The European Community Respiratory Health Survey (ECRHS) was planned to answer specific questions about the distribution of asthma and health care given for asthma in the European Community. Specifically, the survey is designed to estimate variations in the prevalence of asthma, asthma-like symptoms and airway responsiveness; to estimate variations in exposures to known or suspected risk factors for asthma, and assess to what extent these variations explain the variations in the prevalence of disease; and to estimate differences in the use of medication for asthma. The protocol provides specific instructions on the sampling strategy adopted by the survey teams, as well as providing instructions on the use of questionnaires, the tests for allergy, lung function measurements, tests of airway responsiveness, and blood and urine collection. The principal data collection sheets and questionnaires are provided in the appendices, together with information on coding and quality control. The protocol is published as a reference for those who wish to know more of the methods used in the study, and also to give other groups who wish to collect comparable data access to the detailed methodology.

The European Community Respiratory Heath Survey (ECRHS) was the first study to assess the geographical variation in asthma and allergy in adults using the same instruments and definitions. The database of the ECRHS includes information fromy140,000 individuals from 22 countries. The aim of this review is to summarize the results of the ECRHS to date.The ECRHS has shown that there are large geographical differences in the prevalence of asthma, atopy and bronchial responsiveness, with high prevalence rates in English speaking countries and low prevalence rates in the Mediterranean region and Eastern Europe. Analyses of risk factors have highlighted the importance of occupational exposure for asthma in adulthood. The association between sensitization to individual allergens and bronchial responsiveness was strongest for indoor allergens (mite and cat). Analysis of treatment practices has confirmed that the treatment of asthma varies widely between countries and that asthma is often undertreated.In conclusion, the European Community Respiratory Health Survey has shown that the prevalence of asthma varies widely. The fact that the geographical pattern is consistent with the distribution of atopy and bronchial responsiveness supports the conclusion that the geographical variations in the prevalence of asthma are true and most likely due to environmental factors. Eur Respir J 2001; 18: 598-611. During the first half of the 1990s, information on the variation in asthma prevalence, known or suspected risk factors for atopy and asthma, and information on the management of asthma in young adults was collected in the European Community Respiratory Health Survey (ECRHS).The reason for undertaking the ECRHS was a rapid increase in the prevalence of asthma that had been reported from many different countries [1][2][3][4]. This increase was over too short a time period to be explained by genetic factors and must therefore have been related to nongenetic or environmental changes. Further evidence of the importance of environmental factors in asthma was that studies comparing prevalence in urban and rural areas in developing countries had shown large differences in asthma prevalence [5][6][7]. Treatment patterns of asthma [8] and asthma mortality [9] had been found to vary considerably in Europe which raised the question of whether the variation in mortality was due to geographical differences in the prevalence of asthma or differences in asthma fatality. Research directed towards identifying the environmental factors that explain this geographical variation in asthma was required to identify potential strategies to counter the global increase in the prevalence of asthma.The information available on the variation in the prevalence of asthma and allergy at the beginning of the 1990s had been collected through several studies using different protocols. The ECRHS was, therefore, the first study that assessed the prevalence of asthma and allergic disease in a large number of countries

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Attempts to compare bronchial responsiveness between populations have been hampered by between-study differences in the pharmacological agent of provocation, the method of administration and the summary statistic employed. The European Community Respiratory Health Survey used methacholine challenge delivered by Mefar dosimeter according to a standardized protocol used in 35 centres in 16 countries.Data were obtained from 13,161 men and women, aged 20-44 yrs at the start of the study. The dose of methacholine producing a 20% fall in forced expiratory volume in one second (FEV1) (PD20) and the regression coefficient of percentage decline in FEV1 with log dose, were calculated ("slope", after transformation), with and without calibration of nebulizers by weight and adjustment for nonresponse bias. Standardization for baseline lung function and variation in smoking prevalence was applied to slope.Results were robust to whichever summary measure was used, and to the various adjustments. Responsiveness was low in Iceland and Switzerland, and in most centres in Sweden, Italy and Spain, and high in New Zealand, Australia, the USA, Britain, France, Denmark and Germany.Bronchial responsiveness varies considerably in Europe, and high levels are not confined to the English-speaking world. Eur Respir J 1997; 10: 2495-2501 Bronchial challenge has been used for over 20 yrs, and there have been several epidemiological studies of risk factors for bronchial responsiveness. However, there are relatively few prevalence studies in the general population, and most of these have been in Englishspeaking countries. NEUKIRCH and CARTIER [1] identified 12 studies, eight using histamine challenge, three methacholine and one cold air, with a variety of cut-off points to define reactivity, and differing age ranges. Two comparative studies in children have been published [2,3], one involving four countries and one involving two, but to date no comparative data on adults from different countries have been reported.The European Community Respiratory Health Survey (ECRHS) is a multicentre study of the variation in the prevalence, risk factors and management of asthma throughout the European Union and elsewhere [4], and includes measurement of bronchial response to methacholine challenge. Results are reported here from 35 centres in 16 countries which have provided usable data. Methods SamplingThe protocol for the ECRHS has been described in detail elsewhere [4,5]. Briefly, participating centres selected an area defined by pre-existing administrative boundaries, with a population of at least 150,000 people. Where possible an up-to-date sampling frame was used to select randomly at least 1,500 men and 1,500 women aged 20-44 yrs. In stage 1 subjects were sent a questionnaire enquiring about respiratory symptoms and attacks of asthma in the last 12 months, current use of asthma medication and nasal allergies including hayfever. A random sample of subjects were selected to take part in stage 2. Those who had already responded to stage 1 wer...

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