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Volume 9 Number 2

March 2014

Report: Respiratory diseases in the world

Asthma control in cities of developing countries
Advances in the treatment of severe asthma
The Asthma Control Test and lung function parameters
Foreign body aspiration and TB: possible misdiagnosis

News and Notes

MRC funds BREATHE Africa Partnership
The Medical Research Council (MRC) has announced
580 000 of funding to facilitate collaboration between
established trial sites and to increase research capacity
in Africa focused on the health effects of Household Air
preventable cause of disease and death in the Global
Burden of Disease survey 2010.
The BREATHE Africa partnership (Biomass Reduction
and Environmental Air Towards Health Effects) is led and
co-ordinated by Stephen Gordon and Jane Ardrey at the
UKs Liverpool School of Tropical Medicine (LSTM). The
Partnership will draw together experts and investigators
optimise the opportunity to undertake mechanistic work
including testing for new biomarkers not funded in current
trials and to engage African researchers and trainees
in existing and new studies by a bottom-up approach
offering mentored research training projects.
Co-investigators from LSTM (Dr Kevin Mortimer), University of Liverpool (Prof Nigel Bruce), University of Aberdeen (Dr Sean Semple) and Queen Mary University of
London (Prof Jonathan Grigg), focused on Interventions
to reduce HAP, Exposure and Biomarker measurements,
and Mechanisms by which HAP causes Health effects.
BREATHE currently has 50 partners and those partners
Cookstoves (Alliance) and The American Thoracic Society (ATS).
The partnership will work with existing Cookstove
projects that are currently underway in Ghana and Nepal
as well as the Cooking and Pneumonia Study (CAPS),
which is an LSTM led, randomised study being carried
out in Malawi.
Professor Stephen Gordon, who is the head of LSTM's
Department of Clinical Sciences, said, Half the world's
population, including some 700 million people in Africa,
use biomass fuel from animal and plant material to
provide energy for cooking, heating and lighting. Those
using biomass fuel and their young children experience
substantial smoke exposure, which is an established
threat to health. This new partnership will bring together
international experts, African Investigators, and other
stakeholders to ensure the best use of new opportunities
provided by 8 m of recent grant investment directed at
quantifying and reducing the health effects of household
air pollution.
The funding, along with a benefactor donation of
32 000, will also enable the continuation of The Pan
African Thoracic Society Methods in Epidemiological, Clinical and Operations Research (PATS MECOR)
Course for 2014. The course, which was initiated by
Professor Gordon, is designed for pulmonary clinicians,
investigators, and academicians to provide training in research methods. It will take place in Kenya in September.

African Journal of Respiratory Medicine

Global Lung Function Initiative

The Global Lung Function Initiative is an international
group of researchers and healthcare professionals
working towards standardizing reference equations to
improve how we interpret pulmonary function test data.
We recently completed multi-ethnic reference equations
for spirometry and have received ATS and ERS support to conduct this project for transfer factor for carbon
monoxide of the lung (TLCO).
We are seeking expressions of interest from those
researchers and healthcare professionals that have
TLCO data for more than 100 healthy subjects to please
consider contributing your data to the GLI TLCO Task
Force. In addition to the TLCO measurements, we are
requesting basic demographic data (gender, age and
height) as well as some details about the equipment that
was used to collect the data. If you do not know some
of these details, we will work with the manufacturers to
obtain this information. We will accept both paediatric

variables related to smoking status, or medical history.

Complete details of the study and instructions can be
found on the GLI website and if
TLCO group You may
register your project at
A member of the task force will contact you with further
details. You may also wish to read through our Memorandum of Understanding for further details regarding
data privacy, data sharing and publication.

Smoker numbers edge close to 1 billion

Although smoking is becoming less popular in many
parts of the world, the total number of smokers is growIn 2012, 967 million people smoked every day compared with 721 million in 1980, data from 187 countries
show. The rise is linked to population growth, according
to researchers.
With the earth's population having more than doubled
in the last 50 years to 7 billion, there are simply more
people to take up the habit. Some of the highest smoking
rates are now seen in the developing world, according
to the JAMA report from the University of Washington's
Institute for Health Metrics and Evaluation (IHME) in
the US. But global smoking prevalence has gone down.
Lead researcher Dr Christopher Murray, who is director of the IHME, said, Despite the tremendous progress
made on tobacco control, much more remains to be done.
The World Health Organization say millions of additional
lives could be saved with continued implementation of
policies such as increased cigarette taxes and smokefree air laws.
Vol 9 no 2 March 2014

March 2014
First word
Respiratory diseases have been reported to cause immense health burdens worldwide; each
year about 4 million people die prematurely from chronic respiratory diseases.
In recent decades, modern medicine has advanced the length and quality of life in most
health and the effort needed to care for the ill and dying affects national productivity. Poor
health along with lack of education and lack of an enabling political structure are the major
impediments to a countrys development.
In the past, focus has been on communicable diseases with a thrust on tuberculosis. However, there has been an increasing awareness on the importance of the non-communicable
The incidence of lung cancer has been on the increase and the aetiology may differ between
the developing and the more developed countries. However, the role of occupational lung
diseases cannot be overemphasised. The increasing use of biomass fuel and smoking also
has a tremendous role to play.

Dr Evans Amukoye,
KEMRI, Centre for Respiratory Disease
Research, Nairobi
Prof. Gregory Erhabor,
Consultant Chest Physician, OAU
Teaching Hospital, Ile-Ife, Nigeria

Consulting Editor
Prof Stephen Gordon
Head, Department of Clinical Sciences
Professor of Respiratory Medicine,
Liverpool School of Tropical Medicine, UK

Editorial Board
Dr Jeremiah Chakaya, Kenya
Prof Keertan Dedha, South Africa

prevent illness before it occurs.

The FIRS vision of controlling and eliminating respiratory diseases requires the use of current
effective tools, coupled with investment in respiratory research to help control these diseases
by providing better and more effective treatment methods.
In addition to public health measures, developing healthcare capacity requires the education
of clinicians and researchers. The recruitment and input of a wider spectrum of medical personnel from the African sub-region would help to give the document a more balanced outlook.
While the FIRS roadmap has some merits, it has to take a more comprehensive look into
the challenges of these respiratory diseases and proffer pragmatic solutions.
Prof Gregory Erharbor, Co-Editor, AJRM


2 News/Notes
4 Report
Respiratory diseases in the world. Realities of today opportunities for tomorrow
The Forum of International Respiratory Societies

14 Review Article
Advances in the treatment of severe asthma
F Gandia and S Rouatbi

Chronic and occupational lung disease

Prof Ben Nemery, Belgium

18 Review Article

Prof Stephen Gordon, UK

G A Nadeau, I Samji, R D Walters, S F R Godsin, J Lucas, and M Moodley

Prof Lisa Obimbo, Kenya
Dr Regina Oladokun, Nigeria
Prof Elvis Irusen
Dr Joe Aluoch, Kenya

Managing Editor
Penny Lang

Bryan Pearson

24 Original Article
The Asthma Control Test and its relationship with lung function parameters
J Jumbo, B O Adeniyi, P O Ikuabe, and G E Erhabor

28 Original Article
Knowledge, awareness, and practice of the use of peak flow meters by physicians
in the management of asthma in children
A A Raheem, R O Soremekun, and O F Adeniyi

33 Case Report
Foreign body aspiration and tuberculosis: possible misdiagnosis
R C Ideh, U Egere, D B Garba, and T Corrah
Correspondence to:
African Journal of Respiratory
FSG Communications Ltd, Vine
House Fair Green,
Reach, Cambridge CB25 0JD, UK.

FSG Communications Ltd

The Pan African Thoracic

Society exists to promote
respiratory health in Africa.
It is supported by the
and the American Thoracic


Vol 9 No 2 March 2014

African Journal of Respiratory Medicine 3


Respiratory diseases in the world.

Realities of today opportunities
for tomorrow
Forum of International Respiratory Societies (FIRS)

Experts from the worlds leading lung organisations

wide effort to improve healthcare policies, systems,
and care delivery to make a positive difference to the
lung health of the world.
are of immediate and greatest concern. These include
acute respiratory infections, tuberculosis asthma,
COPD, and lung cancer, which are the leading causes
of death or morbidity worldwide.
We here reproduce a selection from the report.


When we are healthy we take our breathing for granted,

never fully appreciating that our lungs are essential
organs for life. But when our lung health is impaired,
nothing else but our breathing really matters. That is
the painful reality for those suffering from lung disease,
which affects people of all ages in every corner of the
world. Lung diseases kill millions and causes suffering to
millions more. Threats to our lung health are everywhere,
and they start at an early age, when we are most vulnerable. Fortunately, many of these threats are avoidable
and their consequences treatable. By acting now, we can
save lives and prevent suffering worldwide.
The Forum of International Respiratory Societies (FIRS)
is comprised of the leading international respiratory
societies in the world. The goal of FIRS is to unify and
enhance efforts to improve lung health throughout the
world. The purpose of this document is to inform, raise
awareness, and assist those who advocate for protecting
and improving respiratory health. It tells of the magnitude
of respiratory diseases and the threats to lung health
across the globe. It is not a comprehensive textbook,
but a guide emphasizing the diseases of greatest and
immediate concern. It outlines practical approaches to
combat threats to respiratory health, and proven stratediseases. It calls for improvements in healthcare policies,
systems, and care delivery, as well as provides direction
for research. In brief, it outlines ways to make a positive
difference in the respiratory health of the world.

African Journal of Respiratory Medicine

We would like to thank everyone involved in the

development of this work, especially Don Enarson and
his colleagues who comprised the Writing Committee.
We would also like to express our sincere appreciation
to Dean Schraufnagel for his careful and expert review.
We intend to update this document regularly, and are
seeking feedback and suggestions for ways to improve it.
On behalf of those suffering from respiratory disease
and those who are at risk of respiratory disease in the
future, from around the world, we ask for your help in
making a difference and a positive impact on the respiratory health of the world.
Darcy Marciniuk MD, FIRS Chair
American College of Chest Physicians (ACCP)
Tom Ferkol MD
American Thoracic Society (ATS)
Arth Nana MD
Maria Montes de Oca MDAsociacin Latinoamericana de
Trax (ALAT)
Klaus Rabe MD
Nils Billo MD
International Union Against Tuberculosis and Lung Disease
Heather Zar MD
Pan African Thoracic Society (PATS)


Respiratory disease causes an immense worldwide health

burden. It is estimated that 235 million people suffer
from asthma;1 more than 200 million people have chronic
obstructive pulmonary disease (COPD); 65 million endure moderate to severe COPD;2 1% to 6% of the adult
population (more than 100 million people) experience
sleep-disordered breathing;3 8.7 million people develop
tuberculosis annually4 millions live with pulmonary
hypertension;3 and more than 50 million people struggle
with occupational lung diseases, totaling more than
one billion persons suffering from chronic respiratory
conditions.5 At least two billion people are exposed to
the toxic effects of biomass fuel consumption; one billion
are exposed to outdoor air pollution; and one billion are
exposed to tobacco smoke. Each year, 4 million people
Vol 9 No 1 March 2014

die prematurely from chronic respiratory disease.5
Infants and young children are particularly susceptible.
Nine million children under 5 years of age die annually,
and lung diseases are the most common causes for these
deaths. Pneumonia is the worlds leading killer of young
children.6 Asthma is the most common chronic disease,
affecting about 14% of children globally and rising.7
Chronic obstructive pulmonary disease (COPD) is the
fourth leading cause of death worldwide, and the numbers are growing.8 The most common lethal cancer in the
world is lung cancer, which kills more than 1.4 million
people each year (2008 statistics),9 and the numbers are
kill 250,000 to 500,000 people and costs 71 to 167 billion
US dollars annually.10
Respiratory infections ranks number one as the greatest single contributor to the overall burden of disease in
the world, as measured in disability-adjusted life-years
lost (DALY), which estimate the amount of active and
productive life lost due to a condition.*
No organ is more vital and no organ is more vulnerable than the lung. Being unable to breathe is one of
the most distressing feelings one can have. The lungs
are the largest internal organ in the body, and the only
internal organ that is exposed constantly to the external
environment. Everyone who breathes is vulnerable to the
infectious and toxic agents in the air. While respiratory
disease causes death in all regions of the globe and in
all social classes, certain people are more vulnerable to
environmental exposures than others are.
In recent decades, modern medicine has advanced the
length and quality of life in most countries, although
changing life styles and infections, such as with human
lenges. At the same time, increasing health care costs
effort needed to care for the ill and dying affects national
productivity. It has become abundantly clear that the
economic development of countries is tightly linked to
the health of its citizens. Poor health, both individual
and public, along with lack of education and lack of an
countrys development and the roots of poverty. Poor
in part related to inadequate access to quality health
care. Even more distressing is the enormous suffering
that living with illness causes. Those who are most disadvantaged suffer most due to poor health. With this
awareness, the United Nations convened a high-level
meeting on noncommunicable diseases to develop a
global plan for their prevention and control.11 The Forum
DALY is composed of two measures, years of life lost (YLL), which
ears lived with disability (YLD), to take into account the
Disability-Adjusted Life Years (DALY) is

Vol 9 No 1 March 2014

of International Respiratory Societies (FIRS) has been

part of this effort. It strongly believes that investing in
public health pays dividends many times in many ways.
burdening economies of all countries. For example, the
annual cost of asthma in the United States is estimated to
be $18 billion.12 If one considers the lost productivity of
family members and others caring for these individuals,
the cost to society is far greater.

