In-depth: The state of asthma in SA
Asthma is a disease that can easily be controlled through the correct use of medications, yet in many low-and-middle-income countries like South Africa, many still die due to lack of effective management of this disease. According to estimates published in the Global Asthma Report 2022, South Africa ranks third out of 28 low-and-middle-income countries for asthma-related mortality. According to the report, although many asthma-related deaths are preventable, about 1 000 people die from asthma worldwide per day.
The 2022 edition of the report was recently released and discussed at a plenary session at this year’s Union World Lung conference.
The report states that asthma is often overlooked by governments in their plans to address non-communicable diseases (NCDs). “And little progress [has been made] in improving access to asthma management and medicines,” the report reads. Also flagged as a concern is that asthma medicines are often “unavailable, unaffordable, or are of unreliable quality, resulting in unnecessary burden and mortality from asthma”. “Patients are dying of asthma in low-income countries from lack of effective management,” the report states.
Children mostly affected
South Africa, the report states, is one of the countries with the highest prevalence of childhood asthma on the African continent. The report also notes “a striking increase in severe [asthma] symptoms in adolescents in Cape Town” where data shows that 8.8% of children aged 13 to 14 have self-reported smoking.
Professor Heather Zar, a physician who specialises in paediatrics and paediatric lung health, concurs that the asthma burden is particularly high in children and adolescents. “Asthma is the commonest non-communicable disease in children and adolescents in South Africa and globally,” Zar says.
But, says Professor Elvis Irusen, Divisional Head of Pulmonology at the Department of Medicine at Stellenbosch University, data on the burden of asthma in South Africa is patchy. He says global estimates are our best indication of the burden of asthma in South Africa. “We do have some data, [but] we don’t have good data. In the past, in some of the surveys we feature as one of the top ten countries for asthma mortality in the world,” he says.
Asthma is the commonest non-communicable disease in children and adolescents in South Africa and globally. – Prof Heather Zar
According to Professor Innes Asher, chair of the Global Asthma Network who presented at the conference, overall, there has been a decline in asthma-related deaths seen from 2011 to 2015 but the number of deaths, which are largely preventable, in low- and middle-income countries remain high.
What is asthma?
Zar explains that asthma is a disease of the airway where a person’s airway narrows due to inflammation and the muscle of the airway constricting. This inflammation, she says, can be caused by a number of things. For someone who is genetically susceptible or has a predisposition to asthma, there is a range of different things that can trigger a response that causes the airways to narrow. This can range from an inhaled irritant like cigarette smoke, allergens like pollen, grass or house dust, or an infection, particularly a viral infection. Other examples of triggers are cold air, exercise, and some animals.
When a person is exposed to an allergen or trigger, the tubes in the lungs – so the airways of the bronchi – become inflamed causing the muscles of the airways to spasm which closes the tubes. Then it’s much like a hosepipe. When you narrow the hosepipe, water can’t flow in. And so, air can’t get into the lungs and then patients have difficulty breathing. – Prof Elvis Irusen
Explaining what occurs in the body when someone who is genetically susceptible to asthma has an asthma attack, Irusen says, “When a person is exposed to an allergen or trigger, the tubes in the lungs – so the airways of the bronchi – become inflamed causing the muscles of the airways to spasm which closes the tubes.” This can happen to adults or children. “Then it’s much like a hosepipe,” he says. “When you narrow the hosepipe, water can’t flow in. And so, air can’t get into the lungs, and then patients have difficulty breathing. If you [someone who doesn’t have asthma] breathes in any of those [allergens or triggers] nothing will happen. But if one is asthmatic and they breathe these in, it will trigger this allergy in the airways.”
He says some people do not initially have an asthmatic reaction to an allergen or trigger but may develop an allergy to this allergen or trigger after exposure over time. This often happens in the workplace. Irusen refers to this as occupational asthma. “These are people who become allergic to things in the workplace. So, lots of industries but a common one is the spray-painting industry, the wood industry, and the baking industry. You’d be surprised – there’s a whole host of industries where they work with things that can cause this allergy and develop into asthma,” he says.
