MINI-SYMPOSIUM: THE BURDEN OF ASTHMAThe burden of asthma in children: a Latin American perspective
Section snippets
INTRODUCTION
Worldwide, epidemiological studies in asthma have shown high prevalence and high morbidity, and the burden of asthma is now receiving more attention from health services and researchers. The burden includes direct/indirect costs and the impact on the quality of life of sufferers. Direct costs include hospitalisations, emergency visits, office visits, medication, diagnostic tests and procedures. The most important indirect costs include loss of working days and school absence.1
Studies on asthma
COST-EFFECTIVENESS OF ASTHMA TREATMENT
Studies on the cost-effectiveness of asthma treatment have been conducted in developed countries, but more studies are needed.2, 3, 4, 5 Inhaled steroids have been shown to be cost-effective compared with sodium cromoglycate and montelukast in the reduction of hospital admissions and emergency room visits.6, 7
Asthma education in association with anti-inflammatory treatment has led to decreased asthma morbidity and reduced asthma-related costs.8 Similar studies in Latin America are not
EPIDEMIOLOGICAL DATA IN LATIN AMERICA
The International Study of Asthma and Allergy in Childhood (ISAAC) found that the prevalence of wheezing in the last 12 months in adolescents aged 13–14 years in Latin American countries ranges from 5 to 10% in Mexico and Argentina and from 20 to 25% in Brazil, Peru and Costa Rica; in the latter group, the prevalence is among the highest of all the countries included in ISAAC.10 These rates show the important morbidity seen in children and teenagers in Latin America. The causes of these high
ADMISSIONS
The admission rate for asthma in children in a given population is an indicator of the quality of available health care. It could reflect the health policy directed towards asthma care and its impact in this age group. In Lima, Peru, acute attacks were responsible for 25% of the total number of all hospitalisations in 1991, mainly in children aged 5–9 years.22 In this study, the majority of admissions due to asthma were children. The same figures were found in Porto Alegre, Brazil where 85% of
RE-ADMISSIONS
Studies on re-admission rates in Latin America are scarce. A Brazilian study showed that 94% of children and adolescents were re-admitted within 18 months of their first admission. However, when the age at first admission was 12 months or younger, re-admission was sooner (34.0% re-admitted within the first month). The re-admission rate in children under 2 years of age was even higher (87.0%). Age between 13 and 24 months and asthma severity were the greatest risk factors for re-admission (3.55
FACING THE BURDEN OF ASTHMA IN LATIN AMERICA
Due to difficulties related to the affordability of inhaled medicines for the majority of the population of Latin America, a specific public health policy should be planned to face the magnitude of asthma and its consequences. In other words, the implementation of a well-planned asthma programme at a national level is necessary and unavoidable.
There are three ways to build these programmes:
- (1)
make inhaled asthma medication affordable;
- (2)
improve training for healthcare providers (especially those
REDUCTION OF THE IMPACT OF ASTHMA EXACERBATIONS
Asthma attacks are a significant contributory factor when considering the burden of asthma, with children at most risk.31 To deal with this problem, it is necessary to include a specific approach for exacerbation in the asthma programme. Every patient must have a written plan for exacerbations including how to recognise the severity, and a step-by-step orientation on the use of bronchodilators, spacers and the early use of oral steroids.17 In the previously mentioned study on asthma admissions,
PROVIDING INHALED CORTICOSTEROIDS AND BRONCHODILATORS
In order to implement a successful asthma programme, it is crucial to provide free access to the medication. Unfortunately, in South America, the budgets of the health systems are generally too small. In order to improve this situation, an aggressive policy must be implemented.
One strategy would be to redirect already earmarked funds to buy anti-inflammatory drugs. The costs would be balanced by the reduction of re-admissions. There are data to suggest that with the reduction of one
TRAINING HEALTH PERSONNEL
When planning courses for healthcare providers, we need to bear in mind that they may have fragmented and out-of-date information. It is necessary to unify and provide them with the newest guidelines for treating asthma.
Continuous educational courses in the management of asthma (and allergic rhinitis), including the differential diagnosis of wheezing disorders, should be given to all members of the health team, not only the physicians. It is crucial to teach healthcare workers how to deal with
EDUCATING PATIENTS, PARENTS AND RELATIVES
Given that persistent asthma requires a long-term approach, patient education should be considered as a continuous process by the health team. At each appointment, inhalation technique, correct use of prescribed drugs and the need for regular physical activity must be emphasised. It is also necessary to stress the importance of regular check-ups and allergy avoidance procedures. The educational process may include meetings with parents and patients to clarify doubts about asthma management.
PROVIDING REGULAR ACCESS FOR CONSULTATION
As is well known, asthma prevalence in Latin America is very high; unless regular consultations are available, no reduction in the burden of this disease is possible. Massive training for health professionals and even distribution in peripheral clinics in every city would improve accessibility and lead to regular consultations. Availability for regular appointments (e.g. every 2 months) would strengthen the relationship between the health team and the asthmatic, leading to better compliance.
PRACTICE POINTS
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Anti-inflammatory asthma treatment reduces admissions and is cost-effective.
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Asthma education programmes need implementing with involvement of the whole health team.
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To reduce the burden of asthma in Latin America, it is important to have a national asthma programme.
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A written asthma plan to reduce re-admissions and exacerbations is vital.
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An asthma programme should have a multi-disciplinary team approach.
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Regular consultations are essential for asthma control.
RESEARCH DIRECTIONS
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Cost-effectiveness of asthma programmes in reducing visits to emergency rooms and hospital admissions in Latin America.
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The reduction of antibiotic use in children with asthma before and after continuous anti-inflammatory treatment.
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The role of poor housing conditions, overcrowding, malnutrition, early exposure to infections and parasites in asthma prevalence in Latin America.
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The role of low educational levels of the patient's parents in the burden of asthma.
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