The Big Five

Five respiratory conditions account for the greatest burden to society: 1. chronic obstructive pulmonary disease
(COPD), 2. asthma, 3. acute respiratory infections, 4.
tuberculosis, and 5. lung cancer.

1. Chronic Obstructive Pulmonary Disease

Scope of the disease

Chronic obstructive pulmonary disease (COPD) affects
more than 200 million people and is the fourth leading
cause of death in the world.5 COPD is the only major
disease that is increasing in prevalence and it is increasing on all continents.1315 Furthermore, studies show that
underdiagnosis ranges from 72% to 93%, which is higher
than reported for hypertension, hypercholesterolemia,
and similar disorders. Misdiagnosis is also common.16
The most important factor leading to the development
of COPD is tobacco smoking. Tobacco smoke causes
destruction of lung tissue and obstruction of the small
airways leading to emphysema and bronchitis, which
are the main diseases of COPD.
Indoor smoke, inhaled occupational exposures through
farming, mining, construction, transportation, and manufacturing pose risks for COPD throughout the world.
Other risks for COPD include genetic syndromes, such
other diseases that involve the airways, such as chronic
asthma and tuberculosis.17 Smoke exposure in childhood
may predispose to the development of chronic lung
disease in adult life.18
priority in preventing COPD. This measure also will
greatly reduce the morbidity and mortality of other
lung diseases. Chimney cook stoves and other devices
to decrease indoor smoke exposure lessen the risk of
respiratory infections in children and potentially the
incidence of COPD in non-smokers, especially women.
Controlling occupational exposure to dust and fumes will
are essential to prevent and treat COPD. All individuals who smoke should be encouraged and enabled to
quit. Spirometry is required for the clinical diagnosis of
African Journal of Respiratory Medicine

COPD, to avoid misdiagnosis, and to evaluate the severthe main medicines that help these patients. Long-term
treatment with inhaled corticosteroids added to longacting bronchodilators can help patients with frequent
Avoiding other precipitating factors and air pollution
is important. Persons with low levels of oxygen in their
blood may require supplemental oxygen. Maintaining
lead to a lack of activity and subsequent deconditioning.
Therefore, exercise-based pulmonary rehabilitation is important for most people with COPD. Treating coexisting

The Global Initiative for Chronic Obstructive Lung

Disease (GOLD) is an organization that has developed
recommendations on the management of COPD and
has guided many national and international programs.5
Despite the availability of guidelines, several studies
have showed that COPD is undertreated in its early as
well as advanced stages. In Latin America, only about
one fourth of persons with COPD were treated according
to these standards.19
Control or elimination
The key element of reducing and controlling chronic
obstructive pulmonary disease is reducing and controlling tobacco use. This is best addressed through political
and public health initiatives. Public health and societal
efforts are needed to reduce indoor smoke exposure
and develop cost-effective management protocols for
COPD in low-income settings. Research could lead to
better understanding how risk factors and comorbidities
interact to affect the severity of disease and what other
factors cause COPD in smokers and non-smokers. Other
research questions include how to identify and treat early
COPD, how to manage it in the context of concomitant
conditions, such as sleep apnea, cardiovascular disease,
depression, osteoporosis, diabetes, lung cancer, aging,
and frailty.

2. Asthma

Scope of the disease

it has been increasing during the past three decades in
both developed and developing countries. Although it
strikes all ages, races, and ethnicities, wide variation exists in different countries and in different groups within
the same country. It is the most common chronic disease

countries. In these settings, under-diagnosis and undertreatment are common, and effective medicines may not
be available or affordable. The burden of asthma is also
greater in urban settings. It is one of the most frequent
reason for preventable hospital admissions among chil6

African Journal of Respiratory Medicine

dren.20,21 Asthma causes about 180 000 deaths worldwide

each year.22 In some studies, asthma accounts for over
30% of all pediatric hospitalizations and nearly 12% of
readmissions within 180 days of discharge.21
The cause for the increase in global prevalence of asthma
is not well understood. Genetic predisposition, exposure
to environmental allergens, air pollution, dietary factors,
and abnormal immunological responses all promote the
development of asthma. The timing and level of exposure
to allergens and irritants may be crucial factors leading
to the development of disease. Early viral infections and
passive tobacco smoke exposure has been associated with
the development of asthma in young children. Airborne
allergens and irritants associated with asthma occur in
the workplace and can lead to chronic and debilitating
disease if the exposure persists.
The cause of most asthma is unknown and thus its prevention is problematic. People who smoke and have asthma
have a much more rapid decline in lung function than
those who do not smoke. Avoidance of smoking during
pregnancy and avoidance of passive smoke exposure
after birth can reduce asthma severity in children. Occupational asthma has taught us that removing allergens
or irritants early may ablate or reduce the disease.
Asthma is a generally a lifelong disease that is not curable, but effective treatment can alleviate the symptoms.
Inhaled corticosteroids are the cornerstone of effective
asthma treatment. When used appropriately, that is,
taken regularly with a spacer or other device to assist
inhalation, these medicines can decrease the severity and
frequency of symptoms of asthma. They also reduce the
need for reliever inhalers (rapid-acting bronchodilators)
and the frequency of severe episodes (exacerbations)
requiring urgent medical care, emergency room visits, and
hospitalizations. Inhaled bronchodilators are important
to give quick relief from asthma symptoms.
Unfortunately, many people suffering from asthma
do not have access to effective asthma medicines. Even
though inhaled corticosteroids and inhaled bronchodidrug list they are either unavailable or unaffordable in
many low-income countries. Universal access to effective, proven therapies for controlling asthma and treating exacerbations is an essential requirement to combat
this disease.
Lack of availability of medicines is not the only reason
that people with asthma do not get effective care. Widespread misconceptions about the nature of the disease
and its treatment often prevent people using the most
appropriate treatments. Educational campaigns to encourage the use of inhaled corticosteroids and avoidance
of exposures that trigger asthma attacks are an important
part of effective asthma control programs.
Vol 9 No 1 March 2014

Control or elimination
Research is critical to understand better the origins of
asthma, the causes of exacerbations, and the reasons
for its rising worldwide prevalence. The International
Study of Asthma and Allergies in Childhood (ISAAC)
has provided insights into the disease and facilitated
standardized research on asthma in children that has
of asthma and allergies worldwide.23
The Global Initiative for Asthma (GINA) has developed an evidence-based strategy for the management
of asthma. Dissemination and implementation of this
strategy will improve asthma control. Making inhaled
corticosteroids, bronchodilators, and spacer devices
widely available at an affordable price and educating
people with asthma about the disease and its management are key steps to improve outcomes for people with
asthma. Policy-makers should develop and apply effective means of quality-assurance within health services
for respiratory diseases at all levels. Strategies to reduce
indoor air pollution, smoke exposure, and respiratory
infections will enhance asthma control.

3. Acute respiratory infections

Scope of the disease

Respiratory infections account for more than four million
deaths annually and are the leading cause of death in
developing countries.24 Because these deaths are preventable with adequate medical care, a much higher proportion of them occur in low-income countries. Pneumonia
is the most common serious respiratory infection. In
children under 5 years of age, pneumonia accounts for
18% of all deaths, or more than 1.5 million annually;6
virus (HIV) or malaria.24 Risk factors for pneumonia
include living in crowded conditions, malnutrition,
indoor smoke.
In Africa, pneumonia ranks among the most frequent
reasons for adults being admitted to hospitals; one in ten
of these patients die of their disease. There is one episode
of pneumonia for every 100 adults under 60 years of age.

remains the most

increases the risk of pneumonia caused by this organism twenty-fold.25 Pneumonia can also lead to chronic
respiratory disease, such as bronchiectasis.
can spread rapidly within communities across the globe.
5 to 15% of the population and severe illness in three to
In 2003, the severe acute respiratory
syndrome (SARS), caused by a previously unrecognized
coronavirus, rapidly spread throughout the world. Its
lethality mobilized international efforts that rapidly

Vol 9 No 1 March 2014

infection control measures reduced its spread and were

claimed the lives of between 30 and 150 million persons.
health. Primary prevention strategies for respiratory infections are based on immunization programs that have
been developed for both viruses and bacteria. Bacteria
are the most common cause of pneumonia;
type b most
are effective against these agents as well as measles and
The S. pneumoniae conjugate vaccine is highly effective in
reducing pneumonia in children, but this vaccine is still
not available as part of the national expanded program
on immunization in many low-income countries.
Childhood respiratory disease can be prevented or
ameliorated by several basic measuresimproving childhood nutrition, promoting breastfeeding, comprehensive
immunization, improving living conditions to prevent
crowding, avoidance of tobacco smoke exposure, reduc-

Most bacterial respiratory infections are treatable with
antibiotics and most viral infections are self-limited.
Yet, millions of people die of pneumonia. The failure to
prevent these deaths largely results from lack of access
to health care or the inability of the health care system
to care for these individuals.
The most effective way to manage these diseases is
through standard case management. Case management
planning, facilitation, care coordination, evaluation, and
advocacy for options and services to meet an individuals
and familys comprehensive health needs through communication and available resources to promote quality
cost-effective outcomes.27
For childhood pneumonia this involves a standard
approach to diagnosis and treatment as has been well
of Childhood Illness program. The contribution of case
services developed in Malawi in collaboration with
The Union. In this resource-limited country, adopting a
standardized case management program, training health
workers, and developing the infrastructure to implement
the program steadily improved the outcome for children
under 5 years of age with pneumonia.28 The cornerstone
of pneumonia management is appropriate diagnosis and
use of antibiotics.

African Journal of Respiratory Medicine

Control or elimination

Individuals become infected by inhaling tuberculous

bacteria. Tuberculosis usually develops subtly so that

as part of the expanded program on immunization in

all countries. Development of improved vaccines with
broader coverage are needed to control or eliminate

about one in ten infected but otherwise healthy persons

develop symptomatic disease, although this rate is much

Antibiotics have made most bacterial pneumonia easily curable. As with other diseases in which the causes
are known and cures are available, the key efforts must
be in improving the availability and delivery of quality health care and medicine. Diagnosis must be made
earlier, which entails more awareness in the community.
Better diagnostic tests include more effective sampling
procedures and better methods for rapid laboratory
detection of the infectious agents or microbial molecules
in sputum, blood, and urine.
Improved diagnosis enables targeted therapy. More intelligent use of antibiotics will decrease the huge problem
of antimicrobial drug resistance. Misuse of antibiotics
leads to the emergence and selection of resistant bacteria. Physicians worldwide now face situations where
infected patients cannot be treated adequately because
the responsible bacterium is totally resistant to available
antibiotics. Three strategic areas of intervention include:
(a) prudent use of available antibiotics, giving them only
when they are needed, with the correct diagnosis and
in the correct dosage, dose intervals, and duration; (b)
hygienic precautions to control of transmission of resistant strains between persons, including hand hygiene,
screening for carriage of resistant strains, and isolation
of positive patients, and (c) research and development of
effective antibiotics with new mechanisms of action [29].

