The reality of managing asthma in sub-Saharan Africa – Priorities and strategies for improving care

Asthma strategies and guidelines in SSA

A national asthma strategy (or national asthma program) is a set of actions agreed upon and enacted by governments to systematically improve asthma outcomes across the population. A comprehensive national asthma strategy requires political commitment at the national government level (including policies, legislation, and funding for capacity building) and can involve the creation of a registry for outcome data, asthma management guidelines, economic analysis and process evaluation, and provision of universal health coverage with essential asthma medicines and support of asthma research.^[14,15]

A cross-sectional survey of GAN centers was conducted in 2013–2015 to ascertain which countries have a national asthma strategy.^[14] Of the 18 African countries surveyed, only Sudan and Malawi reported having an asthma strategy.^[14] GAN also maintains an updated list of national guidelines^[16] and documented these in the Global Asthma Report 2014^[17] [Table 1].

There are no regional asthma guidelines for SSA. However, guidelines developed for LMICs by the WHO,^[18] the Union^[19] and Medicines Sans Frontières^[20] [Table 2] are relevant in this region and are being used by some SSA countries with context-specific local adaptations.^[16] The WHO also publishes a regularly updated Model List of Essential Medicines,^[21] which includes one or more asthma medicines from each of the following classes: Short-acting beta₂ agonists (SABAs), inhaled corticosteroids (ICSs), ICS plus long-acting beta₂-agonist (LABA) combinations, short-acting muscarinic antagonists, and long-acting muscarinic antagonists.

Some SSA countries adopt the GINA strategy report to guide asthma diagnosis and management. GINA was launched in 1993 in collaboration with the National Heart, Lung, and Blood Institute, National Institutes of Health, USA, and WHO.^[22] The GINA report^[23] is an annually updated global strategy for asthma, underpinned by an ongoing process of reviewing published evidence on asthma management and prevention.^[24] This evidence-based strategy can be adapted for local health systems and medicine availability, recognizing the need for asthma care to be tailored to the circumstances of individual countries. However, at present, the recommended GINA approaches to diagnosis and asthma medication [Figures 1-3] cannot be implemented in countries with the most severe resource limitations.

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Figure 1:

GINA 2022 personalized asthma management for children 5 years and younger. ICS: Inhaled corticosteroids, LTRA: Leukotriene receptor antagonist, SABA: Short-acting beta2 agonist. Source: Boxes 6–5, GINA strategy 2022.^[23]

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Figure 2:

GINA 2022 personalized asthma management for children 6–11 years. BUD-FORM: Budesonide-formoterol, ICS: Inhaled corticosteroid, LABA: Long-acting beta2 agonist, LTRA: Leukotriene receptor antagonist, MART: Maintenance and reliever therapy with ICS-formoterol, OCS: Oral corticosteroid, SABA: Short-acting beta2 agonist. Source: Box 3-5B, GINA strategy 2022.^[23] For initial asthma treatment in children aged 6–11 years, Boxes 3–4C and 3–4D in GINA strategy 2022. For low, medium, and high ICS doses in children, Boxes 3–6 in GINA strategy 2022.

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Figure 3:

GINA 2022 personalized asthma management for adults and adolescents. HDM: House dust mite, ICS: Inhaled corticosteroid, LABA: Long-acting beta2-agonist, LAMA: Long-acting muscarinic antagonist, LTRA: Leukotriene receptor antagonist, OCS: oral corticosteroid, SABA: Short-acting beta2 agonist, SLIT: Sublingual immunotherapy. Source: Box 3-5A in GINA strategy 2022.^[23] For recommendations about initial asthma treatment in adults and adolescents, Boxes 3-4A and 3-4B in GINA strategy 2022. For low, medium, and high ICS doses for adults and adolescents, Boxes 3-6 in GINA strategy 2022.

