By Dr. Allen Steele-Dadzie
(Family Physician and Asthma expert, Korle Bu Teaching Hospital)
Asthma is a dangerous illness which afflicts many individuals of all ages worldwide. It claims the lives of many Ghanaians daily. In 2017, an estimated 1,704 individuals died from asthma in Ghana. This means four to five individuals die daily from the disease. It is also estimated that about 65% of people who die from asthma, succumb to death before they are able to reach health facilities. Most people who succumb to asthma die unexpectedly. An estimated 10% or more persons in African countries, including Ghana, have asthma. These alarming statistics should arouse the concern of all well-meaning Ghanaians for urgent action.
The main cause of asthma is chronic airway inflammation of the wind pipe through which we breathe into our lungs. The chronic inflammation makes the wind pipe become excessively reactive to harmless environmental substances like dust and strong-scented perfume. So, the individual who has asthma struggles to breathe from time to time. Thus, there are two main problems in asthma – the underlying chronic inflammation of the windpipe and occasional symptoms of shortness of breath, cough, chest tightness and wheezing. The cardinal problem in asthma is the chronic inflammation of the windpipe. The underlying chronic inflammation means the windpipe of the person who has asthma is always sick, even when they are not experiencing symptoms. Treating the underlying chronic inflammation of the windpipe is the cornerstone of effective asthma treatment.
Unfortunately, asthma is not curable. Unlike other chronic diseases like hypertension and diabetes, there is no known effective way of preventing individuals from getting asthma. The most effective strategy for tackling the asthma menace is effective health care, especially at primary care facilities such as health centers, clinics and polyclinics, which are the first point of call for people with asthma. Effective asthma care at primary care facilities is the most viable strategy for curbing the asthma menace.
This was the focus of the recently-held international conference on asthma in Dubai, dubbed ‘Primary Right Asthma Care Forum’. It drew delegates from several countries, including Ghana. Ghana was represented by Dr. Allen Steele-Dadzie and Dr. Nana Ayisi-Boateng, who are family physicians at the Korle Bu Teaching Hospital and Kwame Nkrumah University of Science and Technology hospitals respectively. The participants received training on strategies for effective asthma care, with focus on primary care facilities.
Global experts in asthma care highlighted the global burden of asthma and why the disease continues to be a problem worldwide. Notable causes of asthma deaths include ineffective health care and people with asthma not adhering to effective care. They educated the participants about effective strategies for curbing asthma. Primary Right Asthma Care is a strategy espoused by the International Primary Care Respiratory Group (IPCRG) as an effective strategy for tackling the asthma menace.
Asthma is treated with two main types of medicines – reliever medicines and controller medicines. The reliever medicines are taken when individuals experience shortness of breath. They include salbutamol or ventolyn. Individuals experience quick relief and are able to breathe better after taking these medicines. However, reliever medicines do not tackle the underlying cause of asthma symptoms, which is the chronic inflammation of the windpipe. The individual who uses only the reliever therapy will experience relief of symptoms, but the sickness continues to simmer. The second group of drugs, which are known as controller medicines, are the most important asthma treatment. They contain corticosteroids which tackle the underlying chronic inflammation of the airway. These medicines ought to be inhaled daily in most asthma patients. Recently, scientific evidence shows that the most effective controller medicines are those that contain formoterol such as Symbicort.
The experts, at the forum, highlighted the fact that the main cause of asthma deaths is ineffective treatment. The most common forms of ineffective treatment are patients using mostly reliever medicines like salbutamol and asmadrin, and not using enough of controller medicines. Patients who do not use controller medicines will continue to experience frequent symptoms, and are at risk of unexpected death from asthma. Because asthma affects the windpipe, inhaler medicines are the best forms of medicine. Tablets taken for relief of symptoms are inappropriate, and relying on them during acute attacks can result in avoidable deaths, as they do not work fast and are not effective enough.
Another major cause of asthma death is poor health care. Poor health care involves health workers treating the asthma patients during acute attack with reliever medicines. But after the patient is relieved of the symptoms, they are sent home without controller medicines and schedule for review. The ideal is that asthma patients are treated by well trained health workers in asthma clinics at primary care continuously. Asthma patients must attend reviews regularly, and reviews done in a structured way administered by trained health workers. Effective use of the inhaler devices is crucial. These devices, which contain the asthma medicines, ought to be used correctly in order for the patients to get the stated doses into their windpipes. Ineffective technique of using these devices is another major reason for poor results in the treatment of asthma. When the technique of use is poor, it results in only a small fraction of the medicine reaching the windpipe. Thus, the medicine will be ineffective.
Current guidelines on asthma management have changed, the experts pointed out. Emphasis is now placed on the liberal use of controller medicines, especially combination drugs, which contain formoterol. Currently these drugs are preferred, even for relief of symptoms. These drugs have been proven to be the most effective asthma drugs. Adoption of these guidelines will help reduce asthma deaths in Ghana.
All heath facilities should have health workers specifically trained in asthma care. Each facility must have a structured follow-up care for asthma patients, which ensures that asthma patients receive continuous care, based on assessment of their current state. Health facilities must always have nebulizers and oxygen available for acute asthma care.
There should be a national policy on chronic disease management, which will include asthma. Asthma medicines are expensive and unaffordable to the ordinary Ghanaian. The National Health Insurance Scheme has been very helpful in ensuring people have access to asthma medicines, as most asthma medicines are supplied to subscribers. However, the most effective asthma controller drugs, which are combination of corticosteroids and long-acting beta-2 agonists, are only to be prescribed at tertiary facilities. With the recent changes in the WHO guidelines, which recommend the use of formoterol-based combination therapy more liberally, the scheme has to permit the prescription of these drugs at the primary care level, rather than the current limitation of their prescription at higher level health facilities, which are accessible to only few asthma patients.
These strategies will help reduce the grim statistics of asthma deaths in the country.