Prevalence and determinants of chronic respiratory diseases in adults in rural Sudan.

BACKGROUND: Chronic respiratory diseases (CRDs) greatly contribute to worldwide mortality. Despite new data emerging from Africa, prevalence estimates and determinants of CRDs in rural settings are limited. This study sought to extend the existing research conducted in urban Sudan by conducting a rural comparison.METHODS: Participants aged ≥18 years (n = 1,850), living in rural Gezira State completed pre-and post-bronchodilator spirometry and a questionnaire. Prevalence of respiratory symptoms and spirometric abnormalities were reported. Regression analyses were used to identify risk factors for CRDs.RESULTS: Prevalence of chronic airflow obstruction (CAO) was 4.1% overall and 5.5% in those aged ≥40 years. Reversibility was seen in 6.4%. Low forced vital capacity (FVC) was seen in 58.5%, and at least one respiratory symptom was present in 40.7% of the participants. CAO was more common among people aged 60-69 years (OR 2.07, 95% CI 1.13-3.82) and less common among highly educated participants (OR 0.50, 95% CI 0.27-0.93). Being underweight was associated with lower FVC (OR 3.07, 95% CI 2.24-4.20).CONCLUSIONS: A substantial burden of CRD exists among adults in rural Sudan. Investment in CRD prevention and management strategies is needed.

Prevalence and determinants of chronic respiratory diseases in adults in Sudan.

BACKGROUND: Chronic respiratory diseases (CRDs) are considered a significant cause of morbidity and mortality worldwide, although data from Africa are limited. This study aimed to determine the prevalence and determinants of CRDs in Khartoum, Sudan.METHODS: Data were collected from 516 participants aged ≥40 years, who had completed a questionnaire and undertook pre- and post-bronchodilator spirometry testing. Trained field workers administered the questionnaires and conducted spirometry. Survey-weighted prevalence of respiratory symptoms and spirometric abnormalities were estimated. Regression analysis models were used to identify risk factors for chronic lung diseases.RESULTS: Using the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III) reference equations, the prevalence of chronic airflow obstruction (CAO) was 10%. The main risk factor was older age, 60-69 years (OR 3.16, 95% CI 1.20-8.31). Lower education, high body mass index and a history of TB were also identified as significant risk factors. The prevalence of a low forced vital capacity (FVC) using NHANES III was 62.7% (SE 2.2) and 11.3% (SE 1.4) using locally derived values.CONCLUSION: The prevalence of spirometric abnormality, mainly low FVC, was high, suggesting that CRD is of substantial public health importance in urban Sudan. Strategies for the prevention and control of these problems are needed.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries.

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Chronic respiratory disease in adult outpatients in three African countries: a cross-sectional study.

BACKGROUND: The greatest burden of chronic respiratory disease is in low- and middle-income countries, with recent population-based studies reporting substantial levels of obstructive and restrictive lung function.OBJECTIVE: To characterise the common chronic respiratory diseases encountered in hospital outpatient clinics in three African countries.METHODS This was a cross-sectional study of consecutive adult patients with chronic respiratory symptoms (>8 weeks) attending hospital outpatient departments in Ethiopia, Kenya and Sudan. Patients were assessed using a respiratory questionnaire, spirometry and chest radiography. The diagnoses of the reviewing clinicians were ascertained.RESULT: A total of 519 patients (209 Kenya, 170 Ethiopia, 140 Sudan) participated; the mean age was 45.2 years (SD 16.2); 53% were women, 83% had never smoked. Reviewing clinicians considered that 36% (95% CI 32-40) of patients had asthma, 25% (95% CI 21-29) had chronic bronchitis, 8% (95% CI 6-11) chronic obstructive pulmonary disease (COPD), 5% (95% CI 4-8) bronchiectasis and 4% (95% CI 3-6) post-TB lung disease. Spirometry consistent with COPD was present in 35% (95% CI 30-39). Restriction was evident in 38% (95% CI 33-43). There was evidence of sub-optimal diagnosis of asthma and COPD.CONCLUSION: In Ethiopia, Kenya and Sudan, asthma, COPD and chronic bronchitis account for the majority of diagnoses in non-TB patients with chronic respiratory symptoms. The suboptimal diagnosis of these conditions will require the widespread use of spirometry.

