Although asthma can easily be controlled with medications, in many low-and-middle-income countries like South Africa, many still die from the disease due to lack of effective management, writes Elri Voigt for Spotlight, with this country recording one of the highest rates of childhood asthma on the continent.
According to the Global Asthma Report 2022, SA ranks third out of 28 low-and-middle-income countries for asthma-related mortality. While many asthma-related deaths are preventable, about 1 000 people die daily from asthma worldwide.
The 2022 edition of the report was recently released at a plenary session at this year’s Union World Lung conference.
Asthma is often overlooked by governments in their plans to address non-communicable diseases (NCDs), says the report. “And little progress (has been made) in improving access to its management and medicines,” the report reads. Additionally, asthma medicines are often “unavailable, unaffordable, or of unreliable quality, resulting in unnecessary burden and mortality from asthma”.
Children mostly affected
South Africa has one of the highest rates of childhood asthma on the continent. The report also notes “a striking increase in severe (asthma) symptoms in adolescents in Cape Town” where data shows that 8.8% of children aged 13 to 14 have self-reported smoking.
Professor Heather Zar, who specialises in paediatrics and paediatric lung health, concurs that the asthma burden is particularly high in children and adolescents. “It is the commonest non-communicable disease in children and adolescents in South Africa and globally,” Zar says.
But, says Professor Elvis Irusen, divisional head of pulmonology at the Department of Medicine at Stellenbosch University, data on the burden of asthma in South Africa are patchy, and global estimates “are our best indication of the burden of asthma in SA”.
“We don’t have good data. In the past, in some of the surveys we feature as one of the top ten countries for asthma mortality in the world,” he says.
Professor Innes Asher, chair of the Global Asthma Network who presented at the conference, said overall, there was a decline in asthma-related deaths from 2011 to 2015 but the number of deaths, which are largely preventable, in low- and middle-income countries, remains high.
Irusen says some people do not initially have an asthmatic reaction to an allergen or trigger but may develop one after exposure over time. This often happens in the workplace – known as occupational asthma. “These are people who become allergic to things at work. So, common industries include spray-painting, the wood/timber industry, and baking. A host of industries can cause this allergy and develop into asthma,” he says.
Diagnosis in public healthcare sector
Asher told delegates that despite the availability of asthma medications in South Africa, the lack of diagnosis is a barrier to care.
There is no definitive test for asthma. Instead, a diagnosis is based on symptoms and whether the patient responds to asthma medications. Typical symptoms are when a person’s chest closes up after being exposed to a trigger or allergen. Sometimes other symptoms are already present, like itchy eyes, runny nose, or itchy skin.
Listening to the chest will reveal whistling sounds, and a low-tech device, called a peak flow meter, may then be employed to test lung function. The device works without electricity and contains a little tube with a lever into which the patient blows and, depending on how strongly the air flows into the tube, the lever lifts to a certain measurement. If the patient’s measurement is below normal, it means the airflow from their lungs isn’t good. This can also be done using a computerised lung function machine.
Testing the airflow can then be followed by the patient being given an asthma pump – or inhaler – to relax the muscles of the airways. The test – whether it’s a peak flow or computerised lung function machine – is then repeated. If airflow has improved, it means the muscles have started to relax, and this is normally enough to confirm an asthma diagnosis.
Asthma treatment
Asthma is mainly treated using inhalers. Zar said for frequent sufferers, two inhalers could be used to treat the symptoms. One is a pump that provides inhaled corticosteroids, reducing airway inflammation. This can be combined with a long-acting bronchodilator, relaxing the muscles of the airways.
“For an acute asthma attack, a quick-acting bronchodilator, oral steroids, and oxygen may be needed. Increasing the frequency or dose of a long-acting bronchodilator with inhaled steroid is also used in older children or adults,” she adds.
Inhalers are very effective, according to Irusen, as the medicine is delivered directly into the lungs. Someone living with asthma will typically be given two inhalers: one to relax the muscle of the airways and the other to reduce inflammation in the airways to prevent or reduce asthma attacks.
He says using the first inhaler brings immediate relief and is often overused by patients. The second type of inhaler – and its purpose – is not always well understood by patients and thus not used as often as needed. This causes a snowball effect, where the person who isn’t taking the prevention treatment experiences more asthma attacks, leading to an over-reliance on the first inhaler.
“If one takes more of the prevention (inhaler), then you don’t need the other one to open up the lungs that much. That’s another important lesson and understanding that patients don’t (always) have,” Irusen says.
“Almost all asthma symptoms are controllable and with available effective asthma pumps, asthmatics should have normal lives. There are famous athletes who have asthma, but who compete globally with effective treatment,” she says.
Mitigating the asthma disease burden
She says there is no primary prevention method available to keep someone from developing asthma but secondary prevention of attacks is possible through avoiding triggers or allergens.
“Using a controller medication, mainly inhaled corticosteroids, is effective to control symptoms and prevent attacks,” she says. “The focus should be on (improved) diagnosis (because) around 30% of those with severe asthma have not been diagnosed.”
When asked what else could be done in the health system to help mitigate the disease burden of asthma, Zar said there should be “better use of inhaled medicines to prevent attacks; proper use of inhalers with a spacer especially for children or for those with an acute attack.
Some of the issues influencing adherence are a lack of education among patients and healthcare workers on the proper use of asthma inhalers and the importance of adherence, particularly in using the inhalers that prevent attacks. People living with asthma who rely on the public healthcare sector are provided with asthma medications but might be prevented from accessing these because of socio-economic reasons that keep them from attending clinics.
Workplaces where employees can run the risk of developing “occupational asthma” should ensure they meet the appropriate safety standards and provide personal protective equipment for employees to protect them from potential allergens or triggers, advises Irusen.
He says special care should also be taken with women during pregnancy – either to detect undiagnosed asthma in her or to ensure existing asthma is properly controlled, as some pregnant women can experience a worsening of asthma symptoms during this time.
What the health department is doing
The Global Asthma Report says governments often overlook asthma in their plans to address non-communicable diseases “and have made little progress in improving access to asthma management and medicines, especially the ICS (Inhaled corticosteroids) crucial for the long-term control of asthma”.
In South Africa, however, health spokesperson Foster Mohale told Spotlight asthma is included in the National Strategic Plan (NSP) for the Prevention and Control of Non-Communicable Diseases (2022-2027) recently launched by the department. “The NSP’s aim is to improve wellness and reduce premature morbidity, disability and mortality from non-communicable diseases, including asthma, through the continuum of care across the life course,” he says.
Apart from the NSP, he says, “the department has employed healthcare workers who provide comprehensive healthcare services to patients. The services are informed by evidence-based clinical guidelines and tools including Adult Primary Care (APC) and Standard Treatment Care Guidelines, which are regularly updated.”
When asked about the report’s claims that a lack of asthma diagnosis remains a big barrier to care, Mohale says the department is not aware that this is a problem, however, training on asthma is available for healthcare professionals and managers and is incorporated in the APC guidelines.
Among the report’s recommendations to governments are that they should “use asthma programme data to track improvements in diagnosis and reductions in emergency visits and hospital admissions, and to quantify the effectiveness of and need for essential asthma medicines”. Additionally, “governments must ensure their country has a national asthma programme with curriculum, education, and management guidelines, including essential asthma medicines, and that asthma training materials are current and reach all relevant healthcare workers”.
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Spotlight article – The state of asthma in SA (Creative Commons Licence)
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