Despite being one of the most common non-communicable diseases globally, with highly effective treatments available, asthma is often not well controlled in many low-resource settings, according to a cross-sectional study recently published in The Lancet medical journal.
Closer to home, the Global Asthma Report from 2022 showed that there has been an increase in severe asthma symptoms among adolescents in Cape Town over the past few years. There is little data available for the rest of the country, which makes comparisons with other South African cities very tricky, writes Elri Voigt for Spotlight.
Dr Ahmed Ismail Manjra, a paediatrician and allergologist at Durban’s Allergy and Asthma Centre, said that globally, more children than adults have asthma. The centre is in the Life Westville Hospital and provides specialist services to adults and children with asthma or allergic disorders.
“Asthma is quite common in children. It is estimated (globally) that one in 10 youngsters have it, and in adults, the prevalence is less,” he says. “But the problem is that here, we see a disproportionate number of children with severe asthma. And what’s been shown is that over the years the prevalence is rising, as is the severity.”
The impact of undiagnosed or uncontrolled asthma on children is huge. First, says Professor Refiloe Masekela, paediatric pulmonologist and HoD of Paediatrics and Child Health at the University of KwaZulu-Natal, the symptoms are very noticeable, which can affect children socially.
Second, a child with undiagnosed asthma will miss school because of their symptoms and be unable to participate in activities like sport. They will also become less active because exercise may trigger symptoms, with further effects on their health.
Another implication of uncontrolled asthma, says Manjra, is poor sleep quality, which can affect a child’s academic performance.
“And in severe cases without proper treatment, it can lead to recurrent admissions to hospital, placing a burden, which could easily be prevented with proper management, on the healthcare system. In a small percentage of cases where the asthma is not well controlled, it can also lead to fatality.”
He says asthma treatment is extremely effective, very safe as well, with few side effects.
Asthma trends in children: what the data say
Masekela says the Global Asthma Report is published by the Global Asthma Network (GAN), comprising a network of worldwide centres – including three in South Africa – that contribute data on asthma in their regions every few years.
This collection effort started with the ISAAC one and ISAAC three studies (International Studies of Asthma and Allergens in Children). The GAN centre in Cape Town contributed data to ISAAC I in 1995 and for ISAAC III, data were collected in Cape Town in 2002 and Polokwane in 2004-2005, where adolescents were also included.
Masekela added that the latest study collecting data on asthma was the Global Asthma Network (GAN) phase one study, to which the Cape Town centre contributed. The data from the ISAAC studies – ISAAC 1 and ISAAC 3 as well as GAN, are available in South Africa only for Cape Town.
This means it’s possible to compare trends in childhood asthma in Cape Town over a longer time period, and data from ISAAC 3 can be used to compare Polokwane and Cape Town. But there are not current data collected by the GAN to give a clear picture of childhood asthma in the other cities and provinces.
In the 2022 Global Asthma report, changes in the prevalence of symptoms – measured as a 12-month prevalence rate of wheezing among adolescents aged 13 to 14 – showed that in ISAAC 1, 16% of the 5 000 adolescents surveyed in Cape Town had symptoms, which increased to 20.3% of just more than 5 000 surveys in ISAAC 3 and finally 21.7% of the just under 4 000 adolescents surveyed for the 2022 study.
Masekela says in Cape Town, looking at the period between ISAAC phase one and phase three, there was an increase in the prevalence (of asthma in children), but from the ISAAC 3 to the GAN phase one, there has been a stabilisation in the asthma prevalence (among children. “So, it’s very high, more than 20%, but it’s stable so it hasn’t been increasing, which it was doing before.”
When comparing data from Polokwane and Cape Town in ISAAC 3, at the time of the study, more children and adolescents in Cape Town had severe asthma than in Polokwane. The prevalence in children and adolescents was also higher in Cape Town.
Situation is ‘interesting and worrying’
Masekela said in many low-and-middle-income countries, people with asthma don’t have access to the right medications, namely inhalers. And often, when they do, they are only able to get the reliever inhaler, not the controller inhaler.
Asthmatics need two types of inhalers, a reliever inhaler which brings relief and opens up the chest during an attack, and a control medication, used every day to reduce inflammation in the long run. To control asthma adequately, both inhalers need to be used and used correctly.
In South Africa, both types are on the Essential Medicines List.
“The story of South Africa is interesting and worrying. We have in our essential medicine list inhalers (both relievers and controllers),” she says. “It should be available. It’s on the essential medicine list for the primary care level. So any person who has asthma in South Africa should have access to that first step of treatments.”
