In December 2019, a lady in her early 20s, Joy Udofia (not real name) suddenly began to gasp for breath while attending a public function in Lagos. She caused a stir as people around wondered what had befallen her.
But while some persons approached her for assistance, she was already fumbling for something in her handbag. In about a minute, she grabbed a blue inhaler and began to apply it with shaky hands.
“Oh, I’m sorry,” said about three persons, as if they were on cue. She nodded in response. Then about five minutes later, she moved on with her business and interacted with her colleagues. She, obviously, had asthma.
As the number of people suffering from asthma continues to rise, experts have said that though there might not be a cure for the ailment, it could be managed for decades while the patient leads a normal life. But they believe that the burden should not be left alone for the patient to bear.
Sadly, the ailment has claimed many lives due to avoidable factors on the part of the patient, society and government.
One of the leading consultant chest physicians in Nigeria, a professor of Medicine, Gregory Efosa Erhabor, while speaking during the World Asthma Day recently, called for improved asthma awareness and care in Nigeria.
On how Nigeria has fared in the management of asthma so far, he said there was relative better public alertness, thereby prompting quick response to patients with asthma when they need help. He stated that more resident doctors were showing interest in pulmonology and training to become chest physicians. This has resulted in more standardised ways of management in various tertiary and secondary hospitals, particularly as basic asthma medications, inhalational therapy and nebulizers were increasingly being used by a lot of hospitals.
However, he said the progress already made still falls short of what is expected. He pointed out that there was still a big divide between what happens in tertiary hospitals and primary and secondary care services. For the advancement of any disease, the specialist explained that it entailed a triangle of patient management, training and research.
“There is still poor government involvement and active support to strengthen research and patient care in asthma in Nigeria. Moreover, asthma is poorly diagnosed and still inadequately treated even in tertiary hospitals. This is because of poor education and lack of availability and affordability of asthma medications,” he said.
Having practised for over three decades and currently training and mentoring students at undergraduate and postgraduate levels at the Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Erhabor stressed that government plays a major role in making policies that favour health care delivery and establishment of standard health facilities nationwide.
In a chat with Daily Sun, he opined that government at different levels could mitigate the burden of asthma on patients and caregivers by subsidising the cost of care. He advised government to also partner with non-governmental organisations in the provision of free or subsidised peak flow meters and nebulizers for asthma patients. He said government could also partner with others in the production of ‘M’Health applications that could help patients in monitoring their asthma.
Erhabor, the president/founder of Asthma and Chest Care Foundation, a non-governmental organisation targeted at research, education and patient care among asthmatics and those with other chest diseases, disclosed that the foundation has been in the forefront of educating, counselling, and caring for patients. Other areas of focus, according to him, are training of health professionals, advocacy and conducting research towards the enhancement of the lives of people with asthma and other lung diseases.
Decrying that anecdotal evidence had shown that about 15 million Nigerians might have asthma, the head of the Respiratory Unit, Department of Medicine, OAU, urged philanthropists to support NGOs working round the clock to reduce the plight of asthma patients. He maintained that this was necessary to augment the efforts of government in asthma management.
Hear him: “Asthma prevalence ranges from high prevalence countries like South Africa, which has 33.1 per cent, to low prevalence countries like Gambia with 4.4 per cent. Nigeria’s prevalence falls in-between.
On some of the risk factors associated with asthma management, “basically, asthma results from interplay of genetic and environmental factors, a situation known as nature and nurture. Individuals with family history of asthma are prone to developing asthma. When individuals with genetic predisposition to asthma get exposed to certain triggers in the environment, they develop symptoms of asthma.
“Triggers are extremely small and lightweight particles transported through the air and inhaled into the lungs. They precipitate asthma attacks and are usually found in the environment. Triggers include pollens, house dust mite, cockroach allergens, cold air, spores, fumes, smoke, sprays, perfumes, exercise, certain drugs like aspirin, tobacco smoke, prolonged exposure to air pollution, and agents found at workplace like chemicals, among others. People with allergies such as allergic rhinitis, conjunctivitis, sinusitis, or atopic eczema are predisposed to developing asthma. The most common trigger still remains house dust mite,” the expert said.
