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The increasing burden of asthma in South African children: A call to action

Authors:
Refiloe Masekela at University of KwaZulu-Natal
Refiloe Masekela
Claudia L Gray
Claudia L Gray
Robin J Green at University of Pretoria
Robin J Green
Ahmed Ismail Manjra at University of KwaZulu-Natal
Ahmed Ismail Manjra
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Abstract

Background. Asthma is a heterogeneous condition characterised by chronic inflammation and variable expiratory airflow limitation, as well as airway reversibility. The burden of asthma in children is increasing in low-and middle-income countries and remains under-recognised and poorly managed. Objectives. To quantify the burden of asthma in the South African (SA) population and identify the risk factors associated with disease severity in the local context. Methods. The SA Childhood Asthma Working Group (SACAWG) convened in January 2017 with task groups, each headed by a section leader, constituting the editorial committee on assessment of asthma epidemiology, diagnosis, control, treatments, novel treatments and self-management plans. The epidemiology task group reviewed the available scientific literature and assigned evidence according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Conclusions. Asthma in children remains a common condition, which has shown an increasing prevalence in urban and rural populations of SA. Of concern is that almost half of children in urban communities experience severe asthma symptoms, and many asthmatics lack a formal diagnosis and thus access to treatment. Exposure to tobacco smoke and living in highly polluted areas increase the severity of wheezing in young children. © 2018, South African Medical Association. All rights reserved.
Available via license: CC BY-NC 4.0
Content may be subject to copyright.
537 July 2018, Vol. 108, No. 7
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Asthma is a heterogeneous condition characterised by chronic
inflammation and variable expiratory airflow limitation,[1] as well as
airway reversibility. Worldwide, asthma is the most common chronic
non-communicable disease in children. The most recent global
estimate of asthma in adults and children (2008 - 2010) suggests that
as many as 334 million people have asthma.[2] The historical view of
asthma being a disease of high-income countries no longer holds.
Most people affected reside in low- and middle-income countries,
where asthma prevalence is estimated to be increasing fastest,
while plateauing in high-income countries. Asthma carries a high
economic cost to society and the healthcare system, with costs being
both direct (hospitalisation, medications and outpatient visits) and
indirect (related to absenteeism and loss of productivity). Improving
access to care and medications, coupled with use of and adherence
to evidence-based treatments, can reduce the economic burden of
asthma.
Accurate diagnosis of childhood asthma may be especially
challenging in African settings, where respiratory infectious
diseases predominate. In non-English-speaking populations, asthma
terminology may not be easily translated into local languages. In
resource-constrained areas, poor access to healthcare and lack of
availability of lung function testing to confirm the diagnosis also
contribute to delayed diagnosis.[3] Questionnaire-based studies must
be interpreted with caution, as these often rely on literate populations
who understand the meaning of words such as ‘wheezing’ and
‘asthma’; this group of individuals may be prone to recall bias.[3]
Despite these limitations, the International Study of Asthma and
Allergies in Childhood (ISAAC) has provided the most reliable
global, comparative data on the prevalence of asthma and other
allergic conditions in children, using standard written and video
questionnaires, enabling comparison of asthma prevalence between
different parts of the world.
Objectives
We reviewed the current literature on the burden of asthma in South
Africa (SA) in the context of other low- and middle-income countries
and on rural and urban differences in prevalence and severity of asthma.
Methods
The SA Childhood Asthma Working Group (SACAWG) convened in
January 2017 with six task groups, each headed by a leader (Appen-
dix A), constituting the editorial committee on assessment of asthma
epidemiology, diagnosis, control, treatments, novel treatments and
self-management plans. The task groups reviewed the available
scientific literature on the burden of asthma from high-quality
datasets and any local data on asthma prevalence and severity in
This open-access article is distributed under
Creative Commons licence CC-BY-NC 4.0.
e increasing burden of asthma in South African children:
A call to action
R Masekela,1 PhD; C L Gray,2 PhD; R J Green,3 PhD, DSc; A I Manjra,4 FCPaed (SA), M Clin Pharm; F E Kritzinger,5 Cert Pulmonology (SA) Paed;
M Levin,2 PhD; H Zar,2 PhD; on behalf of the South African Childhood Asthma Working Group
1 Inkosi Albert Luthuli Central Hospital and Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences,
University of KwaZulu-Natal, Durban, South Africa
2 Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and Medical Research Council Unit on Child and
Adolescent Health, Faculty of Health Sciences, University of Cape Town, South Africa
3 Steve Biko Academic Hospital and Department of Paediatrics and Child Health, School of Medicine, Faculty of Health Sciences,
University of Pretoria, South Africa
4 Private Practice, Life Westville Hospital, Durban, South Africa
5 Netcare Christiaan Barnard Memorial Hospital, Cape Town; and Department of Paediatrics and Child Health, Faculty of Medicine and
Health Sciences, Stellenbosch University, Cape Town, South Africa
Corresponding author: R Masekela (masekelar@ukzn.ac.za)
Background. Asthma is a heterogeneous condition characterised by chronic inflammation and variable expiratory airflow limitation,
as well as airway reversibility. The burden of asthma in children is increasing in low- and middle-income countries and remains under-
recognised and poorly managed.
