Pediatric Asthma in Egypt Implementation of ... - Progetto LIBRA

Pediatric Asthma in Egypt
Implementation of Guidelines
(GINA Mediterranean 2012 )
Mona El-Falaki
Prof. of Pediatric Allergy & Pulmonology
Head of Pediatric Allergy & Pulmonology Unit
Cairo University

Worldwide prevalence of clinical asthma
Masoli M, et al. The global burden of asthma: GINA
Dissemination Committee report. Allergy 2004;59:469-78.

Lower Egypt
Aim :
Determination of the prevalence of asthma among Egyptian
children in the Nile Delta region of Egypt applying an ISAAC
phase I questionnaire modified according to validated Arabic
Egyptian wordings.

Distribution of the sample population in urban and
rural areas according to gender, response to written
questionnaire and prevalence of asthma.
3410 children from schools of 3 urban cities and 2 large villages
located in the Nile Delta region of Egypt (2515 from urban and 895
from rural regions) . Age Range 5-16 yrs , Mean age 7.4 ± 2.1 yrs.

Aim :To investigate the prevalence of asthma and other atopic diseases
Aim :To investigate the prevalence of asthma and other atopic diseases
in school children of Egypt.
Questionnaire based ( ISAAC) in primary and secondary school
students in 2 villages (Telwana and kafr elghadra ), and El Menofia
city, 1250 student were included , age range 6 to 15 yrs.
Asthma prevalence in 5-10 yrs old students (13%) compared to 11-15
yrs old students (10%)
The prevalence of asthma in males and females among the
whole study group was 10.3% & 11.9%, respectively.
Prevalence in Urban and Rural areas 13.8 % & 7.7% respectively.

Prevalence of Bronchial Asthma and Other Allergic
disorders in a Sample of Egyptian Children from Cairo
and Giza Governorates
Conjoint Surveillance done between the Pediatric Allergy and
Pulmonology Unit, the Department of Epidemiology and Community
Medicine , Cairo University and the Ministry of Education .
A cross sectional study including children attending primary and
preparatory schools at Cairo and Giza governorates using. a written
ISAAC study model questionnaire translated into the Egyptian
language .
Sample size was calculated using SATCAL software, assuming a
prevalence rate of 15±3% with a confidence level of 90% and power
of 0.05, sample will include 2000 child (500 children at each site).
Sample chosen using a stratified sample technique. Performed in the
period from January 2010 up to April 2010.

The 2000 students included in the study were randomly selected and
distributed as follows:
-1000 students were collected from each of Giza and Cairo
schools, 500 students from primary and 500 students from preparatory
schools.
1320 students completed the questionnaire with a response rate of
66%, 690 students from Giza ( gp A), 630 students from Cairo ( gp B).
Giza is on the edge
of the Western Desert

Distribution of allergic diseases among
studied students
%
%
Giza governorate ( group A) Cairo governorate ( group B)

Prevalence of asthma
in age groups 6-11
and 12-15 years
Giza governorate ( group A)
%
Cairo governorate ( group B)
Prevalence of asthma
in urban and suburban
areas.
%

Prevalence of asthma in males
and females age 6-15 yrs.
Prevalence of asthma in males
and females age 6-11yrs 12-15yrs

Distribution of
students on regular
asthma medications
%
Hospitalization
Due to asthma
%

Comparison between severity of asthma and hospitalization due to asthma
severity of bronchial asthma
%
Comparison between
severity of asthma
and hospitalization
%

Prevalence of bronchial asthma in relation to
type of feeding during the first six month of life
%

Distribution of asthma
in relation to presence
Passive smoking
%
Distribution of asthma
in relation to presence
of nearby pollution
%

Prevalence of current wheeze according to the
written questionnaire in the 13–14 year age group
,
5% (blue square), 5 to
,
10% (green circle), 10 to
,
20% (yellow diamond) and
.
20% (red star).
5% (blue square),
5 to10% (green circle),
10 to 20% (yellow diamond)
20% (red star)