He explained that there was new interest in the role of obesity in the development of asthma. Within the last few years, there has been a growing body of literature on the obese asthma syndrome. He expatiated on how obesity contributes to asthma in an individual in various ways: “These are a few ongoing factors that have come up as the relationship. Obese people are more susceptible to many strong risk factors of asthma like allergens, chemicals, cigarette smoking and air pollution. There are many things that have been attributed to it but one common one is that the diet that promotes obesity such as the western diet has high levels of saturated fatty acids, low fibre, low antioxidants and is high in sugar.
“There is a growing literature that the harmful effects of these dietary components could lead to increased neutrophilic inflammation, which predisposes to asthma and increased bronchodilator response. Also, there have been some studies showing that obesity can lead to low circulating vitamin D, and vitamin D deficiency has been implicated in the development of asthma and obesity. There is also what we call a bidirectional relationship. Obesity predisposes to asthma and asthma also predisposes to obesity.
“For example, 60 per cent of adults with severe asthma in the United States are obese. Obese patients have worse asthma control and lower quality of life. Obese asthmatics do not respond as well to standard controller medications. Furthermore, obese adults have 1.6 to three times more risk of developing wheeze and asthma. Obesity can cause or worsen gastroesophageal reflux disease (GERD) and sleep apnea and both of these conditions have caused increased risk of developing asthma.
“Asthma runs a bimodal pattern, childhood asthma and adult asthma. Asthma tends to be more in number and in severity among boys than girls in childhood. This becomes balanced at puberty between the ages 12 and 14. However, from 15 to 50 years of age, females predominate. Early childhood events may influence the development of asthma, the so-called hygiene hypothesis. However, what determines the progression is being debated. Some believe once you develop childhood asthma, you continue to have symptoms. Others believe that there is a rule of third; that, following development of asthma, a third goes into quiescence, some recover and others progress.”
The medic advised asthma patients to work with their physicians to develop a self-management plan, which includes a plan for acute exacerbation of asthma. He said that asthma management and treatment must be individualised and personalised. He also emphasised the need to educate patients on how to recognise their triggers, inhaler techniques and self-management plan, among others.
He recommended, as a principle, embracing inhaled medications for asthma because these get delivered to the site of action, and small doses give maximum effect. He, however, warned that some inhaled medications could cause oral thrush, and this could be prevented by using spacer devices or rinsing the mouth immediately after use.
“Asthmatics should be managed as when there was no pandemic. When they notice deterioration in their health, they should contact the nearest health facility as soon as possible. The continual use of medications like aminophylline can be dangerous and should be discouraged. Early use of steroids is encouraged because of the anti-inflammatory properties.
“Severe allergic asthma could sometimes be very difficult to treat, in other words, they may not respond to the commonly used asthma medications. In recent times, several new medications, known collectively as ‘biologics,’ have been approved for the treatment of moderate-to-severe asthma. Biologics are unique in that they target a specific antibody, molecule, or cell involved in asthma.”
When asked if the COVID-19 pandemic could lead to more triggers in asthmatic patients, Erhabor said: “Observational research has shown that asthmatics do not come up with increased exacerbation during COVID-19, which affects the parenchyma of the lungs rather than the lung airways.”
At this period of coronavirus, wouldn’t coughing or wheezing be misconstrued for symptoms of COVID-19? The expert said that wheezing is not one of the symptoms of COVID-19.
His words: “Cough in COVID-19 is dry, continuous, associated with fever, sore throat, muscle aches, breathlessness and other constitutional symptoms. Cough in asthma is usually episodic, associated with wheeze, breathlessness, chest tightness, and triggered by exogenous factors.
“Having said this, the best way to have diagnosis for COVID-19 is to do the testing and tracking of symptomatic and exposed individuals. If you are having symptoms suggestive of COVID-19, report to centres responsible for testing, tracking and managing the disease. For asthma, diagnosis is from spirometry and demonstration of airway reversibility.”
To save more asthma patients, Erhabor advocated increase in public awareness through television, newspapers, radio, social media networks and use of various public fora. He also harped on mass education in schools, churches and mosques and massive distribution of asthma information booklets.