Objectives. To quantify the burden of asthma in the South African (SA) population and identify the risk factors associated with disease
severity in the local context.
Methods. The SA Childhood Asthma Working Group (SACAWG) convened in January 2017 with task groups, each headed by a section
leader, constituting the editorial committee on assessment of asthma epidemiology, diagnosis, control, treatments, novel treatments and
self-management plans. The epidemiology task group reviewed the available scientific literature and assigned evidence according to the
Grades of Recommendation Assessment, Development and Evaluation (GRADE) system.
Conclusions. Asthma in children remains a common condition, which has shown an increasing prevalence in urban and rural populations
of SA. Of concern is that almost half of children in urban communities experience severe asthma symptoms, and many asthmatics lack
a formal diagnosis and thus access to treatment. Exposure to tobacco smoke and living in highly polluted areas increase the severity of
wheezing in young children.
S Afr Med J 2018;108(7):537-539. DOI:10.7196/SAMJ.2018.v108i7.13162
538 July 2018, Vol. 108, No. 7
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children, and graded the level of evidence and recommendations
based on the current evidence.
Asthma prevalence
Worldwide asthma prevalence
ISAAC phase I and phase III studies, using identical questionnaires,
were performed ~7 years apart and enabled the investigation of time
trends with regard to the symptoms of asthma. Studies were carried
out in two age groups: children aged 6 - 7 years and adolescents aged
13 - 14 years.[4-6] The large number of children surveyed (>1 million),
centres (N=233) and countries (N=98) that participated in ISAAC
phase III, made this the most comprehensive global survey of child-
hood asthma to date.[7]
The current overall worldwide prevalence of asthma (ISAAC
phase III), measured by reported symptoms in children aged 6 - 7 years
and 13 - 14 years, was 11.5% and 14.1%, respectively.[8] There was a
significant variation in the prevalence of asthma between countries
(Table 1). The prevalence of asthma in 13 - 14-year-old black African
children was 15.3%, which was higher than the global average.[6]
Moreover, the prevalence of childhood asthma in African countries
is increasing, compared with that in many high-income settings,
where it has stabilised or is decreasing.[3,4] Only two African centres in
addition to SA centres included the younger age group of 6 - 7-year-
olds. In these centres in Nigeria and Mozambique, the 12-month
prevalence of wheeze was 5.6% and 13.3%, respectively.[9] Overall,
in Africa, the 12-month prevalence of wheeze was 10.0% in the 6 -
7-years age group. Globally, the current prevalence of wheeze in this
age group is 11.5% and that of severe wheeze 4.9%.
The high, increasing prevalence of childhood asthma in Africa
reported by ISAAC has been supported by studies measuring
bronchial hyper-responsiveness (BHR) for diagnosing asthma. Such
studies have shown a consistent increase in asthma prevalence in
rural and urban settings in African countries.[10-14] Furthermore, black
African children with asthma have been reported to have more severe
symptoms than those in high-income countries, which may relate
to factors such as lack of diagnosis, access to care, affordability of
therapy, as well as environmental irritants and genetic susceptibility
to more severe disease, or a combination of these.[15]
Asthma prevalence in South Africa
The prevalence of asthma in SA children was measured using the
ISAAC methodology in Cape Town in 1995 (phase I) and repeated
7 years later in 2002 (phase III). Children aged 13 - 14 years, from all
population groups, were included in the study.[8] In 1995, a total of
5 178 child ren completed the questionnaire and in 2002, 5 037 child -
ren responded.
The prevalence of lifetime and 12-month wheezing increased
between phase I and phase III from 27.7% to 33.1% and 16.0% to
20.3%, respectively (Table 2).[8] Similarly, the 12-month prevalence of
night waking with wheeze, severe wheeze, exercise-induced wheeze
and nocturnal cough all increased significantly from 1995 to 2002.