Prevalence of symptoms of severe asthma according to
the written questionnaire in the 13–14 year age group.
Wide variations exist in the symptom
prevalence of childhood asthma worldwide.
Although asthma symptoms tend to be more
prevalent in more affluent countries, they
appear to be more severe in less affluent
countries
2.5% (blue square)
2.5 to 5% (green circle)
5 to 7.5% (yellow diamond)
7.5% (red star)
Thorax , 2009; ,64 ,476–483. doi:10.1136/thx.2008.106609

Variation of prevalence of asthma between
countries in the Middle East.
In the Middle East, The lowest 12-months wheezing prevalence rate
in rural Palestinian (5.5%) and the highest was in the desert population of
Saudi Arabia (23%).
Georgy V, et al . Eur Respir J. 2006;28:756-62 - El-Sharif N Eur Respir J. 2002;19:1026-34.
Graif Y, Ann Allergy Asthma Immunol. 2004;92:245-9 - Hijazi N, Eur Respir J. 1998;12:41-4
Shohat T, Ann Allergy Asthma Immunol. 2002;89:386-92.
Behbehani NA, Ann Allergy Asthma Immunol.2000;85:58-63.

Quality of care of Egyptian
asthmatic children:
Clinicians adherence to asthma
guidelines

Objectives: To evaluate the quality of care delivered to children
suffering from index chronic diseases using specific indicators of
health care delivery, how far it complied with recent therapeutic
guidelines, and to study the predictors of suboptimal quality of
care(SQC) and its outcome on children. ( children suffering from bronchial
asthma , childhood epilepsy , type I diabetes mellitus , and rheumatic heart disease )

Socio-demographic Characteristics of the Study Population

Predictors of SQC :
Multivariate Analysis of Socio - demographic and Health Care
System-Related Predictors of SQC Delivered to Asthmatic Children
SQC : suboptimal quality of care -
A line beside percentages indicates significant difference

Quality of Care of Children With Chronic Diseases in
Alexandria, Egypt: The Models of Asthma, Type I
Diabetes, Epilepsy, and Rheumatic Heart Disease
The pattern of asthma management was
characterized by:
A significant underuse of prophylactic drugs in
moderate/severe chronic asthma,
Underuse of the inhalation mode of delivery,
Corticosteroids abuse as a prophylactic in between
acute exacerbations in mild asthma.
Also, assessment of pulmonary function (peakflow
rate) was rarely performed.

Conclusion and Recommendation:
Cultural and economic factors are the primary predictors of SQC .
Noncompliance to medication reflects the quality of delivered care in
terms of defective health education rather than problems in the
availability of medications in the local market .
Parental satisfaction with care seems to be a reliable marker of the
quality of health care delivery regardless of the educational level of the
community ( a sensitive marker for quality of health care ).
Chronic diseases have a profound impact on children, especially those
belonging to the lower socioeconomic levels of the society, their
scholastic performance, and the health care system.
Regular monitoring of the health system performance is warranted,
along with emphasis on health education programs for caretakers of
children with chronic diseases.

Aim : Assessment of the current situation as regard clinician attitude
Aim : Assessment of the current situation as regard clinician attitude
towards guidelines for management of pediatric asthma and their
adherence to its recommendations through written questionnaire.
Methods: 352 clinicians (101 GP, 131 pediatric specialists, 35 pediatric
consultants and 85 doctors ) engaged in direct childhood asthma care in
Cairo, Egypt , (165 governmental hospitals, 68 private clinics and 119
in both).
Questionnaire based with 35 questions aiming at assessment of
physician's knowledge, practice and attitude.

