**2. Discussion**

environmental risks. This variant of asthma appears to be more severe, associated with increased psychological burden as well as morbidity and mortality, has a diverse array of predisposing factors, and poses significant challenges in management and treat‐ ment. One important aspect of treatment is education which leads to the participation of

**Keywords:** asthma, primary care, WHO, chronic respiratory diseases, essential drugs

This chapter deals with asthma in developing nations and touches on one variant of asthma in the developed world which has significant resemblance to its counterpart in developing nations. The first section is derived from studies in Syria, while the second from the United States.

According to the International Study for Asthma and Allergies in Childhood (ISAAC), comparing phase one in 1994 to three in 2000–2003, asthma prevalence expressed by wheezing the last 12 months in 13–14 years old is increasing in developing countries. Asthma prevalence is higher in developed countries, but asthma is more severe in developing countries [1].

The definition of a primary care facility is the site where the first patient contact occurs [2]. If we take Syria as an example of developing county, primary healthcare (PHC) facilities are officially healthcare centers under the control of the Ministry of Health, which among other services provided, host World Health Organization (WHO) programs for tuberculosis and chronic respiratory diseases [3, 4]. In addition, there are many other providers of PHC services which include emergency departments(ED), general outpatient clinics in public hospitals, school health clinics, clinics in workplace settings, and internal and general clinics within the

Asthma patients may present for treatment in any of these primary care facilities in Syria. A multicenter survey of primary care clinics revealed that 13% of patients aged over 6 years attended with asthma [5]. Another study showed that 51% of asthma patients are treated in ED only, and only 9% are treated in primary care centers [6]. Many developing countries like Sudan, Algeria and some African countries had the same use of ED [6]. The same underutilization of community primary healthcare services has also been observed in China in 2014

There are questions about the quality of care provided in these clinics with regard to their adherence to Global Initiatives for Asthma (GINA) guidelines. Evidence suggests that there may be over prescribing of oral corticosteroids and antibiotics and under-prescription of

**1. Introduction - Managing bronchial asthma in primary health care**

the patient and the families in the care resulting in a more favorable outcome.

for asthma, inner city, developed nations

186 Asthma - From Childhood Asthma to ACOS Phenotypes

**Background**

private sector.

[7].

#### **2.1. Field surveys and what we learned**

Asthma is under-diagnosed in primary care [5, 6, 8, 12–14]. The Global Alliance against chronic respiratory disease (GARD–WHO: www.who.int/gard ) survey on chronic respiratory diseases prevalence and risk factors in Syria revealed that although 27% of the 1599 patients surveyed had evidence of reactive airway disease and reversible obstruction by spirometry, but only 13% had been diagnosed as asthma by the primary care practitioners. Indicating that 50% were under-diagnosed [4]. This finding is not unique to Syria. Under-diagnosis has also been reported in the same GARD survey in Cape Verde [12]. There are several hypotheses for these high rates of under-diagnosis. The condition's variability of symptoms, misdiagnosis such as an infection, some may be mislabeling of patients as COPD when in fact, they may have uncontrolled asthma [5, 15], increasing workload, and demand on services and limited experienced doctors. It is important for practitioners to follow standard diagnostic procedures and good history taking such as recurrent symptoms (wheezing, cough, difficult breathing, and chest tightness) and the presence of triggers. In addition, practitioners should obtain objective tests and look for reversibility of peak expiratory flow rate (PEFR) expressed as increase of 20% and 60 l/min, or 12% increase in forced expiratory volume in one second (FEV1) and 200 ml after short-acting beta agonists (SABA), or a decrease in these measurements after exercise testing. Practitioners could also rely on variability of PEFR or FEV1 between two visits. In situations where spirometry or peak flow meter results are not available, or patients are under 5 years of age, practitioners should rely on clinical history and treatment trials [16]. WHO recommend peak flow meter to be available in the most remote healthcare centers, and referral for spirometry in healthcare centers or hospitals at central level is available [3, 4].

Asthma is under-treated and under-controlled: The GARD–WHO multicentre national survey 2010 for chronic respiratory diseases [5] revealed that only 25% of inhaled corticosteroid (ICS) prescriptions included adequate doses according to the GINA guidelines. In addition, 46% of patients received oral corticosteroids which could be avoided if ICS were prescribed in PHC according to the guidelines. Similarly, 56% of asthma patients received oral antibiotics without a clinical indication. Another important issue is that 56% of asthma patients surveyed have FEV1 < 80% after bronchodilators, which points to poor control [5, 16].