Worryingly, approximately half of all children with asthma had
severe, uncontrolled symptoms.[7,8] ISAAC phase III was conducted
in a rural population in Polokwane, Limpopo, in 4 660 children
aged 13 - 14 years. The 12-month prevalence of asthma was 18%,
while the prevalence of severe asthma symptoms in Cape Town
was less (6.6%).[6] Using the ISAAC phase III methodology in a
younger cohort (N=2437) of 6 - 7-year-old black African children in
Polokwane, the 12-month prevalence of wheeze and severe wheeze
was 11.2% and 5.7%, respectively.[9] In this cohort, various potential
risk factors and asthma symptoms were investigated. Living in a rural
area was protective, which significantly decreased the likelihood of
wheeze by 31%. Risk factors for the increased likelihood of wheeze
included: exposure to environmental tobacco smoke (77%), eczema
(104%) and rhinoconjunctivitis (226%) symptoms. The presence of
rhinoconjunctivitis increased the likelihood of severe wheeze by 107%.[9]
Studies in SA children measuring BHR confirmed the increase in
asthma prevalence. In 1979, the first study of asthma prevalence in SA
Table 1. Current prevalence of asthma symptoms by world region in 6 - 7-year and 13 - 14-year age groups as measured in ISAAC
phase III*
Region
6 - 7 years 13 - 14 years
N n %N n %
Africa 5 865 589 10.0 66 308 10 168 15.3
Asia-Pacific 59 979 5 719 9.5 99 634 8 731 8.7
Eastern Mediterranean 40 573 3 824 9.4 51 705 4 801 9.2
Indian subcontinent 50 092 3 392 6.7 55 783 3 884 6.9
Latin America 93 774 16 256 17.3 165 900 26 350 15.9
North America 4 012 767 19.1 141 009 30 427 21.6
Northern and Eastern Europe 42 548 3 715 8.7 72 057 7 009 9.7
Oceania 13 888 3 020 21.7 36 299 6 301 17.4
Western Europe 77 722 7 487 9.6 107 673 15 483 14.4
Global total 388 811 44 799 11.5 798 685 112 630 14.1
ISAAC = International Study of Asthma and Allergies in Childhood; n = number of participants with a positive asthma-screening questionnaire.
*Adapted from Aït-Khaled et al.[6]
Table 2. Current prevalence of asthma symptoms (12-month prevalence rate of wheeze) by region in South Africa in 6 - 7-year and
13 - 14-year age groups as measured in ISAAC phase I and phase III
Region
6 - 7 years 13 - 14 years
N%N%
Cape Town (ISAAC I) --5 178 16.0
Cape Town (ISAAC III) --5 037 20.3
Polokwane (ISAAC III) 2 437 11.2 4 660 18.0
ISAAC = International Study of Asthma and Allergies in Childhood.
539 July 2018, Vol. 108, No. 7
CME
children found a 30-fold higher prevalence in urban (3.1%) compared
with rural (0.01%) Xhosa children aged 7 - 9 years.[10] A follow-up
study in 2003 reported an increase in asthma prevalence in urban
and rural children, with a reduction in the urban-rural gradient.[13]
Increased BHR was associated with rural children adopting an urban
lifestyle. A later study measuring BHR also confirmed an increase in
asthma prevalence in urban (15%) and rural (9%) Xhosa children,
with a reduction in the urban-rural gradient.[14] Obesity was identified
as a risk factor for an increase in BHR. The most recent study showed
BHR in 16% of peri-urban black African teenagers, with high rates of
allergen sensitisation in individuals with BHR.[15]
Risk factors for asthma
Eczema is an important risk factor for asthma, and longitudinal
studies have shown that from one-third to one-half of children
with eczema develop asthma.[17] In a SA study of 100 children with
atopic dermatitis, 39% described symptoms of asthma according to
the ISAAC questionnaire, and in 29% asthma was diagnosed by a
do cto r.[18] Asthma prevalence increased with age: at the time of the
study asthma symptoms were present in 22% of children <2 years old,
43% of 2 - 4-year-olds and 50% of children >4 years old.[18]
Industrial pollution is a further risk factor associated with a higher
prevalence of asthma. A study in Durban questioned 422 learners
(average age 10.5 years) on symptoms of asthma. In this cohort, the
presence of symptoms that were consistent with asthma of any sever-
ity was 32%, and the prevalence of doctor-diagnosed asthma was 13.0
- 16.5%, depending on the area surveyed. Children from areas with
higher levels of industrial pollution had a higher prevalence of respi-
ratory health problems.[19] In a separate study in a highly pollu ted
area in the south of Durban, which included 248 school- aged partici-
pants from grades 3 to 7, 52% had asthma of any severity, 11% had
moderate-to-severe persistent asthma, and 21% had marked airways
hyperreactivity on methacholine challenge testing.[20]
Asthma morbidity and mortality
Almost half of children in Cape Town who reported asthma in ISAAC
phase III had severe symptoms.[8] Furthermore, >30% of children
with severe asthma symptoms had never been formally diagnosed
with asthma.[7,14] In addition to morbidity from childhood asthma, SA
has a very high rate of asthma-related deaths, suggesting that lack of
appropriate diagnosis, treatment or access to care may be important
considerations.[16-18] Although SA was ranked 25th worldwide for the
prevalence of asthma, it ranked 4th in asthma mortality in the 5 -
34-year-old age group and 5th for asthma case fatality rates, with an
estimated 18.5 per 100 000 asthmatics.[17,18]
Conclusion
Childhood asthma remains a common condition, which has shown an
increasing prevalence in urban and rural populations in SA. Of concern
is that almost half of children in urban communities experience severe
asthma symptoms, and many asthmatics lack a formal diagnosis and
thus access to treatment. Exposure to tobacco smoke and living in highly
polluted areas increase the severity of wheezing in young children.