Chronic respiratory disease in adults treated for tuberculosis in Khartoum, Sudan.

Background: Chronic respiratory disease (CRD) causes substantial morbidity and mortality. Although the global CRD epidemic collides with the tuberculosis (TB) epidemic in many low- and middle-income country settings, the risk of TB-associated CRD is not well described in countries with a high burden of TB. Methods: We recruited 136 patients with a history of sputum smear-positive pulmonary TB (PTB) from the TB clinic at Omdurman Teaching Hospital in Khartoum, Sudan, and 136 age- and sex-matched community controls, between 28 July 2013 and 30 December 2013. Data were collected using standardised questionnaires and spirometry was performed before and after bronchodilator. Results: The mean age of the subjects with previous PTB and controls was respectively 44.0 years (SD 8.5) and 44.5 years (SD 8.6), with 27.2% females in both groups. Chronic respiratory symptoms such as chronic cough (OR 6.67, 95%CI 2.98-14.90, P < 0.001) and the presence of chronic airflow obstruction (OR 12.4, 95%CI 1.56-98.40, P = 0.02) were both strongly associated with a past history of PTB after adjusting for potential confounders. Conclusion: The clinical features of CRDs are strongly associated with past history of PTB. An integrated approach to improve the management of these common conditions should be considered. Contexte : Les maladies respiratoires chroniques (MRC) sont à l'origine d'une morbidité et d'une mortalité considérables dans le monde. Bien que l'épidémie mondiale des MRC entre en conflit avec l'épidémie de tuberculose (TB) dans de nombreux pays à revenu faible ou moyen, le risque de MRC associée à la TB n'est pas bien décrit dans les pays durement frappés par la TB. Méthodes : Nous avons recruté 136 patients ayant des antécédents de tuberculose pulmonaire (TBP) à frottis positif dans le service de pneumologie du Centre Hospitalier Universitaire Omdurman à Khartoum, Soudan, et 136 témoins de la communauté, appariés sur l'âge et le sexe, entre le 28 juillet 2013 et le 30 décembre 2013. Les données ont été recueillies grâce à des questionnaires standardisés ainsi qu'à une spirométrie avant et après bronchodilatateur. Résultats : L'âge moyen des cas et des témoins a été de 44,0 ans (DS 8,5) et 44,5 ans (DS 8,61), respectivement, avec 27,2% de femmes dans les deux groupes. Des symptômes respiratoires chroniques comme une toux chronique (OR 6,67 ; IC95% 2,98-14,90 ; P < 0,001) et la présence d'une obstruction chronique des voies aériennes (OR 12,39 ; IC%95 1,56-98,40 ; P = 0,02) ont été tous deux fortement associés à des antécédents de TBP après ajustement sur les facteurs de confusion potentiels. Conclusion : Les caractéristiques cliniques des MRC sont fortement associées à des antécédents de TBP. Une approche intégrée visant à améliorer la prise en charge de ces pathologies fréquentes devrait être envisagée. Marco de referencia: La enfermedad pulmonar crónica (EPC) es una causa importante de morbilidad y mortalidad. Aunque la epidemia mundial de EPC rivaliza con la epidemia de tuberculosis (TB) en muchos entornos de países con bajos y medianos recursos, el riesgo de aparición de EPC asociado con la TB se ha descrito cabalmente en los países con una alta carga de morbilidad por TB. Métodos: Entre el 28 de julio y el 30 de diciembre del 2013, participaron en el estudio 136 pacientes con antecedente de tuberculosis pulmonar (TBP) y baciloscopia positiva del esputo que habían recibido tratamiento en el consultorio de neumología del Hospital Universitario Omdurman de Jartún, en Sudán, y 136 testigos sanos de la comunidad, emparejados en función de la edad y el sexo. Se recogieron datos mediante cuestionarios normalizados y se practicó una espirometría antes y despuès una prueba de broncodilatación. Resultados: El promedio de la edad en el grupo de los casos fue 44,0 (desviación estándar 8,5 años) y en el grupo de testigos fue 44,5 años (8,6 años); la proporción de mujeres en ambos grupos fue 27,2%. Se observó una fuerte asociación entre la presencia de síntomas respiratorios crónicos como la tos (OR 6,67; IC95% 2,98-14,90; P < 0,001) y la presencia de obstrucción crónica al flujo en las vías respiratorias (OR 12,39; IC95% 1,56-98,40; P = 0,02) en las personas con antecedente de TBP, una vez corregidos los posibles factores de confusión. Conclusión: La presencia de rasgos clínicos de EPC exhibe una fuerte correlación con el antecedente de TBP. Es preciso considerar la posibilidad de aplicar un enfoque integrado con el fin de mejorar la atención de ambas enfermedades tan frecuentes.

