Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria

Chronic respiratory disease observatory for Africa (CHEST-Africa): study protocol for the prevalence, determinants and economic impacts of asthma and COPD in Africa

INTRODUCTION

Contemporary data on the burden of chronic respiratory diseases in sub-Saharan Africa is limited. More so, their economic burden is not well described. This study aims to establish a chronic respiratory disease observatory for Africa. Specific study aims are (1) to describe the prevalence and determinants of asthma with a target to screen up to 4000 children and adolescents across four African cities; (2) to determine the prevalence and determinants of chronic obstructive pulmonary disease (COPD) with a target to screen up to 3000 adults (≥18 years) across five African cities; (3) to describe the disease burden by assessing the frequency and severity of symptoms and exacerbations, medication use, emergency healthcare utilisation and hospitalisation; and (4) to assess the economic burden and affordability of the medicines for these diseases.

METHODS AND ANALYSIS

Surveys will be conducted in schools to identify children and adolescents with asthma using the Global Asthma Network screening questionnaire in Ghana, Nigeria, the Democratic Republic of Congo, and Uganda. Community surveys will be conducted among adults using an adapted version of the Burden of Obstructive Lung Disease Questionnaire to identify persons with COPD symptoms in Nigeria, Burkina Faso, Mozambique, Rwanda, and Sierra Leone. Fractional exhaled nitric oxide and pre-bronchodilator and post-bronchodilator spirometry will be done for children with asthma or asthma symptoms and for all adult participants. Children and adults with respiratory symptoms or diagnoses will complete the health economic questionnaires. Statistical analysis will involve descriptive and analytical statistics to determine outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from participating institutions. This study's results will inform deliberations at the United Nations General Assembly high-level meeting on non-communicable diseases in 2025. The results will be shared through academic conferences and journals and communicated to the schools and the communities.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19

BACKGROUND

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss.

METHODS

This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach.

RESULTS

On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs.

CONCLUSIONS

The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

Review on Alopecia Areata in the Middle East and Africa: Landscape and Unmet Needs

BACKGROUND

Alopecia areata (AA) is an autoimmune disease characterized by non-scarring hair loss in adults and children. Clinical manifestations range from hair loss in small, well-circumscribed patches to total hair loss on the scalp or any other hair-bearing areas. Although the exact pathogenesis of AA is not fully understood, it is thought that loss of immune privilege caused by immunological dysregulation of the hair follicle is key. Genetic susceptibility also plays a role. Response to currently available treatments is widely variable, causing patient dissatisfaction and creating an unmet need. AA is frequently associated with multiple comorbidities, further affecting patient quality of life.

AIMS AND FINDINGS

AA causes a significant burden on dermatologists and healthcare systems in the Middle East and Africa. There is a lack of data registries, local consensus, and treatment guidelines in the region. Limited public awareness, availability of treatments, and patient support need to be addressed to improve disease management in the region. A literature review was conducted to identify relevant publications and highlight regional data on prevalence rates, diagnosis, quality of life, treatment modalities, and unmet needs for AA in the Middle East and Africa.

[Availability and affordability of diagnosis and treatment for asthma and COPD in Ouagadougou, Burkina Faso]

INTRODUCTION

Chronic respiratory diseases, particularly asthma and Chronic Obstructive Pulmonary Disease (COPD), pose a significant threat to public health. This study aims to determine the accessibility and affordability of means of diagnosis and treatment.

METHODS

This was a cross-sectional study covering the period from August to December 2021 in Ouagadougou, Burkina Faso. This study involved 107 health centers and 135 pharmacies. The World Health Organization/Health Action International definition was used as a benchmark for accessibility to medicines.

RESULTS

Out of 107 health centers, 29 (27.1%) had a spirometer. The average cost of spirometry represented 19.88 days of salary for a patient paid at the minimum wage. The most widely available drugs were salbutamol in a pressurized metered dose inhaler (pMDI) (88.1%) and prednisone 20mg tablet (87.4%). No disease-modifying drug was available in public pharmacies. Affordable drugs were salbutamol 4mg tablet and aminophylline 100mg tablet.

