Why polluted Hong Kong needs a better programme to deal with asthma awareness and control
There are between 300,000 an 400,000 asthmatics in Hong Kong and the disease is becoming more prevalent every year. Proper diagnosis and treatment would help relieve suffering and save lives
About 300 million people suffer from asthma globally, with 250,000 annual deaths traced to the disease. The number of people with asthma will grow by more than 100 million by 2025, according to The American Academy of Allergy, Asthma and Immunology. So it’s not surprising that there’s an annual World Asthma Day dedicated to raising asthma awareness and care around the world. This year, it falls on May 2.
According to the Hong Kong Asthma Society, about 10 per cent of children and 5 per cent of adults in Hong Kong have asthma, which means there are some 300,000 to 400,000 asthmatics in the city.
The disease is more prevalent in developed countries than in developing countries. It’s become more prevalent in Hong Kong over the past 30 years, where dismal air quality adversely affects the lungs. The city’s chronic air pollution is affecting its global liveability rankings, as seen earlier this month when it dropped on the annual ECA International ranking, to the 29th most liveable location for Asian expatriates out of 470 countries around the world (last year it was 28th), and was described as “a first-world city with third-world air quality levels” by ECA’s regional director for Asia, Lee Quane.
“It is well documented that high pollutant exposure in childhood inhibits lung growth,” says Dr Lee Tak-hong, the director of the Allergy Centre of Hong Kong Sanatorium & Hospital. Children between the ages of four and eight are most susceptible to asthma.
As it is a chronic disease, good follow-up is key. However, asthmatics across Asia are not well controlled. Some patients are given the wrong diagnosis, as asthma can be mistaken for bronchitis or having sensitive airways.
The most common form in children is allergic asthma and if the allergen can be identified and removed, the children improve. According to Lee, the problem is a lack of specialist staff in Hong Kong, and too often the children’s symptoms are being treated without sufficient attention being paid to identifying the allergen and instituting avoidance measures.
As oral medication is not particularly effective, asthmatics are recommended to rely on inhalation medication such as the metered dose inhaler. “There is little support for teaching proper technique and encouraging adherence for using the inhaler across Asia,” says professor Gary Wong Wing-kin of the department of paediatrics at the Faculty of Medicine at The Chinese University of Hong Kong. “If the doctor doesn’t give instructions for using an inhaler correctly, patients might not use it properly, reducing its effectiveness. Furthermore, due to short doctor-patient contact time, it is difficult for a physician to assess the patient.”
He cites the example of Finland’s national programme, where doctors receive extensive training and there’s a network of nurse practitioners to assess a patient’s technique with an inhaler. Fewer than 10 people die of asthma per year in Finland (out of a population of around five million), compared to Hong Kong (population of around seven million), where 80 to 100 people die each year.
What can parents do to minimise the amount of medicine an asthmatic child needs? The first step is to create a healthy environment. Exposure to smoke should be avoided; second-hand smoke can worsen asthma in children and often increases their need for medication. Even adults who only smoke outside carry enough residue on their clothes to harm the sensitive lungs of asthmatic children. Pet hair (or dander), mould, dust, obesity and a high fat diet can also aggravate asthma symptoms. Many families find it helpful to use anti-allergen pillow and mattress covers and remove carpeting in children’s rooms.
“Never underestimate the power of eating healthily and exercising every day,” says Daniel Hall, a paediatrician at Massachusetts General Hospital for Children. “Children (and adults) should get out and exercise enough to break a sweat every day – this is important for many reasons, including keeping good control over asthma.”
The latest research on asthma has focused on comparisons of prevalence in children between rural areas in southern China and urban cities such as Hong Kong. Similar research in Germany and the US has looked at populations in rural areas where children are exposed to farm animals, strengthening their immune systems and decreasing the risk of developing asthma. Children from urban areas are more sensitive to environmental allergens such as house dust mites. Researchers are looking into environmental factors that children in rural areas are exposed to, so that they can develop new treatments.
It’s also important to correctly diagnose the type of allergy, says Dr Adrian Wu, a registered specialist in immunology and allergy at the Centre for Allergy and Asthma Care in Hong Kong. It could be allergic rhinitis, asthma, or a food or a drug allergy. Wu cites the case of an 18-year-old asthmatic student with a shellfish allergy who ate snails at a restaurant, not realising that they are related to shellfish. He went home and thought he was having an asthma attack. So he took his inhaler and went to bed, never to wake up again.
The National Review of Asthma Deaths by the Royal College of Physicians (RCP) in 2014 looked into the circumstances surrounding 195 deaths from asthma in Britain over a year. They found that 45 per cent had died without seeking medical assistance. The majority of these people were not under specialist care during the year before death and less than half were receiving secondary or tertiary care. Suboptimal clinical management was identified by the RCP panel, including the lack of timely use of medication. If properly addressed, 46 per cent of the fatalities could have been avoided. The panel found that 65 per cent of the deaths could have been avoided with better environmental control (such as reducing exposure to second-hand smoke) and proper medical advice.
Similarly, a landmark study by respiratory specialist physician Dr Fanny Wai San-ko in 2010 suggested that one of the reasons for poor asthmatic control in Hong Kong might be inadequate implementation of asthma treatment guidelines by doctors. This emphasises the need for education about asthma management at all levels.
Children often experience fewer symptoms as they get older. Every child is different, but those who develop asthma symptoms when they are very young and only have occasional symptoms while suffering from colds are more likely to outgrow asthma. Children with lots of relatives with asthma and those who have more severe symptoms at a young age are less likely to grow out of it.
Global Initiative for Asthma (GINA), the organiser of World Asthma Day emphasises the need to implement asthma control by measuring of how a patient is responding to medicine and assessing how well the asthma therapy is reducing symptoms and impairments. In order to reduce avoidable mortalities, not only is it essential that Hong Kong implements a better structure for specialist care, better education is needed for asthmatics and their families to manage their condition effectively.