No more business as usual: Call to manage asthma well



By Shobha Shukla, CNS
May 3, 2013
The author is the Managing Editor of Citizen News Service - CNS. She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored a book on childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, and MDR-TB. Email: shobha@citizen-news.org, website: http://www.citizen-news.org

Despite evidence that asthma can be effectively managed, not only asthma-related health literacy is very low in most settings but also quality-assured affordable essential medicines are very seldom available. With slow growth in awareness of asthmatic conditions, increasing number of children and adults are being diagnosed with asthma. Once diagnosed, we must ensure that they are educated about asthma, empowered to live positively with proper management of asthma, and in-country mechanisms are robust enough to ensure uninterrupted supplies of required quality-assured affordable essential medicines, healthcare workers are skilled enough to comprehensively support people who need care, and aggravating factors or triggers are controlled effectively where possible.

We do not know yet what exactly causes asthma, but we do know that a person is more likely to develop asthma if she has a family history of asthma, eczema or allergies. It is likely that this family history, combined with certain environmental factors, influences whether or not she develops asthma.

Dr Karen Bissell, Deputy Coordinator, Asthma Drug Facility (ADF), International Union Against Tuberculosis and Lung Disease (The Union), and a co-author of a 2011 study on pricing, affordability and availability of asthma medicines; and Global Asthma Report 2011 chapters on asthma and poverty, and the economic burden of asthma, said in an interview with Citizen News Service - CNS that a small number of children who get diagnosed with asthma are lucky in the sense that asthma might go away as they grow up. But most children with asthma will need lifelong asthma management and care.

Asthma is a lifelong condition and it is possible to live a normal life with regular asthma management and care.

Christophe Perrin, Pharmacist and Coordinator, Asthma Drug Facility (ADF), International Union Against Tuberculosis and Lung Disease (The Union) also spoke to CNS and added that: "The percentage of children and adults which are reported for asthma over the past years has been increasing significantly. It is very much linked to the fact that they were not aware of these asthmatic condition."

According to the The Global Asthma Report 2011, published by The Union and the International Study of Asthma and Allergies in Childhood (ISAAC): Asthma is the most common chronic disease among children, besides affecting millions of adults. The WHO reports that lack of awareness probably represents the most important barrier to progress in the diagnosis, treatment and care of individuals with non-communicable diseases, including asthma. Part of the problem is that quality-assured asthma inhalers, that are essential to well-managed asthma, are either not available or are prohibitively expensive in many low income countries.

The reason for more and more children developing asthma is not known with certainty. Some experts suggest that children are being exposed to more allergens like house dust mites in beddings and carpets, pollens and moulds, as well as vehicle exhaust and second-hand tobacco smoke, which trigger or cause the symptoms of cough and breathlessness in asthma. Others think that a disorder of the immune system where the body fails to make enough protective antibodies may play a role in causing asthma. And still others believe that not breastfeeding infants prevent important substances of the immune system from being passed on to them.

According to Professor (Dr) Surya Kant, Head of the Pulmonary Medicine Department, King George’s Medical University, “If one of the parents has asthma then there are 25% chances of the child having it too. If both parents are asthmatic then this increases to 50%. One study says that caesarean children are more likely to get asthma as compared to those delivered normally, irrespective of the mother being asthmatic or not, perhaps because the vaginal fluids create immunity in the baby’s body, providing protection from many diseases, including asthma. If the mother is asthmatic then she should become more cautious about her asthma during pregnancy. Her environment should be kept clean and not harbour dust mites hidden in carpets, soft toys, cobwebs. Smoking by or before a pregnant lady is a crime.”

Researchers at Imperial College in London found a sharp fall in the number of children admitted to hospital with severe asthma after smoke-free legislation was introduced in England in 2007. The study published in the journal Pediatrics shows a 12% drop in admissions the first year after the law banning smoking in enclosed public places came into force and a further 3% in each of the following two years. The fall was seen among boys and girls of all ages, across wealthy and deprived neighbourhoods, in cities and in rural areas. Prior to the ban, the number of children admitted to hospital with severe asthma attacks was rising by more than 2% a year.

These findings reinforce evidence on the impact of smoke-free legislation on lung health, especially in case of children who are often the most innocent victims of second hand smoke.