CONCLUSION

The means of diagnosis and treatment of asthma and COPD are insufficiently available, especially in the public sector, which is characterized by a nearly total absence of basic treatment.

Implementing essential diagnostics-learning from essential medicines: A scoping review

The World Health Organization (WHO) model list of Essential In vitro Diagnostic (EDL) introduced in 2018 complements the established Essential Medicines List (EML) and improves its impact on advancing universal health coverage and better health outcomes. We conducted a scoping review of the literature on implementing the WHO essential lists in Africa to inform the implementation of the recently introduced EDL. We searched eight electronic databases for studies reporting on implementing the WHO EDL and EML in Africa. Two authors independently conducted study selection and data extraction, with disagreements resolved through discussion. We used the Supporting the Use of Research Evidence (SURE) framework to extract themes and synthesised findings using thematic content analysis. We used the Mixed Method Appraisal Tool (MMAT) version 2018 to assess the quality of included studies. We included 172 studies reporting on EDL and EML after screening 3,813 articles titles and abstracts and 1,545 full-text papers. Most (75%, n = 129) studies were purely quantitative in design, comprising descriptive cross-sectional designs (60%, n = 104), 15% (n = 26) were purely qualitative, and 10% (n = 17) had mixed-methods approaches. There were no qualitative or randomised experimental studies about EDL. The main barrier facing the EML and EDL was poorly equipped health facilities-including unavailability or stock-outs of essential in vitro diagnostics and medicines. Financial and non-financial incentives to health facilities and workers were key enablers in implementing the EML; however, their impact differed from one context to another. Only fifty-six (33%) of the included studies were of high quality. Poorly equipped and stocked health facilities remain an implementation barrier to essential diagnostics and medicines. Health system interventions such as financial and non-financial incentives to improve their availability can be applied in different contexts. More implementation study designs, such as experimental and qualitative studies, are required to evaluate the effectiveness of essential lists.

Nigerian doctors’ experiences of guideline-based asthma management: a qualitative study

Background

The Global Initiative for Asthma (GINA) report sets out an updated evidence-based strategy for asthma management. Little is known about how this report is perceived and implemented in low-income and middle-income countries (LMICs) like Nigeria. We explored the experiences of asthma management as informed by the current GINA guideline among doctors in Lagos, Nigeria.

Methods

Using a qualitative research approach, in-depth interviews were conducted among doctors in Lagos, Nigeria to explore their experiences of asthma management in the context of the current GINA report. The thematic framework approach was used for data analysis.

Results

Eleven doctors aged 28-46 years (five general practitioners (GPs) and six family physicians (FPs) took part. Four overarching themes were identified: (i) knowledge of, and attitude towards the GINA strategy – whilst most doctors were aware of the existence of the GINA report, there was limited knowledge about its content including current recommendations for mild asthma treatment; (ii) asthma diagnosis and treatment – there was limited access to lung function testing facilities, and its role in asthma diagnosis was underappreciated; (iii) barriers to managing asthma according to GINA recommendations – these included complexity of the GINA report, unavailability and unaffordability of asthma medicines and poor patient adherence to medications, driven by socio-cultural factors; and (iv) enablers of GINA-recommended asthma management – improvement in asthma education for doctors and the general population and better access to diagnostic tests and medicines.

Conclusions

Whilst there was awareness of the existence of the GINA report, there was limited knowledge about its content and several barriers to its implementation were reported. Education about the GINA report, investment in diagnostic and treatment services and simplification of recommendations were identified as possible solutions.

The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) cause a considerable burden of morbidity and mortality in low-income and middle-income countries (LMICs). Access to safe, effective, quality-assured, and affordable essential medicines is variable. We aimed to review the existing literature relating to the availability, cost, and affordability of WHO's essential medicines for asthma and COPD in LMICs.

