Improving paediatric asthma care in Zambia

Abstract Problem In 2008, the prevalence of paediatric asthma in Zambia was unknown and the national treatment guideline was outdated. Approach We created an international partnership between Zambian clinicians, the Zambian Government and a pharmaceutical company to address shortcomings in asthma treatment. We did two studies, one to estimate prevalence in the capital of Lusaka and one to assess attitudes and practices of patients. Based on the information obtained, we educated health workers and the public. The information from the studies was also used to modernize government policy for paediatric asthma management. Local setting The health-care system in Zambia is primarily focused on acute care delivery with a focus on infectious diseases. Comprehensive services for noncommunicable diseases are lacking. Asthma management relies on treatment of acute exacerbations instead of disease control. Relevant changes Seven percent of children surveyed had asthma (255/3911). Of the 120 patients interviewed, most (82/120, 68%) used oral short-acting β2-agonists for symptom control; almost half (59/120, 49%) did not think the symptoms were preventable and 43% (52/120) thought inhalers were addictive. These misconceptions informed broad-based educational programmes. We used a train-the-trainer model to educate health-care workers and ran public awareness campaigns. Access to inhalers was increased and the Zambian standard treatment guideline for paediatric asthma was revised to include steroid inhalers as a control treatment. Lessons learnt Joint activities were required to change paediatric asthma care in Zambia. Success will depend on local sustainability, and it may be necessary to shift resources to mirror the disease burden.


Introduction
Asthma is the most common paediatric chronic disease. 1 In 2006, approximately 14% of the world's children experienced asthma symptoms. 2,3 In African countries, the prevalence of asthma ranges from approximately 10% to more than 20%. [2][3][4] Poorly treated asthma can lead to school absence, hospitalization and death. 5 Yet, effective medical management of patients with asthma is available. During acute exacerbations, inhalation of short-acting β 2 -agonists is recommended to provide relief. Long-term control of the disease is normally achieved using inhaled steroids, but long-acting β 2 -agonists, oral leukotriene modifiers or injectable anti-immunoglobulin E antibodies are also used in more severe cases. 6,7 The paediatric clinic of the main teaching hospital in Zambia often sees children with severe asthma. However, these children are rarely diagnosed as having asthma and most have not been treated with β 2 -agonists or steroid inhalers. Until recently, asthma inhalers have not been readily available in the country, in part because the national guideline preferentially endorsed oral and intravenous treatments for asthmatic children (Box 1). 8 When inhalers were offered, patients were often reluctant to use them because of misconceptions about efficacy and addiction.
The prevalence of paediatric asthma in Zambia is unknown and there is a poor understanding of disease progression and management on the part of patients, families and health-care providers. Hence, we were faced with the complex problem of disease recognition, misconceptions about diagnosis and therapy and poor access to asthma medicines.

Local setting
The health-care system in Zambia is primarily focused on acute care delivery with a particular focus on infectious diseases. Comprehensive services for noncommunicable diseases are lacking. Asthma management relies on the treatment of acute exacerbations instead of disease control. 8

International partnership
To address the problem of paediatric asthma, we formed an international public-private partnership involving clinicians at the Lusaka University Teaching Hospital, officials from the noncommunicable diseases unit at the Zambian Ministry of Health, the Spanish Society of Pneumology and Thoracic Surgery, the International Center for Advanced Respiratory Medicine and Novartis. Nearly a year of planning with our partners preceded the implementation of the programme's multifaceted activities.

Original research
The partnership conducted two epidemiological studies, one that documented paediatric prevalence and risk factors for asthma and one that characterized existing attitudes and practices of patients with the disease. The prevalence study Lessons from the field Paediatric asthma care in Zambia Somwe Wa Somwe et al.
was conducted using questionnaires from the International Study of Asthma and Allergies in Childhood (ISAAC). 10 We used the information from the studies to improve care through training programmes for health workers, public education and government advocacy.
To estimate the asthma burden in Lusaka, we used methods and tools developed by the ISAAC. 11 The prevalence of asthma in children aged 7-8 years was 5% (100/2026) and that in adolescents aged 13-14 years was 8% (155/1885), similar to those measured in neighbouring African countries. 2 To assess attitudes and practices of people with asthma, we surveyed 10 children older than nine years and 110 people older than 18 years with asthma attending four primary health-care clinics in Lusaka. 12 Most (68%; 82/120) used oral short-acting β 2 -agonists for symptom control, while inhaled steroids were used by only 14% (17/120). Nearly 30% (35/120) did not think an inhaler is a good treatment for asthma and 43% (52/120) believed inhalers were addictive. Almost half (49%; 59/120) of the participants did not think that asthma symptoms were preventable with medications.