Yet the data show there is a problem. When looking at the symptoms of asthma among SA schoolchildren from the GAN phase one study, Masekela says many children with asthma symptoms don’t have an asthma diagnosis and of those who do, most only have the reliever inhaler: very few use both the reliever and the controller inhaler.
“We know asthma is under-diagnosed and actually the data from Cape Town, as well as Durban, are very similar. You see that 50% of adolescents have severe symptoms, half of them have never got the label – they’ve never been diagnosed as having asthma,” she told Spotlight.
Under-diagnosed
A possible reason for the under-diagnosis is that when a child arrives at a clinic with wheezing, he or she is treated for something else that might be causing the symptoms and sent home. Then when the child returns a few weeks or months later with the same symptoms, they are seen by a different doctor or nurse and there isn’t continuity, so the fact that the symptoms are recurrent isn’t picked up on.
Manjra said asthma can sometimes be difficult to diagnose in small children because its symptoms – wheezing, shortness of breath, tight chest and coughing – can be caused by a number of other diseases. Wheezing, in particular, can be caused by various conditions that can affect children.
“The most common is viral upper respiratory tract infection, particularly with RSV and rhinovirus. And sometimes, it can be extremely difficult to make a correct diagnosis of asthma because there’s overlap between viral-induced wheezing and asthma,” he says.
“However, if the child has an underlying – what we call atopic predisposition – meaning if he or she has eczema, allergic rhinitis, food allergy or (an) inhalant allergy, then the possibility of that child having asthma is very high,” he says.
Other childhood conditions causing wheezing are TB and inhaling foreign bodies into the lungs.
“So, the diagnosis of asthma in children is basically made by an exclusion of other causes of wheezing,” he says. “Asthma diagnosis is made over a period of time because, as I’ve mentioned, it’s recurrent wheezing.”
Another problem, says Masekela, is that those people who do receive a diagnosis of asthma are often not getting the right treatment.
“People who have a label at least should have access to the treatments, but we see that even with those who have the diagnosis, many are not using their medicine because they’re getting repeated attacks; they have severe symptoms. So, something is not right. Either they are not getting the label, we know that’s happening, or they’re not getting the right treatment.”
This is a bi-directional problem, Masekela adds, in that either healthcare workers are not adequately teaching patients how to use both inhalers or patients are relying on the reliever medications, despite being taught how to use both.
Manjra says that while inhalers are on the EML, this doesn’t necessarily translate to healthcare facilities having stock. Meaning there can be stock-out of the medication, but also of the spacers children need to use with the inhalers.
According to Manjra, children are unable to use inhalers properly with spacers, because the inhaler releases the plume of medication too quickly for the children to be able to breathe it into their lungs. The spacer allows the medication to go into a holding chamber where the child is able to breathe the medication into the lungs in a controlled way, through a special valve.
Better education needed
The solution to the problems of the under-diagnosis of asthma and incorrect inhaler use is better education on all fronts, says Masekela. There must be better training among healthcare workers on how to recognise asthma, how to manage it and how to teach patients to manage it properly.
“We know there’s a system problem about them (children) getting the correct medication, using the correct medication – that all boils down to education of the patient and of the health workers. And really, overall education in the community about how to handle asthma,” she says.
Patients and the wider community also need education on what asthma is and how to manage it properly and destigmatise it, she observes. A good starting place is in schools so that children with asthma and their peers can better understand the condition and be more accepting of the use of inhalers.
“It’s important that we then find strategies to help people understand the need for using these medicines, even when they’re feeling well,” she says.
Study details
Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study
Luis García-Marcos, Chen-Yuan Chiang, Innes Asher, Guy Marks, Asma El Sony, Refiloe Masekela et al.
Published in The Lancet in February 2023
Summary
Background
Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings.
Methods
We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015–20). A validated, written questionnaire was distributed via schools to three age groups (children, 6–7 years; adolescents, 13–14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group.
Findings
Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3–85·3% participants) and inhaled corticosteroids (12·6–51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40–3·15] for children; 2·45 [2·25–2·67] for adolescents; and 2·75 [2·38–3·16] for adults) or any type of oral medicine (1·86 [1·63–2·12] for children; 1·53 [1·40–1·68] for adolescents; and 1·78 [1·55–2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32–4·14] for children; 3·46 [1·83–6·54] for adolescents; and 4·86 [2·55–9·26] for adults).
Interpretation
Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries.
See more from MedicalBrief archives:
Urgent need to improve asthma control worldwide – global study
Asthma management key to reducing SA’s high childhood mortality – global report
GINA: Over-reliance on reliever pumps linked to increased risk of asthma attacks