4. Tuberculosis

Scope of the disease

In 2011, there were about 8.7 million new cases of tuber30
killed 1.4 million people and took an extraordinary high
occurred in Africa where tuberculosis is the leading
Tuberculosis is contagious (airborne) and therefore clusters in countries and
regions; nineteen countries account for 80% of existing
cases of tuberculosis worldwide.4 Multidrug-resistant
tuberculosis is increasing and approached 60 000 cases
in 2011.30 Eastern Europe has been particularly hard hit
by drug-resistant disease.
The good news is that the intense multinational efforts
for tuberculosis control of the past decade have paid dividends. New cases are falling at a rate of about 2.2% per
year and mortality has dropped 41% since 1990.30 New
diagnostic tests and drugs are becoming available and
considerable progress is being made in understanding
the bacterium and developing vaccines. Unfortunately,
this progress masks other persistent serious problems
and regional variations.

African Journal of Respiratory Medicine

other illnesses. The disease lies dormant because the infection is contained by the bodys immune system, but can
become active at any point in the persons lifetime. Active
disease usually develops slowly so that individuals may
cough and spread the disease without knowing it. With
the ease and frequency of international travel, spread
to other people is easy. No one is safe from tuberculosis
until the world is safe from tuberculosis.
Tuberculosis is a particular problem in children where
are especially susceptible to developing severe or disseminated tuberculosis. Tuberculosis can strain national
health care systems because of the effort and cost needed
for contact tracing and treatment, especially if the tuberculosis bacteria are resistant to the commonly used drugs.
In no disease is the phrase treatment is prevention
truer than with tuberculosis. The factors promoting
the spread of infection relate to the chance that an uninfected individual is exposed to persons with infectious
tuberculosis: the more cases in the community, the more
likely it is that an individual will become infected. Factors promoting the development of disease in infected
individuals relate to the function of the immune system.
conditions that affect immunity, such as certain medications and the presence of poorly controlled diabetes
increase the risk of developing active disease.
Comprehensive public health programs that search
out cases and contacts and effectively treat tuberculosis
reduce the presence of the bacteria in society and thus
prevent its spread. Treatment of contacts of patients
with active tuberculosis and those with latent tuberculosis that are at high risk for developing active disease,
The current vaccine, Bacille-Calmette-Gurin (BCG),
is largely ineffective for pulmonary tuberculosis, but offers some protection against disseminated tuberculosis.
on developing new vaccines for tuberculosis.
Most cases of tuberculosis can be cured if diagnosed
and treat; there are many nuances to its management.
Tuberculosis is best managed by a standardized approach
that is based on evidence derived from clinical trials. The
Vol 9 No 1 March 2014

long duration of therapy (usually 6 months with three
or four drugs in uncomplicated cases) makes adherence
to treatment challenging especially in individuals who
Failure to take the full course of prescribed drugs may
result in relapse with drug-resistant disease, which is
could be infected by that person. For this reason, supervised or directly observed therapy is recommended to
ensure adherence throughout the course of treatment
for tuberculosis.
To complement the standard case management proStop TB Department, the Tuberculosis Coalition for
Technical Assistance developed a document to engage
all providers in the best care for tuberculosis patients
wherever they may be found.32
Control or elimination
Many areas of tuberculosis research are producing enhas generally relied on seeing bacteria microscopically
in the sputum. New diagnostic technologies, such as
GeneXpert MTB/RIF that analyze sputum for mymicroscopic sputum smear examination. In addition,
DNA technology can detect drug resistance. These tools
are becoming available to high prevalence countries
technology and enabling treatment for drug resistance
be used because of drug-resistance, drug-intolerance, or
drug-interactions, treatment must extend much longer.
Treating drug resistant disease costs much more and
the chance for cure is much less. Fortunately, several
new drugs are on the horizon for drug-resistant disease.
Shorter course therapy for both sensitive and resistant
tuberculosis is urgently needed to further reduce the
prevalence of this disease. Shorter duration of therapy
is also needed for latent tuberculosis. A recent study
showed that the treatment with only 12 weekly doses
of medicine, directly observed over three months, was
as good as the current 9 month daily regimen.33 Public
health efforts to reduce the tuberculosis burden include
improved Infection control).4

5. Lung cancer

Scope of the disease

Lung cancer is the most commonly diagnosed cancer in
the world, making up 12.7% of the total reported cancers
and affecting over 1.61 million people. Lung cancer is
also the most common cause of cancer death, killing 1.37
million, or about 18% of the total cancer deaths.9 Lung

Vol 9 No 1 March 2014

its ratio of mortality to incidence is 0.86.9 In the United

States, lung cancer causes more deaths than breast, colon,
and prostate cancer combined.
Tobacco smoke is the cause of most cases of lung cancer.
Many components of tobacco smoke mutate DNA and
are carcinogenic. These effects correlate with the amount
and duration of smoking. Because damage accumulates
over time, lung cancer occurs years after people begin
smoking. As smoking rates rise, lung cancer rates follow.
Although most lung cancer is associated with smoking,
it can occur in non-smokers, especially in those who are
passively exposed to the tobacco smoke. Among those
who do not smoke and do not live with those who do,
exposure to the smoke from biomass fuel is a cause of
lung cancer. Exposure to radon, asbestos, and other
environmental and workplace elements also cause lung
countries, it is still in the environment in buildings and
previous manufacturing sites. Some countries where
its use is banned still produce and market it to poorer
countriesthis must stop.
Lung cancer is largely preventable by smoking prevention
and cessation. At the beginning of the twentieth century,
lung cancer and smoking were rare. As the number of
smokers grew, the number of lung cancer cases grew
about twenty years later. Smoking began to decrease in
the last third of the twentieth century in certain countries
and lung cancer is now slowly declining in those countries. Public programs that reduce smoking are urgently
needed to halt the rise in respiratory cancers in nations
where smoking has increased because the incidence of
lung cancer will also increase in those countries.
Environmental sources of lung cancer, such as radon
and asbestos, can be monitored and reduced. Lung cancer
can also occur in nonsmokers without known environmental exposure. Research is needed to determine other
causes of lung cancer.
The care of patients with lung cancer is complex. To
guide treatment and to determine prognosis, lung cancer patients undergo a staging process. Early stage lung
cancer is treated with surgery. More advanced stages
or a combination of these interventions. Patients who
have advanced stage lung cancer are rarely cured of their
disease. Individualized or personalized therapy directed
results of treatment. Research is ongoing to identify targets in different patients with different lung cancers that
can give a greater chance of cure with fewer side effects.
Treatment of lung cancer in the elderly and people
with other serious health problems pose a challenge.
risks of adverse effects in individual patients. Patients
African Journal of Respiratory Medicine

young but they usually present with advanced disease
and have a poor prognosis. The treatment with chemodrug interactions and toxicity.
Identifying and treating early cancer is a potential
life saving strategy. The national lung cancer screening
trial undertaken in the United States was the largest
(53,454 participants) randomized trial of a single cancerscreening test in the history of US medicine. The study
randomly assigned current and former smokers to plain
chest radiography (control) or low-dose chest computed
tomography (intervention) yearly for three years and
followed them for another 3.5 years. The study showed
tervention group and a 7% reduction in overall mortality.
test result, and 96% of these were false positive meaning
that many people will need additional investigations as
a result of screening and most of these will not derive
is likely to be costly but, as of yet, there have been no
cost effectiveness studies with this technology.
Control or elimination
cancer lies with efforts to decrease smoking by helping
current smokers stop and developing methods to decrease
the number of smokers who start. It is important to limit
smoke exposure in the workplace and home. Legislation
to regulate tobacco use and its promotion, to eliminate
exposure to cigarette smoke in public areas, and to raise
taxes on tobacco products are proven techniques that
decrease tobacco use. These are particularly important
in countries where smoking rates are rising.
Comparative effectiveness research into strategies
aimed at tobacco reduction, cessation, and public policy
are needed. Research into improving early diagnosis,
understanding genetic and molecular mechanisms that
and genetic predisposition to lung cancer are important.
tant for secondary prevention.

Breathing unhealthy air is a cause or contributor

to most respiratory conditions. The most common
sources of unhealthy air are tobacco smoke, indoor
air pollution from burning solid fuels, unhealthy
industrial sources, air containing microbes, and air
with toxic particles or fumes.
tion of tobacco use. Smoking was estimated to be
responsible for one in seven deaths in men and one

Of these deaths, the greatest proportion is due to

respiratory diseases, including lung cancers. In the
more likely to die of lung cancer than those who
never smoked.36 The rate of death from all causes is
three time higher in smokers than nonsmokers and
life-expectancy is shortened by 10 years in smokers.37
In Europe, the total health cost of tobacco is about
544 billion annually, which represents about 5% of
the European Union GDP.38 Passive smoke exposure
leads to respiratory illness in children including
pneumonia and asthma.
Tobacco smoking is a global problem that can be
solved. Intensive campaigns in Western Europe and
North and South America have decreased the number of smokers in several countries, but the tobacco
industry moved its target to susceptible populations
in Eastern Europe, Asia, and developing countries
to increase sales of its products. An estimated 350
million Chinese smoke an average of 11 cigarettes
per day, a level of smoking that has not been seen
in Western countries in 50 years. Passive smoke
exposure also leads to respiratory disease. Children
who are exposed to tobacco smoke before birth (from
a smoking pregnant mother) or as infants have a
greater risk of developing wheezing-associated illnesses, pneumonia, and asthma.

What can be done to combat respiratory


Framework Convention on Tobacco Control.39 It is

an important mechanism by which governments can
control the tobacco industry by using laws, regulations, administrative decisions, and enforcement
measures. Effective strategies, termed MPOWER

before it occurs. Identifying and ameliorating the factors

that cause or promote respiratory diseases can prevent
them, especially because respiratory diseases are often
linked to the environment. More than any other system
disease, respiratory conditions are preventable. The cost
of prevention is only a fraction of the cost of treatment.
Because preventing and combating respiratory disease is
so cost-effective, targeting respiratory diseases represents a
best buy

Free Initiative to support implementation of the

Framework to prevent and reduce smoking and
the demand for tobacco products. FIRS calls on all
governments, communities, health care practitioners,
and individuals to promote these effective preventive
measures that have reduced tobacco consumption in
many countries. Much, however, remains to be done,
particularly in low and middle-income countries to
mitigate the pernicious impact of tobacco smoking.


African Journal of Respiratory Medicine

Vol 9 No 1 March 2014

Poor indoor air quality is an important contributor to
respiratory disease. About 50% of all households in the
world and 90% of rural households use solid fuels, exposing 23 billion people to noxious smoke.40 The World
38.5 million DALYs per year can be attributed to indoor
smoke. Most disease and death attributable to exposure
to poor indoor air quality occurs in women and children,
especially in low income families.41 Exposure to indoor
smoke used for heating and cooking leads to COPD, lung
cancer and, in children, pneumonia and asthma.42 People
with lung disease are particularly susceptible to the effects of outdoor air pollution. Increased concentrations
hospital admissions and deaths.4345 It is estimated that
poor air quality in Europe leads to an average loss of 8.6
months of life expectancy.46 There is a growing body of
evidence that air pollution affects the unborn child leading to enhanced susceptibility to infection, respiratory,
and cardiovascular disease.47 Children, especially those
with chronic lung disease, are also more susceptible to
the adverse effects of air pollution.48 The environmental
risks are greater in low and middle-income countries
and among the disadvantaged and low socio-economic
sections of society. The respiratory societies of the world
believe that everyone has the right to breathe clean air.46
and we ask lawmakers to enact and enforce clean air
air policies are far reaching. In one large urban area, it
was estimated that complying with current standards
would reduce the annual death toll by 1200 deaths per
year, reduce the hospitalizations for heart and lung
diseases by 600 per year, reduce the cases of chronic
bronchitis in adults by 1,900 per year, reduce the cases
of acute bronchitis in children by 12,100 per year, and
reduce asthma attacks in children and adults by 18,700
per year.49 Greater improvements in air quality would
the past two decades have been shown to be associated
with increases in life expectancy in the USA and improved
respiratory health.46 Legislation and political action on
clean air makes a difference.
Appropriate nutrition and physical activity are critical
for health. Both malnutrition and obesity contribute to
respiratory diseases. Obesity is linked with obstructive
sleep apnea in Western societies and to asthma, heart
disease, and diabetes. Malnutrition is an important risk
factor for childhood pneumonia and severe illness.
Prevention of respiratory disease entails strengthening health care systems, using established guidelines
for health promotion and disease prevention, training
medical personnel, and educating the populace.
Treatment and cure
Once disease occurs, the goal is to lessen its effects and
cure it if possible. Reducing its effects is best accomplished
by early detection, prompt diagnosis, and early, effecVol 9 No 1 March 2014

