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Risk factors for Bronchial Asthma among primary school children of two different regions in Saudi Arabia Paper

1.         Introduction (from World Health Organization [11])

1.1       Asthma: Definition

Asthma attacks all age groups but often starts in childhood. It is a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day. This condition is due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in the airways so they become easily irritated. In an attack, the lining of the passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs.

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1.2       Asthma: Scope

Between 100 and 150 million people around the globe — roughly the equivalent of the population of the Russian Federation — suffer from asthma and this number is rising. World-wide, deaths from this condition have reached over 180,000 annually. Around 8% of the Swiss population suffers from asthma as against only 2% some 25-30 years ago. In Germany, there are an estimated 4 million asthmatics. In Western Europe as a whole, asthma has doubled in ten years, according to the UCB Institute of Allergy in Belgium. In the United States, the number of asthmatics has leapt by over 60% since the early 1980s and deaths have doubled to 5,000 a year. There are about 3 million asthmatics in Japan of whom 7% have severe and 30% have moderate asthma. In Australia, one child in six under the age of 16 is affected.

Asthma is not just a public health problem for developed countries. In developing countries, however, the incidence of the disease varies greatly. India has an estimated 15-20 million asthmatics. In the Western Pacific Region of WHO, the incidence varies from over 50% among children in the Caroline Islands to virtually zero in Papua New Guinea. In Brazil, Costa Rica, Panama, Peru and Uruguay, prevalence of asthma symptoms in children varies from 20% to 30%. In Kenya, it approaches 20%. In India, rough estimates indicate a prevalence of between 10% and 15% in 5-11 year old children.

1.3       Asthma: Causes

Asthma cannot be cured, but could be controlled. The strongest risk factors for developing asthma are exposure, especially in infancy, to indoor allergens (such as domestic mites in bedding, carpets and stuffed furniture, cats and cockroaches) and a family history of asthma or allergy. A study in the South Atlantic Island of Tristan da Cunha, where one in three of the 300 inhabitants has asthma, found children with asthmatic parents were much more likely to develop the condition.

Exposure to tobacco smoke and exposure to chemical irritants in the workplace are additional risk factors. Other risk factors include certain drugs (aspirin and other non-steroid anti-inflammatory drugs), low birth weight and respiratory infection. The weather (cold air), extreme emotional expression and physical exercise can exacerbate asthma. Urbanization appears to be correlated with an increase in asthma. The nature of the risk is unclear because studies have not taken into account indoor allergens although these have been identified as significant risk factors. Experts are struggling to understand why rates world-wide are, on average, rising by 50% every decade. And they are baffled by isolated incidents involving hundreds of people in a city, who suffer from allergies such as hay fever but who had never had asthma, suddenly being struck down by asthma attacks so severe they needed emergency hospital treatment.

1.4       Bronchial asthma

Asthma is a chronic lung condition characterized by difficulty in breathing. People with asthma have extra sensitive or hyper responsive airways. The airways react by narrowing or obstructing when they become irritated. This makes it difficult for the air to move in and out. This narrowing or obstruction can cause one or a combination of symptoms such as wheezing, coughing, shortness of breath and chest tightness.

1.5       Asthma: Management

Because asthma is a chronic condition, it usually requires continuous medical care. Patients with moderate to severe asthma have to take long-term medication daily (for example, anti-inflammatory drugs) to control the underlying inflammation and prevent symptoms and attacks. If symptoms occur, short-term medications (inhaled short-acting beta2-agonists) are used to relieve them. Medication is not the only way to control asthma. It is also important to avoid asthma triggers — stimuli that irritate and inflame the airways. Each person must learn what triggers he or she should avoid.

Although asthma does not kill on the scale of chronic obstructive pulmonary diseases (COPD), failure to use appropriate drugs or comply with treatment, coupled with an under-recognition of the severity of the problem, can lead to unnecessary deaths, most of which occur outside hospital.

2.         Objectives of study

The objective of the study involves finding out about the incidence of bronchial asthma among children of 6-12 years in two different regions in Saudi Arabia. It also endeavors to investigate the level of awareness that the parents possess about the disease, its prevention and management. A comparative study between the socio-economic levels, and the subsequent health care facilities/awareness shall also be disused.

