Inflammatory Bowel Disease in Central and South America – an opportunity to identify the etiology of these conditions

Farrukh A. MD. (1), Mayberry JF. MD. (1)

(1) Department of Digestive Diseases, University Hospitals of Leicester NHS Trust. Gwendolen Road, Leicester LE5 4PW. UK

Received:     27-07-14   Accepted:    02-08-14

In 1985 following reviews of the epidemiology of ulcerative colitis (1), Crohn’s disease (2) and a study of mortality(3)it was suggested that: “Particular attention in the future will focus on such countries as Spain and Portugal; Central and South America are of interest for similar reasons” (1).

 In a review to be published in Arquivos de Gastroenterologia (4) more than 20 studies that subsequently came from Spain and Portugal are cited. A major drive to this work was the Concerted Action funded by the European Union during the 1990s (5). It was a descriptive study of the incidence of inflammatory bowel disease in Northern and Southern Europe. It achieved this through standardisation of definitions of disease (6) and of the methodologies used to identify candidate cases and separate them into confirmed cases and non-cases (7). Additional benefits that arose from the program included:

- The creation of networks of research teams in Europe;

- Promotion of national financing of research projects relevant to European priorities in health research;

- Transfer of expertise from centres of excellence to less advanced research teams (5).

However, by the 1990s the incidence of ulcerative colitis and Crohn’s disease had dramatically increased in Spain (8). A Concerted Action ten years earlier would have allowed more direct observation and assessment of those factors responsible for the worldwide expansion of these conditions. Such changes have now been reported in China, India and many other communities. Central and South America are the last major regions where inflammatory bowel disease is still uncommon and in which there is hope that the aetiology of these conditions might be identified through basic epidemiological research. A major purpose of this editorial and the associated review is to stimulate a co-ordinated international effort to establish an on-going data base in Central and South America in which new cases are registered and through which investigations into aetiology can be conducted.

It also presents a unique opportunity to investigate cohorts and the subsequent occurrence of Crohn’s disease or ulcerative colitis. For example, young people who are recruited for military service are healthy and basic data on demography, social habits and family history can be recorded. Such a cohort can be followed long-term as in Korea, which is another low incidence area (9). The Millenium Cohort Study (10) uses traditional and web based methods to follow almost 100,000 service personnel and such an approach could be adopted in Central and South America.

The main impact of the Concerted Action in Europe was to create an atmosphere in which multi-national studies became a real possibility. Clinicians with an interest in inflammatory bowel disease from a range of countries came together and worked out common agendas for research and shared their methods and pooled results. Into these groups they drew statisticians and patient representatives. The development of such networks, the facilitation of meetings and support of a research program with common protocols and clearly defined endpoints, which will include measures of incidence and an investigation of potential aetiological factors, will require funding. In days when such funds are hard to achieve the role of pharma companies should not be dismissed. South America will be a major market for 5ASA compounds and biologic therapies. It is not unreasonable to expect them to provide seeding funds to, at least, initiate an international meeting of clinicians in Central and South America so that a “Concerted Action” on the epidemiology and aetiology of inflammatory bowel disease can happen.