Asthma: moving toward a global children's charter

The RECHARGE-IPCRG ‘Teach the Teacher’ programme: building capacity for pulmonary rehabilitation in low- and middle-income countries

Introduction

Chronic respiratory diseases are the most common causes of morbidity and mortality globally. Pulmonary rehabilitation (PR) is a low-cost, high-impact intervention with patient education and exercise at its core. Although supported by a well-established evidence base, demand greatly exceeds capacity in low- and middle-income countries (LMIC), including limited workforce training opportunities to support PR development and implementation. The International Primary Care Respiratory Group’s (IPCRG) Teach the Teacher (TtT) is an established education programme designed to build sustainable local clinical teaching and delivery capacity.

Methods

A collaboration between the National Institute for Health and Care Research (NIHR) funded Global RECHARGE Group for PR and IPCRG to deliver a ‘Teach the Teacher’ (TtT) programme for PR capacity building. Our Tier 1 TtT programme combined educational and PR service development concepts with core clinical content adapted for RECHARGE partners in India (Pune and Delhi), Sri Lanka, Kyrgyzstan and Uganda. Due to the severe acute respiratory syndrome coronavirus-2 (SARS‑CoV‑2) pandemic, the programme was adapted to a digital environment using online platforms such as Zoom video conferencing and Google Classroom. We used an adapted framework to evaluate professional learning and its impact.

Findings

Fifteen Tier 1/local leader participants attended a sixteen-hour online programme in September-October 2021. Participants included nurses, physiotherapists, doctors and early career health professionals/researchers. As local leaders in PR, participants created a tiered teaching programme for developing a critical mass of PR expert teachers, contextualised to their local healthcare systems and cultures. Participants also explored how to engage and influence multiple professional groups and stakeholders to support the widespread sustainable implementation of PR.

Conclusions

The RECHARGE-IPCRG TtT programme provided a clear education and service development framework to support PR capacity development in LMIC. We address a lack of empirical evidence concerning capacity-building initiatives by being explicit about the programme’s learning design, management and evaluation. A whole system perspective to PR allowed consideration of health systems, culture, referral pathways and scalability. Sustainable national PR education programmes will require additional resources and a long-term strategy, potentially aligning with the TtT three-tier cascade model.

Prevalence of chronic respiratory diseases and medication use among children and adolescents in Brazil - a population based cross-sectional study

Abstract Objectives: to describe the prevalence of chronic respiratory diseases and their pharmacological management in children and adolescents in Brazil. Methods: data from the Pesquisa Nacional de Acesso, Uso e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM)(National Access Survey, Use and Promotion of Rational Use of Medicines in Brazil),a population-based cross-sectional study, were analyzed. Household surveys were conducted between September 2013 and February 2014. We included the population under 20 years of age with chronic respiratory diseases. Prevalence of disease, indication of pharmacological treatment, and their use were assessed. Results: the prevalence of chronic respiratory diseases in children aged less than 6 years old was 6.1% (CI95%= 5.0-7.4), 4.7% (CI95%= 3.4-6.4) in those 6-12 years, and 3.9% (CI95%= 2.8-5.4) in children 13 years and older. Children under 6 showed a higher prevalence of pharmacological treatment indication (74.6%; CI95%= 66.0-81.7), as well as medication use (72.6%; CI95%= 62.8-80.7). Of those using inhalers, 56.6% reported using it with a spacer. The most frequent pharmacologic classes reported were short-acting β2 agonists (19.0%), followed by antihistamines (17.2%). Conclusion: children and adolescents who report chronic respiratory diseases living in urban areas in Brazil seem to be undertreated for their chronic conditions. Pharmacological treatment, even if indicated, was not used, an important finding for decision-making in this population.

Current Asthma Management Practices by Primary School Teaching Staff: A Systematic Review

BACKGROUND

The likelihood of children with asthma experiencing an exacerbation at school is significantly high when considering that they spend a substantial part of their day at school. This study, therefore, aimed to systematically review the literature to determine current asthma management practices by primary school teaching staff and any existing supporting legislation/policies/guidelines.

METHODS

Search terms were adapted to search literature across databases: CINAHL, Cochrane Library, Education Database-ProQuest, IPA, MEDLINE, SCI. Primary research studies, reviews, systematic reviews, and meta-analyses in English about primary school teaching staff dated between 2007 and 2017 were included. Primary outcomes comprised teaching staff' practices regarding asthma management and supporting guidelines, policies, or legislation.

RESULTS

Analysis of the 13 papers eligible for full review identified that: teachers were unable to deal with an asthma exacerbation; they lacked knowledge regarding exercise-induced asthma and that there was poor communication between schools and parents of children with asthma. The only documented relevant asthma legislation found pertained to New York schools.

CONCLUSIONS

Limited evidence regarding asthma management practices and inadequate asthma management knowledge amongst teaching staff highlight the need for supporting teaching staff with asthma policies and guidelines to minimize risks associated with inappropriate asthma management.

Inequalities and Inequities in Pediatric Respiratory Diseases

Social inequality refers to disparities in society that have the effect of limiting a group's socioeconomic, educational, and intellectual potential. Inequity in health means any limitation to access comprehensive health services that also hinders the achievement of well-being and favorable health outcomes. Strategies for more equitable growth to eradicate global poverty would contribute to reducing health inequities and improve health care outcomes. Coordinated efforts between governments, private sector, families, and interested stakeholders are needed. This article discusses inequality and inequity in pediatric respiratory diseases, the challenges confronted, and the strategies needed to mitigate these disparities.

Associations of short-term exposure to air pollution and emergency department visits for pediatric asthma in Shanghai, China

There is limited evidence regarding the relationship between air pollution and pediatric asthma in developing countries. This study aimed to investigate the association between short-term exposure to ambient air pollutants and pediatric asthma emergency department (ED) visits in Shanghai, China. We collected data on six criteria air pollutants (PM_2.5, PM₁₀, NO₂, SO₂, CO, and O₃) and daily ED visits for pediatric asthma patients from 66 hospitals in Shanghai from 2016 to 2018. The generalized additive model combined with polynomial distributed lag model was applied to explore the associations. We fitted two-pollutant models and stratified the analyses by sex, age, and season. In total, we identified 108,817 emergency department visits for pediatric asthma. A 10 μg/m³ increase in the concentrations of PM_2.5, NO₂, SO₂, and O₃ was significantly associated with increased risks of pediatric asthma ED visits, with relative risk of pediatric asthma of 1.011 [95% confidence interval (CI): 1.002, 1.021], 1.030 (95%CI: 1.017, 1.043), 1.106 (95%CI: 1.041, 1.174), and 1.009 (95%CI: 1.001, 1.017), respectively. The associations of NO₂ remained robust in the two-pollutant models. There were stronger associations for older children (6-18 years) and in warm seasons. The concentration-response curves for pediatric asthma and PM_2.5, NO₂, SO₂, and O₃ were steeper at lower and moderate concentrations but became flatter at higher concentrations. This analysis provided evidence that short-term exposure to air pollutants (PM_2.5, NO₂, SO₂, and O₃) could increase the risk of asthma exacerbations among children, and health benefits would be gained from improved air quality.

A worldwide charter for all children with asthma

Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.

Burden of asthma exacerbations and health care utilization in pediatric patients with asthma in the US and England

Background

Data on asthma burden in pediatric patients are limited; this real‐world study investigated exacerbation frequency and health care resource utilization (HCRU) in pediatric asthma patients from the US and England.

Methods

Data from pediatric patients (aged 6‐17 years) in the Optum claims database (US) or Clinical Practice Research Datalink with linkage to Hospital Episode Statistics (England) were analyzed. Patients were categorized into four hierarchical groups: treated asthma (patients with ≥1 baseline asthma medication), severe asthma (plus Global Initiative for Asthma Step 4/5), severe refractory asthma ([SRA] plus ≥2 baseline severe asthma exacerbations), and eosinophilic SRA (SRA plus blood eosinophil count ≥150 cells/µL). Exacerbation frequency and HCRU during the 12 months postindex were described.

Results

Of 151 549 treated asthma patients in the US, 18 086 had severe asthma, 2099 SRA, and 109 eosinophilic SRA. There were 32 893 treated asthma patients in England, of whom 2711 had severe asthma, 265 SRA, and 8 eosinophilic SRA. In the 12 months postindex, ≥1 exacerbation occurred in 12.4% and 10.8% of patients with severe asthma, and 32.6% and 42.6% with SRA in the US and England, respectively. The proportions of patients with ≥1 asthma hospitalization in the 30 days after the first asthma exacerbation were 2.7% and 4.4% (treated), 3.5% and 8.2% (severe asthma), and 6.0% and 16.8% (SRA) in the US and England, respectively.

Conclusion

This study provides insights into current asthma management practices in the US and England and indicates that some patients with severe disease have an unmet need for effective management.