2.1       Importance to Saudi Arabia

This study shall be of significant value to the Ministry of Health in the Kingdom. Firstly, only a scant amount of work has been done in the same realm. But more importantly, it will give an ideation into the incidence, trends and awareness of this condition in Saudi Arabia. This will help the Government to establish working patterns and future strategies into the disease that is still a potent challenge even n the developed world. Special significance would be the condition of the children, and the subsequent response of the parents to their condition. This would also give a psycho-sociological impression into the differences that two different regions in the Saudi Arabia have towards the importance that parents give towards their children. It would also help the Ministry in disseminating more information about the disease among the masses, through pamphlets as given in Appendix C.

2.2       Background – Literature review

Over the years and over the regions, a lot has been written and published in asthma. Interestingly, much of the work done is characteristically similar to each other, unlike some other disease of an international domain. A very brief discourse of some of the relevant works shall be mentioned hereunder, in reference in to the study in question. These are just the tip of the iceberg as far as work on asthma all over the world is concerned.

However, what is most important is the fact that the facts, figures and incidence will keep changing with every region of the world. Therefore, if specified care packages are to be prepared for Saudi Arabia, ten exclusive studies of this sort must be conducted so that specialized data is made available, and subsequent strategies may be adopted.

2.2.1    Adult Asthma

It has also been highlighted that “exposure to ammonia gas in the workplace is significantly associated with increase in respiratory symptoms and bronchial asthma.” [2]. To add, it is also considered that “educational programs based on self – learning in small peer groups, seem to be effective in improving asthma management” [5]. Furthermore, “the prevalence of asthma has increased in most countries since the 1970s. Levels may have plateaued in developed countries but as prevalence is associated with urbanization and a western lifestyle the problem worldwide is likely to increase over the next two decades” [17]. In a nutshell, “the prevalence of asthma in adults has increased more than twofold in 20 years, largely in association with trends in atopy, as measured indirectly by the prevalence of hay fever” [20].

2.2.2    Child Asthma

“Asthmatic school children have a higher mean period of school absenteeism compared to their non asthmatic classmates. The risk of suffering the impacts of this disease is shown to be particularly increased among questionnaire-diagnosed asthma belonging to less socio-economically advantaged families” [1]. The diagnosis age is of prime importance. “Repeated viral infections other than lower respiratory tract infections early in life may reduce the risk of developing asthma up to school age” [16].

Taking some facts of Great Britain, it can be seen that “prevalence of self reported symptoms, diagnosis, and treatment of asthma was high among 12-14 year olds throughout Great Britain with little geographical or urban-rural variation. Under diagnosis and under treatment were substantial” [14]. “The burden of self reported asthma and other allergic diseases among adolescents has changed substantially for the better in recent years throughout the British Isles. These trends correspond to those seen in the 10-14 year age group in hospital admissions, consultations with general practitioners, and parentally reported symptoms in the health survey for England” [12]. Overall, it is considered that “factors directly or indirectly related to the heating systems used in rural Bavarian homes decrease the susceptibility of children to becoming atopic and to developing bronchial hyper responsiveness” [15].

Further evidence surfaces when it is declared that “asthma, as defined by combined symptoms and test criteria, was seriously under diagnosed among adolescents. Under diagnosis was most prevalent among girls and was associated with a low tendency to report symptoms and with several independent risk factors that may help identification of previously undiagnosed asthmatic patients” [18]. But as far as the purposes of this particular study goes, the primary factor is that “a considerable proportion of children presenting to a district general hospital with pneumonia either already have unrecognized asthma or subsequently develop asthma. The high cumulative prevalence of asthma suggests that careful follow up of such children is worth while” [19].

2.2.3    Comparison between Adult and Child Asthma

While making a comparison among adults and children, some other facts come in view. “Another issue is that in both children and adults, wide variations in the prevalence of current asthma symptoms are often observed between centers within the same country. This indicates that the asthma symptom prevalence rate reported for each country is dependent to some extent on the number of centers studied” [3]. Then, there also seems to be a link among the family members. “The prevalence may actually be higher since a significant number of subjects with symptoms suggestive of asthma reported themselves as non-asthmatic subjects. As expected, positive family history was forthcoming in subjects with asthma symptoms. Most asthmatic subjects have not experienced a significant improvement in their quality of life, which could indicate sub-optimal management” [4].

Furthermore, “the parents of the asthmatic children scored significantly higher in DSSI/sAD compared to parents of the controls. Maternal anxiety reached the level of clinical disease. Maternal anxiety and left-handedness of the child were associated with asthmatic attacks 1 year later” [6]. However, “the major differences between populations found in the International Study of Asthma and Allergies in Childhood Phase One are likely to be due to environmental factors” [13].