Acknowledgements. We acknowledge the hard work and contribution of the
South African Childhood Asthma Working Group (SACAWG) members.
We also acknowledge the huge contribution of the late Prof. Cas Motala,
who was convener of the past three SACAWG guidelines.
Author contributions. RM: review, write-up and manuscript editing; HZ,
CLG: conceptualisation, methodology, write-up and manuscript editing;
and ML, RJG, AIM, FEK: write-up and manuscript editing.
Funding. SACAWG conducted a workshop that received an unconditional
educational grant from the Allergy Society of South Africa – funded by Novartis.
Conicts of interest. None.
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Accepted 7 May 2018.
Appendix A. The SA Childhood
Asthma Working Group (SACAWG)
Epidemiology: H Zar (leader), Western Cape; C Gray, Western Cape.
Diagnosis of asthma: R Masekela (leader), KwaZulu-Natal; S M Risenga ,
Limpopo; O P Kitchin, Gauteng; P Goussard, Western Cape.
Assessment of asthma control: R J Green (leader), Gauteng; D White,
Gauteng; G Davis, Gauteng.
Pharmacotherapy: F E Kritzinger (leader), Western Cape; A Jeevana-
thrum, Gauteng; P de Waal, Free State; S Kling, Western Cape; A Vanker,
Western Cape; T C Gray, Western Cape; J Morrison, Western Cape;
A Puterman, Western Cape; E Zollner, Western Cape; D Rhode, Western
Cape.
Pharmacotherapy – other therapies: A I Manjra (leader), KwaZulu-Natal;
P M Jeena, KwaZulu-Natal; V Naidoo, KwaZulu-Natal; M Annamalai,
KwaZulu-Natal; A van Niekerk, Gauteng.
Self-management plans: M Levin (leader), Western Cape; S Emanuel,
Western Cape; D Hawarden, Western Cape; H Katz, Gauteng.
... Over triage of respiratory complaints in the EMD is known to be 58.21 % [31] however, South Africa is facing a problem of growing rates of asthma (18.5 per 100 000) ranking in the top five globally for mortality rates [35,36]. Making the situation worse is that there is a lack of appropriate diagnosis, treatment, and access to medical care for these patients, [36] hence leaving the patient no alternative but to initiate an EMS response. ...
... % [31] however, South Africa is facing a problem of growing rates of asthma (18.5 per 100 000) ranking in the top five globally for mortality rates [35,36]. Making the situation worse is that there is a lack of appropriate diagnosis, treatment, and access to medical care for these patients, [36] hence leaving the patient no alternative but to initiate an EMS response. South Africa also ranks among the top thirty Tuberculosis burdened countries (500 per 100 000) [37] with one of highest prevalence of Chronic Obstructive Pulmonary Disease (COPD) in the world [38]. ...
... Fig. 2 Variables that is predictive of non-conveyance pf patients to hospital have been highlighted. The development of guidelines to support onscene discharge and referral within the broader healthcare system may prove beneficial [36]. Further resolutions based on international recommendations include additional training and implementation of supportive tools such as non-conveyance guidelines in improving the rate of non-conveyance of patients to hospital [28]. ...
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... Among adolescents, the prevalence of asthma was 17% in rural regions and increased to 21% in urban areas. The prevalence of diagnosed asthma was 16.6%, although more than half of the population exhibited severe asthma symptoms [21,22]. According to a multicountry study conducted by the ISAAC, the intercountry prevalence was approximately 9.1% for Ethiopia, 15.8% for Kenya, 13.0% for Nigeria, 8.7% for Algeria, 10.4% for Morocco, and 11.9% for Tunisia, while South Africa had the highest prevalence of 20.3% [23]. ...
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Full-text available
  • Jul 2024
Asthma poses a significant health burden in Africa despite being often underdiagnosed and undertreated. With rising incidence rates and large variations in healthcare infrastructure, its management remains threatened by limited access to medical resources and qualified specialists. The prevalence of asthma in Africa is highlighted, with broad estimates and insufficient information on the disease's burden and determinants. In addition to diagnostic challenges, under treatment, medication unavailability, sociocultural misunderstandings, and poor healthcare infrastructure remain the hallmarks of asthma management in Africa. This review synthesized evidence on the prevalence of asthma in Africa, explored the challenges in managing asthma across the continent, and proposed potential strategies to improve treatment outcomes. Literature was obtained via electronic databases, including PubMed, Web of Science , and Scopus, with additional searches conducted via Google Scholar to identify all available studies. Studies have reported a staggeringly high prevalence of asthma, exceeding 12% on average. Notably, a significant number of these cases are suboptimally controlled, with limited access to healthcare and deficiencies in healthcare delivery systems identified as major contributing factors. Numerous strategies have been proposed to circumvent the limitations faced in effective asthma management. Measures such as the development of national and regional evidence-based asthma guidelines, the provision of affordable medicines and diagnostic equipment, and the improvement of community based asthma education programs can expedite the goals of asthma control programs. Furthermore, reorienting health systems to incorporate asthma care into primary care and investing in human resource capacity are critical steps. Adopting evidence-based treatment guidelines, such as those established by the Global Initiative for Asthma (GINA), can drastically reduce asthma morbidity and mortality. Through concerted collaboration and synergistic integration of these strategies, the potential for effective asthma management across the continent holds, transcending existing disparities and ushering in an era of improved healthcare services for individuals grappling with this chronic respiratory ailment in Africa.
