If we listen to asthma experts and look at evidence, one reality becomes starkly clear: we have neglected asthma in children for far too long! "I think we have 'gone to sleep a bit' on asthma in resource-limited settings. The International Union Against Tuberculosis and Lung Disease (The Union) and partners had done studies on asthma (called ISAAC studies), but there is nothing really ever been done since" said Dr Steve Graham, Professor, Department of International Child Health, University of Melbourne, and senior child health consultant at the The Union.
ISAAC (International Study of Asthma and Allergies in Childhood), is a unique worldwide epidemiological research programme established in 1991 to investigate asthma, rhinitis and eczema in children due to considerable concern that these conditions were increasing in western and developing countries. ISAAC formally finished in December 2012. The Global Asthma Network was founded in 2012 and is extending the work of ISAAC in the asthma field.
Asthma is a huge problem in the world, causing wheezing and difficulty breathing. It is a common chronic disease and cause of disability affecting 334 million people of all ages in all parts of the world.
Data is power?
One might wonder: how 'latest' is the latest Global Asthma data? "The World Health Organization (WHO) has not done any asthma survey in last 12 years so no new data from WHO on asthma. Last Global asthma data which is now old came in 2003" said Dr Innes Asher, Department of Paediatrics, Child and Youth Health, University of Auckland, New Zealand; and Chair of the ISAAC and Global Asthma Network. Agreed Dr Guy Marks, Chair of Scientific Committee of the 5th Asia Pacific Region Conference on Lung Health in Sydney: "Data is power!" emphasizing the urgent need to collect new data on asthma, so that policies and programmes are appropriately informed.
"Asthma is seriously neglected. Asthma is invisible compared with obesity that is easily seen, or stroke or cancer etc. Asthma causes disability – asthma is the 14th most important disorder in terms of global years lived with the disability" said Dr Innes Asher.
Dr Asher added: "Economies suffer because of asthma - children miss their school or preschool and adults are not able to work too (either due to asthma or while caring for a child with asthma). Many people are not able to work effectively due to asthma causing serious loss of productivity. Economic cost of inaction due to asthma is huge! For example, Europe loses Euros 19 billion for 2011 due to asthma."
Deaths related to asthma are more common in some low and middle income countries. Almost 1000 persons per day die of asthma. "ISAAC study had found that asthma occurred everywhere in the world, was more common than was thought, and there were large variations. ISAAC had also found that asthma rates were overall increasing, but increases were more common in low and middle income countries" said Dr Asher.
Dr Asher listed the common environment factors that have a positive association with asthma and can potentially increase asthma prevalence or make its symptoms worse: "Tobacco smoke exposure, open fire cooking, farm animals, high intensity truck traffic exposure, dampness in homes, fast food intake, obesity, paracetamol/ antibiotic use in first year of life, migration to higher prevalence country or greater family size (severe asthma)." She further said that asthma has an inverse association with "fresh fruits and vegetables intake, and breastfeeding of the child (in first six months of life) in non-affluent countries."
Assumption: All countries have national asthma strategies and management guidelines!
Not surprisingly, with long neglect asthma has faced from governments, national asthma strategies exist in only 23% of 103 countries surveyed in a study. Asthma management guidelines were available in 89% of 103 countries, said Dr Asher.
Dr Steve Graham, who has been advocating for accelerating response to childhood asthma over the years, said to Citizen News Service (CNS): "We know for fact that deaths due to asthma are much more common in resource limited settings, as people are unable to get on inhaled steroids or preventer therapies. Asthma remains a very important but neglected non-communicable disease (NCD) in children and adolescents in the world, there is no doubt about that."
United Nations Secretary General Ban Ki-moon had also said in a review meeting in July 2014 that "The global epidemic of NCDs is a major and growing challenge to development. Each year in developing countries alone, stroke, heart attacks, cancer, diabetes, or asthma kill more than 2 million people between the ages of 30 and 70…”
Dr Karen Bissell, a senior consultant with The Union shared that asthma is also prioritised in the WHO Global NCD Action Plan of 2013-2020. The Action Plan has listed 25% reduction target for premature mortality from NCDs and 80% coverage of essential NCD medicines and technologies - we need to look for asthma as well in these targets, said Dr Bissell.
As Millennium Development Goals (MDGs) are about to expire at end of 2015, and new set of sustainable development goals (SDGs) might get adopted in UN General Assembly later this month (for 2015-2030), target 3.4 of draft SDGs aim to reduce premature mortality from NCDs through prevention and treatment and promoting mental health and well being, by one-third. Target 3.8 aims to achieve universal health care (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. The post 2015 development agenda does present a strong opportunity to push governments to act upon asthma related issues as well.
Barriers to access to asthma medicines
Dr Karen Bissell said that access to asthma medicines relies on policy, procedures and communications all working well in a country. Dr Bissell enlisted few factors that directly influence the access to medicines:
- Procurement: Who sets the agenda when medicines get procured
- Distribution: Public and private health services, other agencies
- Prescription by doctors or nurses (is the medication right?)
- Education: Healthcare workers such as doctors, nurses, pharmacists, patients, etc need to access training on how to educate patients, standard messaging, etc.
"Almost all countries have no national programme and no national information system for asthma. Many have no real national consensus, and or implemented asthma management guidelines, strategy or dedicated budget. Some countries follow guidelines that are more for high income countries. Essential medicines list (EML) often does not include inhaled cortico-steroids for asthma management, and if they do, then often these are not updated" said Dr Bissell.
Speaking about challenges in health services, Dr Bissell underlined that "few medical professionals understand the essential role of inhaled cortico-steroids in asthma management, rather they prescribe the reliever medication alone. Health services are often not organized for long term chronic care and health workers are not trained in asthma care."
"Procurement environment can effect access to medicines: market usually does not encourage rationale procurement. Nonessential medicines are often pushed by pharmaceutical companies and specialist physicians" said Dr Bissell.
A report brought out by The Union and Global Asthma Network, states that asthma medicines were part of essential medicines list (EML) in only 10 countries surveyed and these were available in 41% of private pharmacies surveyed and 17% of public hospitals surveyed.
Asthma Drug Facility was created by The Union and made commendable contribution during 2005-2013 by providing affordable access to quality-assured essential asthma medicines for low and middle income countries. Although critically needed in today's context too, yet it is on hold since 2013 due to lack of funds and demand from countries.
Because of Asthma Drug Facility (ADF), more than 50% reductions in annual costs for a patient with severe asthma became a reality, said Dr Bissell. There were enormous cost savings for countries that were using standardized long-term management of asthma and helping avoid unnecessary hospitalization.
But is cost of hospitalization for asthma patient significant? Cost of hospitalization for an asthma patient of 2 days 4 times a year was calculated to be Euros 269 in Benin, Euros 585 in Sudan, and Euros 852 in El Salvador.
Are asthma medications expensive? Dr Bissell shared data that "to buy one inhaler a patient spends: over 5 days wages in Ethiopia, over 8 days wages in Malawi, and almost 14 days in Madagascar. we must remember that a person with severe asthma needs approximately 16 inhalers a year!"
Lot more action needed on asthma
Dr Bissell recommended that at the country level, we need to write national asthma management guidelines, based on standardized management of asthma (pro-equity) and essential medicines. We also need to get WHO essential medicines on to the national EMLs. Countries must resist undue pharmaceutical influence in policy making particularly related to setting up EMLs. Countries must strengthen and monitor procurement, distribution, prescription and education practices on asthma.