            3.         Methodology

The methodology for the study entails a simple yet sequential process. Primarily, it is a comparative, cross-sectional study between two different regions in Saudi Arabia, to find out the incidence and awareness of Bronchial Asthma. It is questionnaire-based study, which shall give us demographic as well as technical data into the subject.

3.1       Study design

It is a cross sectional study, which means that it shall have a sample that is representative of varying segments of the society. It is not merely a study of one group, one community or one class within Saudi Arabia. The subjects for this study shall be in two categories. Firstly, there would be children from 6-12 years from two different places; Madinah Munawara and Yanbu as industrial and non industrial city respectively. Then, the parents of the same children would also be administered with questionnaires. Questionnaires shall be devised that shall be specific for the two tiers, and would attempt to find out varying information on the subject. As the questionnaires would primarily have objective and closed-ended items, thus the statistical analyses at the end would involve item and questionnaire analysis.

3.2       Sampling frame

The children would of course be from primary and lower grades. They would be belonging to two different cities, and hence would represent different living, climatic and socio-economic conditions. Similarly, their parents would possess the same difference in primary characteristics that would be taken as variables in case individual factor analysis needs to be considered at any point in time.

3.3       Sample size determination

A sample of 2000 students in each city (a total of 4000), is considered as suitable to make a reasonable comparison for the sake of the study. These would be a fair enough sample of a population, to establish a trend of the incidence of Bronchial asthma among the two cities. Further, it would help in establishing the trend analysis for the disease, including its incidence and management.

3.4       Study Setting

The study would be set at the schools in the two cities mentioned. Prior permission would be taken firstly from the school administration, and then from the parents. A consent form for participation of the parent and the child shall be made available before the actual questionnaires shall be administered. For ethical and secrecy reasons, the parents shall be confirmed on the consent form that no information about them or their children’s identity shall be disclosed at any point in the study. It is important to consider this, as parents may not like to share any information about their child’s health if they believe that he/she may be labeled in the future for any types of special and/or biased treatment.

3.5       Study plan

Firstly, data would be collected from the population. For that purpose, personal presence would be mandatory at the institution. The parents may like to take the questionnaires home and return them the next day duly completed if physical presence is not possible. After the data is collected, then subsequent information would be tabulated and analyzed for the consequent discussion upon the study.

3.6       Questionnaire Survey

There are three different types of questionnaires that have been made available. Firstly, there is the form for the parents that will seek information about their child, his life style, and incidence of asthma (Appendix A). Secondly, there is also another questionnaire that would be available to be filled by the medical health care professionals, based on the guidelines of the Medical Research Council. (Appendix B).

3.7       Data handling and statistics

Once the objective data is made available through the questionnaires, then the data shall be fed to the computer software SPSS, and subsequent evaluation shall be done. Special areas of interest as far as the results are concerned shall include the incidence of asthma, the awareness about it, and the knowledge of the parents about the same. Finally, a comparison would be done on these three parameters among the two cities mentioned.

4.                  Conclusion

Despite the advances made in the medical world today, bronchial asthma still possess to be a potent threat to life and living all around the world. This means that proactive steps need to be taken so that all prevention can come before cure. However, all of this can only be possible once we know what exactly the nature of the enemy is. Therefore, the epidemiology of the disease must be established in specific region so that it can be adequately tackled. Saudi Arabia is no alien to this disease, and it also needs to establish its working parameters so that it can provide its inhabitants a healthier life style.

Studies like this are imperative to the cause of health care all over. It is extremely important, for the purposes of appropriate distribution of resources, and proper development of medical facilities that the true nature of the problem is found out. For that, the incidence, awareness, and management needs to develop ever more so that the people can breathe an air with the technical and administrative problems that asthma may like to offer.

Parents Questionnaire (Adapted from ISAAC [9] and Asthma.org.uk [10])              Appendix A

Demographic Information

a)         Age of Child              _______

b)         Year of schooling       _______

c)         No. of siblings                        _______          Brothers          _______          Sisters _______

d)        Number of Child in Birth order         _______

e)         Average monthly income of parents(s) and/or other bread earners (in Riyals):

            0 – 2000 ___              2000 – 5000 ___        5000 – 8000 ___        8000 + ___

f)         Any other medical condition or history of disease for the child

            _____________________________________________________________________

g)         History of Bronchial Asthma in Family

            _____________________________________________________________________

h)         Birth place of child (city/country)     _______________________________________

i)          Different cities/countries in which the child has lived for over 3 months till now

            _____________________________________________________________________

Questions

1. Has your child ever had wheezing or whistling in the chest at any time in the past?

            Yes _____                  No _____

2. Has your child had wheezing or whistling in the chest in the last 12 months?

            Yes _____                  No _____

3. How many attacks of wheezing has your child had in the last 12 months?

            Never _____   Monthly ______     Fortnightly _______  Weekly _______ Daily _____

4. In the last 12 months, how often, on average, has your child’s sleep been disturbed due to wheezing?

            Never _____   Monthly ______     Fortnightly _______  Weekly _______ Daily _____

5. In the last 12 months, has wheezing ever been severe enough to limit your child’s speech to one or two words at a time between breaths?

