Asthma burden can be rapidly reduced by the implementation of relatively simple measures within a systematic strategy to improve early detection and provide effective anti-inflammatory treatment.
NATIONAL ASTHMA STRATEGIES
There are many examples worldwide of systematic strategies which have successfully reduced the burden of asthma, in low-, middle- and high-income contexts. Properly implemented strategies have been proven repeatedly to work. From the public health perspective, the key issue in reducing the burden of asthma is to implement the best standards of care in everyday practice. The benefits can be remarkable; systematic implementation of the best standards of care can reduce both human suffering and the associated societal costs. It is the responsibility of asthma experts and healthcare professionals to collaborate with national public health authorities and international organisations to improve efficiency in management and care. In 2013, roughly 1 in 4 countries had national asthma strategies in place, for children and/or adults.
Successfully managed asthma
When asthma is successfully managed, the person with asthma will have no symptoms or only very mild symptoms, no attacks, no emergency department visits, no limitation of exercise or activities, no loss of sleep due to asthma, minimal use of an asthma reliever medicine(<2 times/week), and the least side effects possible of asthma medicines. The person will have no impediments to their lifestyle due to asthma, and will be able to attend their place of education or work with no time off due to asthma. National asthma strategies are aimed at achieving successful management for all people with asthma.
Examples of successful strategies
In Finland, patients and society have benefitted from the systematic and consistent development and implementation of asthma management. A comprehensive nationwide Asthma Programme was undertaken from 1994 to 2004 to lessen the burden of asthma on individuals and society. In 2010, it was estimated that the total asthma costs (healthcare, drugs, disability, and productivity loss) would have been €500-800 million annually by then, if nothing had been done and if 1990s trends had continued. However, the realised costs in 2010 were less than half of that, around €200 million. This implied a potential cost saving from €300-600 million every year, depending on the scenario used.
Several other encouraging examples now exist, e.g. in Poland, Portugal, Brazil, and recently in Costa Rica. As not all such programmes are reported, we encourage publication of strategies and outcomes. The problems to be addressed are different in high-income compared to low- and middle-income countries, and the solutions need to be tailored according to local needs and resources. There is, however, no question that the burden of asthma can be markedly reduced using strategies that have been adapted to the local societal, economic and health care environments.
Patients from a low resource setting in Salvador, Brazil, received free medication for asthma and rhinitis in accordance with international guidelines. The outcome was impressive. The costs for asthma care were reduced on average by US$ 733 per patient per year for the families and by US$ 387 per patient per year for the public health system. In the entire Salvador population a 74% reduction in asthma hospitalisation rates occurred after the implementation of the programme. The educational effort targeting both patients and professionals was paid back in a few years. In Benin, in 2008 a pilot study of asthma management was conducted. The cohort analysis after one year of standardised management (see Asthma Management in Low-Income Countries) demonstrated a dramatic decrease in asthma severity, the number of exacerbations and hospitalisations (see Asthma - A Global Priority/Asthma in Low- and Middle-Income Countries).
Inhaled corticosteroids are essential to success
Asthma projects and programmes in Argentina, Australia, Brazil, China, Japan, Mexico, the Philippines, Russia, South Africa, and Turkey were discussed in 2009 in Berlin by a group of experts in asthma care, the Advancing Asthma Care Network. Their report “Asthma programmes in diverse regions of the world: challenges, successes and lessons learnt” concluded that the major barriers for all programmes are: 1) low rates of dissemination and implementation of treatment guidelines, 2) low levels of continuing medical education and training of primary health care professionals, and 3) poor access to and distribution of inhaled corticosteroids. Additionally, under-diagnosis and inadequate treatment further limit the success of less developed programmes.
All successful asthma programmes seem to have the following characteristics: 1) improving early diagnosis and the introduction of first-line treatment with anti-inflammatory medication (mainly inhaled corticosteroids), 2) improving long-term disease control, 3) introducing simple means for guided self-management to proactively prevent exacerbations/attacks, and 4) effective education and networking with general practitioners, nurses and pharmacists. A systematic approach is required and must aim to motivate and organise. Improvements can be achieved with relatively simple means. All the main stakeholders should be represented when multidisciplinary actions are being planned. Especially important is the involvement of the non-governmental patient organisations, which are aware of the grass-root problems. Any programmes should set 3-5 goals, preferably accompanying each with at least one quantifiable indicator and target. For example, one goal could be to reduce asthma exacerbations, measured by the number of emergency visits, with the target of reducing emergency visits by 50% over the next 3-5 years. For each goal, more specific targets (what to do?), tools (how to do it?) and outcomes (what to follow and measure?) should be defined (Figure 1). The strategic flow for a programme is indicated in Figure 2.
Regardless of the health care system and its coverage, experience gained from national and local interventions should be brought together. A major change for the better can be achieved by local efforts, systematic planning, and networking to implement the best possible asthma management practice. The gains can be remarkable, both in reducing human suffering as well as associated societal costs. The asthma burden can be tackled, and it is the responsibility of asthma experts and healthcare professionals to collaborate with national public health authorities and international organisations to improve efficiency in management and care.
Following in the successful footsteps of the Asthma Programme in Finland 1994-2004, an Allergy Programme 2008–2018 was launched there to combat the allergy epidemic, and to further assist the asthma epidemic. This new activity aims to increase immunological tolerance and improve management of severe allergy phenotypes, including asthma. The early results are promising and, in addition, economic costs for all allergy and asthma are declining.
Global Asthma Network survey 2013-2014: national asthma strategies
A short survey for Global Asthma Network (GAN) centres was carried out in 2013. One of the questions was: “Has a national asthma strategy been developed in your country for the next five years? For children, for adults?” Of the 105 countries that answered, 25% had a programme for children and 23% had one for adults. Of the high-income countries (n=69), 34% reported a programme for children and 35% reported one for adults, while the corresponding figures were 20% and 17% for the low- and middle-income countries (n=34) (Figure 3 ). The details of the programmes are quite variable and would need further evaluation. Only a few countries have reported results of any nationwide, comprehensive programme.
Generally, asthma responds favourably to effective drug treatment. The earlier the correct diagnosis is obtained, the better the response. Patients should adhere to long-term management, use inhalers correctly, and proactively prevent exacerbations by themselves after receiving education. In Europe, improved management has resulted in a remarkable decline in mortality (6287 asthma deaths in 1980 and 1164 in 2012). Asthma mortality, however, is the tip of the iceberg when considering the overall asthma burden. Systematic national and regional asthma plans (programmes ) have been employed in many countries to tackle emergency visits, hospitalisations, disability, costs, and loss of productivity. When programmes involve community stakeholders and are tailored to the characteristics of the community, they work successfully. Benchmarking against specific indicators of asthma outcomes would improve implementation of best practices.
Health authorities in all countries should develop national strategies and action plans to improve asthma management and reduce costs.