Results:
Agreement with asthma guidelines in 76.2% of
physicians,
Not in agreement with the guidelines due to patient
factors.
1) poor socioeconomic standard of the patient
(18.1%)
2) poor patient compliance (16%).
Poor knowledge was found in 28.5%, poor practice
was found in 43.6%

Implementation of The
GINA Guidelines

TYPICAL PROBLEMS WITH IMPLEMENTING
STANDARDS IN DEVELOPING COUNTRIES
Adapted from: Implementation of guidelines: some practical aspects,
Marcos von Sperling and Badri Fattal , IWA Publishing, London, UK.. , 2001

TYPICAL PROBLEMS WITH IMPLEMENTING
STANDARDS IN DEVELOPINGCOUNTRIES(Cont.)
Measures that
do not lead to
immediate
compliance with
the standards do
not obtain
licensing or
financing.
There is no
affordable
technology to
lead to
compliance of
standards.
Control agencies and financial
institutes should license and fund
control measures which allow for
stepwise improvement of
even though the standards
are not immediately achieved.
Control technologies should be
within the countries’ financial
conditions. The use of appropriate
technology should be always
pursued.
Agencies or financial
institutions do not support
control measures which,
based on their design,
do not lead to immediate
compliance with the
standards.
Existing technologies are in
many cases too expensive for
developing countries. Either
because the technology is
inappropriate, or because
there is no political will or
the countries’ priorities are
different,

Comparison between developed and developing countries

Strategies for
Implementation

STEPWISE IMPLEMENTATION OF GUIDLINES
IN DEVELOPING COUNTRIES
• Gradual improvement to reduce the initial costs (cost-benefit
favorable).
• Implementation of an initial stage that is not optimally efficient
graduating at a later stage (as funds become available) to a
system that is more efficient.
• Naturally a great deal of care must be exercised to prevent a
temporary situation from becoming permanent (a common
occurrence in developing countries).
• The country has more time to develop its own standards.
• The country has more time and better conditions for developing
a suitable regulatory framework and institutional capacity.

Local adaptation and incorporation
The effectiveness of implementation of guidelines may be
enhanced if local “Key Opinion Leaders” adapt the guidelines
for local use, while taking into account geographic, religious
cultural, resource , customs and other factors.
The process of local adaptation exposes clinicians to the
guidelines, makes the guidelines more relevant to local
conditions, and encourages a feeling of ownership.
Care should be taken not to impair the scientific integrity of
the primary guidelines while making local adaptations. If local
groups alter the guidelines in the light of evidence not previously
considered, the guideline developers should informed of the
availability of that evidence.

Local adaptation and incorporation
It is preferable to use existing networks, facilities and
publications rather than to develop new processes.
Not only is this less costly, guidelines provided through
existing channels and capable of being incorporated in normal
practice are more likely to be accepted as part of the routine
than anything that requires new structures or changed modes of
practice.
Integrating the guidelines into the local health care delivery
processes. Organizations such as health care units, hospitals,
and divisions of general practice could establish such an
approach..

The Egyptian health care system consists of:
Public ( funded by the government ) or private health services.
Public hospitals providing outpatient and inpatient services for the
majority of children in our community include University
Hospitals, Ministry of Health Hospitals (MOH) delivering
medical care to preschool and children not attending regular
schools(uninsured), and the Student’s Health Insurance Hospitals
(SHIH) providing medical care to schoolchildren.
University Hospitals includes all pediatric subspecialties
with separate outpatient clinics, wards, and staff but with common
emergency services for pediatric emergencies. It also includes an
intensive care unit for critical conditions.
Private health services consists of private clinics or pediatric
wards in private hospitals and is primarily for the higher
socioeconomic levels that can afford costly medical services.

Strategies for implementation
A variety of approaches have been shown to change
clinicians’ behavior or health outcomes, or both:
As a general rule, one-to one approaches , that is ,
‘champions’ or academic detailing ,“Key Opinion Leaders”
are most effective
The interventions most likely to induce change are those
that require the clinicians’ participation in the change process
and are actually used in clinical decision making.
Short summaries for use in professional or general
publications or brochures, as posters, on the Internet, as
audio or video tapes, or on disk.