            Never _____   Monthly ______     Fortnightly _______  Weekly _______ Daily _____

6. Has your child ever had asthma?

            Yes _____                  No _____

7. In the last 12 months, has your child’s chest sounded wheezy during or after exercise?

            Never _____   Monthly ______     Fortnightly _______  Weekly _______ Daily _____

8. In the last 12 months, has your child had a dry cough at night, apart from a cough associated with a cold or chest infection?

            Never _____   Monthly ______     Fortnightly _______  Weekly _______ Daily _____

Adapted from Medical Research Council [8]                 Appendix B
Bronchial Asthma (BA)
Research Strategy Questionnaire

Q1       About you

1.1       Please mark the boxes next to the categories that apply to you
(you may need to mark more than one)

I am a…

person with BA                                                         researcher

person who has recovered from BA                          researcher specializing in BA

carer                                                                           clinician with BA patients

charity representative                                                GP or nurse

                                                                                          clinical specialist

other (please specify)………………………………….

1.2
Name…………………………………………………………………………………………………
Address………………………………………………………………………………………………

Email…………………………………………………………………………………………………

(This part can be left blank if you prefer)

Based on your knowledge and experience, please give your opinion to the following questions:-

Q2       Understanding BA

2.1       What is your understanding of the term Asthma?

2.2       What is your understanding of the term Bronchial Asthma?

2.3       In your opinion, is BA

                a) a single disorder with a wide range of symptoms?

OR

                        b) are there distinct differences, ie subgroups or entities?

2.4       If you think that b) is true and there is a basis for subdividing it, how would you advise that it be done?

2.5       In your opinion, how could improvements in health of people with BA be measured?

Q3       Research now

3.1       Which areas of research currently provide the strongest research evidence base for understanding BA?

3.2       Where are the gaps in research evidence?

3.3       Why do you think this is?

3.4       If there are obstacles to closing the gaps, how can they be overcome?

Q4       Research for the future and your vision for a research strategy

NB A research strategy includes assessing current national and international knowledge and gaps in knowledge in a given disease/disorder. It helps to decide what further areas of research are needed and how this might be achieved.

4.1       What do you see as the most important areas for research that will increase our understanding of BA?  Please list them in order of priority.

4.2       Why are they important?

4.3       What do you want a research strategy to achieve in the short term (3 years)?

4.4       What do you want a research strategy to deliver in the longer term (more than five years)?

4.5        What would make the strategy work?

4.6       If you were asked, how could you or your organization contribute to the strategy?

4.7       What do you think the barriers could be to implementing the strategy?

4.8       Is there any other advice or comment that you would like to give to MRC that will help it produce its strategy?

Thank you for completing the questionnaire.

Information Pamphlet (from HealthNet [7])                    Appendix C

Bronchial Asthma in Saudi Arabia

Although the incidence of asthma is increasing world widely, there is many voices many specialists say that asthma tends to be under diagnosed and under treated. Yet, the Bronchial Asthma (B.A.) affects 5 – 10 % of world population… including Saudi Arabia.

What is B.A.?

This disease is defined as a reversible obstinction of large and small airways due to hyper-responsiveness to various Immunologic and non-imunologic stimuli.

It is a chronic inflammatory disorder of the airway in which many cells play role in particular mast cells, eosinophils and T.lymphocytes.

What are the major symptoms of B.A.?

The main symptoms of this disease are: wheezing, cough, dyspnea, tachypnea and chest pain. Post tussive emesis and cough following cold air exposure or with laughter are suggestive of asthma. In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and early morning.

To what extent has this disease spread in the Kingdom?

In Saudi Arabia, the increased use of artificial irrigation, greenery, pollution and change of lifestyle have been cited as some of the factors that are responsible for the growing incidence of bronchial asthma. The prevalence of asthma among school children in Riyadh, for example, to be about 10%, and that range in the entire Kingdom is between 4% and 23% in different areas all over Saudi Arabia.

What are the reasons behind these increased prevalence of B.A. in the Kingdom?

