Studying the status of asthma in students at primary and secondary schools in Thai Nguyen city and the effectiveness of controlling asthma with ICS + LABA

1 BACKGROUND Bronchial asthma (AB) is a fairly common disease among respiratory tract diseases in our country as well as many countries around the world. Bronchial asthma (AB) is caused by many factors and tend to increase gradually. According to the World Health Organization 2004 (WHO), the world has more than 300 million patients of Bronchial asthma. There are 6-8% of adults, over 10% of children under 15 years old. It is to estimate that this number will increase to 400 million in 2025. The Western Pacific and South East Asia regions, the situation of BA of children within 10 years (1984-1994) had increased considerably, such as in Japan from 0.7% to 8%, Singapore from 50- 20%, Indonesia 2.3 to 9,8%, the Philippines from 6 to 18.8%. In Viet Nam, the average rate of BA accounts for 5-6% of BA population, in which, there are 5% in adults, 10% of children under 15 years old, and it depends on regional changes and environmental pollution. Recently, the prevention and treatment of BA complied with instruction from the GINA (Global Initiative for Asthma) has achieved good results. However, many research results have showed that the control and treatment of BA is still to have shortcoming, many patients diagnosed BA is only treated to stop BA without prophylactic treatment of BA. Therefore, frequently BA recurrent attacks cause more severe disease and take more cost for treatment of BA. It increases the rate of emergency hospital admissions, and effect of BA treatment is not high. In Thai Nguyen, there is not any research on this issue. Therefore, we carry out this research with 3 following objectives: 1. To describe the status of pupils of primary schools and secondary schools with bronchial asthma in Thai Nguyen city. 2. To identify some risk factors of BA for pupils of primary and secondary schools in Thai Nguyen city. 3. To evaluate BA control effectiveness by ICS + LABA (Seretide) for pupils of primary and secondary Schools in Thai Nguyen city 2 NOVEL CONTRIBUTIONS OF THE THESIS Determination BA rate of pupils of primary schools and secondary schools with bronchial asthma in Thai Nguyen city. Identification of some risk factors of BA for pupils of primary and secondary schools in Thai Nguyen city. Giving evidences of positive effect of asthma control with ICS + LABA (Seretide) in the community Use of Peak flow meter to follow up changes of indexes of PEF morning, PEF evening, variation of PEF morning and PEF evening in the diagnosis and monitoring of asthma control in community. Application of ACT scores to assess the results of asthma control in community. THE STRUCTURE OF THE THESIS The main part of the thesis consists 107 pages. It includes the following sections: Introduction: 2 pages Chapter 1 - Overview: 29 pages Chapter 2 - Subjects and research methods: 22 pages Chapter 3 - Outcomes of the study: 19 pages Chapter 4 - Comments: 32 pages Conclusions and Recommendations: 3 pages The thesis has 35 tables, 7 charts and 129 literature references, of which, there are 37 Vietnamese literature references, 92 English references. 3 Chapter 1 OVERVIEW 1.1 Epidemiology of Bronchial Asthma 1.1.1 The circulation of Bronchial Asthma Bronchial asthma (AB) is a chronic lung disease and the most common disease in the world. BA happens in all ages and in all countries. Within 20 years, the recent incidence is increasing more and more, especially in children. The percentage of children with symptoms of BA changes from 0 to 30%. It is depended on the survey in each region in the world. According to GINA 2004, the global percentage of BA are as follows: 12 countries with rate of BA above 12%, 16 countries with rate of BA from 8-12%, 23 countries with rates of BA between 5-8% , 33 countries with rate of BA below 5%. High rate of BA focuses on European countries such as