INTRODUCTION
Recent evidence indicatesthat asthma in children from developing regions is as prevalent asin developed areas of the world (1, 2). However, there are strikingdifferences in several aspects of asthma management in childrenwhich depend on the level of development of countries where theylive. The awareness of asthma, not just at community level but alsoat health staff level, availability of modern medications, impactof pharmaceutical industries on determining treatment modalities,cultural aspects inherent to each country or region, among others,are all important conditioning factors for global programs onchildhood asthma. Thus, several factor should be considered whenplanning guidelines or statements for asthma management indeveloping regions of the world, particularly those related to thesocioeconomic status of their populations (3). The latter isdifficult to interpret because the uneven distribution of theincome with very few individuals concentrating the most of themoney and a vast proportion of the others with very low income.This obviously results in several well known situations that areinherent to poverty i.e. lower education standards, superficialperception of the importance of disease and symptoms, higherexposition to environmental risk factors, higher prevalence ofchronic respiratory infections, larger rates of infantile morbidityand mortality due to acute respiratory infections, unprivilegedlife conditions, deficient health care, malnutrition, etc. At ahigher level of responsibility, very few governments of developingcountries have implemented efficient national programs for asthmaand this could be an explanation for the virtual absence ofreliable registries of asthma morbidity and mortality (especiallyin children). This is easy to corroborate by trying to obtain dataon morbidity and mortality due to asthma in childhood in countriesfrom developing regions of the world.
Low income populationsare also at higher risk for asthma in developed countries, wherelow socioeconomic status and ethnicity play an important role inasthma death and near-death in some localities (4). In a recentstudy undertaken school children in Chicago, it was found thatasthma prevalence is higher than previously noted, with ratesgreatest in minority and low income populations. Differences weremore striking for measures of severity than for symptoms ofwheezing, but are far less than previously reported differences inmortality, suggesting that additional factors, such as differentialaccess to continuous health care, may be affecting high death ratesfrom asthma in Chicago (5). In other study, it was found thatinsurance category was the most influential factor predictingasthma treatment site, suggesting that economic status may be themost important determinant of higher morbidity (6). Regarding theseverity of the clinical picture, it has been reported that asthmahospitalization rate is positively correlated with poverty rate andwith the proportion of nonwhite residents and inversely correlatedwith income and educational attainment (7).
The reported risk factorsfor asthma in children from developing regions are mainly crowding,tobacco smoke at home, use of kerosene or wood stoves, use of fanturned on for sleeping, living in coastal and humid areas,helmintic infection, sudden temperature changes, weather changes,viral respiratory infections, pneumonia, family history for asthmaand other allergic conditions, and air pollution (8-11). Most ofthese risk factors are clearly related to low socioeconomic statusand are very similar to those mentioned in the literature as riskfactors for more severe acute respiratory infections in children.Thus, environmental exposure risk factors for asthma seems to playa major role in the prevalence and severity of asthma in childrenfrom developing regions, and also in the burden and severity ofacute respiratory infections.
If risk factors forrespiratory infections and asthma in infants and children fromdeveloping regions are similar then higher rates of acute lowerrespiratory infections (ALRI) are expected to occur in asthmaticchildren since very early in their lives. This sort of viciouscircle driven by ARI increasing bronchial responsiveness orsustaining it high, what at its time would determine next ARI, orother triggering factors, causing more severe symptoms of bronchialobstruction and lung disease, may explain why both wheezing and ARIare more severe in infants from developing countries. Probablybecause ALRI is the predominant clinical picture at the time ofconsultation and diagnosing, this will also be the predominantdiagnosis in children and infants who consulted due to ALRI, evenwhen the most of them have or have had clinical evidence ofbronchial obstruction at the moment of physical examination. Thisalso happens in older children. A case-control study of patientswith pneumonia conducted to investigate whether wheezing diseasescould be a risk factor found that wheezing diseases, interpreted asproxies of asthma, were found to be an important risk factor forpneumonia with an odds ratio of 7.07 (95% CI = 2.34-21.36). Therisk of pneumonia attributable to wheezing diseases was tentativelycalculated at 51.42% (12).
Despite the well knownrelationship between recurrent wheezing or asthma and pneumonia ininfants and children by physicians from developing regions, many ofthese infants and children with mild to moderate asthma triggeredby a viral respiratory infection are unrecognized and treated withmedications, usually antibiotic and cough suppressant, that mightworse their condition. As mentioned, the most of these children areregistered under the label of acute respiratory infection as finaldiagnosis what will result in altering the true prevalence of bothconditions.
In a birth-cohort studyin children from low income population. We have found that the mainrisk for bronchopneumonia during the first year of life isrecurrent wheezing (Mallol, et al, unpublished data). We suggestthat recurrent wheezing illness in infants from developing regionsis the most important preventable risk factor for pneumonia anddeath due to ALRI in this group of age. It is worth to remind thatabout 100.000 of infants under one year of age die every year inLatin America due to ALRI (13). It has been reported that about 70%of children admitted due to severe ALRI also had symptoms and signsof bronchial obstruction (14). This suggests that better diagnosisand initial management of infants and children with bronchialobstruction could help to decrease the rate of pneumonia andmortality due to pneumonia in children from developingregions.
