Asthma is an increasing problem in low- and middle-income countries.

The Global Asthma Report 2014

Asthma is an important NCD in all regions of the world, affecting people in non-affluent as well as affluent countries.

ASTHMA AS AN NCD PRIORITY

The asthma epidemic experienced by high-income countries over the past 30 years is now an increasing problem in low- and middle-income countries as they become more urbanised. Non-communicable diseases (NCDs) are emerging as a major global public health problem and asthma is an important component of this group of diseases, particularly with regard to morbidity, but its importance is being ignored and neglected. This chapter provides a summary of the current challenges facing asthma management worldwide and suggests several approaches addressing these issues.

Asthma is a global concern

Asthma has become an issue of international development. The asthma epidemic experienced by developed nations over the last 30 years is now hitting developing countries in a big way as they become more urbanised. Whilst it is true that communicable diseases such as malaria are still a major health problem for many developing countries, NCDs including asthma, allergic rhinitis, and eczema are now emerging as serious additional problems in these countries and authorities believe that they will be responsible for tomorrow’s pandemics. The majority of people with these conditions live in the developing world, and in some of those countries asthma has become more common than in some western countries.

Asthma is one of the significant NCDs

Asthma is now recognised as one of the most important NCDs in all regions of the world, affecting people in non-affluent as well as affluent countries. NCDs now outstrip communicable diseases as the leading causes of death in the world - 60% among people of all ages, most (80%) of these deaths occurring in non-affluent countries. Chronic respiratory diseases (CRDs) cause 15% of the world’s deaths, and many of these have their origins in childhood influences including asthma, which may be aggravated by tobacco use in pregnancy, exposure to second hand smoke in childhood, and taking up smoking in adolescent or adult years. The burden and suffering caused by CRDs has been identified by the World Health Organization (WHO) as a priority issue.

NCD priority actions will help asthma

Asthma symptoms will be helped by two of the five priority interventions for the NCD crisis - tobacco control and access to essential medicines. The reduction in obesity that will be achieved through a third priority of improved diets and physical activity is likely to be beneficial as a relationship between obesity and asthma is becoming more evident.

Asthma surveillance needs to be extended

We know that asthma has become a serious global health issue because health researchers (paediatricians, respiratory physicians, and epidemiologists) in 306 centres in 105 countries, wanting to estimate how large the problem was for children in their locality, joined the International Study of Asthma and Allergies in Childhood (ISAAC) research programme; it was found that asthma affects about one in seven of the world’s children. Through that information from ISAAC (children) and the European Community Respiratory Health Survey (ECRHS) (adults), and with the recent estimates from the Global Burden of Disease Study (GBD), we now know that asthma is an important NCD. The WHO has resolved that there needs to be “better surveillance to map the magnitude of CRDs and analyse their determinants with particular reference to poor and disadvantaged populations and to monitor future trends”. Thus surveillance of asthma needs to continue using simple instruments which can be widely used around the world and repeated at regular intervals, such as those used in ISAAC and including younger age groups, such as preschool children.

Economic prosperity will be helped by treating asthma well….

The GBD found that asthma affects approximately 334 million people worldwide, causing an estimated 345,736 deaths annually (1 in 150 deaths worldwide). Around 22 million disability-adjusted life years (DALYs) are lost annually, and children with untreated asthma miss much of their primary school education, resulting in reduced educational opportunities and increased time off work for the parents/guardians which then impacts on the economy through loss of productivity. People with asthma are less able to work or look after their families, which causes huge financial and emotional stress. Emergency visits, hospitalisation, and inappropriate treatments are a great financial drain on struggling health systems.

….especially in non-affluent countries

The burden of severe asthma symptoms (frequent attacks, waking at night, or breathing difficulty affecting speech) disproportionately falls among children with wheeze in low- and middle-income countries. These children especially need access to affordable asthma medicines to help reduce attacks and relieve symptoms.

More asthma research is needed

Asthma research is decades behind cardiovascular research, and needs further investment. A key challenge now is to identify modifiable environmental risk factors suitable for public health interventions which have the ability to reduce the morbidity and severity of this increasing global problem. An important emerging problem is asthma or recurrent wheeze in infants, which was found, in a large international multi-centre study in 2008, to be highly prevalent and associated with greater severity in developing countries (see The Burden of Asthma/Wheezing in Infants).

Universal access to quality-assured and affordable asthma drugs

Universal access to good-quality affordable drugs for NCDs is an important issue. For everyone with asthma, access to affordable medicines is needed, appropriate to the severity of their asthma – a β2 agonist reliever for all people with asthma, and an inhaled corticosteroid preventer for those with more frequent symptoms. These essential medicines, particularly inhaled corticosteroids, are not available or affordable to patients, or to the health service in many developing countries, and as a consequence people become disabled or die from asthma. Thus, asthma is a factor in increasing the poverty of individuals and countries, especially low- and middle-income countries. The International Union Against Tuberculosis and Lung Disease (The Union) developed a process to provide access to quality-assured, affordably priced asthma inhalers in resource-constrained settings (see Management of Asthma/Asthma Management in Low-Income Countries). Such an approach must be continued. It must be added that quality-assured and affordable holding chambers or spacers attached to inhalers are critical for the success of inhaled asthma therapy in childhood.

Organisation of health services for long term treatment

In addition to the difficulty of accessing affordable essential medicines, the other main obstacle for management of NCDs, including asthma, is the lack of organisation of health services for long term management of patients with regular follow-up. Usually these diseases are treated only in an emergency. Training of health personnel and organisation of health services are needed. The Union has provided training material for health care workers; and, for regular monitoring and evaluation, an EpiData programme has been designed for registration and follow-up of patients.

Conclusion

Asthma is an NCD which causes a high burden of disease and economic impact throughout the world. The reasons for the increasing prevalence of asthma have not yet been clarified. Many people with asthma are not receiving effective treatment, often because quality-assured essential medicines are unavailable or unaffordable, or health care is not delivered well. There is a great deal that can be done to address all these issues, monitor their impact, and reduce the suffering of people with asthma in the world.

Recommendation

Governments should include asthma in all their actions arising from WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020.

Neil Pearce, Javier Mallol

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