Scotland, Giosey, Guosey, Wales, Isle of Man, England, Newzeland and Australasia (Australia). Lowe rates of BA are Russia, China, Anbania, Indonesia, Macao etc… Asia - Pacific regions, recently, epidemiologists have studied showed that the rates of BA of pupils at the 6-7 years old in Bangkok increases from 11.0% in 1995 to 15.0% in 2001 and those in Chiang Mai increase from 5.5% in 1995 to 7.8% in 2001. The rates of BA of pupils at the age of 13 and 14 in Chiang Mai increases from 12.7% in 1995 and 8.7% in 2001 and those in Bangkok increase from 13.5% in 1995 and 13.9% in 2001. Pupils at the 12-15 years old in Taiwan, the rate of BA diagnosed physicians was 4.5% in 1995 and 6% in 2001 , in Singapore from 1994 to 2001, the rate of asthma at the age from 12 to 15 increase from 9.9 % to 11.9%. However, the rates of BA decrease from 16.6 to 10.2% at the age of 6 and 7. In Hong Kong, the group of the 13-14 years old diagnosed asthma was 11.2% in 1995 and 10.2% in 2002. The rate of asthma of Japanese children was 7.6%. 4 Vietnam is a country of Southeast Asia Region and has a accelerated rate of BA in recent years. The rate of BA of children under 15 years old in some residential areas in Hanoi in 1998 was 2.7%. Recent studies on the rate of BA of pupils at school age, the rate of BA in Hai Phong in 2002 was 9.3%. BA percentage of pupils at school age in urban and suburbs of Hanoi in 2005 was 10.42%. Studies of pupils at some secondary schools in Ha Noi in 2003 and in 2006 were 10.3% and 8.74% consecutively. 1.1.2 The burden of Bronchial Asthma The burden from BA is for not only patients, but also affects to economics, well-being of families and the burden of the whole society. For patients with negative health affects to study, work and work, affects to quality of life and happiness for themselves and their families, many cases are death or disability. Study of AIRIAP in Asia and Pacific region, including Vietnam, shows that proportion of patients leave school and leave of work in a year is 30-32% (16-34% in Viet Nam) and the ratio of emergency hospital admission is 34% (of which, that in Vietnam is 48%); patients with insomnia in the four weeks was 47% (71% in Vietnam). 1.2 Risk factors of BA Risk factors affecting bronchial asthma can be divided into two categories: pathogenic factors of bronchial asthma and triggering factors the onset of BA attack. The precise role of several factors is unclear. Some other factors such as allergens are within two above types above. Pathogenic factors of BA includes factor of subject (mainly genetic factors) and factors causing BA attack are usually environmental factors. Factors affecting development and expression of Bronchial Asthma - Subject factors • Gene - Gene creating atopy allergy - Gene creating allergic increase response of the airway. • Obesity 5 • Gender - Environmental factors • Allergens - In the house: house dust, animal hairs (dog, cat, and mouse) and allergens from cockroaches, mold, fungi, and spores. - Outside the house: pollen, mold, fungi and spores. • Infections (predominantly viral) • Allergens from work • Tobacco smoke: Passive and active • Air pollution inside and outside of the house • Diet Mechanisms affecting development process and manifestation of BA of factors are complex and they interact with each other. Many multi-gene patterns related to susceptibility to asthma and allergies. Complex interaction between genes and environment seem to play a key role in formation of the disease. 1.3 Prophylactic treatment (control) of Bronchial Asthma (BA) 1.3.1 The aims of control treatment (prevention) of BA: According to GINA 2006 - Gaining and maintaining control of symptoms of BA - Maintaining normal activities, including to make efforts - Upholding lung function as close as to normal lung function as possible - Preventing from a paroxysmal attack of BA - Avoiding adverse effect of drugs used to treat BA - To prevent deaths from BA 1.3.2 Treatment of control of Bronchial Asthma (BA) Novel concepts in prophylaxis treatment of BA: Prophylactic treatment of BA is mainly with mild and moderate types in communities. Several and critical types of BA are treated in hospitals. Drugs for the preventive treatment are used daily prolonged medications to control of BA primarily through anti-inflammatory effects of drugs. 