Education on asthma(particularly diagnosis and treatment) to health personnel(including physicians, nurses, therapist, social workers, etc.) andcommunity, appears as a fundamental task prior to the diffusion ofguidelines for asthma management. There are still several countriesat developing regions where asthma is grossly under recognized,under diagnosed and under treated, with many of asthmatic childrensuffering from complications that results in several antibiotictreatments, multiple consultations, admissions, school absence,exercise restrictions, and low life quality for them and theirfamilies. Additionally, it should be also considered thatunnecessary expenses done in non effective medications decreaseeven further the low income per year in these families. At present,efforts should be done at the most of developing localities tochange asthma treatment from crises-orientated management into apreventive management. Interventions which consider education andtraining to those involved in asthma care for low-incomepopulations living at developed countries have been undertaken withgood success. It has been reported that although effectivepreventive therapy is available, many African-American and Latinochildren receive episodic treatment for asthma that does not followcurrent guidelines for care. Training health staff to providecontinuing, and preventive care for asthma, substantially increasedtheir ability to identify children with asthma, involve them incontinuing care, and provide them with state-of-the-art care forasthma (15). Relatively low-cost model intervention to controlasthma in multiethnic, low-income, inner-city communities (in adeveloped country) has demonstrated that continuing education,provided to a high proportion of physicians, pharmacists,nurses/respiratory therapists, emergency medical technicians,school personnel, and allied health professionals involved inasthma care resulted in a substantial penetration into the targetcommunity improving asthma awareness and actions directed toself-management (16).
There is very fewinformation on this respect from developing countries, however,using international asthma guidelines in low-income asthmaticchildren in the city of São Paulo, Brazil, there was anotorious decrease in emergency room visits and no need forhospital admissions. There was also a significant decrease inasthma severity and impairment scores suggesting that combinationof good medical care and an educational program can reduce thesymptoms of asthma and significantly increase the quality of life,as well as decreasing the costs of asthma treatment (17). Many ofthese successful initiatives could be also implemented in otherdeveloping countries.
The cost of asthmatreatment has significantly decreased in the last years with theintroduction of generic inhaled bronchodilators and corticosteroidsand it is more affordable for some governments to buy anddistribute these MDI medications for free at the primary carelevel. In Chile, during the last decade salbutamol, beclomethasoneand spacers are available for free to infants and children fromlow-income populations who need to be treated with suchmedications. At the same time the ARI program has several centerswith trained chest therapist to recognize and do the firsttreatment to infants and children with acute bronchial obstruction.The health impact of the ARI Program seems to be very important,especially in decreasing infant mortality due to acute respiratoryinfections. Recently, it has been reported a decrease in the rateof mortality due to pneumonia in infants under one year from3.0/1000 to 1.7/1000 in a 4 years period (18).
However, in the most ofdeveloping countries no modern medication to treat asthma isprovided by public health system because it still resultsexpensive. In order to get good medications, patients have to buytheir treatment what many times is just impossible for them to do.At present, the approximate monthly cost for covering MDIbeclomethasone 400 mcg/day and salbutamol 200 inhalations, and thespacer, is about 25 US$ when using generics, and 75 US$ when usingoriginals. However, the former 25 US$ represents about the 5% tothe 30% of the basic salary (or more) at some developing regions.Then it is quite easy to understand that these patients will lookfor and receive a crisis-based treatment that is usually free atemergency rooms in hospitals pertaining to the public healthsystem. The savings derived of stopping to buy ephedrine, oralaminophyline, cough suppressants; the savings derived of theexpected decrease in admissions and emergency rooms consultationsdue to asthma when adequate preventive treatment is employed bypatients; and the savings derived from improving education onasthma management to health staff, will for sure provide withenough funds to get effective asthma medications for patientslooked after at the public health systems.
Another very importantmatter, probably related with low income, is the lack of reliableregistries for asthma morbidity and mortality in many of thecountries from developing regions. Authorities' responsibility cannot be overlooked and international institutions of health shouldalso direct efforts to convince governments to implement asthmaprograms with good registries at these localities. At present thechronic lack of data on emergency room visits, admissions,consultations, treatment modalities employed, age-related aspects,economic status influence, etc., do not allow for valid comparisonswith developed regions, neither with other countries at similarlevel of development. Under these conditions it seems superficialand difficult to determine what would be the best asthma managementin children in those countries.
Education strategiesshould also be directed to convince health authorities that it ischeaper treating asthma with currently available preventivemedication than spending much larger amount of money in old unsafemedications, antibiotics, cough medications, admissions, and soon... Probably establishing pilot asthma programs would help to getconvincing economic and medical evidence. The good experience ofARI Program in Chile that it is effective, saving-money and perhapswith some modifications it might be oriented to asthma in childrenand taken as a module to reproduce in some other developingcountries.