Strategies for implementation (cont.)
Using the media, professional journals and publications
of other groups (medical – nonmedical) .
Reminder systems incorporated in clinicians’ daily
work.
Arranging for a credible health provider to visit
practitioners in the clinical setting.
Discussing the guidelines at conferences, seminars and
other professional meetings.
Using the education processes of appropriate colleges
and other groups.
Using new I T ( Tele conferences – Web viewing )
particularly for clinicians in remote parts of Egypt.

Evaluation of the guidelines’ contribution to
changes in clinical practice and health outcomes
Comparing changes in clinical practice or health
outcomes, or both, in areas of exceptionally high guideline
promotion with changes in areas of exceptionally low
guideline promotion.
Comparing health outcomes in areas of exceptionally
high guideline uptake with outcomes in areas of
exceptionally low guideline uptake—focus group testing
can be useful to elucidate factors that have influenced this
uptake.

Further Information:
National Health and Medical Research Council , 1998 , A guide to the
development, implementation and evaluation of clinical practice guidelines
Implementation of guidelines: some practical aspects, Marcos von Sperling and
Badri Fattal , IWA Publishing, London, UK.. , 2001.
Implementation of clinical practice guidelines , Registered Nurses Association of
Ontario (2002).
Global variation in the prevalence and severity of asthma symptoms: Phase Three of
the International Study of Asthma and Allergies in Childhood (ISAAC) C K W Lai,
R Beasley, J Crane, S Foliaki, J Shah, S Weiland, :Thorax , 2009; ,64 ,476–483.
483.
doi:10.1136/thx.2008.106609
Quality of Care of Children With Chronic Diseases in Alexandria, Egypt: The
Models of Asthma, Type I Diabetes, Epilepsy, and Rheumatic Heart Disease , A.
Bassili, A. Zaki, I. H. El-Sawy
Sawy, R. Bedwani and G. Tognoni : PEDIATRICS
Vol. 106 No. 1 July 2000; e12
Prevalence of bronchial asthma Egyptian school children : M Zedan, A Settin,
M Farag, M Ezz-Elregal, E Osman, A Fouda : Egyptian J of Bronchology, Vol 3,
No 2, December, 2009.

%
Prevalence of asthma in urban and rural
areas.

Severity of Bronchial Asthma
%
%

A large epidemiological study was conducted on
school children aged 6-15years, which was adopted
from ISSAC (International Study of Asthma and
Allergies in Childhood) project and has revealed
that the prevalence among Egyptian school
children ranged from 10.9 to 18.7 with a mean of
15.1%.
From these results, they concluded that the
prevalence has increased during the last few
years especially in urban areas compared to rural
ones.
Deraz T (2009): Analysis of the filed data of a sample of Egyptian children
with bronchial asthma. Egypt J Pediatr Allergy Immunol 2009; 7(2):59-64

P value
Prevalence of asthma in
children with other atopic
disorders in group A
%
Prevalence of asthma in
children with other atopic
disorders in group B
%

A variety of approaches have been shown to change
clinicians’ behavior or health outcomes, or both:
• Using opinion leaders and clinical ‘champions’ in the
media and for marketing; Practice visits from influential
experts;
• Endorsement by key clinical groups;
• Educating patients;
• Educating patients;
• Provision of educational materials;
• Seminars and conferences;
• Reminder systems incorporated in clinicians’ daily work;
• Continuing quality assurance and data feedback;
• Local adaptation and incorporation;
• Local involvement in evaluation; and incentives.

Local adaptation and incorporation
The interventions most likely to induce change are
those that require the clinicians’ participation in the
change process and are actually used in clinical decision
making.
There is also evidence that the most effective
implementation strategies are those that have a direct
effect on consultation between patient and health care
professional.
Special

Conclusion

The best approach to making sure guidelines work would
appear to be a mix of strategies suitable for local conditions
and developed in concert with local clinicians, consumers
and managers.
Step wise approach.
Incorporation and building up on already existing
system.
As a general rule, one-to one approaches, that is ,
‘champions’ or academic detailing ,“Key Opinion Leaders”
are most effective.
Special measures involving in particular new information
technology for clinicians in remote parts of Egypt.