6 Prophylaxis drug include glucocorticoid (ICS) for inhaling and entire body, transformed drug leukotriene, Long Acting β 2 Agonist combining with ICS, theophylline released slowly, Cromone, anti-IgE, and treatments of symptoms of other entire body . ICS is the sole drug inhibiting inflammation in a effective way. ICS reduces the increase of reaction of the respiratory tract, controls inflammation, relieves symptoms and paroxysmal attacks leading to reduce needs of relieve medications. Today, ICS is recommended as the first choice in controlling Bronchial Asthma. Recent studies show that BA patients do not controlled by low or high doses. Combination with LABA (Long Acting β 2 Agonist) has more effective than increase of ICS dose. Effect of LABA is bronchodilator for 12 hours and ICS is used twice per day. So, two combinated drugs are well suited to control better clinical symptoms of BA patients without increase ICS dose or maintain the control status of BA symptoms when reduction of ICS dose. 1.3.3 Seretide is a medication of effective coordination in prophylaxis treatment of Bronchial Asthma (BA) Ingredients of Sertide composed of Salmeterol and Fluticasone propionate. Salbutamol Contains Salmeterol (belonging to LABA group ) and Fluticasone propionate (belonging to ICS group). Both substances have effects on the various aspects of BA pathogenesis: Salmeterol is to control symptoms, while Fluticasone propionate prevents BA recurrent attacks by controlling inflammation. 7 Chapter 2 RESEARCH OBJECTS AND METHODOLOGY 2.4 Phương pháp nghiên cứu 2.1 Subjects of study Pupils at primary and secondary schools (from 6 to 15 years old). Parents or careers of pupils (in the case of pupils from 6 to 7 years old). 2.2 Duration of study: From October 2007 to October 2010. 2.3 Research location: Primary and secondary schools of Thai Nguyen city. 2.4 Research Methodology 2.4.1 Research of description: Design of cross-sectional descriptive study to determine BA percentage of pupils at primary and secondary schools in Thai Nguyen city in 2008. Sample size: Applying the formula for sample size for described study ( ) 2 2 2 1 d pq Zn α − = n is minimum number of pupils from 6 to 15 years old to research Z 2 (1- α/2) : coefficient of confident limit (with α = 0,05, Z 2 (1- α/2) = 1,96) p : ratio of pupils with BA estimated 10% q = 1-p; d: desired error = 1% Since then we have: 34579,0.1,0. 01,0 96,1 2 2 = pupils. 2.4.2 Research of disease symptom: Applying the formula for sample size of disease symptom study to identify risk factors. ( ) ( ) ( ) ( ) { } ( ) 2 21 2 2211)1(2/1 1112 pp ppppZppZ n − −+−+− = −− βα n is sample size needed in each group α = 0,05 , Z 1-α/2 = 1,96, β = 0,2, Z 1-β = 0,84 8 ( ) ( ) 75,0 1 . 22 2 1 = −+ = ppOR pOR p 67,0 2 21 = + = pp p p 1 is the rate of exposure to risk factors of BA group p 2 is the rate of exposure to risk factors in the control group (about 60% of exposure to tobacco smoke without BA). OR odds ratio expected is 2 ( ) ( ) ( ) } { ( ) 2 2 6,075,0 6,016,075,0175,084,067,0167,0.296,1 − −+−+− =n Replacing the formula, we calculate 152 students To fix BA groups/ control group is 1/2, we have a sample size to study: BA group is 152 pupils and the control group is 304 pupils (sampling rate at schools are 161 pupils of BA group and 322 pupils of the control group). 