The burden of asthma in children: a Latin American perspective

doi:10.1016/j.prrv.2004.11.002

Paediatric Respiratory Reviews

Volume 6, Issue 1, March 2005, Pages 8-13

https://doi.org/10.1016/j.prrv.2004.11.002 Get rights and content

Summary

Worldwide, studies on asthma prevalence have shown major rises over the last 30 years. The impact on the burden of asthma is being increasingly recognised. In some countries in Latin America, the prevalence of asthma is among the highest in the world. Asthma admissions are very common in children, leading to high costs for the health systems of those countries. Unfortunately, Latin America has limited resources to pay for appropriate treatment. The main goals of the international guidelines for asthma treatment are not being met. However, asthma programmes operating in some countries are showing promising results in reducing asthma admissions and consequently decreasing the burden of asthma. Local adaptation of international guidelines must be implemented in order to decrease costs and optimise outcomes.

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

•
Anti-inflammatory asthma treatment reduces admissions and is cost-effective.
•
Asthma education programmes need implementing with involvement of the whole health team.
•
To reduce the burden of asthma in Latin America, it is important to have a national asthma programme.
•
A written asthma plan to reduce re-admissions and exacerbations is vital.
•
An asthma programme should have a multi-disciplinary team approach.
•
Regular consultations are essential for asthma control.

RESEARCH DIRECTIONS

•
Cost-effectiveness of asthma programmes in reducing visits to emergency rooms and hospital admissions in Latin America.
•
The reduction of antibiotic use in children with asthma before and after continuous anti-inflammatory treatment.
•
The role of poor housing conditions, overcrowding, malnutrition, early exposure to infections and parasites in asthma prevalence in Latin America.
•
The role of low educational levels of the patient's parents in the burden of asthma.

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Cited by (52)

Asthma Control and Cost in Latin America
2014, Value in Health Regional Issues
Citation Excerpt :
In addition, mortality rates from asthma are higher in Latin American countries than in other regions [2,3]. Asthma is also a significant cause of missed school and work in Latin America [4]. Although medications that have been shown to be highly effective at managing asthma have been available since the 1990s [5], most of the patients do not have well-controlled asthma, particularly in Latin American countries [6].
Few patients with asthma have disease that is well-controlled, particularly in Latin American countries. The purpose of this study was to investigate whether partly controlled and uncontrolled asthma are associated with increased costs for asthma-related medications and health care utilization compared with well-controlled asthma in five Latin American countries.
Using the Global Initiative for Asthma guidelines, we classified respondents from the Latin American Asthma Insights and Management survey into those with well-controlled, partly controlled, and uncontrolled asthma and compared the utilization of health care services and costs among these groups.
Most respondents to our survey (93%) had asthma that was classified as partly controlled or uncontrolled. Across all countries, patients whose asthma was partly controlled or uncontrolled had greater use of asthma-related medications and medical services than did patients whose asthma was well-controlled. After adjusting for age, sex, and country of residence, total costs for asthma-related medications and health care were greater in patients whose asthma was classified as partly controlled and uncontrolled.
Our findings indicate that patients with asthma that are not well-controlled used more health care resources and had greater medical costs in Latin America.
Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: A community guide systematic review
2011, American Journal of Preventive Medicine
Citation Excerpt :
Environmental tobacco smoke creates a substantial risk for childhood and adult asthma. Smoking is a major cause of respiratory symptoms and diseases including asthma.6–10 Asthma episodes can be triggered by not only adverse direct effects of air pollution on the respiratory system, but also psychological factors.
A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit–cost ratios, and incremental cost-effectiveness ratios).
Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost–benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information).
Program costs per participant per year ranged from $231–$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit–cost ratios ranged from 5.3–14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30–$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12–$57 (in 2007 U.S.$) per asthma symptom–free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12–$57.
The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost–benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.
Uniform definition of asthma severity, control, and exacerbations: Document presented for the World Health Organization Consultation on Severe Asthma
2010, Journal of Allergy and Clinical Immunology
Asthma is a global health problem affecting around 300 million individuals of all ages, ethnic groups and countries. It is estimated that around 250,000 people die prematurely each year as a result of asthma. Concepts of asthma severity and control are important in evaluating patients and their response to treatment, as well as for public health, registries, and research (clinical trials, epidemiologic, genetic, and mechanistic studies), but the terminology applied is not standardized, and terms are often used interchangeably. A common international approach is favored to define severe asthma, uncontrolled asthma, and when the 2 coincide, although adaptation may be required in accordance with local conditions. A World Health Organization meeting was convened April 5-6, 2009, to propose a uniform definition of severe asthma. An article was written by a group of experts and reviewed by the Global Alliance against Chronic Respiratory Diseases review group. Severe asthma is defined by the level of current clinical control and risks as “Uncontrolled asthma which can result in risk of frequent severe exacerbations (or death) and/or adverse reactions to medications and/or chronic morbidity (including impaired lung function or reduced lung growth in children).” Severe asthma includes 3 groups, each carrying different public health messages and challenges: (1) untreated severe asthma, (2) difficult-to-treat severe asthma, and (3) treatment-resistant severe asthma. The last group includes asthma for which control is not achieved despite the highest level of recommended treatment and asthma for which control can be maintained only with the highest level of recommended treatment.
The effect of family routines on care for inner city children with asthma
2010, Journal of Pediatric Nursing
This article provides the results of a study utilizing baseline data from the School-Based Asthma Therapy Trial, an ongoing comprehensive school-based intervention for urban children. We examined the effect of family routines as measured by the Asthma Routines Questionnaire on asthma care measures of trigger control and medication adherence, as well as on parental quality of life. We found that families with more asthma routines had better adherence with preventive medications (r = .36) and less exposure to environmental triggers (r = −.22). These findings suggest that assisting families in developing routines around asthma care might improve preventive care for urban youth.
Urbanisation is associated with prevalence of childhood asthma in diverse, small rural communities in Ecuador
2011, Thorax
Citation Excerpt :
There is evidence that the prevalence of allergic diseases is increasing with increasing levels of urbanisation.9 10 Nevertheless, such studies have not explored in detail which elements of the process of urbanisation are responsible, and there are no published studies evaluating the effects of urbanisation on asthma prevalence in Latin America.11 12 Urbanisation is defined as a gradual process of transformation where rural areas and their populations lose their rural characteristics and gradually become urban.13
Studies conducted in transitional communities from Africa and Asia have pointed to the process of urbanisation as being responsible for the increase in asthma prevalence in developing regions. In Latin America, there are few published data available on the potential impact of urbanisation on asthma prevalence. The aim of the present study was to explore how the process of urbanisation may explain differences in asthma prevalence in transitional communities in north-eastern Ecuador.
An ecological study was conducted in 59 communities in Esmeraldas Province, Ecuador. Indicators of urbanisation were grouped into three indices representing the processes associated with urbanisation: socioeconomic, lifestyle and urban infrastructure. Categorical principal components analysis was used to generate scores for each index and a fourth index—a summary urbanisation index—was derived from the most representative variables in each of the three indices. The authors analysed the associations between community asthma prevalence and the indices, as well as with each indicator variable of every group. The overall prevalence of asthma was 10.1% (range 0–31.4% between communities). Three of the four indices presented significant associations with community asthma prevalence: socioeconomic (r=0.295, p=0.023), lifestyle (r=0.342, p=0.008) and summary urbanisation index (r=0.355, p=0.006). Variables reflecting better socioeconomic status and a more urban lifestyle were associated with greater asthma prevalence.
These data provide evidence that the prevalence of asthma increases with increasing levels of urbanisation in transitional communities, and factors associated with greater socioeconomic level and changes towards a more urban lifestyle may be particularly important.
Asthma exacerbations in the pediatric emergency area: Evaluation and prospects for improvement of pre-hospital care
2023, Allergologia et Immunopathologia

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MINI-SYMPOSIUM: THE BURDEN OF ASTHMAThe burden of asthma in children: a Latin American perspective

Summary

Section snippets

INTRODUCTION

COST-EFFECTIVENESS OF ASTHMA TREATMENT

EPIDEMIOLOGICAL DATA IN LATIN AMERICA

ADMISSIONS

RE-ADMISSIONS

FACING THE BURDEN OF ASTHMA IN LATIN AMERICA

REDUCTION OF THE IMPACT OF ASTHMA EXACERBATIONS

PROVIDING INHALED CORTICOSTEROIDS AND BRONCHODILATORS

TRAINING HEALTH PERSONNEL

EDUCATING PATIENTS, PARENTS AND RELATIVES

PROVIDING REGULAR ACCESS FOR CONSULTATION

PRACTICE POINTS

RESEARCH DIRECTIONS

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Ann Allergy

Allergol Immunopathol (Madr)

Chest

Pediatr Respir Rev

An update on the health economics of asthma and allergy

Curr Opin Allergy Clin Immunol

Cost effectiveness of pediatric asthma treatments

J Allergy Clin Immunol

Cost effectiveness of guidelines advice for children with asthma

Pediatr Pulmonol

Impact of inhaled anti-inflammatory therapy on hospitalisations and emergency department visits for children with asthma

Pediatrics

An update on the health economic of asthma and allergy

Curr Opin Allergy Clin Immunol

The effect of inhaled fluticasone proprionate in the treatment of young asthmatic children: a dose comparison study

Am J Respir Crit Care Med

Worldwide variations in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC

Lancet

Influences in allergy: epidemiology and the environment

J Allergy Clin Immunol

Worldwide trends in asthma mortality during the twentieth century

Tendencia de la mortalidad por asma em México

Bol Oficina Sanit Panam

MINI-SYMPOSIUM: THE BURDEN OF ASTHMA
The burden of asthma in children: a Latin American perspective