Case management of childhood tuberculosis in children's hospitals in Khartoum.

No published information is available on the case management of childhood tuberculosis (TB) in Sudan. The aim of this study was to describe the case management of childhood TB in 4 children's hospitals in Khartoum State, Sudan. Data on 467 children aged 0-14 years registered in 2009 were collected from patient records; 52.9% males and 53.0% aged 5-14 years. Most cases were registered as new cases (89.5%) and most had pulmonary TB (72.4%). Of all cases, 31.0% had sputum smear microscopy done, 35.8% had X-ray and none had a record of being culture confirmed. Category III regimen was given to 58.5%. Reported outcomes were: cured (1.5%), completed treatment (14.6%), transferred out (13.1%), default (17.3%), death (4.3%) and treatment failure (0.6%). Age was significantly associated with treatment outcome, while sex, type of patient, site of TB and treatment category were not significant. Case management of childhood TB is suboptimal in this region.

Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members.

BACKGROUND: Policies involving the use of involuntary incarceration for tuberculosis (TB) are highly ethically controversial. To encourage ethical reflection within the International Union Against Tuberculosis and Lung Disease (The Union), the Ethics Advisory Group (EAG) surveyed members regarding their attitudes and values relating to involuntary incarceration for TB. METHODS: Members of the Union TB section were invited to respond to an anonymous web-based survey. The survey included both multiple choice questions describing a range of scenarios regarding involuntary incarceration, and free-text fields inviting respondents to provide general comments on ethical issues. RESULTS: The survey was completed by 194 participants, 33 (17%) of whom were opposed to involuntary incarceration on principle. The age and sex of the respondents was not associated with likelihood of principled opposition; respondents from North America were least likely to be opposed to involuntary incarceration (P = 0.02). Respondents were most likely to consider involuntary incarceration for persons with known multidrug-resistant TB or a history of previous treatment default, and least likely where people lived alone, were university-educated or the main income provider for their families. CONCLUSION: This survey found a wide range of viewpoints regarding involuntary incarceration, and highlights a number of key elements in ethical engagement with the tensions surrounding involuntary incarceration. We provide commentary on approaches to ethical policy making in the light of these findings.

How well are asthma treatment cards filled out in public health centres in Gazeera State, Sudan?

SETTING: Four public district hospitals offering asthma treatment in Gazeera State, Sudan. Incomplete recording of patient data directly affects the quality of asthma care and the evaluation of asthma management programmes. OBJECTIVE: To assess the completeness of filling out of treatment cards and accuracy of calculating peak expiratory flow (PEF) for confirming diagnosis and grading severity of asthma. DESIGN: Cross-sectional audit of asthma treatment cards from asthma centres, 2006-2012. RESULTS: Of 959 patient cards assessed, completeness ranged from 47% to 98%. Six of 13 variables had an unsatisfactory grade of completeness (<80% complete). Calculated PEF was indicated in 885 (92%) cards, but was correct in only 609 (69%). PEF variability was recorded in 835 (87%) cards, but was correctly calculated in 442 (53%). A scheduled follow-up visit was attended by only 359 (37%) patients, indicating 63% loss to follow-up. Contact telephone numbers were missing from 453 (47%) cards. CONCLUSION: This is the first study in Africa to assess the data completeness and integrity of asthma patient cards, identifying important shortcomings. This affects quality of management of asthma patients and programme evaluation. Steps to rectify this situation are urgently needed.