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Underdiagnosis of asthma

Asthma is commonly underdiagnosed in SSA. In a recently reported cross-sectional survey of 519 adults with chronic respiratory symptoms not explained by TB, attending hospital clinics in Kenya, Ethiopia, and Sudan, asthma was the diagnosis made in 34% of cases, but a history of wheeze in the past 12 months was reported by 71%.^[25] This discrepancy suggests substantial underdiagnosis. In Nigeria, it has been estimated that <50% of people with asthma receive the diagnosis, with children in rural regions at high risk of underdiagnosis.^[26] People with chronic respiratory symptoms in SSA often seek help from widely available TB services, but such assessment typically concludes with a diagnosis of “not TB” with few receiving an alternative diagnosis or treatment.^[27]

Limited access to diagnostic tests

International guidelines recommend the use of spirometry to demonstrate variable expiratory airflow limitation to support the diagnosis of asthma, if possible, before starting treatment.^[23,28] However, in many SSA healthcare facilities, spirometry is absent or not consistently available. Furthermore, where payment is required, may be unaffordable for patients and caregivers. On the other hand, facilities and staff often lack training on how to perform and interpret spirometry accurately.^[29-33] In Nigeria, doctors have also reported a lack of access to diagnostic facilities as a major barrier to good asthma practice.^[33] In Uganda, spirometry testing is reported to be largely unaffordable, costing the lowest paid government worker a month’s salary (a frequently used benchmark metric for affordability).^[30]

The use of peak expiratory flow (PEF) meters is proposed in some guidelines as an alternative and usually less costly method for demonstrating variable expiratory airflow limitation.^{[18,23,28,34]} However, even so, they are not available in many countries in SSA. A study of health system preparedness for managing chronic lung diseases in Sudan and Tanzania identified the lack of access to PEF meters for diagnostic purposes as an important barrier to care.^[35]

Psychosocial factors contributing to underdiagnosis of asthma

It is also important to recognize that a diagnosis of asthma may not be welcomed by patients and parents of children with asthma, especially where myths and stigma surround the diagnosis.^[36] Such obstacles present substantial barriers to effective long-term treatment. For example, in Kenya, studies of children and adults with asthma report reluctance to admit to or accept this diagnosis, even within families.^[37]

PEF meters

When clinical history supports the diagnosis of asthma, but spirometry is not available, the PEF measurement can be used to confirm variable expiratory airflow limitation, either as a rapid response to bronchodilator or as within-day variability measured over 2 weeks.

Guidance on using PEF in diagnosis is provided in the GINA strategy report,^[23] the WHO Package of Essential Non-communicable Disease Interventions for Primary Care (WHO-PEN),^[18] and the European Respiratory Society (ERS) guidelines for the diagnosis of asthma in adults^[34] and in children 5–16 years.^[28] Training in the use of PEF meters is relatively simple. Such tests should preferably be completed before starting long-term controller treatment.

Based on a Grading of Recommendations, Assessment, Development, and Evaluation analysis, ERS guidelines advise that PEF may be considered in the diagnosis of asthma if no other lung function test is available. However, they suggest that PEF variability should not be considered the primary test for making a diagnosis of asthma (low-quality evidence).^[28,34]

Spirometry

In SSA countries where ready access to spirometry is not feasible, we recommend either centralized spirometry offered in secondary or tertiary care centers where patients may be referred for spirometry or promoting the use of PEF meters in the primary and secondary care levels.

Where spirometry is available, it should be used as part of the diagnostic workup, as per the guidance in the GINA strategy report (2022).^[23] It is important to note that in patients with long-standing asthma, especially those with a history of severe exacerbations, airflow limitation may become persistent (i.e., with less likelihood of demonstrating a significant bronchodilator response).

All patients

We suggest that all patients, regardless of what asthma medicines are available, should receive asthma education and an action plan (written or pictorial) including advice about when to seek emergency treatment. This should be tailored to the individual patient’s circumstances and the health services they might access in the event of an exacerbation. Patients receiving any inhaled medications should be taught how to use the inhaler, and the technique should be checked at each visit to a healthcare center. Individual asthma education for self-management or parental management can be delivered by doctors, trained allied health professionals such as nurses, or trained lay health workers.^[44,45]

Oral salbutamol, theophylline, and prednisolone

Oral salbutamol, theophylline, and prednisolone are widely available and affordable. In some countries, these are the only available medicines for the maintenance treatment of asthma and emergency management of asthma exacerbations. This limited range of treatment options is common in SSA and represents the lowest quality of asthma care as it is associated with a high risk of serious side effects. GINA does not recommend the use of oral salbutamol or theophylline where inhaled therapy is available.^[23] While acknowledging that clinicians in some contexts are constrained to work with this restricted formulary, all involved in health care in SSA are urged to work toward the phasing out these asthma treatments and their replacement with inhaled therapies both for relief and as maintenance treatment, on the basis that these are both safer and considerably more effective.