2.4.3 Intervention study: formula for calculating sample size of intervention. ( ) ( ) ( ) 2 21 2211 2 ),( 11 pp pppp Zn − − + − = βα n is the minimum sample size to calculate α is statistical significance and probability of a error type 2. it is estimated 0.01. Z 2 is looked up the table of value with α= 0,01, β = 0.1; ( ) 9,14 2 , = βα Z β is probability of a error type 2. It is estimated 0.01. p 1 is the rate of patients estimated asthma control of pretreatment. It is estimated 30% p 2 is proportion of patients estimated after treatment. Estimation is 30% ( ) ( ) ( ) 2 3,005,0 3,013,005,0105,0 9,14 − − + − =n 9 - From then, it is calculated n = 61 (estimated 10% give up, n chosen is 68). 2.5 The studied criteria - The group of criteria on the status of BA - The group of criteria on risk factors - The group of criteria on intervention effect + Assessing effectiveness of asthma control according to GINA criteria + Assessing the effectiveness of BA control according to tools of assessment of asthma controlling ACT (Asthma Control Test), the acceptance of patients. 2.6 Diagnostic criteria of Bronchial Asthma (BA) according to GINA 2004. 2.7 Methods and techniques of data collection Collecting screened information through forms of surveys: All pupils (or parents) are given a questionnaire and instructed answer to questions (Appendix 1). Interview, examination, measurement of respiratory function: pupils, having one of six questions to be answered “yes”, are invited to visit medical doctor, asked disease history, measurement of respiratory function (PEF) to diagnose BA (the Appendix 2). Những học sinh ở nhóm nghiên cứu bệnh chứng ñược phỏng vấn theo phiếu ñiều tra (phụ lục 3 và 4). Những bệnh nhân can thiệp: Khám làm bệnh án, khám lại sau 2 tuần, 4 tuần, 8 tuần, 12 tuần (phụ lục 5). Pupils in the disease group were interviewed by questionnaire (Appendix 3 and 4). The patients of intervention: Take medical records and re- examine after 2 weeks, 4 weeks, 8 weeks and 12 weeks (Appendix 5). 2.8 Data processing Analysis and data processing by in medical statistical methods using the software of Epi-Info 6.04 and SPSS 13.0 version. 10 Chapter 3 RESULTS OF STUDY 3.1 Percentage of Bronchial Asthma (BA) Table 3.1 Percentage of Bronchial Asthma (BA) by gender: Number of questionnaires forms distributed are 4329 and these collected are 4329. There are 4292 questionnaires forms full enough information processed. Overall morbidity rate was 9.5%. The rate of BA in boy pupils is 10.4% and is higher than that girl pupils (8.6%) with p <0.05. Table 3.2 Percentage of Bronchial Asthma (BA) by age: The rate of BA of the groups of 6-10 yeas old and the 11-15 years old group are 10.1% and 9.0% (p> 0.05) consecutively. Table 3.3 The rate of asthma according to asthma status The rates of BA at level 1, level 2, level 3 are 66.7%, 20.8% and 12.5% consecutively. Table 3.6 Knowledge of patients with BA on BA control and BA control status: Rates of patients knowing drugs cutting BA attacks, BA being a disease able to be controlled are 64.9% and 3.4% consecutively. The rate of patients has been treated control by physicians is 1.9%. 18,8 4,8 74,1 29,4 84,3 49 38,5 15,4 0 10 20 30 40 50 60 70 80 90 Asthma level 1 Asthma level 2 Asthma level 3 General Rate of patients off shool Rate of patients admitted ICU Figure 3.2 The rate of pupils being off school and admitted ICU due to asthma in last year 3.2 Some risk factors cause Bronchial Asthma (BA) Table 3.8 Family history has persons with BA [...]... Coordinating these two drugs has proper role in the treatment from mild to moderate bronchial asthma, increase of convenience, and improvement of compliance by patients, increase control results and reduce incidence of severe attack of BA, reduce the cost of treatment 23 CONCLUSION 1 Status of Bronchial Asthma (BA) of pupils in elementary and secondary schools in Thai Nguyen city Rate of pupils at primary and. .. assuring treatment Table 3:35 The compliance of patients in treatment: 100% of patients changing lifestyle behaviors, avoiding risk factors causing asthma, 91.2% of patients with full dose spray 100% Chapter 4 DISCUSSION 4.1 Status of Bronchial Asthma (BA) Through screening 4292 pupils at primary and