Despite asthma being poorly diagnosed and treated, it is possible to observe improvements in asthma control to the level of published guidelines in underserved areas. In a pilot study conducted on economically deprived patients in an underserved area, we systematically followed up patients with uncontrolled asthma in a general free of charge outpatient clinic in a public hospital 2006–2007 [8]. A trained postgraduate medical student asked every patient questions about the parameters of asthma control, measured PEFR, and ensured prescription of ICS at their first presentation. The student also taught patients proper inhaler technique and educated them about how to avoid risk factors. Weekly follow-up data were collected by the GP. After 3 months, 44 of 66 patients who had not been followed up previously were properly controlled. We conclude that GINA guidelines could be realistic even in underserved areas. In 2006, an international multicenter survey of the Union showed that implementation of asthma guidelines was possible in primary care in developing countries [13]. The same recently in Sudan (2014): In a new model specialized center for asthma, a survey aiming at describing the epidemiological and clinical characteristics of asthma patients concluded that most patients had abnormal spirometry with more than half having an FEV1 that is 60% or less of their predicted normal reading. The majority improved with combined treatment (Formoterol, budesonide) with 60% normalizing their spirometry highlighting the feasibility and applica‐ bility of specialized asthma care centers in resource-poor countries [10].

The global initiative for asthma guidelines are based on the level of control [16] such that for each asthmatic presenting to a primary healthcare facility, the general practitioner (GP) should ask standard questions about the clinical control of asthma including:

**•** Frequency of symptoms

surveyed had evidence of reactive airway disease and reversible obstruction by spirometry, but only 13% had been diagnosed as asthma by the primary care practitioners. Indicating that 50% were under-diagnosed [4]. This finding is not unique to Syria. Under-diagnosis has also been reported in the same GARD survey in Cape Verde [12]. There are several hypotheses for these high rates of under-diagnosis. The condition's variability of symptoms, misdiagnosis such as an infection, some may be mislabeling of patients as COPD when in fact, they may have uncontrolled asthma [5, 15], increasing workload, and demand on services and limited experienced doctors. It is important for practitioners to follow standard diagnostic procedures and good history taking such as recurrent symptoms (wheezing, cough, difficult breathing, and chest tightness) and the presence of triggers. In addition, practitioners should obtain objective tests and look for reversibility of peak expiratory flow rate (PEFR) expressed as increase of 20% and 60 l/min, or 12% increase in forced expiratory volume in one second (FEV1) and 200 ml after short-acting beta agonists (SABA), or a decrease in these measurements after exercise testing. Practitioners could also rely on variability of PEFR or FEV1 between two visits. In situations where spirometry or peak flow meter results are not available, or patients are under 5 years of age, practitioners should rely on clinical history and treatment trials [16]. WHO recommend peak flow meter to be available in the most remote healthcare centers, and referral for spirometry in healthcare centers or hospitals at central level is available [3, 4].

188 Asthma - From Childhood Asthma to ACOS Phenotypes

Asthma is under-treated and under-controlled: The GARD–WHO multicentre national survey 2010 for chronic respiratory diseases [5] revealed that only 25% of inhaled corticosteroid (ICS) prescriptions included adequate doses according to the GINA guidelines. In addition, 46% of patients received oral corticosteroids which could be avoided if ICS were prescribed in PHC according to the guidelines. Similarly, 56% of asthma patients received oral antibiotics without a clinical indication. Another important issue is that 56% of asthma patients surveyed have

Despite asthma being poorly diagnosed and treated, it is possible to observe improvements in asthma control to the level of published guidelines in underserved areas. In a pilot study conducted on economically deprived patients in an underserved area, we systematically followed up patients with uncontrolled asthma in a general free of charge outpatient clinic in a public hospital 2006–2007 [8]. A trained postgraduate medical student asked every patient questions about the parameters of asthma control, measured PEFR, and ensured prescription of ICS at their first presentation. The student also taught patients proper inhaler technique and educated them about how to avoid risk factors. Weekly follow-up data were collected by the GP. After 3 months, 44 of 66 patients who had not been followed up previously were properly controlled. We conclude that GINA guidelines could be realistic even in underserved areas. In 2006, an international multicenter survey of the Union showed that implementation of asthma guidelines was possible in primary care in developing countries [13]. The same recently in Sudan (2014): In a new model specialized center for asthma, a survey aiming at describing the epidemiological and clinical characteristics of asthma patients concluded that most patients had abnormal spirometry with more than half having an FEV1 that is 60% or less of their predicted normal reading. The majority improved with combined treatment (Formoterol,

FEV1 < 80% after bronchodilators, which points to poor control [5, 16].


To improve care, training should emphasize that: Patients with uncontrolled asthma need to be prescribed low-dose or medium-dose inhaled corticosteroids, educated on inhaler techni‐ que, and referred to higher level of care for further assessment if not controlled after followup visits [3–5, 16], and referred back to primary care for long-term follow-up and education.