For patients living in remote areas, it is particularly important that action plans make provision for potentially life-saving management in the event of a severe asthma attack. This may include an emergency supply of oral prednisolone (a single dose or short course) to be taken according to written instructions when symptoms worsen. It is important to note that an inhaled SABA kept at home for emergencies (even if unaffordable for day-to-day use) together with a short course of oral prednisolone may be lifesaving.

In some regions, daily or alternate-day oral prednisolone is the only option for controlling symptoms and limiting exacerbations. However, clinicians and patients need to acknowledge and be alert to the high risk of adverse effects of long-term use of this treatment.^[46]

Inhaled SABA

Inhaled SABA (usually salbutamol) offers a considerable advantage over oral bronchodilators both in terms of effectiveness and safety, and used as needed should be preferred to oral bronchodilators. As with all inhaled therapies, it is important that careful attention is given to ensuring that the patient can use the inhaler effectively. A spacer device that may improve delivery can be made at little cost from disposable plastic drink bottles and this has been noted to be as equally effective.^[47] The use of SABA alone to manage asthma is intended only for settings in which ICS cannot be obtained. On grounds of safety, GINA recommends against the use of as-needed SABA without the concurrent use of an ICS, since the addition of a reliever combined or taken concurrently with an ICS is associated with a large reduction in severe exacerbations and potentially asthma mortality.^[23]

ICS and ICS-formoterol

Where ICS is available, it is important that this is offered to all patients with asthma, in line with GINA 2022 recommendations and based on evidence that it substantially reduces asthma mortality and morbidity.^[23]

Where appropriate ICS-formoterol combinations are available and affordable, we recommend using ICSformoterol according to GINA 2022 “Track 1” for adolescents/adults.^[23] Formoterol is a rapid-onset LABA. While several ICS-LABA combinations have been developed, ICS-formoterol, used either as-needed only (for patients with mild asthma) or as both maintenance and reliever therapy (“MART”), is the preferred option for managing asthma of all severities, based on published evidence.^[23] The budesonide-formoterol combination can be used as needed for symptom relief in either of these regimens, with safety and efficacy demonstrated for formoterol up to a total daily dose (maintenance plus as-needed doses) of 72 mcg (54 mcg delivered dose).

There is now a large body of evidence, primarily from high-income countries, supporting the use of MART with ICS-formoterol in adolescents and adults,^[48,49] and one large study in children.^[50] MART with budesonideformoterol and beclometasone-formoterol is approved by regulators in many countries. More recently, the SYGMA 1&2,^[51-53] PRACTICAL,^[54] and Novel START^[55] trials have demonstrated that mild asthma in adolescents and adults can be managed effectively with just “as-needed” budesonideformoterol ICS, with particularly large reductions in severe exacerbations and emergency visits/hospitalizations compared with inhaled SABA alone.^[56] In that study, as-needed-only low-dose budesonide-formoterol also reduced need for emergency department visits and hospitalization, compared with maintenance ICS plus as-needed SABA.^[56]

In addition to its demonstrated efficacy^[56] and excellent safety profile,^[57,58] the use of ICS-formoterol to manage asthma across all severity levels may have special advantage for countries of SSA: Even among patients with mild asthma, the reduction in exacerbations, compared with SABA only^[51-56] or maintenance ICS plus as-needed SABA,^[56] would reduce the burden of acute asthma on health services. This strategy ensures that all patients receive doses of ICS. In settings where access to care is limited, even symptom prompted the use of ICS-containing medications is likely to be beneficial. The simplicity of a single inhaler for both symptom relief and (where required) maintenance treatment might make it easier for patients to use their medicines correctly. Even in well-resourced health systems, where patients have access to self-management education provided by health professionals, the historical approach that begins with SABA, along with the later addition of daily maintenance treatment, commonly confuses patients about the roles and correct use (timing and technique) of multiple inhalers. The use of a single ICSformoterol inhaler also simplifies the process of stepping up and down between treatment levels, as it does not involve adding a second inhaler device when initiating maintenance treatment or when increasing or decreasing maintenance treatment. For some health services, this strategy may simplify drug procurement by reducing the requirement for a wider variety of products.