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... 20 The ISAAC revealed that among 13-14-year-old participants in Cape Town, South Africa, the prevalence of severe asthma increased from 5.1% to 7.8%, while in Polokwane, the same age group had 8% prevalence rates of severe asthma; a follow-up epidemiological survey in Polokwane in 2009 revealed a 5.7% prevalence rate of severe asthma among a cohort of 6-7-year-old participants. 21 On analysis of patients' Body Mass Indexes, the majority of participants (55%) had a healthy weight, (10.5%) of participants were overweight, and only (9%) were obese. According to the American Lung Association, people with a BMI of 30 or more have a higher risk of developing asthma. ...
Frequency of Severe Asthma and Its Clinical Phenotypes at the Asthma Clinic in One of the Largest Sudanese Tertiary Pediatric Hospitals: A Cross-Sectional Hospital-Outpatient-Based Study
Article
Full-text available
  • Jul 2024
Background Asthma is one of the most common non-communicable diseases. Childhood asthma has been increasing in Sudan, with a 13–16% prevalence among Khartoum school children. To achieve and maintain good asthma control, proper diagnosis, assessment of severity, and appropriate medication administration are crucial, with phenotyping being a key factor in determining patients’ specific treatment. Objective To study the frequency of severe asthma and the distribution of its different phenotypes and to investigate associations between age and gender and different phenotypes of asthma. Methodology This descriptive cross-sectional hospital-based study was conducted in the Asthma Clinic of Mohamed Al-Amin Hamid Pediatrics Hospital. It included 229 patients who were presented to the clinic from September 2021 to April 2022. Data were collected from the patients and/or their caregivers using a modified validated standard questionnaire and were analyzed using SPSS version 26.0. A p-value of 0.05 or less was considered statistically significant. Results In this study of 229 participants, 14.4% had severe asthma, with 44.5% and 41% exhibiting mild and moderate asthma, respectively. Most were effectively managed in steps 2 or 3. The cohort, primarily aged 5 or younger (40.2%) with a male majority (62%), showed a mean diagnosis age of 2.9 ± 2.8 years. Impressively, 90% maintained well-controlled asthma. Within severe asthma cases (87% atopic), 39.4% represented a severe allergic asthma phenotype. Elevated eosinophil counts were noted in 45.5% (serum) and 78.8% (sputum cytology), while 57.6% had normal serum IgE levels. The predominant symptom pattern in severe asthma was episodic multi-trigger wheezing (48.5%). Age and gender displayed no significant association with severe asthma phenotype. Conclusion This study reveals a concerning rise in childhood asthma prevalence in Sudan, emphasizing the importance of tailored treatment strategies. Severe asthma, characterized by atopic eosinophilic involvement, necessitates targeted interventions in pediatric asthma care for specific phenotypes.
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... The findings pertaining to the prevalence of asthma were slightly lower than anticipated, as it was lower than that of the African (27.91%) and global regions (17.79%) [9], but were within the anticipated range. Moreover, our findings were still lower than those reported by ISAAC phase 3 studies in children aged 6-7 in African and global regions [29,30]. This observation aligns with the outcomes of a systematic review conducted by Adeloye et al., which examined the estimated prevalence of asthma in Africa [10]. ...
Prevalence of asthma and wheeze among preschool and school‐aged children in Africa: A meta‐analysis
Article
Full-text available
  • Jun 2024
Background In Africa, asthma and wheezing are major health issues for children. There is a dearth of prior research examining the prevalence of asthma and wheezing in both preschool and school‐aged African children. Therefore, this meta‐analysis aimed to estimate the prevalence of asthma and wheezing in African infants and children aged 0 month to 8 years. Methods We conducted a thorough electronic search of Academic Search Complete, MEDLINE, CINAHL, Scopus, Web of Science, PubMed, and Web of Science to find papers published between January 2012 and July 2023. We reviewed only research that was published in English. Independently, two review authors examined the studies, extracted the data, and evaluated the research studies. A fixed effects model and STATA 17 software were used. Using I², heterogeneity was assessed. Results We considered 10 papers from Africa that examined the prevalence of asthma and/or wheezing in preschool and school‐aged children. Asthma prevalence ranged from 1.70% to 20.85% (n = 7 134 total participants), with a meta‐analysis showing an overall prevalence of 4.41% (95% CI: 3.95–4.87), with no heterogeneity (I² < 0). The historical prevalence rate of wheezing ranged from 4.71% to 67.72% (n = 8769 total participants), with a meta‐analysis revealing an overall prevalence of 22.91% (95% CI: 22.12–23.70), with no heterogeneity (I² < 0) and no significant differences observed between studies. Conclusions Asthma and wheezing are prevalent among African preschool and school‐aged children, highlighting the need for comprehensive and localized research to address this public health issue.
