Summary/Abstract (249/250 words)
Background: Wheeze-associated disorders are common in
childhood, associated with considerable morbidity, if not detected and
treated. Under diagnosis of asthma remains a problem, especially in
resource-limited settings.
Methods: We used a validated school-based screening
questionnaire to detect children likely to have asthma. Children with
positive screening were referred to the Pulmonology Department for
clinical review and lung function testing. We compared asthma-like
symptoms, activity limitation, school absence and health service
utilization before and after in those diagnosed with, and treated for
asthma.
Results: 6400 children, from a potential population of
70,000 were screened between 2010 and 2016, with 900 (14.1%) screening
positive. Lung function data were available from 578 (64.2%) children
(5.7 to 6.5 years old). Asthma was confirmed in 549 children; 438 were
treated with short acting bronchodilator alone and 111 with inhaled
corticosteroids. Asthma control improved in 58% of children, with fewer
daytime [mean 4.7 (SD1.9), vs 11.1 (0.6) days per week,
p<0.001] and nocturnal [4.3 (1.1) vs 0.89 (0.5) days per
month, p<0.001] symptoms. Activity improved and fewer school
days were lost due to asthma [12.8 (3.0) vs 1.9 (0.9) days in past 3
months, p<0.001] in over 50% of children. Emergency
department visits were reduced [1.8 (0.7) vs 0.3 (0.2) visits in past
3 months, p<0.001] in over 80% of children.
Conclusions: Asthma under diagnosis remains a problem in
Argentina. Our school-based assessment is an effective tool for
detecting children with undiagnosed asthma. Instituting effective asthma
treatment in these children reduces symptoms and improves control.
Introduction
Wheezing disorders in children, frequently called asthma (1), are common
causes of morbidity and mortality in children. The world has seen an
epidemic increase in asthma in recent decades, starting in high income
countries and proceeding to middle and low income countries (2). Seminal
studies conducted as part of the International Study of Asthma and
Allergies in Children (ISAAC) have documented changes in prevalence in
various part of the world between the late 1990s and mid 2000s (3-5).
The prevalence reported for Latin American countries showed considerable
variability (3-5), with that reported for Argentina being around 10 to
20%.
Despite improved diagnosis and management in many parts of the world,
under diagnosis of asthma is still a major problem, especially in
impoverished communities and in low and middle income countries (LMICs)
(2, 6-8). This is especially true for young children, despite specific
guidelines produced for the under five year olds (9). Under diagnosis is
frequently associated with inappropriate management and increased
morbidity including school absence and disturbance of family work
practices with consequent economic consequences for the family and
society (6, 7). The need for timely and accurate diagnosis in young
children is recognized (7), is considered as a research priority (10),
and forms part of a recently published Children’s Asthma Charter that
sets out the rights and expectations of children with asthma (11).
Appropriate diagnosis and management leads to improved outcomes for
children and their families (7).
Wheeze and asthma-like symptoms are common in preschool-aged children
and around 80% of those with persistent asthma have symptoms
originating in early life (12). However, only approximately 30% of
preschoolers with recurrent wheeze will go on to have childhood asthma
(12). The consequence of not having an accurate diagnosis is often
inappropriate treatment with antibiotics or with inhaled corticosteroids
plus long-acting beta agonists (9, 13, 14). Appropriate diagnosis at
early school age with appropriate management according to guidelines is
likely to improve outcome in individual children and reduce the need for
health care utilization (7, 14, 15).
Very few studies worldwide (and none in Latin America) have evaluated
the impact of the programs designed to screen for asthma in children in
the early school years. We developed and validated programs for early
detection of under-diagnosed or under-treated asthmatic children
attending the first grade of school (16) or kindergarten (17). The aim
of the present study was to determine the impact of early diagnosis and
treatment of asthma in school-aged children in Chubut, Argentina.
Material and methods
The program, known locally as PDPACh (Programa de Detección Precoz de
Asma en escuelas de la Provincia de Chubut [Early School
Case-Detection Asthma Program in Chubut province]), aids early
detection of asthma in first grade school children in Chubut province,
Argentina (16). Parents completed a previously validated questionnaire
(Table 1) and children with a positive result were referred to the
Pulmonology Department, Trelew Hospital, for assessment. The study
protocol was approved by the Bioethics Committee and Committee for
Teaching and Research, Trelew Hospital and Parents gave written consent
for their child’s participation.
Data were collected from children referred for asthma assessment before
and after parents completed PDPACh. We compared data from the 3 months
prior to receiving the questionnaire with the 3 months after in terms
of: 1) number of days per week with daytime symptoms; 2) number of days
per month with nocturnal symptoms; 3) number of days per week with
restriction of usual activity; 4) number of lost school days due to
asthma in the 3 months period; 5) number of visits to an emergency
service due to asthma symptoms; 6) asthma control using the Asthma
Control Test and classified according to the Global Initiative for
Asthma (GINA) criteria; and 7) lung function.