Current initiatives supporting improvement in asthma care in SSA

The WHO has a strong mandate to reduce the burden of chronic respiratory diseases in LMICs.^[8] Its current (13^th) General Programme of Work sets out clear frameworks for patient-centered health services to deliver care across disease types and settings.^[59] The WHO considers integrated care for chronic respiratory diseases to be central to meeting these objectives. Strategies developed by the WHO to address lung health in LMICs include the Practical Approach to Lung Health (PAL)^[60] and WHO-PEN^[18] disease interventions to provide protocols for the diagnosis and treatment, both acute and long term, of asthma and COPD in resource-constrained settings.

GARDs focus on the needs of LMICs and vulnerable populations. It supports the WHO to establish and strengthen national policies and tailored initiatives for the prevention and control of chronic respiratory diseases.^[61] GARD goals for LMICs are to improve diagnosis, acknowledging that a syndromic approach to diagnosis will be necessary for most countries, and secure accessible and affordable treatment for all patients. The current GARD activities include demonstration projects in South Africa and Mozambique.^[62,63]

GINA has made a considerable effort, particularly over recent years, to maximize the relevance of the GINA recommendations to resource-constrained settings in LMICs (and under-resourced settings within high-income countries).^[23] Sections of the strategy have been expanded to address the needs of patients living in these resource-constrained settings. GINA activities include publishing articles on the implementation of the GINA strategy in the context of LMICs,^[7,64-66] World Asthma Day advocacy efforts to shine a spotlight on the needs of patients with asthma around the world, including in LMICs,^[67] and promoting management of asthma in LMICs as a key topic for research.^[68] An important aspect of all these efforts is to ensure patients with asthma, wherever they may be and are provided with care that meets a basic quality standard as outlined in the GINA strategy.

Regional initiatives in SSA include Practical Approach to Care Kit (PACK) developed by the Knowledge Translation Unit of the University of Cape Town Lung Institute.^[69-73]

Strengthening asthma education for health professionals

Training health workers to conduct high-quality spirometry are an important priority in SSA. The Pan African Thoracic Society (PATS) has a program to provide training and education on spirometry, but there remain challenges to be overcome.^[29]

In some SSA countries where ICS is available, ongoing prescribing of oral salbutamol, theophylline, and prednisolone, or sole prescription of inhaled salbutamol, may be influenced by patient preference in populations with low health literacy, or lack of access to ongoing medical education on evidence-based asthma management. A similar problem has been documented in India, where primary care physicians’ lack of awareness of the importance of ICS treatment in asthma management is one of the main reasons why, even when ICS is available, many people with asthma do not use it.^[66]

Therefore, we recommend that regular and updated asthma education for doctors and other health care workers be prioritized, as well as considering patient asthma education delivered by non-health professionals, especially in rural settings.

Enabling effective asthma care delivered by non-physician health workers

The GINA report^[23] cites several studies showing the effectiveness of asthma education provided by nurses, pharmacists, and lay health workers.^[74-79]

Nurse-led asthma care has been shown to markedly reduce asthma exacerbations among adults in rural Cameroon.^[80] Studies in Malawi have demonstrated that asthma symptoms and exacerbations can be reduced by clinical assessment, optimization of inhaled treatment, and individualized asthma education delivered by trained non-physicians,^[45] and that this education is well received by parents.^[44]

Policy recommendations for SSA healthcare systems

We make the following recommendations for policy and decision-makers:

• Develop national asthma strategies based on relevant evidence

• Develop evidence-based national asthma management guidelines (or adapt guidelines from elsewhere that can be implemented nationally at all levels of care)

• Develop evidence-based regional asthma management guidelines that can provide the basis for national guidelines where individual countries lack resources to develop these

• Ensure WHO essential medicines and devices for the treatment of asthma are made available and affordable to all children, adolescents, and adults

• Improve access to diagnostic tools to facilitate diagnosis of asthma in children, adolescents, and adults

• Support community-based programs that improve asthma literacy

• Reorient health systems to integrate asthma care into primary health care and improve human resource capacity through training, mentorship, and supervision programs.