METHODS

A systematic review of the literature was done by searching seven databases to identify research articles published between Jan 1, 2010, and June 30, 2022. Studies on named essential medicines for asthma and COPD in LMICs were included and review articles were excluded. Two authors (MS and HT) screened and extracted data independently, and assessed bias using Joanna Briggs Institute appraisal tools. The main outcome measures were availability (WHO target of 80%), cost (compared with median price ratio [MPR]), and affordability (number of days of work of the lowest paid government worker). The study was registered with PROSPERO, CRD42021281069.

FINDINGS

Of 4742 studies identified, 29 met the inclusion criteria providing data from 60 LMICs. All studies had a low risk of bias. Six of 58 countries met the 80% availability target for short-acting beta-agonists (SABAs), three of 48 countries for inhaled corticosteroids (ICSs), and zero of four for inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) combination inhalers. Costs were reported by 12 studies: the range of MPRs was 1·1-351 for SABAs, 2·6-340 for ICSs, and 24 for ICS-LABAs in the single study reporting this. Affordability was calculated in ten studies: SABA inhalers typically cost around 1-4 days' wages, ICSs 2-7 days, and ICS-LABAs at least 6 days. The included studies showed heterogeneity.

INTERPRETATION

Essential medicines for treating asthma and COPD were largely unavailable and unaffordable in LMICs. This was particularly true for inhalers containing corticosteroids.

FUNDING

WHO and Wellcome Trust.

Estimating the prevalence of COPD in an African country: evidence from southern Nigeria

# BACKGROUND

Though several environmental and demographic factors would suggest a high burden of chronic obstructive pulmonary disease (COPD) in most African countries, there is insufficient country-level synthesis to guide public health policy.

# METHODS

A systematic search of MEDLINE, EMBASE, Global Health and African Journals Online identified studies reporting the prevalence of COPD in Nigeria. We provided a detailed synthesis of study characteristics, and overall median and interquartile range (IQR) of COPD prevalence in Nigeria by case definitions (spirometry or non-spirometry).

# RESULTS

Of 187 potential studies, eight studies (6 spirometry and 2 non-spirometry) including 4,234 Nigerians met the criteria. From spirometry assessment, which is relatively internally consistent, the median prevalence of COPD in Nigeria was 9.2% (interquartile range, IQR: 7.6-10.0), compared to a lower prevalence (5.1%, IQR: 2.2-15.4) from studies based on British Medical Research Council (BMRC) criteria or doctor's diagnosis. The median prevalence of COPD was almost the same among rural (9.5%, IQR: 7.6-10.3) and urban dwellers (9.0%, IQR: 5.3-9.3) from spirometry studies.

# CONCLUSIONS

A limited number of studies on COPD introduces imprecision in prevalence estimates and presents concerns on the level of response available across different parts of Nigeria, and indeed across many countries in sub-Saharan Africa.

Asthma management in low- and middle-income countries: case for change

Asthma is the most common non-communicable disease in children, and among the most common in adults. The great majority of people with asthma live in low- and middle-income countries (LMICs), where they suffer disproportionately high asthma-related morbidity and mortality. Essential inhaled medications, particularly those containing inhaled corticosteroids (ICS), are often unavailable or unaffordable, and this explains much of the global burden of preventable asthma morbidity and mortality.Guidelines developed for LMICs are generally based on the outdated assumption that patients with asthma symptoms <1-3 times/week do not need (or benefit from) ICS. Even when ICS is prescribed, many patients manage their asthma with oral or inhaled short-acting beta₂ agonist (SABA) alone, due to issues of availability and affordability. A single ICS-formoterol inhaler-based approach to asthma management for all severities of asthma, from mild to severe, starting at diagnosis, might overcome SABA overuse/over-reliance and reduce the burden of symptoms and severe exacerbations. However, ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. There is a pressing need for pragmatic clinical trial evidence of the feasibility and cost-effectiveness of this and other strategies to improve asthma care in these countries.The global health inequality in asthma care that deprives so many children, adolescents and adults of healthy lives and puts them at increased risk of death - despite the availability of highly effective therapeutic approaches - is unacceptable. A World Health Assembly Resolution on universal access to affordable effective asthma care is needed to focus attention and investment on addressing this need.