Contexte : Quatre hôpitaux publics de district offrant un traitement de l'asthme dans l'état de Gazeera, Soudan. La saisie incomplète des données relatives aux patients affecte directement la qualité des soins de l'asthme et l'évaluation des programmes de prise en charge.Objectif : Evaluer l'exhaustivité du remplissage des cartes de traitement et l'exactitude des calculs de débit expiratoire de pointe (DEP) pour la confirmation du diagnostic et l'estimation du degré de gravité de l'asthme.Schéma : Audit transversal des cartes de traitement de patients asthmatiques dans les centres de prise en charge, de 2006 à 2012.Résultats : Sur 959 cartes de patients évaluées, l'exhaustivité variait de 47% à 98%. Six variables sur 13 n'étaient pas correctement relevées (<80% d'exhaustivité). Le DEP calculé était indiqué sur 885 (92%) cartes, mais n'était juste que sur 609 (69%) cartes. La variabilité du DEP était notée sur 835 (87%) cartes mais était correctement calculée sur seulement 442 (53%). Seuls 359 (37%) patients ont assisté à leur consultation de contrôle, ce qui signifie que 63% ont été perdus de vue. Il manquait un numéro de téléphone de contact sur 453 (47%) cartes.Conclusion : Cette première étude africaine d'évaluation de l'exhaustivité des données et de l'intégrité des cartes de traitement des patients asthmatiques a identifié des lacunes importantes. Celles-ci affectent la qualité de la prise en charge des patients asthmatiques et l'évaluation des programmes. Il est urgent de prendre des mesures afin de rectifier ces problèmes.

Marco de referencia: Cuatro hospitales distritales del sector público que suministran tratamiento del asma en el estado de Gazeera en Sudán. El registro incompleto de los datos de los pacientes menoscaba directamente la calidad del tratamiento del asma y la evaluación de los programas de atención.Objetivo: Evaluar el carácter integral del llenado de las tarjetas de tratamiento y la exactitud del cálculo del flujo espiratorio máximo (FEM) al confirmar el diagnóstico de asma y evaluar su gravedad.Método: Se examinaron las tarjetas de tratamiento de los pacientes asmáticos en los centros especializados del 2006 al 2012.Resultados: De las 959 tarjetas de tratamiento examinadas, entre 47% y 98% contaban con la información completa de los pacientes. Seis de las 13 variables presentaban un grado de integridad deficiente (menos de 80% de compleción). En 885 tarjetas se había consignado el FEM (92%), pero el cálculo era correcto en solo 609 casos (69%). La variabilidad del FEM se registró en 835 tarjetas (87%), pero su cálculo fue correcto solo en 442 (53%). Solo 359 pacientes (37%) acudieron a una cita de control programada, lo cual corresponde a 63% de pérdidas durante el seguimiento. En 453 tarjetas (47%) faltaba un número telefónico de contacto.Conclusión: El presente fue el primer estudio de evaluación de la compleción y la integridad de los datos de las tarjetas de tratamiento del asma en África y reveló carencias considerables. Esta situación deteriora la calidad del tratamiento de los pacientes con asma y la evaluación de los programas. Es necesario adoptar con urgencia medidas encaminadas rectificar estas deficiencias.