tive treatment. Successful treatment is based on sound

medical evidence, is cost-effective, and is generally in
accordance with standardized guidelines. Patients and
health care workers can manage diseases better if they
are properly trained and resources are available. The
respiratory societies have developed recommendations
Unfortunately, effective and uniform implementation,
promotion, and adherence to these standards have been
if they do not reach the communities and patients that
with programmatic research, education, a trained work
which to operate.
Economic barriers limit access to care even in many
resource-rich settings. Many people simply cannot afford
to obtain good quality care. In resource-poor settings,
many people do not seek care from the public system
because it is lacking, of poor quality, or inaccessible. In
many countries, public health care systems are seen as
a drain on public coffers. They are vulnerable to abrupt
change in funding, which depends on the political and
economic climate. In some countries, there are health
insurance systems that limit medications or services.
age of care, but that care may not be adequate. Restrictions on health-care should be based on evidence-based
standards of care.
Disease control and global reduction or elimination
The FIRS vision of controlling and eliminating respiratory diseases requires use of the current effective tools
coupled with additional research. Antibiotics can cure
most pneumonia or tuberculosis and smoking-cessation
programs can be effective, yet enormous problems remain in managing these illnesses. In the last few years,
application of what is available, bolstered by research,
have reduced the rate of pneumonia and tuberculosis
worldwide4 and tobacco use in certain countries. These
successes must stimulate the world to consolidate and
extend these gains to more countries and regions. It
cannot be a shortsighted rationale for reducing effort.
In addition to public health measures, developing
health care capacity requires the education of clinicians
and researchers. Several FIRS member societies have
created training programs. Nearly two decades ago,
the American Thoracic Society developed the Methods in
Clinical and Operational Research (MECOR) program in
Latin America to increase the numbers of public health,
academic, and clinical leaders to facilitate research and
its application to public health and health care related
to respiratory diseases. These courses are now available
in Asia and Africa, and the program has trained more
than 1000 health care workers worldwide. The Asociacin
Latinoamericana de Trax has taken over the courses in
African Journal of Respiratory Medicine


Latin America. The Pan African Thoracic Society has developed similar courses that have operated since 2007. The
Union has many programs for operational research and
management training. Administration is an important
component of the health care system that is often ignored.
has sought to improve
respiratory care in Europe by developing a Europeantion in Respiratory Medicine for European Specialists
an authorized post-graduate examination in respiratory
medicine. The American College of Chest Physicians offers
dedicated courses, attended by participants from around
The other main tool to reduce respiratory diseases lies
in research. Public health and clinical research improves
and promotes health for a population by improving health
care systems ability to deal with disease and promote
health and to set improved guidelines and standards
for the care of patients. Basic research aims to uncover
the mechanism of disease and develop newer and better
diagnostic tools or treatments to alleviate or cure diseases.
The investment in respiratory research has paid enormous dividends. People are living longer and healthier,
and we are only on the threshold of even greater advances.
are working hard to uncover the basic processes that go
wrong in disease. The complicated network of cells, signals, and structures is being revealed and used to identify
susceptible individuals, to develop better diagnostic
people and to control disease. The results of clinical trials are distilled into guidelines on to how best to manage an illness. These evidence-base recommendations
can be powerful tools to secure uniform high quality
medical care throughout the world. Respiratory medical
research has been shown to represent a six-fold return
on investment.50 Knowledge created through research
is cross-cultural and enduring.


Respiratory diseases are an enormous challenge to life,

health, and productive human activity. Prevention, cure,
and control of these diseases and promotion of respiratory
health must be the top priority in global decision-making
in the health sector. The ability to control, prevent, and
cure respiratory diseases make this among the most
cost-effective health interventions available. Investment
in respiratory health will pay manifold dividends in the
longevity, healthy living days, and national economies.
Public awareness and control of the environment are
important steps to preventing respiratory diseases. The
key controllable factors are reduction in tobacco smoking


African Journal of Respiratory Medicine

and improvement in air quality that includes reduction

unhealthy public and workplace air. Strengthening
childhood immunization programs and greater availprioritized in low-income countries. Improved nutrition,
especially in pregnant women and children, can have
respiratory illness.
Effective training of health care workers and making
available medications and appropriate diagnostics are
keys to better lung health. Tuberculosis and pneumonia
are two respiratory diseases that can be cured and controlled if the resources devoted to them are increased.
Finally, research in respiratory diseases is the hope
for today and the promise for tomorrow. Research must
answer many questions: how do lung diseases arise,
how do they are spread, who is vulnerable, and what
actions can be used control or cure them, to name a few.
Research must also help us understand what keeps people
healthy. Measures developed from the research must be
cost-effective and widely applicable. Increased funding
to support respiratory research is needed.


FIRS calls for these essential actions to reduce the burden

of respiratory disease and improve global health:
1. Increase the public and policy makers awareness




global health and that improving respiratory health

will improve national economies
Increase the public and policy makers awareness
of childhood illness and has long-term negative
consequences on adult health
Urge policy makers to enable universal access to
quality health care, including the availability of
essential medications for all those with respiratory
Reduce, and then eliminate, the use of all tobacco
Reduce ambient, indoor, and occupational air pollution
Provide universal coverage for childhood and adult


Improve early diagnosis of respiratory diseases

Recognize the impact of malnutrition, obesity, and
physical activity on respiratory conditions and implement plans to correct these concerns
9. Increase education and training of health professionals in respiratory disease worldwide
10. Increase respiratory research to develop programs,
tools, and strategies to better prevent and treat respiratory diseases

Vol 9 No 1 March 2014


2013; Available from:
of COPD. 2013; Available from:
. Available
2012; Available from:

Available from:

6. Black, R.E., et al.,
Lancet, 2010. 375(9730):
p. 1969-87.
7. Pearce, N., et al.,
gies in Childhood (ISAAC). Thorax, 2007. 62(9): p. 758-66.

in children in Malawi. PLoS Med, 2009. 6(11): p. e1000137.

29. Control, E.C.f.D.P.a. Antimicrobial resistance. 2013; Available
WHO Global Tuberculosis Control,


income countries. 2011; Available from:

Available from:
36. Thun, M.J.C., B.D.; Feskanich, D.; Freedman, N.D.; Prentice, R.;
related mortality in the United States. N Engl J Med, 2013. 368: p.

Int J Cancer, 2010. 127(12): p. 2893-917.

. 2003; Available from:

. Available from:

12. Asthma and Allergy Foundation of America.
Worldwide burden
of COPD in high- and low-income countries. Part I. The burden of
Int J Tuberc Lung Dis,
2008. 12(7): p. 703-8.
14. Menezes, A.M., et al.,
Cad Saude Publica, 2005. 21(5): p. 1565-73.
15. Chan-Yeung, M.A.-K., N.; White, N.; Ip, M.S.; Tan, W.C.; , The

16. Talamo, C., et al.,

cities. Chest, 2007. 131(1): p. 60-7.
17. Eisner, M.D., et al.,
182(5): p. 693-718.
18. Grigg, J.,
p. 105-6.

14: p. 840-848.


N Engl J Med, 2013. 368:

. 2012.

A study

Control Available from:


. 2011; Available from:

Torres-Duque, C., et al.,
Proc Am Thorac Soc, 2008. 5(5): p. 577-90.
Fullerton, D.G., et al.,
lung function in Malawian adults. Int J Tuberc Lung Dis, 2011.
15(3): p. 391-8.
Bell, M.L., et al.,
Am J Respir Crit Care Med, 2009. 179(12):
p. 1115-20.
Katsouyanni, K., et al.,
2009(142): p. 5-90.

Proc Am Thorac Soc, 2009. 6(7): p.

46. Brunekreef, B., et al.,

Eur Respir J, 2012.
39(3): p. 525-8.
47. Cohen, A.J., et al., The global burden of disease due to outdoor air
68(13-14): p. 1301-7.
48. Schwartz, J.,
Pediatrics, 2004.
113(4 Suppl): p. 1037-43.
49. (CREAL), E.C.d.R.e.E.A.
. 2013.
50. Society, E.R.
Policy Makers, 2012.

Arch Bronconeumol, 2012. 48(4):

Available from:
International Study of Asthma and Allergies in Childhood.
Available from:
World Lung Foundation,
2010, New York: World Lung Foundation.
Scott, J.A., et al.,
Lancet, 2000. 355(9211):
p. 1225-30.
Centers for Disease Control and Prevention. Available from:
Case Management Society of America Standards of Practice for
Case Management. 2010.
Enarson, P.M., et al.,

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p. 341-50.

. 2010;
Available from:

readmission. Prev Chronic Dis, 2004. 1(2): p. A07.


R.N.; McAfee, T.; Peto, R.;,

Am J Respir Crit Care Med, 2010.

C.; Redd, S.C.; ,

MMWR Surveill Summ, 2002. 51: p. 1-13.
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latent tuberculosis infection. N Engl J Med, 2011. 365(23): p. 215566.

. 2007.

9. Ferlay, J., et al.,

Clin Infect Dis, 2010. 50 Suppl 3: p.


In the article Frontline healthcare workers knowledge

of TB in rural south-east Nigeria, which appeared in
the September 2013 issue of
the authorss details
appeared as U K Nnanna, I Alobu, and O E Mbah.
requested that the citation be as follows:
workers knowledge of TB in rural south-east Nigeria.
2013; 9 (1): 710.
African Journal of Respiratory Medicine


Review Article

Advances in the treatment of

severe asthma
F Gandia and S Rouatbi



Major criteria (must have one):

Two of seven minor criteria

Defining severe asthma


Table 2 Definition: ATS workshop, requires diagnosis

and drug treatment of comorbidities (adapted from the
American Thoracic Society)3


Untreated severe asthma.

Prevalence and morbidity



Table I WHO classifications of severe asthma


Fedoua Gandia and Sonia Rouatbi, Laboratory of

Physiology, Faculty of Medicine, University of Sousse,
Sousse, Tunisia.
Correspondence to: Dr Fedoua Gandia.

African Journal of Respiratory Medicine

Vol 9 No 2 March 2014

Review Article
Asthma has an
Anti-IgE: omalizumab

Treatment of severe asthma


Current treatment of severe asthma


Anti interleukin-5 (IL-5): mepolizumab



Biological agents
IL-4 and IL-13 inhibitors: altrakincept and pitrakinra

Table 3 Stepwise treatment of acute asthma10

Vol 9 No 2 March 2014

African Journal of Respiratory Medicine


Review Article



Inhibitors of tumour necrosis factor: golimumab and etanercept


IL-2 inhibitors: daclizumab



Inhibition of chemokines
Am J Crit Care Med

Eur Respir J

Non pharmacological targeted treatment

Bronchial thermoplasty

J Allergy Clin Immunol

Respir Med

Prim Care Respir J

Afr J Emerg Med


S Afr

Med J
Eur Respir Rev

Cochrane Database of Systematic Reviews

High-altitude treatment


Clin Exp Allergy

Eur Respir Rev


African Journal of Respiratory Medicine

Vol 9 No 2 March 2014

Review Article
Am J Respir Crit Care Med

N Engl J Med

N Engl J Med

Engl J Med

Am J Respir Crit Care Med

. Thorax


J Allergy Asthma Immunol

Am Crit Care Med

J Allergy Clin Immunol

N Engl J Med


Am J Respir Crit Care Med

BMC Pulm Med


Eur Respir J

Paediatric and Adult African Spirometry working group

About us

The Paediatric and Adult African Spirometry (PAAS) project is a research venture set up to address the lack of

Our Aim

Who to contact
before the 31st of May 2014:

Vol 9 No 2 March 2014

African Journal of Respiratory Medicine


Review Article

Asthma control in cities of developing

G A Nadeau, I Samji, R D Walters, S F R Godwin, J Lucas, and M Moodley


Over 80% of asthma-related deaths occur in low and

lower-middle income countries,1 with asthmatic children
in low and middle income countries having more severe
symptoms than those in high income settings.2-4 Asthmaassociated symptoms, sleep disturbances, impairment of
lung function, increased use of rescue medication, and
limitation of daily activity and quality of life impose a
burden on affected individuals, the updated
Global Initiative for Asthma (GINA) guidelines5 therefore
emphasise that asthma management should be based
on achieving and maintaining clinical asthma control.69
Surveys assessing the current level of asthma control
in asthmatic children and adults in different regions of
the world1020 have indicated that asthma control was
suboptimal and that the disease was still under-diagnosed
and under-treated globally. Inadequate asthma control
results in poor health outcomes; including greater
numbers of emergency room visits and hospitalization/
urgent healthcare utilization, increased mortality, lower
physical and mental health-related quality of life scores,
absenteeism from work/school, and higher levels of
activity impairment/overall work productivity loss.20, 2226
Most of these observations are based on information
from Western Europe and North America. In view of the
dearth of asthma control information from developing
countries, the objectives of this study were to understand,
for urban settings of developing countries from diverse
regions of the world, the perception of asthma in the
general population through a household survey and
the level of asthma control through a complementary
survey with asthmatics.