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... According to the Global asthma report 2018, South Africa ranks 5th in asthma mortality worldwide [1]. The asthma prevalence among 13-14 years-old in Cape Town, South Africa (SA) was 20% in 2002 [2]. Furthermore, 47% of asthmatic children living in Cape Town were undiagnosed especially in areas of low socioeconomic status [3]. ...
The Association Between Urinary Concentrations of Organophosphate Metabolites and Asthma-Related Outcomes Among Schoolchildren From Informal Settlements
Article
Full-text available
  • Aug 2023
  • INT J PUBLIC HEALTH
Objectives: There is inconsistent evidence on the relationship between pesticide exposure and childhood respiratory outcomes in non-agricultural settings. This study investigated the association between organophosphate (OP) pesticide exposure and asthma-related outcomes in children residing in four informal settlements. Methods: The study was a longitudinal study of 590 schoolchildren, with a 12 months follow-up period. A standardised questionnaire adopted from the International Study of Asthma and Allergies in Childhood was administered to caregivers for child’s respiratory symptoms and household characteristics. Spirometry and fractional-exhaled nitric oxide, including a phadiatop test (atopy status) and urinary dialkyl phosphate (DAP) metabolites were measured at baseline and follow-up. DAP metabolites included diethylphosphate (DEP) and dimethyl phosphate (DMP) measured at baseline and follow-up and dimethylthiophosphate (DMTP) measured only at baseline. Results: The mean ages of schoolchildren were 9.9 ± 0.91 years and the overal incidence proportions of new doctor diagnosed asthma was 2.2%. No consistent patterns of increased risk of asthma outcomes with increasing DAP concentrations was found in multivariate analysis. Conclusion: Future studies with longer follow-up periods and repeated OP biomonitoring are recommended.
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Epidemiology of Allergic Airways Diseases
Chapter
  • Jun 2024
The epidemiology of allergic airways diseases, encompassing asthma and allergic rhinitis, is a complex domain influenced by genetic predispositions, environmental factors, and lifestyle choices. This paper offers a comprehensive synthesis of current research, shedding light on the prevalence, risk factors, and global impact of these conditions. Epidemiological investigations demonstrate significant variability in disease occurrence across different regions, age brackets, and socio-economic backgrounds, underscoring the intricate interplay between genetic susceptibilities and environmental triggers. Furthermore, recent findings emphasize the profound effects of urbanization, air pollution, dietary habits, and early-life exposures on the initiation and progression of allergic airways diseases. An in-depth comprehension of the epidemiological patterns and determinants of these ailments is pivotal for guiding public health policies, resource allocation, and targeted interventions to alleviate their burden on individuals and healthcare systems globally.
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Ambient pollution and respiratory outcomes among schoolchildren in Durban, South Africa
Article
Full-text available
  • Dec 2013
  • SAJCH
To examine associations between ambient air pollutants and respiratory outcomes among schoolchildren in Durban, South Africa. Primary schools from within each of seven communities in two regions of Durban (the highly industrialised south compared with the non-industrial north) were selected. Children from randomly selected grade 4 classrooms were invited to participate. Standardised interviews, spirometry, methacholine challenge testing and skin-prick testing were conducted. Particulate matter (PM), sulphur dioxide (SO2) and carbon monoxide were monitored at each school, while nitrogen oxides (NOx) and other pollutants were monitored at other sites. SO2 was significantly higher in the south than in the north, while PM concentrations were similar across the city. The prevalence of symptoms consistent with asthma of any severity was 32.1%. Covariate-adjusted prevalences were higher among children from schools in the south than among those from the north for persistent asthma (12.2% v. 9.6 %) and for marked airway hyperreactivity (AHR) (8.1% v. 2.8%), while SO2 resulted in a twofold increased risk of marked AHR (95% confidence interval 0.98 - 4.66; p=0.056). Schoolchildren from industrially exposed communities experienced higher covariate-adjusted prevalences of persistent asthma and marked AHR than children from communities distant from industrial sources. Our findings are strongly suggestive of industrial pollution-related adverse respiratory health effects among these children.
