Letter from Iraq.

Abstract

Asthma is the most common chronic childhood illness with many hospital visits and school absences. Many parents do not allow their children with asthma to engage in sports with their peers, often leading to great psychological impact on the children. The International Study of Asthma and Allergies in Childhood (ISAAC) recorded the incidence of childhood asthma in 97 countries and found a wide range of prevalence, from 0.8% to 37.6%. Furthermore, childhood asthma seems particularly common in developed countries and is strongly linked with other allergic conditions. In contrast, children living in rural areas of developing countries are less likely to develop asthma and allergy. In Iraq, ISAAC recorded the prevalence of clinically diagnosed childhood asthma as 16.3% in primary school children. Several epidemiological studies on the prevalence of childhood asthma were conducted in different regions of Iraq; the largest one was carried out by Al-Thamiri et al.1 in Baghdad and involved 3360 primary school children. This is the only study from Iraq that is included in ISAAC. A further study was conducted by Salem et al.2 in Basra City, involving 424 children younger than 5 years; the prevalence of childhood asthma was 15.8%. A specific problem in Iraq is the management of childhood asthma. This reflects a lack of specialists in paediatric pulmonology, no standard guidelines for treatment, limited availability of spacer devices for inhaled medications and lack of asthma educational programmes. In fact, many paediatricians and general practitioners have limited knowledge about how to use inhaler devices. To this day, the disease is treated inadequately in most cases and asthma patients receive treatment only when acute exacerbations occur, without paying attention to long-term asthma control. From this position, we established a paediatric asthma outpatient clinic in the city of Kerbala (100 km south of the capital Baghdad) with three senior doctors, Professor Zuhair M. Al-Musawi and Dr Akeel M. Hussein (consultant paediatricians), Dr Haidar A. N. Abood, and three asthma nurses. The clinic was opened in Kerbala Pediatric Teaching Hospital and it is the first clinic of its type in our country. Preparations for the clinic started in 2012 by establishing a literature database, textbooks and international guidelines on supplying needs such as medications, inhalation devices, specific investigations and other instruments needed for the management of asthmatic patients. Furthermore, the staff completed training courses on asthma management and pulmonary function tests in paediatrics through several workshops in nearby countries such as Lebanon, Iran and India. The official opening was on 20 May 2013. Since that time, a data file system for follow-up was used for every patient who had visited the asthma clinic. The file system includes personal and demographic data, general and specific medical history, findings of clinical examination, investigations, assessing asthma severity and the recommended treatment. Each patient registered in the clinic was supplied with appropriate medications and inhalation devices after a full course of training and education for the patient and their parents. Scheduled regular visits were given to all patients to assess asthma control and adjust treatment accordingly, as well as an asthma action plan for each patient with explanation of its contents to the parents. The management programme followed strict guidelines adopted from the National Asthma Education and Prevention Program (NAEPP) and Global Initiative of Asthma (GINA). Investigations available in the asthma clinic include spirometry (using Spirolab III device with disposable turbine system) with exercise challenge test, total and specific immunoglobulin E (IgE) level, complete blood picture with five differential counts for eosinophil, chest X-ray and computed tomography (CT) scan if needed, in addition to specific biomarkers for research purposes. By early 2020, more than 2000 patients are receiving controller therapy for asthma through regular clinic visits. Several educational and prevention programmes are held annually for patients; five children returned back to school after extended absence due to poor asthma control and hundreds of children are able to practice sports activities now with proper asthma management. More than 14 research papers were published in local and international journals using data from the clinic. Research mostly focused on studying biomarkers that are used in phenotyping childhood asthma,3 which helped us give a new treatment option for patients with severe asthma. Other research improved our ability to assess asthma severity.4 Recently, we started to present our experience and research data to other Iraqi paediatricians and medical professionals at several national paediatric conferences that were held in Kerbala City, the last of which was held in April, 2019, with two asthma workshops included in the conference (Fig. 1). In the future, we will try to expand our research to involve most paediatric hospitals in Iraq, hoping to improve our affected children's quality of life.