Case management of childhood tuberculosis in children’s hospitals in Khartoum

لا تتوافر معلومات منشورة حول معالجة حالات سل الأطفال في السودان.وتهدف هذه الدراسة الأترابية إلى وصف معالجة حالات سل الأطفال في أربعة مستشفيات للأطفال في ولاية الخرطوم في السودان. وقد جمعت البيانات حول 467 طفا تراوح أعمارهم بين 0 - 14 عاما تم تسجيلهم عام 2009 ، وذلك من سجلات المرضى، وكان 52.9 % منهم ذكورا و 53 % منهم تراوح أعمارهم بين 5 - 14 عاما، وقد سجلت معظم الحالات على أنها حالات جديدة [89.5 %]، معظمها سل رئوي [72.4 %]، ومن بين جميع الحالات أجري الفحص المجهري للطاخات البلغم في 31 % من الحالات. وكان لدى % 35.8 منهم صور شعاعية، ولم يكن لدى أي واحد منهم سجل يفيد تأكيد التشخيص بالزرع. وقد أعطي النظام العلاجي من الفئة III لـ 58.5% منهم، وكان الإباغ عن النتائج بأنها: شفيت [1.5 %]أو استكملت المعالجة [14.6 %]، أو تم تحويلها [13.1 %]، أو تخلفت [17.3 %]، أو ماتت [4.3 %]، أو فشلت المعالجة في [0.6 %]. ولوحظ ترابط يعتد به إحصائيا بين العمر وبين نتيجة المعالجة، أما الجنس ونمط المريض وموقع الآفة السلية وفئة المعالجة فلم يكن لها اعتداد إحصائي. وتخلص الدراسة إلى أن معالجة حالات سل الأطفال في هذه المنطقة لا ترقى إلى المستوى الأمثل

ABSTRACT No published information is available on the case management of childhood tuberculosis (TB) inSudan. The aim of this study was to describe the case management of childhood TB in 4 children’s hospitals inKhartoum State, Sudan. Data on 467 children aged 0–14 years registered in 2009 were collected from patientrecords; 52.9% males and 53.0% aged 5–14 years. Most cases were registered as new cases (89.5%) and mosthad pulmonary TB (72.4%). Of all cases, 31.0% had sputum smear microscopy done, 35.8% had X-ray and nonehad a record of being culture confirmed. Category III regimen was given to 58.5%. Reported outcomes were:cured (1.5%), completed treatment (14.6%), transferred out (13.1%), default (17.3%), death (4.3%) and treatmentfailure (0.6%). Age was significantly associated with treatment outcome, while sex, type of patient, site of TB andtreatment category were not significant. Case management of childhood TB is suboptimal in this region.

RÉSUMÉ Il n'y a pas d'informations publiées sur la prise en charge de la tuberculose chez l'enfant au Soudan.L'objectif de la présente étude était de décrire la prise en charge de la tuberculose chez l'enfant dans quatrehôpitaux pour enfants de l'État de Khartoum (Soudan). Les données de 467 enfants âgés de 0 à 14 ans enregistréesen 2009 ont été recueillies à partir de leurs dossiers médicaux ; 52,9 % étaient des garçons et 53,0 % étaientâgés de 5 à 14 ans. La plupart des cas étaient enregistrés comme des nouveaux cas (89,5 %) et la majorité étaitatteinte de tuberculose pulmonaire (72,4 %). Sur l'ensemble des cas étudiés, 31,0 % avaient fait l'objet d'examensmicroscopiques de frottis d'expectoration, 35,8 % avaient été soumis une radiographie mais aucun cas n'avaitété confirmé par culture en laboratoire. Un traitement de catégorie III a été administré à 58,5 % d'entre eux.Les résultats recueillis étaient les suivants : guérison (1,5 %), traitement achevé (14,6 %), réorientation (13,1 %),abandon du traitement (17,3 %), décès (4,3 %) et échec du traitement (0,6 %). L'âge était significativement associéà l'issue du traitement, tandis que le sexe, le type de patient, le site de la tuberculose et la catégorie du traitementne l'étaient pas. La prise en charge de la tuberculose chez l'enfant n'est pas optimale dans cette région.

Tuberculosis stigma in Gezira State, Sudan: a case-control study.