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The relationship between asthma and ambient air pollutants among primary school students in Durban, South Africa
Article
Full-text available
  • Jan 2008
We examined the prevalence of asthma among students in Grades 3 and 6 at a primary school located in the highly industrialised South Durban Industrial Basin. After baseline interviews and methacholine challenge testing (MCT), students completed bihourly symptom logs during an 18‐day study period. Continuous measurements of ambient contaminants at the school included sulphur dioxide (SO2), oxides of nitrogen (NOx), and respirable particulate matter less than 10 µm (PM10). Generalised estimating equations were used to examine associations between lagged fluctuations in ambient air pollutant concentrations and daily reported symptoms. Among the 248 participants, 52% had asthma of any severity; including 11% with moderate to severe persistent asthma. On MCT, 21% of the children had marked (PC20 ≤ 2 mg/ml), 29% had probable, and 19% had possible airway hyperreactivity. Concentrations of air pollutants at the school during the study period fell below international and South African standards and guidelines. Increased lower respiratory symptoms (cough, wheezing, chest tightness or heaviness, and shortness of breath) were strongly and consistently associated with prior day fluctuations in ambient levels of both SO2 and PM10 in both single‐pollutant and two‐pollutant models. We note the important role of local stakeholders in implementing and conducting this study.
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Global variation in the prevalence and severity of asthma symptoms: Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC)
Article
Full-text available
  • Mar 2009
  • THORAX
Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) measured the global prevalence and severity of asthma symptoms in children. A cross-sectional questionnaire survey of 798 685 children aged 13-14 years from 233 centres in 97 countries, and 388 811 children aged 6-7 years from 144 centres in 61 countries, was conducted between 2000 and 2003 in >90% of the centres. The prevalence of wheeze in the past 12 months (current wheeze) ranged from 0.8% in Tibet (China) to 32.6% in Wellington (New Zealand) in the 13-14 year olds, and from 2.4% in Jodhpur (India) to 37.6% in Costa Rica in the 6-7 year olds. The prevalence of symptoms of severe asthma, defined as >or=4 attacks of wheeze or >or=1 night per week sleep disturbance from wheeze or wheeze affecting speech in the past 12 months, ranged from 0.1% in Pune (India) to 16% in Costa Rica in the 13-14 year olds and from 0% to 20.3% in the same two centres, respectively, in the 6-7 year olds. Ecological economic analyses revealed a significant trend towards a higher prevalence of current wheeze in centres in higher income countries in both age groups, but this trend was reversed for the prevalence of severe symptoms among current wheezers, especially in the older age group. Wide variations exist in the symptom prevalence of childhood asthma worldwide. Although asthma symptoms tend to be more prevalent in more affluent countries, they appear to be more severe in less affluent countries.
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Burden of asthma and chronic obstructive pulmonary disease and access to essential medicines in low-income and middle-income countries
Article
  • Feb 2015
Demographic and epidemiological transitions are changing the age structure of the population and the most common diseases. Non-communicable respiratory diseases are an increasing problem at both ends of the age range in low-income and middle-income countries. In children, who represent a large proportion of the total population, the increasing problem of asthma is a strain on health services. Improved survival of the older population is increasing the proportion of morbidity and mortality attributable to chronic lung diseases. Health services in low-resource countries are poorly adapted to treating chronic diseases. Designed to respond episodically to acute disease, almost all historical investment has focused on infectious diseases. Crucial to the successful management of chronic diseases is an infrastructure designed to support pro-active management, providing not only an accurate diagnosis, but also a secure supply of cost effective drugs at an affordable price. The absence of such an infrastructure in many countries and the market failure that makes drugs generally more expensive in low-resource regions means that many people with chronic non-communicable lung diseases are not given effective treatment. This has damaging economic consequences. The common causes of poor lung health in low-income countries are not the same as those in richer countries, and there is a need to study why they are so common and how best to manage them. Copyright © 2015 Elsevier Ltd. All rights reserved.
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Food allergy in South African children with atopic dermatitis
Article
Background The prevalence of food allergy in South Africa is unknown, but previously thought to be rare in black South Africans. This study aimed to determine the prevalence of, and risk factors for, IgE-mediated food allergy in South African children with atopic dermatitis (AD). MethodologyThis was a prospective, observational study in a paediatric university hospital in Cape Town. Children with AD, aged 6months to 10yrs, were randomly recruited from the dermatology clinic. They were assessed for sensitization and allergy by questionnaire, skin prick tests, Immuno Solid Phase Allergen Chip (ISAC) test and incremental food challenges. Results100 participants (59 black Africans and 41 of mixed race) were enrolled, median age 42months. There were high overall rates of food sensitization (66%) and food allergy (40%). Egg (25%) and peanut (24%) were the most common allergies. Black participants had comparable sensitization (69% vs. 61%) but lower allergy rates (34% vs. 46%) than mixed race participants. This was especially evident for peanut allergy (15% Blacks vs. 37% mixed race allergic to peanut, p=0.01). Early-onset AD (<6months), severe eczema, and young age <2yrs were significant risk factors for food allergy. Conclusion The prevalence of food allergy is unexpectedly high in South African children with AD, and comparable with food allergy rates in patients with AD in developed countries. There are ethnic differences, with significantly lower peanut allergy rates in Blacks compared to mixed race patients. These results are not generalizable to an unselected South African population, which requires further study.