secondary schools in Thai Nguyen city, the rate of BA is 9.5% Of which, the rate of BA in male pupils... effectiveness of controlling asthma with ICS + LABA for pupils at primary and secondary schools in Thai Nguyen city , Medical Journal, (ISSN 1859-1663), National Workshop on Astham and COPD in June 2011, No.766 4 Khong Thi Ngoc Mai, Truong Viet Dung (2011), "The prevalence of asthma and some risk factor causing asthma among pupils at primary and secondary schools in Thai Nguyen city , Clinical Medicine, Bach Mai... measured in the morning before taking bronchodilator and the highest PEF in the evening after using 20 bronchodilator It takes 2 times of measurement with a 12-hour interval and compares with theoretical PEF to evaluate variation of peak flow morning and evening and improvement of PEF morning index after intervention This method is convenient and feasible for school pupils We obtained the following results:... of patients changing lifestyle behaviors, prevention of risk factors causing onset of asthma attacks under physician's advice, 91.2% of patients inhaling medication regularly and fully 100% , only 8.8% of patients forgetting to inhale medication from 4 to 6 doses at 2nd month and 3rd month Patients often forget to inhale 2 doses of medication in the evening, 2 inhaled doses are sprayed in the morning... 95.6% of patients are comfortable to be treated 4.4% of patients do not assured and show that long duration of treatment affecting the health Thus, Seretide is evaluated weekly by community Patients believe of treatment and acceptance of treatment 22 costs The results of our study are consistent with findings of Bergmann KC and Mai Lan Huong When assessing on the compliance of patients in treatment... that are without symptoms at the day, without waking up at night and it should use medications to cut BA attacks at group treated combination compared with the treatment group with Flutication propionat The percentage of patients affected physical activity, off school, intensive care due to asthma in four weeks (Chart 3.4) Before intervention, rates of pupils affected physical activity, off school and. .. at the day The study of Nguyen Thu Ha monitoring the effectiveness of Seretide in the prevention of 31 BA patients at Ha Noi 19 Club of BA prevention and protection also showed that after 2 weeks of treatment, symptoms at the day of patients reduced 53.12% The study of Le Anh Tuan and Nguyen Nang An on preventive treatment with Seretide Before treatment, 71.9% of patients have symptoms at the day, but... grading controlling BA according to ACT Score of BA control This score is simple, convenient, easy to use and evaluate BA control in community 1 OTHER PUBLISHED RESEARCHES RELATED TO THE THESIS 1 Khong Thi Ngoc Mai, Nguyen Van Son (2008), "Studying the status of asthma in pupils at Gia Sang primary schools in Thai Nguyen city" , Ho Chi Minh Medical Journal (ISSN 1859-1779), Pediatric theme in The 19th... 88.2% of patients controlled completely asthma and 10.3% of asthma controlled patients achieving criteria Effectiveness of BA control and rate of onset of BA (Chart 3.7; Table 3.32) are namely After 2 weeks of treatment, there are 42.7% of patients controlled asthma, 27.9% of patients uncontrolled asthma and 29.4% of patients controlled partly After 4 weeks, rates of patients controlled asthma and patients . Determination BA rate of pupils of primary schools and secondary schools with bronchial asthma in Thai Nguyen city. Identification of some risk factors of BA for pupils of primary and secondary schools. status of pupils of primary schools and secondary schools with bronchial asthma in Thai Nguyen city. 2. To identify some risk factors of BA for pupils of primary and secondary schools in Thai Nguyen. Status of Bronchial Asthma (BA) Through screening 4292 pupils at primary and secondary schools in Thai Nguyen city, the rate of BA is 9.5%. Of which, the rate of BA in male pupils is 10.4% and