Materials and methods

Study design
This was a pilot survey conducted in two parts: part 1,
a household survey to assess the perceptions of asthma
and part 2, a survey of patients with asthma to assess
the level of asthma control in developing countries. Five
G A Nadeau, I Samji, and R D Walters, GlaxoSmithKline,
Medical Affairs, Uxbridge, UK;
S F R Godwin, J Lucas, and M Moodley,
Ipsos Healthcare, London, UK.
Correspondence to: Gilbert A Nadeau,
Medical Affairs Director,
GSK Respiratory Centre of Excellence.


African Journal of Respiratory Medicine

cities from developing economies in Africa and Asia

were selected: Dakar (Senegal), Dhaka (Bangladesh),
Lusaka (Zambia), Nairobi (Kenya), and Phnom Penh
(Cambodia). We used a multi-modular approach for both
surveys consisting of structured interviews which were
conducted using standardised questionnaires developed
based on discussion with experts and healthcare workers
version for each module of research was reviewed and
approved for medical content and then translated into
the native languages of the different countries by agennative language from each country and by the sponsor.
The study samples/sizes were determined by Ipsos
Healthcare, London, UK; an independent healthcare
market research organisation specialising in such surveys
and contracted to deliver the study. For the household
survey, n=1000 was used as it offers a statistical reliability
of +3% (at 95%). For the survey of patients with asthma,
as it is a smaller population, n=300 was used; it offers a
statistical reliability of +5.7% (at 95%). The survey was
performed according to the European Pharmaceutical
Market Research Association guidelines.27 All study
participants provided written informed consent to
participate in the study as required by the guidelines.
The study followed established practices for market
research projects.
Part 1. Household survey
The main household survey was designed to explore attitudes to asthma across each city. At least 1000 households
per city were interviewed using a random door-to-door
sampling strategy within neighbourhoods, designed
levels. Standardised questionnaires were used for the
interviews. Respondents for this element of the research
had to be over the age of 18 years. As it was important for
the sample to be representative of the city, there were no
served as the target group). Interviewers were instructed
to move to a different household if they were unable
to establish contact or permission to participate in the
study. The tools used to assess socioeconomic class was
for each city; it was based on the Living Standards MeaVol 9 No 2 March 2014

Review Article
sures for the three African cities and was complemented
by questions on education and occupation for Dakar. A
combination of education and occupation was used for
Dhaka, whereas income was used in Phnom Penh for
assessment of socioeconomic class.
Part 2. Asthma survey

cian diagnosis in the last 12 months or breathing problems/symptoms suggestive of asthma were asked to
participate in the asthma survey. Asthmatic adults and
parents/guardians of children with asthma living within
the households from the above described survey were
then interviewed with regard to their own asthma or the
asthma of children under their care.
The aim was to recruit 300 people with asthma in each

current smokers. Assessment of the socioeconomic class

indicated that the vast majority of asthmatics were either
of medium or low socioeconomic status.
Asthma control and acute exacerbations
A large group of asthmatics (between 32 and 56%) indicated that their asthma was well controlled, despite
being short of breath or waking in the night due to asthma
symptoms (see Table 2).
Assessment, according to the ACT score, showed that
asthma control was generally very poor across all cities.
The distribution of ACT scores was largely uni-modal;
with the majority of subjects having scores between 12
and 19 (see Figure 1) and relatively few subjects (1527%)
Table 3). Asthma control was found to be worst in the
lower socioeconomic classes but did not appear to be
to have marginally better control than those from referrals (see Table 4).

professionals and referral from those

interviewed in the household survey. Parameter
A sensitivity analysis on asthma Households surveyed
control was conducted to ensure Total number of





Phnom Penh








































contacts made (n)

in the secondary search was similar Number of no response

to the group of asthmatics identi- or refusals (n)
Asthma control, in asthmatics identi-

Number of completed
surveys (n)

using the Asthma Control Test Asthmatics surveyed

(ACT; Quality Metric Incorporated, Mean age (years)
Lincoln, Rhode Island, USA)28and
% Female
% Male

as self-reported visits to the hospital because of asthma/breathing Mean height (cm)

Mean weight (kg)
% Smokers


% Households in SEC

The disposition of households

surveyed and demographics of the
subjects with asthma in the different
cities are presented in Table 1.
The number of households contacted varied between the cities
due to variations in the numbers
of households either failing to re16
spond or refusing to participate in
the survey.
The mean age of asthmatic subjects Socioeconomic class (SEC) was
27 and 47.5 years in the different cit-

based on the Living Standards Measures

for the three African cities and was complemented by questions on education and occupation for Dakar. A combination of education and occupation
was used for Dhaka, whereas income was used in Phnom Penh for assessment of socioeconomic class.
SEC in only Dakar defined as high, medium, or low.

in the survey, a small majority of

asthmatic respondents were female
and relatively few participants in the Table 1 Disposition of households surveyed and demographics of subjects with
asthma questionnaire reported to be asthma from households interviewed in different cities
Vol 9 No 2 March 2014

African Journal of Respiratory Medicine


Review Article
Asthmatic subjects in our survey were asked to report
repeated asthma exacerbations requiring hospitalisations
in the previous year. The majority of subjects reported
at least 1 exacerbation requiring hospitalisation in the
previous year (between 48% and 82% of responders per
city) and an average hospitalisation rate of between 4.6
and 10.7 per year (see Table 5). The majority of patients
from all cities surveyed stayed for <1 day in hospital and
received tablets as treatment for exacerbations. Aligned
not having inhaled or nebuliser therapy (see Table 5).
Frequently used asthma treatments
Based on reports from asthmatics, large numbers of
patients did not use or even possess an inhaler, whereas
oral bronchodilators were used very commonly and appeared to prevail in most cities (see Table 6).

their understanding of several diseases (asthma, HIV,

arthritis, diabetes and cancer). Between 33% and 54% of
responders indicated that they had a good (rated 4 out
of 5) or very good (rated as 5 out of 5) understanding
of asthma (see Table 7). The reported understanding of
asthma fell below that of diseases like HIV (mean score
varying between 2.6 and 3.5 for asthma and 3.3 and 4.4
for HIV). Negative attitudes and the stigma attached to
inhaled medication seemed to be common among the
responders. A large number of responders (ranging from
16% to 29%) agreed with the statement that asthma
problems should not be discussed openly and even
more (between 31% and 63%) with the statement that the
use of inhalers means you are very sick (see Table 7).


The main objectives of our study were to understand the

perception of asthma in the general population through a
Asthma and/or treatment-associated social stigma
household survey and the level of asthma control through
In the household survey, responders were asked to rate a complementary survey with asthmatics across cities
of the developing countries
Lusaka Nairobi Phnom Penh in Africa and Asia. As far as
(n=302) (n=300) (n=301) (n=300) (n=300)
we can ascertain, this is the
% Patients rating their asthma
as well controlled






% Patients short of breath once

or twice a week






% Patients waking once or

twice a week due to
asthma symptoms






% Patients without an inhaler






Table 2. Perception of asthma control, weekly symptoms, and inhaler use by patients
from different cities

Figure 1 Distribution of Asthma Control Test (ACT) scores by city


African Journal of Respiratory Medicine

asthma control in patients in

major cities of several developing countries.
Our study demonstrated
that asthma control across the
cities surveyed, based on the
ACT scores, was very poor
compared to European and
North American surveys using the ACT to assess degree
of asthma control.10-20 This
was supported by the high
level of reported symptoms
as well as the prevalence
of repeated exacerbations
requiring hospitalisation. To
the best of our knowledge, the
rate of repeated exacerbations
requiring hospitalisation was
higher in our survey than in
any other asthma control survey. It is possible that patients
in developing countries use
emergency departments for
relatively minor worsening of
symptoms and as part of their
ongoing management of the
disease but the poor asthma
ACT score would suggest
Management of asthma
seemed to be based on oral
Vol 9 No 2 March 2014

Review Article





Phnom Penh

2025 (well controlled)

519 (not well controlled)
(1519; 514)

(48; 30)

(38; 35)

(39; 46)

(40; 41)

(36; 49)

% asthmatics with controlled

(uncontrolled) asthma in age group:
<25 years
2535 years
3645 years
4655 years
>55 years

20 (80)
14 (86)
14 (86)
29 (71)
25 (75)

3 (6)
22 (78)
29 (71)
15 (85)
24 (76)

18 (82)
5 (95)
4 (96)
16 (84)
23 (77)

17 (83)
23 (77)
16 (84)
19 (81)
0 (100)

19 (81)
16 (84)
9 (91)
11 (89)
5 (95)

38 (62)

28 (72)
29 (71)

21 (79)

23 (77)

23 (77)

22 (78)
10 (90)

7 (93)

23 (77)

25 (75)
12 (88)

8 (92)

30 (70)

18 (82)

5 (95)

5 (95)

% asthmatics with ACT scores:

% asthmatics with controlled

(uncontrolled) asthma in SEC:

32 (68)
23 (78)
17 (83)

Socioeconomic class (SEC) was based on the Living Standards Measures for the three African cities and was complemented by questions on education and occupation for Dakar. A combination of education and occupation was used for Dhaka,
whereas income was used in Phnom Penh for assessment of socioeconomic class.

Table 3 Asthma control and influence of age and socio-economic class (SEC) in patients from different cities.