#### *2.1.1. Review of international WHO programs and other programs*

*WHO–MOH programs*: Three programs have been introduced for chronic respiratory diseases (CRD) in Syria since 2006 [3, 4, 11, 16]:


#### *2.1.2. Other programs*


### *2.1.3. International Primary Care Respiratory Group (IPCRG)*

The IPCRG tried to resolve the question on how to deal with asthma and COPD in primary care in developing countries, elaborating a symptomatic approach and algorithms, but they recommend providing primary care in developing countries with PEF and Inhalers [17]. While PAL–WHO went further (Spirometry and referral) [4].

Research priority to improve asthma management in primary care have been investigated by the IPCRG, 2009: Conclusion, primary care research should include awareness about local asthma triggers like biomass fuel, early diagnosis, and management in remote areas where there are no tools for diagnosis, the reliability of medication trial, how to overcome taboos about cultural misbelieves and inhalers, how to make essential drugs available, and how to adapt and evaluate guidelines implementation [18].

PEN–WHO opted for an integrated approach with other NCD; the approach was symptoms and PEAK flow measurements; primary care physician prescribes ICS if asthma; and treat acute attacks with oral corticosteroids and inhaled bronchodilators; referral rules to confirm diagnosis or help for better long-term treatment are stated if failure of control at follow-up visit. Necessary tools are PEF, oximetry, oxygen, and nebulisers or inhalers via spacer [3]

PAL–WHO, integrating CRD with tuberculosis program was very ambitious, referral and spirometry were recommended [4], but unfortunately, there were discontinuity and no evaluation process for the implementation of these programs, in conflict zones.

GARD–WHO was a success with the survey, and following publications and guidelines [5]

#### **2.2. The core messages from the field surveys and international national programs**

To empower the role of PHC in controlling asthma and lessen related mortality. Core messages are as follows:

**1.** The first consultation with the uncontrolled patient is crucial. It is vital that the correct diagnosis is made and good education is delivered. The correct treatment should be initiated at this time which will be an appropriate dose of inhaled corticosteroid and a short-acting reliever inhaler (Bronchodilator). Inhaler technique needs to be taught and the initiation of a self-management plan including what to do in an emergency and whom to contact. A follow-up appointment is important, and the PHC should consider a referral if not controlled during a follow-up visit [19]

	- **•** Questions related to symptoms suggestive of asthma diagnosis to face under-diagnosis
	- **•** Asthma control test for initial evaluation and follow up
	- **•** Use of peak flow and table of values
	- **•** Educational photos about inhaler and spacer use (Photos of all available inhalers to educate.)
	- **•** What to do in an emergency

**3.** Educational Program for nurses about asthma and COPD: Two national workshops were run for this purpose in 2004 and 2007 by the Education for health center of Excellence— UK in Syria www.educationforhealth.org, but also in Bangladesh, and many other developing countries, aiming to introduce the role of nurses in national programs.

**4.** The new intensive course of WHO–MOH mentioned above for non-communicable

The IPCRG tried to resolve the question on how to deal with asthma and COPD in primary care in developing countries, elaborating a symptomatic approach and algorithms, but they recommend providing primary care in developing countries with PEF and Inhalers [17]. While

Research priority to improve asthma management in primary care have been investigated by the IPCRG, 2009: Conclusion, primary care research should include awareness about local asthma triggers like biomass fuel, early diagnosis, and management in remote areas where there are no tools for diagnosis, the reliability of medication trial, how to overcome taboos about cultural misbelieves and inhalers, how to make essential drugs available, and how to

PEN–WHO opted for an integrated approach with other NCD; the approach was symptoms and PEAK flow measurements; primary care physician prescribes ICS if asthma; and treat acute attacks with oral corticosteroids and inhaled bronchodilators; referral rules to confirm diagnosis or help for better long-term treatment are stated if failure of control at follow-up visit. Necessary tools are PEF, oximetry, oxygen, and nebulisers or inhalers via spacer [3]

PAL–WHO, integrating CRD with tuberculosis program was very ambitious, referral and spirometry were recommended [4], but unfortunately, there were discontinuity and no

GARD–WHO was a success with the survey, and following publications and guidelines [5]

To empower the role of PHC in controlling asthma and lessen related mortality. Core messages

**1.** The first consultation with the uncontrolled patient is crucial. It is vital that the correct diagnosis is made and good education is delivered. The correct treatment should be initiated at this time which will be an appropriate dose of inhaled corticosteroid and a short-acting reliever inhaler (Bronchodilator). Inhaler technique needs to be taught and the initiation of a self-management plan including what to do in an emergency and whom to contact. A follow-up appointment is important, and the PHC should consider a referral

**2.2. The core messages from the field surveys and international national programs**

evaluation process for the implementation of these programs, in conflict zones.

diseases in Syria and other EMRO countries.

190 Asthma - From Childhood Asthma to ACOS Phenotypes

*2.1.3. International Primary Care Respiratory Group (IPCRG)*

PAL–WHO went further (Spirometry and referral) [4].

adapt and evaluate guidelines implementation [18].

if not controlled during a follow-up visit [19]

are as follows:

