Tackling asthma treatment in Africa

Worldwide, asthma remains one of the most prevalent chronic respiratory conditions across all age groups, with trends of asthma prevalence over the past three decades varying by age group, country income, and geographical regions.^[1] As highlighted previously is this Journal, nowhere more is the gap between diagnosis and meeting appropriate treatment needs greater than on the African continent.^[2] While many factors contribute to this ongoing disparity, the relatively high cost of inhaled corticosteroids (ICS) remains an important factor preventing access to this essential asthma medication. Consequently, the overuse and reliance on short-acting beta-agonists (SABA) have become a widespread problem throughout Africa and contribute to asthma-related morbidity and mortality.

In this issue, Chakaya et al. succinctly address the problem of SABA overuse for asthma symptom relief in Africa and launch a call to action to the Pan African Thoracic Society and all stakeholders to prioritize the redress of correct asthma care on the continent.^[3] We at the Journal of the Pan African Thoracic Society join the authors in this call to action. Over the counter sales of SABA, which leads to SABA without ICS overuse, is a rife practice worldwide and reported to range from 1.4% to 39.6%.^[4] The easy and uncontrolled access to SABAs is a matter of concern that could easily be addressed with stricter regulation around the prescription and sales of these devices or oral solutions. The latest GINA recommendations for the first-step asthma treatment in children and adults over the age of 5 years have adopted the pragmatic MART approach – maintenance and reliever therapy with a combination of ICS/formoterol as a strategy to discourage the use of SABA alone for symptom relief.^[5] Pragmatic as it may be in attempting to overcome universal poor adherence to daily controller therapies, the relatively high cost of combination ICS/formoterol or ICS/long-acting beta-agonist devices makes it challenging to implement such guidelines in many African countries.

Despite these challenges, there are positive signs that asthma care or related morbidity is improving. In the study by Bhavic et al. of teenagers with asthma in South Africa, all participants were on an ICS, and the majority well controlled, but worryingly, 11.5% were active smokers.^[6] This study, unfortunately, did not survey the use of e-cigarettes, which is fast becoming a greater concern in many middle and high-income countries, especially among teenagers. Bold steps such as those taken recently by the South African government to implement a levy on e-cigarettes are a step in the right direction.^[7] As better strategies and tools become more available to improve and monitor asthma control, maintaining awareness of unique regional differences and triggers of asthma exacerbations is important. Ade et al. report the interesting association of pineapple and coconut juice as triggers for food allergies and asthma in Benin.^[8] Reporting such associations is important for our understanding of regional differences in Africa of how unique dietary factors may trigger asthma and other allergic conditions.

Marco Zampoli, PhD

Editor-in-Chief