Lusaka Nairobi Phnom Penh

% subjects controlled from those






% subjects controlled from those






% subjects controlled from total






Table 4 Percentage of asthmatic subjects with well-controlled asthma

therapy. The relatively limited use of inhaled medicause of inhaled medication and with asthma in general.
It could also result from the limited availability of inhaled medication. These observations suggest that care
may be improved by implementing simple educational
programmes aimed at increasing the understanding
of asthma for both the general population and asthma
patients. In addition, healthcare workers should be kept
informed of international and local guidelines and of the
role of inhaled controller medications.
Our study has limitations. The interviewers were
asked to move on to another household if they were
Vol 9 No 2 March 2014

unable to establish contact or

permission to participate in the
study. The responders to the
household survey may therefore be different to the general
population. The sample sizes
were relatively small and based
in urban environments, and
therefore may be unlikely to be
representative of the general
asthmatic population across
each country. The consistency of

cities surveyed, however, suggests that our observations are valid at least for urban settings. We also used
standardised questionnaires developed and translated
for this study during face to face interviews rather than
telephone interviews, which increases the validity of our
observations. Identifying asthmatic subjects in a survey
usually from a more severe consulting population. Reversibility testing is impractical during a cross-sectional
study because of the transient nature of the disease and
sure and ethically complicated. Asthmatics in our survey
African Journal of Respiratory Medicine


Review Article





% patients with acute exacerbations

resulting in hospitalisation in the last year






10.7 (25.16)

5.1 (11.8)

4.24 (4.3)

4.6 (4.9)

6.2 (8.0)

% patients in hospital for:

<1 day
12 days
37 days
>7 days






% patients receiving:






Frequency of hospitalisation
in last 12 months (mean (SD))

Phnom Penh

GPs estimate of asthma treatment






Nurses estimate of asthma treatment






Table 5 Acute exacerbation-associated hospitalisation and treatments in patients from different cities




Phnom Penh


Salbutamol tablet/

Ventolin syrup


Ventolin syrup


Ventolin tablet/

Ventolin tablet

Salbutamol tablet

Ventolin and
salbutamol tablets

Ventolin inhaler



Any other asthma

drug preparation

Ventolin inhaler (6/10)

Asmasol HFA 7/10

Ventosal syrup 5/10

Ventolin tablets 8/10 Ventolin

Ventolin tablets (4/10)

Ventolin inhaler 6/10

tablet 4/10

Ventosal syrup 8/10

Generally used Corticosteroids



Celestine injectable 3/10 Ventolin tablets 4/10

Brodil tablets 3/10

Ventolin Evohaler
inhaler 7/10
Seretide inhaler 4/10

tablet 7/10
Seretide 4/10

Salmolin inhaler 3/10

Table 6 Top three treatments used generally or prescribed by doctors for moderate asthmatics as standard of
care in different cities.
were self-reported as having a physician diagnosis of
asthma in the last 12 months or symptoms suggestive
of asthma in the same period. Although not perfect, this
approach is consistent with major international surveys
including the International Study of Asthma and Allergies
in Childhood (ISAAC) and the European Community
Respiratory Health Survey (ECRHS). It is possible that
more representative of the general population and that
those from the secondary search strategy would be more
severe cases. A sensitivity analysis comparing the ACT
scores in these two groups did not support this hypothesis. The mean age in our surveys was higher than that
based on the search methodology.
In conclusion, this study has shown that asthma control,
as assessed by ACT scores, frequency of symptoms, and
the very high rate of exacerbations requiring hospitalisa22

African Journal of Respiratory Medicine

poor asthma control and acute exacerbations being very

frequent, patients appeared to overestimate their level of
control. Treatment patterns varied greatly from one city
to the other, both in average number of dispensed treatments and in type of treatment, and there often appeared
to be an over-reliance on oral bronchodilators as the
mainstay of therapy. Moreover, treatments were generally
not aligned to international guidelines and appeared to
focus on systemic and inhaled bronchodilators and on
treatment of exacerbations. Use of controller medication and inhalers was low in all cities; probably due to
the combination of cost and stigma/negative attitudes
associated with inhaler use. Educational programmes
and public awareness campaigns could help improve
asthma care and lessen the burden associated with this
disease in developing countries.
Vol 9 No 2 March 2014

Review Article





Phnom Penh

Households ratings for understanding of asthma (%)






Mean rating









































Negative perceptions among households surveyed (%)

Asthma/breathing problems are contagious

Asthma/breathing problems should not be

discussed openly

Use of inhaler means being very ill


Tablets are preferred to prevent awareness of

asthma to others

Living in a dusty house leads to asthma


leads to asthma
Rating scale 1 to 5: with 1 = very little understanding and 5 = very good understanding.
Expressed as percentage of responders who agree, rather than those that were aware of this perception.
Expressed as percentage of total asthmatics surveyed in Dakar (n= 302).

Table 7 Asthma understanding and treatment-associated attitudes and social stigma in different cities


This study was funded by GlaxoSmithKline. The authors

wish to acknowledge Dr Jagdish Devalia for assistance
in the preparation and editing of this article.

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64: 47683.
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America: a public health challenge and research opportunity. Allergy
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Respirology 2005; 10: 57986.



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AIRE Study: data analysis of 753 European children with asthma.
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of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE)
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and reality in the Gulf and the near East. Int J Tuberc Lung Dis 2009;
13: 101522.
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and Reality in Japan (AIRJ) in 2005 since 2000. Arerugi 2008; 57:
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Reality in Japan 2005. Arerugi 2006; 55: 13403.
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America: the Asthma Insights and Reality in Latin America (AIRLA)
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African Journal of Respiratory Medicine


Original Article

The Asthma Control Test and its

relationship with lung function parameters
J Jumbo, B O Adeniyi, P O Ikuabe, and G E Erhabor


The Asthma Control Test (ACT) is a validated, simple,

and inexpensive instrument to assess control among
patients with bronchial asthma. However, its relationship with lung function parameters is yet to be demonstrated among Nigerian asthma patients.
Our study aimed at assessing asthma control using
ACT scores and determining its relationship with lung
function parameters among persons with asthma in a
university respiratory clinic.
The cross-sectional study included 65 patients with
bronchial asthma who underwent routine check-ups in
respiratory clinics at the Obafemi Awolowo University
Teaching Hospital Complex (OAUTHC), Ile-Ife, Nigeria between October 2009 and January 2011. The ACT
was administered to assess for asthma control. Lung
function testing was done using the guidelines of the
American Thoracic Society (ATS).
The mean pre-bronchodilator FEV1 (forced expiratory volume in 1 second) was 1.970.87L and mean
ACT score was 18.2+4.28; 24 (37%) of the study subjects had well-controlled asthma. The ACT scores
were weakly correlated with percentage of predicted,
FEV1(r=0.220, p=<0.078) and PEF (peak expiratory
In this study, most of the patients had poor asthma
control and lung function parameters correlated poorly
with ACT scores. It is important that the ACT complements other physiological measures of assessing asthma
control in our environment.


Bronchial asthma is a worldwide disease which affects

all ages, sexes, and racial groups. It affects 300 million
people globally with an expected increase of prevalence
to 400 million by the year 2025.1 It poses substantial and
unacceptable health and economic burdens.2
International guidelines indicate that the primary goal
of asthma management is to obtain control and reduce the
risk of exacerbation.3 Asthma control refers to the control
of disease manifestations both in terms of symptoms and
laboratory investigations.4
Drs J Jumbo, B O Adeniyi, P O Ikuabe, and G E Erhabor,
Department of Internal Medicine, College of Health
Sciences, Niger Delta University, Wilberforce Island,
Bayelsa State, Nigeria.
Correspondence to: Dr J Jumbo.
Email: johnbulljumbo&

African Journal of Respiratory Medicine

Poor assessment of asthma control is a major cause

of suboptimal asthma management worldwide so the
focus is now shifting to an assessment and treatment
approach based on control. The Gaining Optimal Asthma
Control (GOAL) study5 has suggested that asthma control is a feasible outcome and is associated with marked
improvement in quality of life and substantial reduction
in morbidity.
While there is no comprehensive tool to identify and
veloped, tested, and validated over the last few years for
their reliability and reproducibility to measure control.610
These tools include the Asthma Therapy Assessment
Questionnaire (ATAQ),6,7 the Juniper Asthma Control
Questionnaire (ACQ),8 the Asthma Control Scoring
System (ACSS),9 and the Asthma Control Test (ACT).10
The ACT was developed by Nathan and colleagues in
2004 and is a trademark of the US company Quality
Metric. It is a validated, reproducible, and reliable tool
in assessing asthma control.
Studies conducted in Canada,
and South Africa1115 suggest that substantial cases of
asthma are not well controlled. A study carried out by
Adeyeye et al16 in Lagos, Nigeria has also corroborated
Traditionally, asthma is assessed using spirometry as
a measure of lung function. This provides an objective
and reproducible measure of ventilatory function and
provides complementary information not provided by
other outcome variables. However, its correlations with
is weak.7 In addition, it is unclear how spirometry relates
with ACT as a complimentary measure in the assessment
of asthma.There is paucity of research work assessing
control using ACT and its relationship with lung function parameters among asthmatics in Nigeria. Our study
was aimed at assessing asthma control using a validated
ACT among Nigerian asthmatics and investigating how
it relates and complements lung function parameters.

Patients and methods

This cross-sectional analytical study was carried out in the

medical clinics/wards of Obafemi Awolowo University
Teaching Hospitals Complex (OAUTHC).
A total of 65 patients aged between 16 and 55 years
a bronchodilator reversibility test with change in FEV1
(forced expiratory volume in 1 second) >15% and/or
Vol 9 No 1 March 2014

Original Article
200 ml, 20 minutes after inhalation of 400 microgram
of -agonist (salbutamol))17 were included.In addition,
only those without an acute exacerbation of asthma in
the preceding 4 weeks were included in the sample.
All asthma patients who had co-morbid conditions
such as hypertensive heart failure and chronic obstructive
pulmonary disease (COPD), patients with acute severe
were excluded. A Medical Research Council (MRC)
questionnaire was used to record socio-demographic
data obtained were summarised.
Asthma control was assessed by self-reported asthma
tionnaire that assesses interference with activity, shortness of breath, nocturnal symptoms, rescue medication
use, and self-rating of asthma control. Each item is scored
using a 15 scale and then scores are totalled (total score
525). A score of 20 or higher was found to be the most


Lung function tests were performed according to the

American Thoracic Society guidelines17 as follows:
of the procedure and accompanying demonstration.
The best of three satisfactory readings was recorded.
standardised spirometer: Micro Medical Ltd, USA.
Data obtained were analysed with Statistical Package for Social Sciences (SPSS) version 16.0. Continuous
variables were expressed as means standard deviation
and categorical variables as percentages. The Chi-square
association between categorical variables while Students
t-test was used for the continuous variables. Correlations
between levels of asthma control by ACT scores and
lung function parameters were assessed using Pearsons

cording to the level of control based on the ACT question-

shown, 24 (37%) of subjects had well-controlled asthma,

while 28 (43%) and 13 (20%) had not well-controlled and
poorly controlled asthma respectively.
Table 3 shows the clinical and demographic characteristics of the subjects grouped based on their ACT scores.

Frequency (n=65)


Age (years)
51 and above



Educational status






Civil servant



BMI (kg/metre2)



Table 1 Sociodemographic and health characteristics of

the subjects


Socio-demographic characteristics of the patients who

participated in the study are shown in Table 1. There were
38 females (58%) and 27 males (42%). Twenty (31%) of
the respondents had a body mass index (BMI) greater
than 24. Only 17 (26%) of the subjects were on controlled
medication for asthma and 25 (38%) of the respondents
had asthma disgnosed for 15 years or more.
Table 2 shows the lung function values among the
respondents. The mean pre-bronchodilator FEV1 was
1.970.87 L, while the post bronchodilator FEV1 was
2.320.95 L. The predicted pre-bronchodilator FEV1 was
teria of reversibility of 15% in the FEV1 and PEF.
Figure 1 shows the distribution of the study subjects acVol 9 No 1 March 2014

PEF (L/min)
FEV1 (L)
FEV1/FVC (%)

Pre-bronchodilator Post-bronchodilator
(Mean SD)
(Mean SD)




PEF (%)


predicted (%)



Table 2 Lung function values for the subjects

African Journal of Respiratory Medicine


Original Article
pared with 5 (12%)
controlled group
that used controller
medications. The
difference was sta-

Poorly controlled asthma

Well-controlled asthma

(p<0.029).The relationship between

the levels of asthma
Not well-controlled asthma
control and the lung
function parameters of the subjects
Figure 1 Distribution of study
is shown in Table 4. subjects according to the levels of
There was no sig- asthma control
nificant relationship between lung function variables and ACT scores.

tion between ACT and ventilatory function parameters

in clinical evaluation of persons with asthma. In this
study, bronchial asthma was found to be more common
among the 38 females (58%). The lung function values
for the respondents showed a mean pre-bronchodilator
FEV1 of 2.29 L1.08 and 1.75 L0.59 for males and females
Several studies have been carried out around the world
to assess asthma control using various instruments.1821
The ACT has been validated against specialists rating of
asthma control and spirometry22 and quality of life.23 The
overall mean score as measured by ACT was 18.204.28,
with only 37% of the subjects scoring 20 and above which
denotes well-controlled asthma.