Diagnosis in public healthcare sector
At the conference, Asher told delegates that despite the availability of asthma medications in South Africa, the lack of asthma diagnosis is a barrier to care.
Irusen says that there is no definitive test for asthma. Instead, a diagnosis is based on symptoms and whether the patient responds to asthma medications. Typical symptoms are when a person’s chest closes up after being exposed to a trigger or allergen. Sometimes the person has other allergy symptoms that are already present, like itchy eyes, runny nose, or itchy skin.
If examined by a doctor, listening to the chest will reveal whistling sounds, which will lead the doctor to suspect asthma. A low-tech device called a peak flow meter may then be employed to test lung function. He says the device works without electricity and contains a little tube with a lever that the patient blows into and, depending on how strongly the air flows into the tube, the lever lifts to a certain measurement. If the patient’s measurement is below normal, it means that the airflow from their lungs isn’t good. This can also be done using a computerised lung function machine.
Testing the airflow can then be followed by the patient being given an asthma pump – also known as an inhaler – to relax the muscles of the airways. The test – whether it’s a peak flow or computerised lung function machine – is then repeated. If airflow has improved, it means the muscles have started to relax, and this is normally enough to confirm an asthma diagnosis.
Asthma is mainly treated using inhalers. Zar explains that in those living with asthma who experience frequent symptoms, two inhalers could be used to treat the symptoms. One is a pump that provides inhaled corticosteroids, which reduces airway inflammation. This can be combined with a long-acting bronchodilator, which relaxes the muscles of the airways.
“For an acute asthma attack, a quick-acting bronchodilator, oral steroids, and oxygen may be needed. Increasing the frequency or dose of a long-acting bronchodilator with inhaled steroid is also used in older children or adults,” she adds.
If one takes more of the prevention [inhaler], then you don’t need the other one to open up their lungs that much. That’s another important lesson and understanding that patients don’t [always] have. – Irusen
Inhalers are a very effective form of treatment, according to Irusen, as the medicine is delivered directly into the lungs. He adds that someone living with asthma will typically be given two inhalers to use. One to relax the muscle of the airways used during an asthma attack and the other to reduce inflammation in the airways in order to prevent or reduce asthma attacks. He says using the first inhaler brings immediate relief and is often overused by patients. While the second type of inhaler – and its purpose – is not always well understood by patients and thus not used as often as needed. This causes a snowball effect, where the person living with asthma who isn’t taking the prevention treatment experiences more asthma attacks, which leads to an overreliance on the first inhaler.
“If one takes more of the prevention [inhaler], then you don’t need the other one to open up their lungs that much. That’s another important lesson and understanding that patients don’t [always] have,” Irusen says.
When asthma is uncontrolled, according to Zar it can severely affect someone’s quality of life. The individual could miss work or school, sleep poorly, and be unable to participate in sports. “Almost all the symptoms of asthma are controllable and with available effective asthma pumps, asthmatics should have normal lives. There are famous athletes who have asthma, but who compete globally with effective asthma treatment,” she says.
Irusen says asthma can range in severity from mild to severe and could lead to death. And people living with asthma, regardless of the typical range of symptoms, are at risk of a severe attack and death if they don’t receive treatment.
Almost all the symptoms of asthma are controllable and with available effective asthma pumps, asthmatics should have normal lives. – Zar
Mitigating the asthma disease burden
According to Zar, there is no primary prevention method available to keep an individual from developing asthma but secondary prevention of asthma attacks is possible through avoiding triggers or allergens.
“Use of a controller medication, mainly inhaled corticosteroids, is effective to control symptoms and prevent attacks,” Zar says. “The focus should be on [improved] diagnosis [because] around 30% of those with severe asthma have not been diagnosed.”
When asked what else could be done in the health system to help mitigate the disease burden of asthma, Zar says there needs to be “better use of inhaled medicines to prevent attacks; proper use of inhalers with a spacer especially for children or for those with an acute attack.”
According to Irusen, asthma is a disease that can be easily controlled but due to a poor understanding of the disease and use of inhalers combined with poor adherence, it often isn’t.
He explains that some of the issues that influence adherence are a lack of education among patients and healthcare workers on the proper use of asthma inhalers and the importance of adherence, particularly in using the inhalers that prevent asthma attacks. People living with asthma who rely on the public healthcare sector are provided with asthma medications but might be prevented from accessing these because of socio-economic reasons that keep them from attending clinics.
Workplaces where employees can run the risk of developing “occupational asthma” need to ensure they meet the appropriate safety standards and provide personal protective equipment for employees to protect them from potential allergens or triggers, according to Irusen.
He says special care should also be taken with women during pregnancy – either to detect undiagnosed asthma in the mother-to-be or to ensure existing asthma is properly controlled, as some pregnant women can experience a worsening of asthma symptoms during this time.
What the health department is doing
According to the Global Asthma Report, governments often overlook asthma in their plans to address non-communicable diseases “and have made little progress in improving access to asthma management and medicines, especially the ICS (Inhaled corticosteroids) crucial for the long-term control of asthma.”
In South Africa, however, health spokesperson Foster Mohale says asthma is included in the National Strategic Plan (NSP) for the Prevention and Control of Non-Communicable Diseases (2022-2027) that the department launched recently. “The aim of the NSP is to progressively improve wellness and reduce premature morbidity, disability, and mortality from non-communicable diseases, which include asthma through the continuum of care across the life course,” he says.
[Governments] have made little progress in improving access to asthma management and medicines, especially the ICS (Inhaled corticosteroids) crucial for the long-term control of asthma. – World Asthma Report, 2022
“In addition to NSP,” he says, “the department has employed healthcare workers who provide comprehensive healthcare services to the patients or clients. The services rendered are informed by evidence-based clinical guidelines and tools including Adult Primary Care and Standard Treatment Care Guidelines, which are updated on a regular basis. These clinical guidelines capacitate healthcare workers on prevention and control of diseases/conditions, and provision of routine care, among others.”
Did you enjoy today's plenary session 'Asthma in low-income and middle-income countries'? To learn more about the state of asthma, read the latest Global Asthma Report 2022 published in the International Journal of Tuberculosis and Lung Disease: https://t.co/X46dwrzvOl #UnionConf pic.twitter.com/q28rABmwAY
— The Union (@TheUnion_TBLH) November 10, 2022
When asked about the report’s claims that a lack of asthma diagnosis remains a big barrier to care in the country, Mohale says the department is not aware that this is a problem, however, training on asthma is available for healthcare professionals and managers and is incorporated in the Adult Primary Care (APC) guideline. “The APC clinical tool and training package is approved by the NDoH and is currently being implemented through the provincial Regional Training Centres,” he says.
Among the recommendations to governments, the report states that they should “use asthma programme data to track improvements in diagnosis and reductions in emergency visits and hospital admissions, and to quantify the effectiveness of and need for essential asthma medicines”. Among the recommendations is also that “governments must ensure that their country has a national asthma programme with curriculum, education, and management guidelines, including essential asthma medicines, and that asthma training materials are current and reach all relevant healthcare workers.”
We have qualified healthcare professionals who diagnose and treat asthma at the facilities. Training on asthma is available for healthcare professionals and managers and is incorporated in the Adult Primary Care (APC) guideline. – Foster Mohale, health spokesperson
When asked if there are any programmes besides the NSP on control of NCDs that focused exclusively on asthma and improving diagnosis in the country, Mohale says, “We have qualified healthcare professionals who diagnose and treat asthma at the facilities. Training on asthma is available for healthcare professionals and managers and is incorporated in the Adult Primary Care (APC) guideline.” He says the APC clinical tool and training package is approved by the national department and is currently being implemented through the provincial regional training centres. Training is ongoing and wherever a gap in knowledge or skill is identified, training is instituted,” he says.
Responding to questions relating to tracking programmes to see if there has been an improvement in asthma diagnoses, emergency room visits, and mortality, he says, “There are clinicians at our facilities who manage asthma and monitor patient responses to treatment prescribed. The management of asthma, which includes how to diagnose the condition is included in the Adult Primary Care guidelines which the healthcare providers are trained on.”