fully established, and targets for corrective action are yet to be identified. We assessed the underdiagnosis of OLD and its determinants in France. METHODS: CONSTANCES is a French population-based cohort of adults aged 18-69 years at inception. We analysed data collected at inclusion in 2013-2014. Undiagnosed OLD was defined as spirometry-confirmed airflow limitation (FEV1/FVC < lower limit of normal) without prior diagnosis of asthma, chronic obstructive pulmonary disease, or bronchiectasis. Multivariate analysis was performed with weighted robust Poisson regression models to estimate the adjusted prevalence ratios (aPR) of undiagnosed OLD. RESULTS: Spirometry results were available for 19,398 participants. The prevalence of airflow limitation was 4.6%. Overall, 64.4% of adults with airflow limitation did not report a previous diagnosis of OLD. Individuals with high cumulative tobacco consumption (≥ 10 pack-years) (aPR: 1.72 [1.28-2.32]), without respiratory symptoms (aPR: 1.51 [1.28-1.78]), and with preserved lung function (aPR: 1.21 [1.04-1.41] for a 10-point increase in FEV1% predicted) had a higher risk of being undiagnosed. Half of symptomatic individuals with airflow limitation (45% of those with moderate to severe airflow limitation) were undiagnosed with OLD. CONCLUSION: Underdiagnosis of OLD is very common among French adults, even in patients with respiratory symptoms. Efforts should be made in France to raise awareness about OLD in the general population, improve the detection of respiratory symptoms, and increase the use of spirometry among primary care professionals.

Obstructive sleep apnea: A sharp increase in the prevalence of patients treated with nasal CPAP over the last decade in France.

INTRODUCTION: Obstructive sleep apnea (OSA) is a frequent condition. In the absence of treatment, OSA is associated with a higher risk of traffic accidents and a large variety of diseases. The objectives of this study were to describe the characteristics of patients treated for OSA in France and assess the time trends in treatment. METHODS: The French National Health Data System is an individual database with data on all healthcare reimbursements for the entire French population. Based on this database, we included all patients aged 20 years or over who were treated with continuous positive airway pressure (CPAP) or mandibular advancement splint (MAS) between 2009 and 2018. Negative binomial models, adjusted for age, were used to assess time trends in treatment prevalence and incidence rates. RESULTS: In 2017, 2.3% of French adults aged ≥20 years were treated with CPAP (men: 3.3%; women: 1.3%). The highest prevalence was observed in people aged 70-74 years (5.0%). From 2009 to 2018, the annual prevalence of CPAP increased 3-fold and the annual incidence 1.9-fold. During the same period, the rate of patients reimbursed for MAS (first prescription or renewal) was multiplied by 7.6. The proportion of patients treated with CPAP in 2017 who were no longer treated in the subsequent year was 6.9%. DISCUSSION: The sharp increase in the incidence of OSA treatment probably reflects a better recognition of the disease in France. However, the prevalence of OSA treatment remains lower than expected based on the international literature. Further studies are needed to identify the obstacles to an optimal management of individuals with OSA in France.

Changes in tobacco-related morbidity and mortality in French women: worrying trends.

BACKGROUND: The high prevalence of smoking among French women since the 1970s has been reflected over the past decade by a strong impact on the health of women. This paper describes age and gender differences in France of the impact of smoking on morbidity and mortality trends since the 2000s. METHODS: Smoking prevalence trends were based on estimates from national surveys from 1974 to 2017. Lung cancer incidence were estimated from 2002-12 cancer registry data. Morbidity data for chronic obstructive pulmonary disease (COPD) exacerbation and myocardial infarction were assessed through hospital admissions data, 2002-15. For each disease, number of deaths between 2000 and 2014 came from the national database on medical causes of death. The tobacco-attributable mortality (all causes) was obtained using a population-attributable fraction methodology. RESULTS: The incidence of lung cancer and COPD increased by 72% and 100%, respectively, among women between 2002 and 2015. For myocardial infarction before the age of 65, the incidence increased by 50% between 2002 and 2015 in women vs. 16% in men and the highest increase was observed in women of 45-64-year-olds. Mortality from lung cancer and COPD increased by 71% and 3%, respectively, among women. The estimated number of women who died as a result of smoking has more than doubled between 2000 and 2014 (7% vs. 3% of all deaths). CONCLUSIONS: The increase in the prevalence of smoking among women has a major impact on the morbidity and mortality of tobacco-related diseases in women and will continue to increase for a number of years.

Correction: Wheezing phenotypes and risk factors in early life: The ELFE cohort.

[This corrects the article DOI: 10.1371/journal.pone.0196711.].

Wheezing phenotypes and risk factors in early life: The ELFE cohort.

OBJECTIVE: Different phenotypes of wheezing have been described to date but not in early life. We aim to describe wheezing phenotypes between the ages of two months and one year, and assess risk factors associated with these wheezing phenotypes in a large birth cohort. METHODS: We studied 18,041 infants from the ELFE (French Longitudinal Study of Children) birth cohort. Parents reported wheezing and respiratory symptoms at two and 12 months, and answered a complete questionnaire (exposure during pregnancy, parental allergy). RESULTS: Children with no symptoms (controls) accounted for 77.2%, 2.1% had had wheezing at two months but no wheezing at one year (intermittent), 2.4% had persistent wheezing, while 18.3% had incident wheezing at one year. Comparing persistent wheezing to controls showed that having one sibling (ORa = 2.19) or 2 siblings (ORa = 2.23) compared to none, nocturnal cough (OR = 5.2), respiratory distress (OR = 4.1) and excess bronchial secretions (OR = 3.47) at two months, reflux in the child at 2 months (OR = 1.55), maternal history of asthma (OR = 1.46) and maternal smoking during pregnancy (OR = 1.57) were significantly associated with persistent wheezing. These same factors, along with cutaneous rash in the child at 2 months (OR = 1.13) and paternal history of asthma (OR = 1.32) were significantly associated with increased odds of incident wheezing. Having one sibling (ORa = 1.9) compared to none, nocturnal cough at 2 months (OR = 1.76) and excess bronchial secretions at 2 months (OR = 1.65) were significantly associated with persistent compared to intermittent wheezing. CONCLUSION: Respiratory symptoms (cough, respiratory distress, and excessive bronchial secretion) were significantly associated with a high risk of persistent wheezing at one year. Smoking exposure during pregnancy was also a risk factor for persistent and incident wheezing.

Surface ocean metabarcoding confirms limited diversity in planktonic foraminifera but reveals unknown hyper-abundant lineages.

Since the advent of DNA metabarcoding surveys, the planktonic realm is considered a treasure trove of diversity, inhabited by a small number of abundant taxa, and a hugely diverse and taxonomically uncharacterized consortium of rare species. Here we assess if the apparent underestimation of plankton diversity applies universally. We target planktonic foraminifera, a group of protists whose known morphological diversity is limited, taxonomically resolved and linked to ribosomal DNA barcodes. We generated a pyrosequencing dataset of ~100,000 partial 18S rRNA foraminiferal sequences from 32 size fractioned photic-zone plankton samples collected at 8 stations in the Indian and Atlantic Oceans during the Tara Oceans expedition (2009-2012). We identified 69 genetic types belonging to 41 morphotaxa in our metabarcoding dataset. The diversity saturated at local and regional scale as well as in the three size fractions and the two depths sampled indicating that the diversity of foraminifera is modest and finite. The large majority of the newly discovered lineages occur in the small size fraction, neglected by classical taxonomy. These unknown lineages dominate the bulk [>0.8 µm] size fraction, implying that a considerable part of the planktonic foraminifera community biomass has its origin in unknown lineages.

Asthma-Like Symptoms in Homeless Children in the Greater Paris Area in 2013: Prevalence, Associated Factors and Utilization of Healthcare Services in the ENFAMS Survey.

INTRODUCTION: Asthma remains poorly studied in homeless children. We sought to estimate the prevalence of asthma-like symptoms (ALS) and to identify the factors associated with ALS and healthcare service utilisation. MATERIALS AND METHODS: A cross-sectional survey of a random sample of sheltered homeless families was conducted by interviewing 801 parents of children (0-12 years) in 17 languages. ALS were defined as wheezing or night cough without fever during the previous year. Poisson regression models with robust error variance were used to compute prevalence ratios (PR) for factors associated with ALS and healthcare service utilisation for ALS. RESULTS: The prevalence of ALS among the children was 19.9%. Poor housing sanitation was significantly associated with ALS, as being born in the European Union. Most of the children with ALS had used healthcare services (85.4%). The main barriers to accessing such services were having lived in France for less than 49 months, having difficulties in French and living in poor housing conditions. CONCLUSION: ALS prevalence seemed lower than in the general child population, possibly because of the children's origins. Environmental factors associated with ALS point to the need to improve the indoor environment of family shelters. The relatively high rate of healthcare service utilisation should not overshadow existing barriers.

Ocean plankton. Determinants of community structure in the global plankton interactome.

Species interaction networks are shaped by abiotic and biotic factors. Here, as part of the Tara Oceans project, we studied the photic zone interactome using environmental factors and organismal abundance profiles and found that environmental factors are incomplete predictors of community structure. We found associations across plankton functional types and phylogenetic groups to be nonrandomly distributed on the network and driven by both local and global patterns. We identified interactions among grazers, primary producers, viruses, and (mainly parasitic) symbionts and validated network-generated hypotheses using microscopy to confirm symbiotic relationships. We have thus provided a resource to support further research on ocean food webs and integrating biological components into ocean models.

Life-cycle modification in open oceans accounts for genome variability in a cosmopolitan phytoplankton.

Emiliania huxleyi is the most abundant calcifying plankton in modern oceans with substantial intraspecific genome variability and a biphasic life cycle involving sexual alternation between calcified 2N and flagellated 1N cells. We show that high genome content variability in Emiliania relates to erosion of 1N-specific genes and loss of the ability to form flagellated cells. Analysis of 185 E. huxleyi strains isolated from world oceans suggests that loss of flagella occurred independently in lineages inhabiting oligotrophic open oceans over short evolutionary timescales. This environmentally linked physiogenomic change suggests life cycling is not advantageous in very large/diluted populations experiencing low biotic pressure and low ecological variability. Gene loss did not appear to reflect pressure for genome streamlining in oligotrophic oceans as previously observed in picoplankton. Life-cycle modifications might be common in plankton and cause major functional variability to be hidden from traditional taxonomic or molecular markers.

The chimerical and multifaceted marine acoel Symsagittifera roscoffensis: from photosymbiosis to brain regeneration.

A remarkable example of biological engineering is the capability of some marine animals to take advantage of photosynthesis by hosting symbiotic algae. This capacity, referred to as photosymbiosis, is based on structural and functional complexes that involve two distantly unrelated organisms. These stable photosymbiotic associations between metazoans and photosynthetic protists play fundamental roles in marine ecology as exemplified by reef communities and their vulnerability to global changes threats. Here we introduce a photosymbiotic tidal acoel flatworm, Symsagittifera roscoffensis, and its obligatory green algal photosymbiont, Tetraselmis convolutae (Lack of the algal partner invariably results in acoel lethality emphasizing the mandatory nature of the photosymbiotic algae for the animal's survival). Together they form a composite photosymbiotic unit, which can be reared in controlled conditions that provide easy access to key life-cycle events ranging from early embryogenesis through the induction of photosymbiosis in aposymbiotic juveniles to the emergence of a functional "solar-powered" mature stage. Since it is possible to grow both algae and host under precisely controlled culture conditions, it is now possible to design a range of new experimental protocols that address the mechanisms and evolution of photosymbiosis. S. roscoffensis thus represents an emerging model system with experimental advantages that complement those of other photosymbiotic species, in particular corals. The basal taxonomic position of S. roscoffensis (and acoels in general) also makes it a relevant model for evolutionary studies of development, stem cell biology and regeneration. Finally, it's autotrophic lifestyle and lack of calcification make S. roscoffensis a favorable system to study the role of symbiosis in the response of marine organisms to climate change (e.g., ocean warming and acidification). In this article we summarize the state of knowledge of the biology of S. roscoffensis and its algal partner from studies dating back over a century, and provide an overview of ongoing research efforts that take advantage of this unique system.

Symptoms of sleep apnea syndrome: high prevalence and underdiagnosis in the French population.

OBJECTIVE: To determine the prevalence of symptoms evocative of obstructive sleep apnea (SE-OSA) and the magnitude of obstructive sleep apnea (OSA) underdiagnosis. METHODS: We used data from a cross-sectional survey conducted in 2008 in a representative sample of the French general population. Data were collected through interviews and self-administrated questionnaires and were complete for 12,203 adults (≥16 years old). SE-OSA was defined by snoring almost every night plus witnessed apneas or excessive daytime sleepiness (Epworth sleepiness scale score>10). RESULTS: The prevalence of SE-OSA was 4.9% (95% CI: 4.5-5.3), and that of self-reported OSA diagnosis was 2.4% (2.1-2.7). The prevalence of SE-OSA was 8% among people with hypertension and 11% among obese people. A previous sleep monitoring session was reported by 2.7% (2.4-3.0) of the participants and by 15.1% of people with SE-OSA. This latter proportion increased with age (24% in people with SE-OSA aged 60 years or over) and was higher in obese people (26%) and in those with chronic diseases (27% among people with hypertension). CONCLUSION: The prevalence of SE-OSA is high in France and OSA remains underdiagnosed, even in people with obesity or hypertension. Further efforts are needed to improve the diagnosis of OSA.

Chronic bronchitis in the general population: influence of age, gender and socio-economic conditions.

Chronic bronchitis (CB) is an indicator of an increased risk of developing COPD, but its symptoms are often underestimated. Demographic and socio-economic conditions might influence its prevalence, reporting and impact. Data from a large epidemiological survey of the French general population were analyzed to determine the burden of CB, the magnitude of under-diagnosis and the influence of age, gender and socio-economic conditions. Altogether, 9050 participants aged 45 years or more provided complete data. The prevalence of symptoms and diagnosis of CB was 3.5% and 3.4%, respectively. CB was associated with impaired health status and activity and, in women, work loss. Among subjects with symptoms of CB, only 28.6% declared a known diagnosis of respiratory disease. Factors associated with symptoms of CB in multivariate analysis were male gender, active smoking, lower income and occupational category: the highest prevalence was observed in manual workers (5.6%) and self-employed subjects (5.2%). The under-diagnosis of CB was more marked in men and subjects of higher socio-economic categories. These results confirm that CB is markedly under-diagnosed in the general population. Socio-economic conditions influence both its prevalence (higher in low categories) and rate of diagnosis (lower in high categories), which should be considered when elaborating prevention and detection campaigns.

Hospitalizations for asthma in children are linked to undertreatment and insufficient asthma education.