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Challenges in Treating Pediatric Asthma in Developing Countries
Article
  • Sep 2012
  • Pediatr Drugs
Asthma is the most common chronic disease in children in many low- and middle-income countries. In these settings, the burden of childhood asthma is increasing and is associated with severe disease. There are a number of challenges to providing optimal management of childhood asthma in such settings. These include under-diagnosis of childhood asthma, access to care, ability of healthcare workers to manage asthma, availability and affordability of inhaled therapy, environmental control of potential triggers, education of healthcare providers and of the public, and cultural or language issues. International and national guidelines for childhood asthma have been produced, but implementation remains a real challenge. Access to and affordability of essential inhaled asthma drugs, especially low-dose inhaled corticosteroids and short-acting bronchodilators, are major challenges to effective asthma control in many countries. A low-cost spacer made from a plastic bottle is effective for use with a metered-dose inhaler, but use must be included in asthma educational initiatives. Educational programs for healthcare personnel and for the public that are culturally and language appropriate are needed for effective implementation of asthma guidelines. Socioeconomic and structural barriers to care within health services remain obstacles to achieving optimal treatment of asthma for many children.
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The International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three: A global synthesis
Article
  • Jul 2012
  • ALLERGOL IMMUNOPATH
This ISAAC Phase Three synthesis provides summarised information on the main findings of the study, regional tables and figures related to the prevalence and severity of current symptoms of asthma, rhinoconjunctivitis and eczema in the main regions of the world. The large number of surveyed children (≈1,200,000), the large number of centres (233) and countries (98) that participated in ISAAC Phase Three makes this study the most comprehensive survey of these diseases ever undertaken. Globally, the prevalence for current asthma, rhinoconjunctivitis and eczema in the 13-14-year age group was 14.1%, 14.6% and 7.3%, respectively. In the 6-7-year age group the prevalence for current asthma, rhinoconjunctivitis and eczema was 11.7%, 8.5% and 7.9%, respectively. The study shows a wide variability in the prevalence and severity of asthma, rhinoconjunctivitis and eczema which occurs not just between regions and countries but between centres in the same country and centres in the same city. This study definitively establishes that the prevalence of those diseases can be very high in non-affluent centres with low socioeconomic conditions. The large variability also suggests a crucial role of local environment characteristics to determine the differences in prevalence between one place and another. Thus, ISAAC Phase Three has provided a large body of epidemiological information on asthma, rhinoconjunctivitis and eczema in childhood from contrasting environments which is expected to yield new clues about the aetiology of those conditions and reasons for their marked global variability.
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Associations between asthma and bronchial hyper-responsiveness with allergy and atopy phenotypes in urban black South African teenagers
Article
  • Jul 2011
To determine asthma and allergy phenotypes in unselected urban black teenagers and to associate bronchial hyper-responsiveness (BHR) with asthma, other atopic diseases and allergen sensitisation. This was a cross-sectional study of 211 urban high-school black children of Xhosa ethnicity. Modified ISAAC questionnaires regarding asthma, eczema and rhinitis were administered. BHR was assessed by methacholine challenge using hand-held nebulisers. Skinprick tests (SPTs) were performed for 8 aeroallergens and 4 food allergens. Asthma was reported in 9%, and 16 % demonstrated BHR. Rhinitis was reported in 48% and eczema in 19%. Asthma was strongly associated with BHR. Asthma was associated with eczema whereas BHR was associated with rhinitis. SPTs were positive in 34% of subjects, aeroallergens in 32%, and food allergens in 5%. The most common sensitivities were to house dust mites (HDM) and German cockroach. BHR was associated with sensitivity to any aeroallergen, cat, HDM, cockroach and bermuda grass. The number of positive SPTs was associated with asthma and BHR. With each level of SPT positivity, there was 40% increased prevalence of asthma and 70% increased prevalence of BHR. The rate of allergen sensitisation in subjects with BHR (72%) was much higher than those without BHR (28%); house dust mite sensitivity was 69% in subjects with BHR and 18% in those without. These are the highest rates of allergen sensitisation in subjects with BHR documented in an African setting and the widest difference in sensitisation rates between subjects with and without BHR.
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Prevalence of asthma: A comparative study of urban and rural Xhosa children
Article
  • Aug 1979
  • Clin Allergy
An epidemiological study was undertaken to determine the prevalence of asthma in young urban and rural black (Xhosa) children. One thousand three hundred and seventy five children were studied, 694 from a Cape Town african township and 671 from a rural area in Transkei. The exercise tolerance test which required free range running at maximum effort for 6 min was used to identify asthmatic subjects. A fall of 15% or more in the post‐exercise FEV 1 and PEFR values was regarded as a positive result. Twenty‐three children were found to be asthmatic, twenty‐two from the city area, but only one from the country, giving a prevalence figure for asthma of 3.17% in the first group and 0.14% for the second. Possible reasons for these differences are discussed. The exercise tolerance test was found to be a useful tool for epidemiological studies of asthma.
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