poorly controlled among the respondents. This study

in Lagos University Teaching Hospital (LUTH) who
demonstrated that asthma control was poor among the
This study assessed the level of asthma control using the study subjects.
Findings similar to this index study were reported
ACT among patients with bronchial asthma in a developby
Mendoza et al,22 using the ACT in a hospital-based
ing country. The study also sought to determine the relastudy in The Philippines. They found
Clinical and
ACT well
ACT not well
p-value that only 28% of the respondents had
well-controlled asthma.
survey, The Reality of Asthma Control
Age (years) (Mean SD)
(TRAC)12 study using the Canadian
Duration of asthma
Asthma Consensus guidelines showed
(years) (Mean SD)
that only 47% of respondents had controlled asthma.
Age of onset (years)
Similar observations were made in the
(Mean SD)
Insight and Reality in Europe
FEV1(L) (Mean SD)
(AIRE)13 and International Asthma
Use of controller
Patient Insight Research (INSPIRE)24
studies. Another study, Asthma Insight
Yes n (%)
10 (42%)
5 (12%)
and Reality in Latin America (AIRLA)21
No n (%)
14 (58%)
36 (88%)
survey using GINA (Global Initiative for
Asthma) guidelines also corroborated
Male n (%)
11 (4%)
16 (59%)
control was poor. Overall, only 2.4% of
Female n (%)
13 (34%)
25 (66%)
all patients met all the GINA criteria for
total asthma control.
Table 3 Characteristics of subjects grouped based on their ACT scores
Females appear to have
FEV1 FEV1 PEF PEF FVC FVC FEV1/ Predicted lower overall ACT scores
Post Pre
Post Pre
compared with males. This
ings of Tovt-Korshynska
0.131 0.150 0.148 0.129 0.155 0.100 0.105 0.093
et al25 that in asthma, as
0.30 0.234 0.238 0.306 0.219 0.429 0.404 0.460 (NS)
in several chronic disease
Not well-controlled
settings, females may rer
0.188 0.178 0.076 0.077 0.225 0.234 0.067 0.167
port symptoms differently
0.133 0.156 0.546 0.543 0.071 0.060 0.596 0.183 (NS) from males, being more
likely to seek medical care.
Poorly controlled
However, physiological
0.072 0.086 0.060 0.043 0.077 0.151 0.002 0.107
explanations are also of
0.569 0.778 0.637 0.734 0.151 0.230 0.989 0.398 (NS)
potential importance. NonTable 4 Pearsons correlation between ACT and lung function parameters of the subjects

African Journal of Respiratory Medicine

Vol 9 No 1 March 2014

Original Article
responsiveness has been reported to be more common
among females than males in general population surveys.26 However, this phenomenon needs to be further
evaluated in other socio-cultural setting, and stimulates
further work in ACT in diverse communities.
This study showed that only 26% of the respondents
than others reported in the work of Marks et al,27 who
found that 36% of adult asthmatics with daily symptoms
and 41% with symptoms on most days were taking
controller medication.



and use of controller medications. Subjects on controller

medications appear to have a better ACT scores than re-


done by Green R J28 in South Africa who found that asthmatics on controller medications achieved better control.
Also evaluated in this study was the relationship between ACT scores and lung function parameters. There
was a poor correlation between ACT scores and lung


by several studies.28-30 The poor correlation may be partly

to differences in the magnitude and time course of the
response to treatment.31 Symptoms and lung function
parameters represent different domains of asthma and
they correlate poorly over time in individual patients,32,33
so both need to be monitored by clinicians assessing
asthma control in clinical practice.
However, a study done by Mendoza et al22 showed a
1 and ACT scores. This
size was larger and it was a cohort prospective study which
followed up subjects over time, compared with the index
study which took a cross-sectional look at lung function
variables and ACT scores.


In conclusion, the present study showed that asthma

was poorly controlled among the study subjects. It also
showed that lung function parameters correlate poorly
tance of a control-based approach to management and
the importance of a multi-dimensional strategy in the
evaluation of persons with asthma.
This study is limited because it is a hospital-based study
so may not be generally representative of asthmatics in
the general population. A community-based study would
for a large multicenter study to assess asthma control
using ACT in our environment.


The authors wish to thank all staff of the Respiratory

Unit, Department of Internal Medicine, OAUTCH, Ile-Ife
for all their efforts, time and assistance. We acknowledge
all the participants in this study for their cooperation.
Vol 9 No 1 March 2014



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prospective health maintenance organization-based study. Chest 2007;
132: 115161.
31. Reddel HK, Jenkins CR, Marks GB, et al. Optimal asthma control starting
with high doses of inhaled budesonide. Eur Respir J 2000; 16: 22635.
32. Dorinsky PM, Edwards LD, Yancey SW, Rickard KA. Use of changes in
symptoms to predict changes in lung function in assessing the response
to asthma therapy. Clin Ther 2001; 23: 71014.
33. Sharek PJ, Mayer ML, Loewy L, et al. Agreement among measures of
asthma status: a prospective study of lowincome children with moderate
to severe asthma. Paediatrics 2002; 110: 797804.

African Journal of Respiratory Medicine


Original Article

Knowledge, awareness, and practice of

A A Raheem, R O Soremekun, and O F Adeniyi


asthma monitoring and in determining the severity of
symptoms. Against the background of reported unand prescription for home use, and the paucity of such
data in developing countries, this study was carried
out to assess the knowledge, awareness, and practice
of children with asthma.
The work was a prospective cross-sectional study
involving 67 doctors working in the paediatric departments of two government hospitals in Lagos State, Nigeria. The number of doctors varied as not all responded to
the number of doctors that responded to the particular
issue/question addressed. The survey was conducted
with a self-administered structured questionnaire. Infrequency of prescription, and constraints in prescribing

of asthma. The designation of the respondents and the

years of experience in the management of asthma were
This study revealed that the physicians knowledge
used in diagnosis nor prescribed for home management
by physicians attending to asthmatic children at the
two referral hospitals. The cost and availability of the

Asthma affects an estimated 300 million individuals

worldwide and 250 000 asthma-related deaths are reported each year.1 Approximately 500 000 annual hospitalisations are due to asthma, with 34.6% being individuals age
18 years or younger.2 The management of acute asthma
symptoms in children begins at home with parents and
other caregivers being at the forefront.3 The dynamic
nature of asthma, with waxing and waning symptoms,
treatment plan as needed. It is therefore necessary for
medical practitioners to work with families to help them
develop asthma management skills by providing them
with appropriate resources, teaching them to recognise
asthma symptoms, and to follow an appropriate treatment plan.4 Inaccurate perception of a childs asthma
symptom severity by caregivers may lead to the overuse
or underuse of quick relief asthma medications.3
monitoring and in determining the severity of symptoms.5 Attempts to assess lung function through physical
examinations and patients reports are often inaccurate.
along the airways, thus providing objective measures of
lung function, which is important in making a diagnosis of asthma, assessing the severity, and in developing
and using asthma control plans.6
emergency department units and clinics to quickly and
objectively assess the effectiveness of bronchodilators in
the treatment of acute asthma attacks. It can also be used
of control therapy.7
There is a high degree of under-utilisation and inadin the urban areas of Johannesburg8 showed that only
monitoring. Of the practitioners who reported that a

Afusat A Raheem, Pharmacy Department, Lagos State

Rehabilitation Centre, Lagos, Nigeria;
Rebecca O Soremekun, Department of Clinical
Pharmacy and Biopharmacy, University of Lagos,
Nigeria; and Oluwafunmilayo F Adeniyi, Department of
Paediatrics, College of Medicine, University of Lagos.
Correspondence to: Dr Rebecca Soremekun.


African Journal of Respiratory Medicine

to show it to the researcher and were also unable to adequately demonstrate the correct use of the meter. Only
58% and 63% of practitioners in the public and private

the meter were reported reasons for under-utilisation.

Vol 9 No 1 March 2014

Original Article
In Nigeria, among 68 tertiary hospitals only 38% have a


In Turkey, older and more experienced physicians were

less likely to objectively measure lung function in making
a diagnosis of asthma. They relied more on their experience.11


All 67 doctors returned the completed questionnaire;

64.2% of the doctors were from LUTH while 35.8% were

how to use it, and 67% considered it necessary, but only

49% had ever used it in managing asthma.12 Against
especially in the management of asthma and particularly
in the prescription for home use, this study was carried
out to assess the knowledge, awareness, and practice

children with asthma.

Patients and methods

This work was a prospective cross-sectional study involving 67 doctors working in two government hospitals in
Lagos State, Nigeria. Of the 67 doctors, 43 worked at the
paediatric department of the Lagos University Teaching
children with asthma than doctors in LUTH.
the management of childhood diseases. The number of
doctors varied as not all responded to all the questions.
doctors that responded to the particular issue/question
The study was carried out between July and September, 2012. A convenience sampling technique was used
as all voluntary participants were recruited in the study.
A self-administered, structured questionnaire was
used to collect the data on demographic information
and years of experience in the management of asthma
in children. Other information sought was the presence/

in managing children with asthma was also evaluated.

The data were processed and analysed using Statisti-

a scoring system similar to that of a previous research

was used.8
poor. To have a good knowledge score, doctors needed to
know at least three out of four points about each device.
Knowledge of only two points was scored as fair while
less than two was scored as poor.
Vol 9 No 1 March 2014

Knowledge and awareness of the role of PFMs

study participants and their designations and number

had a poor score. There is however no statistically

the consultants and 69.2% of the senior registrars had a

Of doctors who graduated more than 25 years ago and

6 to 10 years ago only 66.7% and 61.9% respectively had
Role of PFMs

severity of an asthma episode. The majority of the docwas useful in objectively assessing the effectiveness of
caregivers actively involved in managing the asthma
African Journal of Respiratory Medicine


Original Article
Knowledge of PFMs
n (%)

n (%)

n (%)

2 = 6.911
p = 0.546

the years of experience of the doctor in attending to children with asthma and the frequency of prescription of
doctors with 6 to 10 years experience and all doctors
with more than 15 years experience only prescribed the


Constraints to the prescription of PFM for homemanagement of asthma in children

p = 0.950

Years of

the two main constraints. Other reported constraints

time available to teach patients/caregivers the use of the


2 (100.0) 0 (0)
1 (100.0) 0 (0)

0 (0)
0 (0)

surveyed doctors in Lagos State. The relatively inex-


Table 1 Respondents characteristics and their knowledge of

the PFM
useful in detecting worsening of the asthma in a child

Hospital, Ibadan in the South-West of Nigeria had a

predicting an imoending attack.

only 49% had ever used it in managing asthma.12 This

variation in knowledge may be due to differences in the

Practice of the use of PFMs

while all the doctors still relied on signs and symptoms

or did not use it at all.

the designation of respondents and the frequency of

9.5% of the registrars, and 7.7% of the senior registrars.

was prescribed always, only by doctors that graduated

no more than 10 years ago.
African Journal of Respiratory Medicine

into undergraduate curriculum. At an asthma-workshop

in Australia, it was found that medical students had
poor knowledge about several important features of
asthma care.13 The workshop was effective in increasing
the short term, and could be potentially useful later in
nation of respondents in this study and the knowledge


interpretation of its readings, while 53.8% had never

of doctors who graduated more than 25years ago and

Overall, 57.8% of the doctors in this study had a good
reported that only 33% of the doctors attained maximum
or close to maximum scores in a South African study.8
This large difference in scores reported in the two studies
may be due to the fact that there were differences in the
criteria scored. In the South African study, the ability of
was scored but actual demonstration of use was not
evaluated in this study.
Vol 9 No 1 March 2014

Original Article
and management of asthma among the doctors surveyed while only 28.1% of doctors in this study had the instruwas demonstrated in this study. Some 70.3% of the doctors ment in their consulting rooms. Since most of the doctors
78% would use it in assessing the severity of asthma, but rooms nor used it for diagnosis, demonstrating the use
only 16.7% and 20.7% respectively reported regular use of the meter to patients/caregivers would be minimal
if not impossible, hence, the low prescription rate. The
ments and treated more asthma cases than their counlar to reports among health maintenance organisations diagnosis since the instrument was not available in the
where p
clinics. This unfortunately, seems to be the situation in
asthma severity based on measurement of pulmonary many hospitals in Nigeria, as even among 68 surveyed
tertiary hospitals in Nigeria9
This is
review of asthma management in Nigeria, where lack
treatment of asthma.15 However in Johannesburg, South
Africa, 58% of the practitioners in the public sector used in asthma management.16 The experience of the doctors
The reasons
those with 5 years experience or less in management
of paediatric asthma. Doctors with more than 5 years
experience with asthma management in paediatrics


Signs and

66 (100%)



a good knowledge score on the use of the meter and the

edge score on the use of the meter. Thus it appears that
doctors relied more on their clinical experience of sign
and symptoms rather than the objective measure of the
lung function. In India, the years of experience similarly

Table 2 Methods of asthma diagnosis

trends in childhood asthma management and nebulisers/inhalers remained under-used.17

reasons may be due to unavailability of the meters in the

consulting rooms or the patient load in these paediatric reported constraint to its prescription for the home-management of asthma in children. Other workers have also
- reported unavailabity of equipment as a major constraint
tive patient treatment and management depends upon for failure to perform lung function tests in 65% of their
study participants.16,18 The purchase of this equipment
In this study a low prescription rate for home use of the may not receive priority attention since patients are not
- charged for its use compared with other routine laboratory investigations. However, in Spain, 65% availability
of the doctors had never pre- PFM for asthma Designation of respondent
only prescribed it occasionally.
In Johannesburg,8 29% of the

n (%)

n (%)

n (%)

Senior registrar Consultant

n (%)
n (%)

for home use. The relatively

higher prescription rate and
tors in Johannesburg may be
a function of the presence of Notes:
Table 3 Designation of physician and frequency of use of PFM for asthma diagnosis
Vol 9 No 1 March 2014

African Journal of Respiratory Medicine


Original Article

n (%)

n (%)

constraints to the use and prescription

for the home-management of asthma
2 = 16.245, in children.

n (%)

2 = 20.986, of doctors. To reduce asthma morbidity


2 = 8.522,

and mortality, educational efforts should

aim at improving physicians severity
assessment through increased use of
objective measures of lung function.
Hospitals, community pharmacies as
well as doctors consulting rooms should



0 (0)
0 (0)

2 (100.0)
1 (100.0)

0 (0)
0 (0)


1 (9.1)

10 (90.9)

education on underserved children with asthma.