BACKGROUND: Most hospital admissions for asthma exacerbation are avoidable with adequate disease management. OBJECTIVES: The objective of this study was to describe the characteristics of children hospitalized with an asthma exacerbation to identify modifiable factors leading to hospitalization. METHODS: The study was conducted in 14 pediatric units and included children 3-17 years of age who were hospitalized for an asthma exacerbation. The present analysis covers 498 children with known asthma. Staff physicians used a standardized questionnaire to collect data. Asthma history came from a parental interview and included usual asthma care, frequency of symptoms and quick-relief medication use in the previous month, frequency of exacerbations and number of unscheduled healthcare visits during the past year, and prior asthma-related hospitalizations. RESULTS: More than half the children had previously been hospitalized for an exacerbation, 42% used continuous inhaled corticosteroids, and 57% had a regular follow-up for asthma. Asthma had been well controlled over the past year for 11%, 12% had experienced exacerbations during the past year but that had been optimally controlled during the previous month, and 11% had recently become poorly controlled (infrequent exacerbations in the previous year and non-optimal control in the previous month). The remaining 327 children (66%) were consistently poorly controlled (non-optimal asthma control in the previous month and frequent exacerbations over the previous year). Among this group, 69% had at least one of the following preventable risk factors for hospitalization: no regular controller therapy (49%), no asthma action plan (40%), or no follow-up for asthma (35%). CONCLUSIONS: Two-thirds of the children with asthma hospitalized for an exacerbation had been consistently poorly controlled during the previous year. They were frequently undertreated and insufficiently educated about asthma. Further efforts are needed to improve asthma treatment and education in France.

Asthma and major depressive episode in adolescents in France.

RATIONALE: The association between asthma and anxiety disorders in teenagers is well documented, but data about the association with mood disorders are scarce. METHODS: We analyzed data from a cross-sectional study conducted among ninth grade schoolchildren in France in 2003-2004. The teenagers were selected by two-stage sampling and interviewed by school doctors/nurses using a standardized questionnaire including questions about asthma and asthma-like symptoms. They also completed a self-administered questionnaire in which the occurrence of major depressive episodes (MDEs) during the past 12 months was assessed by the Composite International Diagnostic Interview-Short Form. RESULTS: A total of 7000 teenagers (mean age 15.1 years) were included. The prevalence of wheezing in the past 12 months was 10.0% and that of current asthma (wheezing in the past 12 months in children who had already had asthma attacks, or treatment for wheezing or asthma in the past 12 months) was 8.5%. The prevalence of MDE during the past year was 14.2% in teenagers with current asthma versus 9.2% among the others. The association between current asthma and past-year MDE remained significant after adjustment for age, gender, family structure, and the father's employment status. Asthma was uncontrolled (at least four attacks of wheezing, one awakening per week due to wheezing, one severe wheezing, four unplanned medical visits, or one hospitalization for a wheezing attack in the past year) in more than half (58.3%) of asthmatic teenagers with an MDE in the past year versus 35.3% of those without an MDE. CONCLUSION: Asthma is associated with a higher prevalence of MDE. Among adolescents with asthma, MDE is associated with poorer asthma control. These findings highlight the need for a comprehensive care management of asthma in France that takes the psychological dimension into account.

Hospital admissions related to acute exacerbations of chronic obstructive pulmonary disease in France, 1998-2007.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) necessitating hospital admission have a major impact on patient outcome and management costs. We examined temporal trends in AE-COPD-related hospital admissions in France between 1998 and 2007. METHODS: Data were obtained from the French national hospital discharge database for patients aged at least 25 years. AE-COPD was identified with both a "narrow" and a "broad" definition, according to the position (primary or associated) of diagnoses, in order to ensure robustness. RESULTS: In 2007, among adults aged 25 years or more, the crude AE-COPD-related admission rates were 23/10000 in men and 10/10000 in women using the narrow definition. Using the broad definition, these rates were respectively 38 and 16/10000. With the narrow definition, the annual number of AE-COPD-related admissions increased by 38% between 1998 and 2007, while in-hospital lethality decreased from 7.6% to 6.0%. The proportion of male patients decreased from 72% to 68%. Similar trends were found using the broad definition. The age-standardized AE-COPD-related admission rate increased by 4.4% per year in women and by 1.6% per year in men with the narrow definition, and by respectively 3.8% and 1.2% with the broad definition. A strong seasonal pattern of admissions for AE-COPD was found, matching that of general practitioners visits for influenza-like illness. CONCLUSION: Hospitalization rates for AE-COPD have increased in France in recent years, especially among women. By contrast, AE-COPD-related in-hospital lethality has decreased.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis.

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.