Education and awareness
Two main themes emerged from the data that guided the message of our projects. First, paediatric asthma was common; therefore there was a need to improve the diagnostic and treatment skills of health workers. Second, misconceptions about asthma therapies were common. We designed programmes directed to health workers and patients to improve their understanding of the disease, correct prejudices against inhaler therapy and facilitate access to effective medicines.
Few health workers in Zambia had received specialty training in asthma management. Through a train-thetrainer model, local instructors -two paediatricians and one physician from the University Teaching Hospital and the ministry of health -trained doctors, clinical officers and nurses from Lusaka's urban clinics and health facilities in five provinces. During a two-day course, the trainees learned current algorithms of care, spacer and inhaler technique, spirometry and use of peak-flow meters. The participants received travel reimbursement. If trainees needed advice after the course finished, they were able to contact the instructors by phone.
More than 80 trainees have been trained as service providers across Zambia. They provide ongoing tutoring as well as inservice training to clinical staff.
In parallel with the in-country trainings, the three local instructors received sponsored personalized training at specialty centres in Spain.
To improve asthma awareness and care, the World Asthma Day 13 is organized each year by the Global Initiative for Asthma, which distributes materials and resources. In 2011 and 2012, we organized the event in Zambia. Officials from the ministry of health participated as guests of honour. Zambian physicians gave radio interviews and an asthma awareness radio clip was broadcast nationwide. A theatrical group performed an original production that challenged common asthma misconceptions. Inhaler demonstrations were held, and approximately 150 people participated in a 2 km walk-for-asthma in Lusaka.

Access to treatment
To increase access to asthma medicines and tools, Sandoz, 1A Pharma, and Sibelmed donated salbutamol (shortacting β 2 -adrenergic agonist) and beclomethasone (corticosteroid) inhalers, spacers, spirometers and peak-flow meters while our training and awareness activities were scaled up. Between 2010 and 2013, more than 1850 asthma inhalers and spacers were provided free of charge in accordance with World Health Organization guidelines for drug donations. 14 Eleven clinics in Lusaka served as inhaler distribution points. A pharmacovigilance programme was implemented to monitor for adverse effects. Between 2010 and 2013, no adverse effects were reported.

Changing health policy
The bottom-up approach raised awareness of paediatric asthma and enabled advocacy by the partnership's physicians to modernize the health policy concerning disease management. The ministry of health revised the national guideline for paediatric asthma management. In accordance with international recommendations, 5,15,16 β 2 -agonists and steroid inhalers are now used for disease control (Box 1). 9 This achievement is anticipated to promote scale-up of improved asthmacare practices nationwide, especially via educational activities and access to Box 1. Zambia standard treatment guidelines for paediatric asthma before and after the activities of the public-private partnership Guideline before 2008 8 Management instructions for the asthmatic child.
• Child with wheezing but no rapid breathing: oral salbutamol.
• Child with wheezing and respiration rate of over 50 per minute: aerosolized salbutamol using nebulizer and enriched air with oxygen, followed by oral salbutamol. • Very ill child: nebulized salbutamol plus intravenous aminophylline, intravenous hydrocortisone, and oral prednisolone.

Guideline after 2013 9
Management instructions for children aged 5-12 years: step up to improve control as needed and step down to find and maintain the lowest controlling step; patients should start treatment at the step most appropriate to the initial severity of their asthma; check concordance and reconsider diagnosis if response to treatment is unexpectedly poor.
• Step 2 -regular preventive therapy: add inhaled steroid (or other preventer if inhaled steroid cannot be used); start at dose of inhaled steroid appropriate to severity of disease. • Step 3 -initial add-on therapy: first, add inhaled long-acting β 2 -agonist (LABA

Next steps
Changes in the attitude of health workers and patients are underway at some of the larger referral hospitals. However, more work is needed in these hospitals -including refresher courses and continuous medical education for staff -and no changes have yet been implemented at peripheral health facilities, which serve most of the population. Continued investigation of patient behaviours and attitudes will help to tailor further educational messages. Out of the 10 provinces in Zambia, two are predominantly urban and the rest are rural. Assistance from international partners might be helpful in reaching remote populations in Zambia.

Lessons learnt
The main lessons learnt are summarized in Box 2. We show that a public-private partnership to improve care for one specific paediatric chronic disease is feasible in Zambia. A combination of physicians dedicated to the specific illness, a prevalence study, the use of adequate treatment and understanding the misconceptions of patients, have improved the care of asthma. Policy changes, modernization of government regulations and better availability of medicines also contributed to the improvement. We believe that by using the same strategy, improvement of care for other common noncommunicable diseases will be possible. While continuing efforts will be needed to fully understand and address misconceptions relating to asthma therapy, we have anecdotally noted an increase in acceptability of inhaled medications among paediatric asthma patients and their families.
Given the epidemiological transition currently experienced in Zambia and other African countries, the improved asthma programme presented here might be funded by shifting some health-care resources from infectious to chronic diseases. The government's continued role in advocacy, health system strengthening and assuring inhaler availability, will be needed to sustain the improved asthma care established by the new treatment guidelines. ■ Funding: This partnership received financial support from Novartis.