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Multicenter Study
. 2025 Nov 14;80(12):945-954.
doi: 10.1136/thorax-2024-222118.

Risk factors for atopic and non-atopic asthma in school-age children from high-income and low- and middle-income countries

Charlotte E Rutter  1 , Harriet Mpairwe  2 , Camila A Figueiredo  3 , Mary Njoroge  4 , Steven Robertson  5 , Hajar Ali  6 , Collin Brooks  6 , Jeroen Douwes  6 , Philip J Cooper  7   8   9 , Martha Chico  7 , Natalia Romero-Sandoval  8   10 , Álvaro A Cruz  11 , Pius Tumwesige  2 , Mauricio L Barreto  12 , Neil Pearce  4 , Lucy Pembrey  4 ; CAMERA Study Group
Collaborators, Affiliations
Multicenter Study

Risk factors for atopic and non-atopic asthma in school-age children from high-income and low- and middle-income countries

Charlotte E Rutter et al. Thorax. .

Abstract

Background: It is well established that there are different asthma phenotypes, but whereas determinants of atopic asthma (AA) are well studied, little is known about non-atopic asthma (NAA). We compared risk factors for atopy, AA in atopics and NAA in non-atopics in children in a wide variety of countries.

Methods: Using four studies, across 23 countries, we assessed asthma status and atopy (skin prick tests) for children aged 6-17, plus risk factors from housing, heating, pets, family, diet and air quality categories. Using mixed-effects logistic regression models, we assessed risk factors over four pathways: pathway 1-non-atopic non-asthma to NAA; pathway 2-non-atopic non-asthma to atopy (no asthma); pathway 3-atopic non-asthma to AA; pathway 4-non-atopic non-asthma to AA. We compared the log odds of risk factors between pathways using the Pearson correlation coefficient (PCC).

Results: Our final sample of 32 741 children comprised 67% with neither atopy nor asthma, 15% with atopy but without asthma, 8% with AA and 10% with NAA. Risk factors were similar between pathway 1 and pathway 3 (PCC=0.81, 95% CI 0.68 to 0.94). In contrast, risk factors differed between pathway 2 and pathway 3 (PCC=-0.06, 95% CI -0.29 to 0.17).

Discussion: These findings indicate that although atopy increases the risk of asthma, the risk factors for subsequently developing asthma are generally the same in those with and without atopy. This raises important questions about the role of atopy in asthma, particularly whether it is an inherent part of the aetiological process or is coincidental.

Keywords: Asthma; Asthma Epidemiology; Child; Paediatric asthma.

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Conflict of interest statement

Competing interests: MB has received grants from the Wellcome Trust and the NIHR. ÁC has received grants from NIH, ERC and NIHR for related work, consulting fees from taking part in advisory boards for AstraZeneca, GSK, Sanofi and Myralis, and honoraria payments for lectures from AstraZeneca, GSK and Sanofi. JD has participated on the Board of the New Zealand Environmental Protection Authority, which is independent and government funded, and on the Board of the Health Research Council, both of which are unrelated to this work. PJC has been supported by an NIHR grant.

Figures

Figure 1
Figure 1. Pathways of possible asthma causation (adapted from Barreto et al 8).
Figure 2
Figure 2. Estimated ORs of risk factors for atopic asthma (AA) compared with non-atopic asthma (NAA), excluding atopy risk (pathway 3 vs pathway 1). Axes are shown on the natural log scale.
Figure 3
Figure 3. Estimated ORs of risk factors for asthma (in atopic individuals) compared with atopy (pathway 3 vs pathway 2). Axes are shown on the natural log scale. AA, atopic asthma.
Figure 4
Figure 4. Estimated ORs of risk factors for atopic asthma (AA) compared with non-atopic asthma (NAA), excluding atopy risk (pathway 3 vs pathway 1) stratified by country affluence. Axes are shown on the natural log scale.
Figure 5
Figure 5. Estimated ORs of risk factors for asthma (in atopic individuals) compared with atopy (pathway 3 vs pathway 2) stratified by country affluence. Axes are shown on the natural log scale. AA, atopic asthma.
See this image and copyright information in PMC

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