Another study published online in the European Respiratory Journal has, for the first time, confirmed scientifically that poor air quality associated with busy roads can cause (and not merely trigger) asthma in children. Researchers found that 14% of chronic childhood asthma cases could be attributed to near-road traffic pollution. The results were comparable, the authors said, to the burden associated with passive smoking - which the World Health Organisation blames for 4% to 18% of asthma cases in children.

Dr BP Singh, a renowned lung health specialist avers that in India asthma in children is often misdiagnosed as tuberculosis. This is a matter of great concern as it involves misuse of anti-tubercular drugs. So, childhood asthma should be dealt with seriously and diagnosed and treated correctly. Dr Singh insists on giving children a clean environment to live in. “Indoor air pollution should be minimized and environmental tobacco smoke should be stopped by all means as it is a very important risk factor for triggering asthma attacks. If a person is allergic then pollen, dust, fumes and strong perfumes should be avoided. The kitchen must be very well ventilated. If the pets are there, they must keep them away from bedroom. The house mattresses contain a lot of house dust which expose asthma patients to mites--the most important cause for allergies. In countries like India, regular sunlight exposure to pillows and mattresses can wipe out these dust mites.”

However if a person does become asthmatic then the disease can be effectively controlled, if not cured. The focus of asthma management has shifted from severity based management to control based management. A person living with asthma can also lead a very normal life and this message should be conveyed to them properly. The treatment of asthma is cheap in comparison to the disability caused by it. If one uses corticosteroid inhalers (controllers/preventers) regularly, and bronchodilators (relievers) in case of an emergency, then asthma can be managed well without any cause for worry.

Dr Singh says that, “In case of children, once the diagnosis is complete, I would suggest taking controller therapy regularly. Current inhaled corticosteroids provide almost instant relief and are safe for children. They do not cause side effects as the drugs reach the lungs directly and are not absorbed in systemic circulation as compared to oral drugs and injections which get absorbed in the other organs of the body too like liver, kidney, and heart and can cause side effects. Regarding diet of asthmatic kids, parents very often do not allow the child to eat curds, ice cream, rice etc. as they think that it would worsen their asthma. But these foods can be taken by the children without causing any problem. The most important thing is that they should use the inhaler regularly.”

Christophe Perrin from The Union also stressed to CNS that: "Most of the people demand bronchodilators which are of course very important medicine but beside that what The Union is really trying to push forward in as many countries as possible and also through ADF are inhaled corticosteroids. Inhaled corticosteroids are the medicines which would help in healing of lungs of asthma patients because asthma is about inflammation of the lungs and the inhaled corticosteroids are the key medicines to cure these inflammation. Inhaled corticosteroids were not available as desired in many countries such as India, Nigeria, Kenya, Malawi, or Zimbabwe."

Christophe Perrin added: "Education must be provided to people as on how to use the inhalers and on checking the symptoms. They should have the knowledge and they should know when they have their warning sign. If something is out of control they must know what to do. They should know when they have to go to the healthcare facilities for help. Having chronic patient with asthma, knowing how to manage their own asthma, is very important to keep people out of the hospital wards."

In fact a study in Phase Three of ISAAC explored the impact of the intake of types of food on asthma and confirmed that a potential protective effect on severe asthma in adolescents and children was associated with consumption of fruit 3 times or more per week. At the same time an increased risk of severe asthma in adolescents and children was associated with the consumption of fast food 3 times or more per week. If the association between fast foods and the symptom prevalence of asthma is causal, then these findings have a major public health significance keeping in mind the rising consumption of fast foods globally.

Another ISAAC Phase Three study was conducted on 76 164 children aged 6–7 years (from 29 centres and 17 countries) and 201 370 adolescents aged 13–14 years (from 73 centres and 35 countries) to examine the relationship between potential risk factors, such as body mass index categories (underweight, overweight and obesity), vigorous physical activity and television viewing and the symptoms of asthma (and also rhino conjunctivitis and eczema). The study confirmed the association between overweight and obesity (but not underweight) and symptoms of asthma. Vigorous physical activity was positively associated with symptoms of asthma, in adolescents, but not in children. Viewing television for five or more hours/day was associated with an increased risk of symptoms of asthma in adolescents as well as children.

So till a permanent cure for asthma is found, the least we can do as adults is to protect the health our children by letting them breathe clean air devoid of tobacco smoke and vehicular exhaust; giving them healthy (and not fast) food to eat; encouraging more of physical activities and less of television watching; and if need be, learn ourselves and train our children to manage asthma effectively. (CNS)

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Posted on: May 03, 2013 09:08 PM IST