Global burden of COPD attributable to ambient PM2.5 in 204 countries and territories, 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019

The global spatiotemporal pattern of the COPD burden attributable to ambient PM2.5 is unknown in the context of the continuing increase in exposure to ambient PM2.5. Data on COPD burden attributable to ambient PM2.5 from 1990 to 2019 were retrieved from the Global Burden of Disease Study 2019. Cases and age-standardized rates of COPD mortality (ASMR) and disability-adjusted life years (ASDR) were estimated by age, sex, region, and country. The estimated annual percentage change (EAPC) was calculated to quantify the secular trends of ASMR and ASDR from 1990 to 2019. Globally, the number of COPD deaths and DALYs attributable to ambient PM2.5 both increased by over 90% from 1990 to 2019, but ASMR and ASDR both slightly decreased, with EAPC of -0.58 (95% CI: -0.72, -0.44) and -0.40 (95% CI: -0.51, -0.29), respectively. Most COPD deaths and DALYs attributable to PM2.5 occurred in the middle sociodemographic index (SDI) region, but the fastest growth of ASMR and ASDR occurred in the low SDI region, with EAPCs of 2.41 (95% CI: 2.23, 2.59) and 2.34 (95% CI: 2.16, 2.52), respectively. East Asia and South Asia were the high-risk areas of COPD deaths and DALYs attributable to PM2.5, among which China and India were the countries with the heaviest burden. COPD deaths and DALYs attributable to PM2.5 mainly occurred in individuals 70-89 years old and 60-84 years old, respectively. The age-specific rates of mortality and DALYs had a rapid increase in low and low-middle SDI regions from 1990 to 2019. The ASMR or ASDR had a reverse V-shaped relationship with SDI. In summary, the ambient PM2.5-attributable COPD burden is socioeconomic- and age-dependent, and it mediates the heterogeneity of spatial and temporal distribution. Low- and middle-income countries endure the highest ambient PM2.5-attributable COPD burden due to the high exposure to PM2.5 and poor availability and affordability of medicines and diagnostic tests.

The feasibility and effect of a nurse-led, patient-centered asthma education program in a Nigerian context

RATIONALE, AIMS AND OBJECTIVES

Insufficient asthma education is an unmet need in Nigeria. We aimed to assess the feasibility of a nurse-led asthma education program and its effect on asthma knowledge and outcomes in Lagos, Nigeria.

METHODS

Using a quasi-experimental study design, we recruited participants ≥12 years with physician diagnosed asthma. We assessed asthma knowledge, asthma control, medication adherence, health related quality of life and inhaler technique and also measured lung function. A trained nurse delivered asthma education sessions during the regular clinic visits and demonstrated correct inhaler technique. All assessments were repeated at 3-month. Data was analyzed with descriptive and inferential statistics. A p-value of <0.05 was considered significant for all associations.

RESULTS

Of the 80 participants at baseline, 42 (52.5%) completed the follow-up assessment and were included in the outcome analysis. Their ages ranged from 12 to 75 years, 35 (83.3%) were ≥18 years old and 30 (71.4%) were females. There was significant improvement in knowledge score immediately post intervention (15.48 ± 3.05 versus 18.33 ± 2.21, p < 0.001) and at 3 months (17.52 ± 2.63, p < 0.001). Those with uncontrolled asthma (Asthma Control Test score ≤19) had a meaningful (3.8-point) change in ACT score at follow-up. The improvement in the mean score on the Morisky Medication Adherence Scale was significant (p = 0.03), but a change of 0.48 was not considered meaningful. There was significant (p < 0.001) and meaningful (1.08) improvement in Mini Asthma Quality of Life score at 3 months. Pre-bronchodilator FEV1% predicted and scores on the inhaler technique check list for the Diskus and pressurized meter dose inhaler did not significantly change at follow-up (p = 0.38, 0.26 and 0.80 respectively).

CONCLUSION

It is practicable for nurses to deliver effective asthma education during regular clinic visits in our practice setting. This training could meaningfully improve asthma control and health related quality of life.