Arch Ped Adoles Med 2006;

0 (0)

does home management of asthma exacerbations by

parents of inner-city children differ from National
recommendations. Pediatrics
Kids health

n=65, b n=64

Table 4 Respondents characteristics and the prescription of PFMs for homemonitoring of asthma in children

a 15-year review. J Asthma

Soweto community health clinics, S Afr Family Pract

cause of its under-utilisation by public sector practitio-

of asthma management among doctors in south-east Nigeria. Afr J

Resp Med

of pictures.
similar reasons though to varying degrees.8 The variation
in the degrees of importance of the reasons may be due
to differences in the study environments.
Though all categories of doctors seem to be aware of

Hospital, Lagos. The physicians knowledge about the


African Journal of Respiratory Medicine

cians, BMC Health Services Research


and also not prescribed by physicians attending to asth-

Health Policy


able to teach patients/caregivers the use of the meter


clinical practice. Afr J Resp Med


The cost

knowledge and actual use of this valuable instrument.

straints outlined earlier and the need for re-orientation
of physicians on the need to use this tool cannot be
Medscape Reference, 2012.

Nigeria. Chest
, Shah S,


. Teaching asthma manage. Aust N Z J Med

cians knowledge of asthma diagnosis and treatment guidelines in a

health maintenance organization. Ped Asthma, Allergy Immun 2000;
Pediatr Allergy Immunol
systematic review. Ann Med Health Sci Res 2013;
17. Shahid G. Bhinder G. Dhanjal J. knowledge, attitudes and practices
childhood asthma. Int J Asthma Allergy Immunol 2007; 6.
asthma among adults in Ilorin, Nigeria. Afr J Med Med Sci
19. Kools
performance. Patient Educ Counsel

Vol 9 No 1 March 2014

Case Report

Foreign body aspiration and tuberculosis:

possible misdiagnosis
R C Ideh, U Egere, D B Garba, and T Corrah


Childhood tuberculosis (TB) is common in developing

countries whereas foreign body aspiration is relatively
less frequently diagnosed. This report is of a child
contact (same household) of a smear-positive index
case who presented with suggestive clinical features,
and was admitted as a case of pulmonary TB, but
subsequently found to have an aspirated foreign body
was accounting for his symptoms.
Due to the similarity in the clinical features of a delayed clinical presentation of foreign body aspiration
with pulmonary TB, clinicians attending to children
with chronic respiratory pathology in a TB-endemic
area should be mindful of the possibility of a foreign
body in the airway and should always carefully review
chest radiographs.


Most cases of foreign body aspiration are diagnosed

early due to the dramatic initial clinical presentation
with unmistakable pointers such as sudden bouts of
coughing, choking, stridulous respiration, or wheezing.
However in some cases it is asymptomatic or the initial
phase symptoms quickly resolve and the foreign body
remains lodged in the lower airways.1 Missed foreign
bodies present later with chronic ill health and varied
symptoms that could easily be diagnosed as other chronic
respiratory conditions.2
cant contributor to childhood morbidity and mortality in
the developing world, whereas foreign body aspiration is
relatively less frequently encountered/diagnosed.3 The
diagnosis of childhood TB is most frequently based on
clinical symptoms and signs, a history of contact with
a sputum smear-positive adult TB case and suggestive
chest radiographs. A chronic foreign body could be misdiagnosed as TB in a TB-endemic setting and treated as
such with poor outcome.

Readon Chukwugoziem Ideh FWACP,

Uzochukwu Egere FWACP, Danlami Bulus Garba MBBS,
and Tumani Corrah PhD, Medical Research Council Unit,
The Gambia.
Correspondence to: Readon Chukwugoziem Ideh.

Vol 9 No 1 March 2014

Case presentation

A 6-year-old boy presented with a 2-month history of

weight loss, low grade fever, reduced appetite, and cough
productive of whitish, foul-smelling sputum. There was
no history of haemoptysis. He had received treatment at
various health centres with courses of antibiotics including ampicillin, cotrimoxazole, and amoxicillin. Despite
this his symptoms progressively worsened.
medical or surgical history, apart from primary nocturnal
enuresis. The mother claimed he had received complete
vaccinations according to the National EPI (Expanded
Programme on Immunization) schedule. His growth and
development were appropriate for age. He lived in the
of pulmonary TB treated at our TB clinic 3 years earlier.
On examination the boy appeared chronically afebrile
17 kg (approximately 85% of expected weight for age). He
had multiple, discrete non-tender cervical lymph nodes
measuring up to 1 cm in diameter. There was a visible
BCG (Bacillus CalmetteGurin) scar on his left deltoid
wall and intercostal recessions. Oxygen saturation was
98% on air. He had decreased chest movement with dull
percussion notes on the right lower zone anterior and
posterior, with markedly diminished breath sounds in the

Figure 1 X-ray showing air fluid level, collapse

consolidation of the right upper lobe, and a radiopaque
foreign body in the right bronchus (arrowed).
African Journal of Respiratory Medicine


Case Report
right lower zone. Other systems were essentially normal.
hemithorax, occupying the midzone and some collapse
and consolidation of the right upper lobe (see Figure 1).
An initial diagnosis of pulmonary TB with pleural effusion and a pneumothorax was made at the clinic; the
patient was admitted for investigation and TB treatment
A Mantoux tuberculin skin test was non-reactive and
two sputum samples were negative for acid and alcohol
fast bacilli. An initial thoracocentesis yielded 365 mls of
pus which was sent for microscopy and TB culture and
routine microbiology. Microscopy showed a pleocytosis
with 80% neutrophils and 20% lymphocytes. No AFB
(acid-fast bacilli) was seen, however, Gram-positive
cocci were visible on Gram stain. There was no growth
on the culture.
The patient was initially commenced on intravenous
ceftriaxone and metronidazole. A review of X-rays identi-

tion, as well as missed diagnoses were major causes of

prolonged morbidity and high mortality observed in
the reported cases.4
The diagnosis of pulmonary TB in children remains a
samples and the low yield of Mycobacterium tuberculosis
from sputum.5 Diagnosis therefore, is often made on the
basis of clinical history and presentation, contact with
an adult smear-positive TB case, and a suggestive chest
in this child had not been radiopaque, the diagnosis
would have been missed and he would have ended up
being treated for TB with resultant treatment failure
and possibly death. The fact that only a small portion
of inhaled foreign bodies in children are radiopaque
contributes to a high likelihood of foreign bodies not
possible misdiagnosis of the chronic complications.1,2,6 In
some situations also, despite modern imaging techniques,
radiopaque foreign bodies cannot be diagnosed clearly.7
Bronchoscopy appears to be the more reliable and accurate method of diagnosing foreign bodies in the airway.

The diagnosis was revised to right lung abscess secondary to inhaled foreign body. An attempt to remove the
Because of the limited cardiothoracic services available
in our region the patient was transferred to a specialist
centre in Dakar, Senegal where the foreign body, a metal
spring (see Figure 2), was successfully removed by rigid

8, 9


lung abscess and empyema thoracis; the patient was not

treated for TB. A follow-up, 30 months after successful
treatment, showed no clinical or radiological evidence
of lung pathology (see Figure 3).

Healthcare personnel attending children with chronic

respiratory pathology in a TB-endemic area should be
mindful of the possibility of a foreign body in the airway
and always carefully review chest X-rays. A computed
tomography (CT) scan of the chest (if available) and
bronchoscopy should be considered for cases diagnosed
as sputum smear-negative pulmonary TB that have
suggestive complicated chest radiographs, particularly
where there is a failure to respond to standard treatment
with good drug adherence.



Foreign body aspiration into the tracheobronchial tree is

common in children.1,4 In a report from Ethiopia correct
diagnosis was delayed or missed in 20% of the series.4
Late presentation, delay in diagnosis and interven-

Figure 2 (left) Metal spring removed from the childs lung.

Figure 3 (right) chest radiograph taken 30 months after
removal of foreign body showing normal lungs.

African Journal of Respiratory Medicine

We wish to acknowledge Dr Suzanne T B Anderson for

her help in preparing this manuscript.

1. Lima JOB, Fischer GB. Foreign body aspiration in children.

Paediatr Respir Rev 2002; 3: 3037.
2. Karakoc F, Cakir E, Ersu R, et al. Late diagnosis of foreign body
aspiration in children with chronic respiratory symptoms. Int J
Pediatr Otorhinolaryngol 2007; 71: 2416.
3. World Health Organization. Health a key to prosperity. Success
stories in developing countries. Available from: http://www.who.
4. Melaku G. Foreign body aspiration in children: Experience from
Ethiopa. East Afr Med J 1996; 73: 45962.
5. Starke JR. Diagnosis of tuberculosis in children. Pediatr Infect
Dis J 2002; 19: 10956.
6. Tokar R, Ilhan OH. Tracheobronchial foreign bodies in children:
importance of accurate history and plain chest radiography in
delayed presentation. Clinical Radiology 2004; 59: 60915.
turban pin aspiration syndrome. J Bronchol 2000; 7: 2734.
8. Black RE, Choi KJ, Syme WC, Johnson DG, Matlak ME. Bronchoscopic removal of aspiration foreign bodies in children. Am
J Surg 1984; 148: 7788.
9. Weisberg D, Schwartz I. Foreign bodies in the tracheobronchial

Vol 9 No 1 March 2014

Guidance for authors

The Editor welcomes articles on all aspects of respiratory medicine and practice, from all health professionals, medical and non-medical. The philosophy of the journal is to be both an outlet for original
research, as well as a forum for educational review articles. Above all, we want AJRM to be practical
and relevant to health professionals in Africa.
Advice and assistance will, wherever possible, be provided to potential authors on the scope of their
research or method of presenting papers.
If possible, these should be prepared in MicrosoftWord software and submitted as an attachment to an
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If you do not have access to a computer and email, we will accept typed manuscripts. These should be
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We regret, handwritten manuscripts will not be considered.
Original papers should, if possible, be prepared to the Vancouver Convention: abstract, introduction,
in SI units.

help the reader follow a line of reasoning and to provide visual relief for the eye.
Under normal circumstances, only papers/articles of less than 3000 words will be published. This ex-

Photographs are welcome but must be of good quality. Use can be made of colour transparencies, or
possible, line drawings should be supplied to a professionally drawn standard from which the publishers can reproduce directly.
All articles submitted to the African Journal of Respiratory Medicine are deemed to have been offered
exclusively to the journal, unless otherwise stated. Articles must not have been, or about to be, published elsewhere, either wholly or in substantial part. Copyright in papers published will be vested in
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