The high and rapidly increasing in prevalence is attributed to environmental and social changes. Rapid increasing prevalence with increased exposure to indoor allergens and occupational exposure as well as indoor and outdoor pollutants are just some of the reason that tell us why prevalence and morbidity have increased. Regarding society and patient knowledge, it is notable that some patients, depending on their backgrounds, may have various misconceptions about asthma that may interfere with asthma management. These include ideas that asthma is infectious because it runs in families or affect more than a family member at a time.

How can we protect our children from B.A.?

To avoid asthma triggering factors one should follow certain procedures:

One must avoid both active and passive smoking. Wood smoke, incense, strong perfumes, household sprays and cooking oil should be avoided. Ozone, nitrogen dioxide, and acidic aerosol might aggravate the problem. House dust mites, specially in humid areas like Jeddah and Dammam, are bad for asthma patient. Hence, one should encase mattresses and box pillows, wash blankets and beds once a week, remove carpet from time to time, and avoid stuffed toys. Animals should be removed from the home. Insects must be controlled and killed immediately.

References

1.         Al-Dawood, K. Schoolboys with bronchial asthma in Al-Khobar City, Saudi Arabia: are they at increased risk of school absenteeism? Journal of Asthma. 2002 Aug; 39(5):413-20.

2.         Ballal SG, Ali BA, Albar AA, Ahmed HO, al-Hasan AY. Bronchial asthma in two chemical fertilizer producing factories in eastern Saudi Arabia. International Journal of Tuberculosis and Lung Disorders. 1998 Apr; 2(4):330-5.

3.         Clark, T. Global Initiative for Asthma. Saudi Medical Journal. 1992; 13: 521-4.

4.         Khan S, Roy A, Christopher DJ, Cherian AM. Prevalence of bronchial asthma among bank employees of Vellore using questionnaire-based data. Journal of Indian Medical Association. 2002 Nov; 100(11):643-4, 655.

5.         Veninga CC, Lagerlov P, Wahlstrom R, Muskova M, Denig P, Berkhof J, Kochen MM, Haaijer-Ruskamp FM: Evaluating an Educational Intervention to improve the treatment of Asthma in four European Countries. Au. J Respir Crit. Care Med. 1999, 160:1254-1262.

6.         Krommydas, G. et al. Left-handedness and Parental Psychopathology in the Course of Bronchial Asthma in Childhood. Pediatric Asthma, Allergy & Immunology. 2002. Jun, Vol. 15, No. 3: 145-152.

7.         HealthNet. Bronchial Asthma in Saudi Arabia. 2002. 14 April, 2006. <http://www.health.net.sa/english/section/full_story.cfm?catid=11&type=a&id=24>.

8.         Medical Research Council. 2006. 14 April, 2006. <http://www.mrc.ac.uk/>.

9.         Ponsonby, P. et al. Exercise-induced bronchial hyperresponsiveness and parental ISAAC questionnaire responses. European Respiratory Journal. 1996, 9, 1356–1362.

10.       Asthmauk. 60-second-test. 14 April, 2006. <http://www.asthma.org.uk/index.html>.

11.       World Health Organization. Bronchial Asthma. 15 April, 2006. <http://www.who.int/respiratory/asthma/en/>.

12.       Anderson, R. et al. Trends in prevalence of symptoms of asthma, hay fever, and eczema in 12-14 year olds in the British Isles, 1995-2002: questionnaire survey. BMJ 2004;328:1052-1053.

13.       European Respiration Journal. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). 1998; 12: 315-335

14.       Kaur, B. et al. Prevalence of asthma symptoms, diagnosis, and treatment in 12-14 year old children across Great Britain (international study of asthma and allergies in childhood, ISAAC UK). BMJ 1998;316:118-124.

15.       Mutius, E. et al. Relation of indoor heating with asthma, allergic sensitisation, and bronchial responsiveness: survey of children in South Bavaria. BMJ 1996;312:1448-1450.

16.       Illi, S. et al. Early childhood infectious diseases and the development of asthma up to school age: a birth cohort study. BMJ 2001;322:390-395.

17.       Rees, J. Asthma control in adults. BMJ  2006;332:767-771.

18.       Siersted, H. et al. Population based study of risk factors for under diagnosis of asthma in adolescence: Odense schoolchild study. BMJ 1998;316:651-657.

19.       Clark. C. et al. Asthma after childhood pneumonia: six year follow up study. BMJ 2000;320:1514-1516.

20.       Upton, M. et al. Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the Midspan family study surveys of parents and offspring. BMJ 2000;321:88-92.

 

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