OBJECTIVE: To evaluate the prevalence of tuberculosis (TB) stigma and to determine the relation between socio-demographic characteristics and TB stigma among TB cases and their controls in Gezira State, Sudan. METHODS: A case-control study design was used. New smear-positive TB patients registered in Gezira State in 2010 (n = 425) and controls who attended the same health facility for other reasons (n < 850) formed the study population. Stigma was measured using a standard modified World Health Organization TB KAP (knowledge, attitudes, practice) instrument. RESULTS: TB stigma did not differ between TB cases and controls; mild stigma was found in both groups. The higher degree of stigma among both groups was significantly associated with higher age, lower level of education, residence in rural areas, unemployment and poor TB awareness, while sex had no association with the degree of stigma in either group. CONCLUSION: Although TB stigma among the Gezira population was found to be mild, it can affect treatment adherence. Empowering both TB patients and communities by increasing their knowledge through proper education programmes could effectively contribute to the effort of controlling TB in the state.

Standard case management of asthma in Sudan: a pilot project.

SETTING: A pilot project for asthma management in selected hospitals in Khartoum and Gezira States, Sudan. OBJECTIVE: To assess standard case management of asthma in 2007-2008. DESIGN: Local adaptation of guidelines, followed by situational analysis, pre-intervention study, training and implementation. Treatment outcome was assessed 1 year after patient enrolment. RESULTS: Situational analysis revealed that inhaled beclometasone was not available in the public sector. During the project, 2068 patients were enrolled: severity of asthma was intermittent in 185 (9.0%), mild persistent in 231 (11.2%), moderate persistent in 640 (31.0%), severe persistent in 812 (39.3%) and unclassified in 200 (9.7%). Of the 1654 patients with persistent asthma who were treated with inhaled corticosteroids, 1157 (70.0%) had treatment cards available for outcome assessment. Of these, 652 (56.4%) did not attend their annual evaluation, among whom 1 (0.1%) died and 651 (56.3%) were lost to follow-up. Of the 505 patients who attended their annual evaluation, 417 (82.6%) improved, 32 (6.3%) were stable and 56 (11.1%) were worse. The frequency of emergency visits and hospitalisation decreased substantially among those who presented for the 1 year follow-up assessment. CONCLUSION: The results of standard case management of asthma were encouraging; however, a high proportion of patients did not return for long-term management.

Research ethics in The Union: an 8-year review of the Ethics Advisory Group.

SETTING: The Ethics Advisory Group (EAG) of the International Union Against Tuberculosis and Lung Disease (The Union) was established in 2004 to provide ethical guidance and promote ethical standards within The Union, including reviews of proposed research projects associated with The Union. OBJECTIVES: To describe research proposal reviews conducted by the EAG in the period 2005-2012 in terms of 1) annual numbers, 2) the Union departments in which the proposals originated, 3) study designs, 4) regions and countries where studies were to be conducted, 5) study topics, 6) problems encountered by the EAG, and 7) review outcomes. DESIGN: Descriptive study of application records of the EAG. RESULTS: A total of 292 applications were reviewed; 79% were proposals for operational research; 85% were from Africa and Asia, with 64% from India, South Africa, Malawi, Kenya and Zimbabwe. Tuberculosis was the topic in 68%; only three studies in the 8 years were on other lung diseases. Several problems encountered are highlighted. All applications were approved except six, either immediately or after modification. CONCLUSION: The proposal review process of the EAG serves to maintain ethical standards of research within The Union. Ideas for expanding the scope of the EAG are discussed.

Surveillance for MDR-TB: is there an obligation to ensure treatment for individuals identified with MDR-TB?

This article raises ethical issues that result if individuals, during the course of research to measure the prevalence of drug-resistant tuberculosis, are identified with the disease but are not provided with or referred for appropriate treatment. It draws attention to and applauds recently published World Health Organization guidelines on the subject. Questions posed are: 1) Should treatment be provided for individuals identified through surveillance projects for MDR-TB, whatever their purpose (specific research or 'routine' national prevalence studies)? 2) If treatment availability is a problem, who is responsible for assuring this?

Assessing allergic rhinitis in developing countries.

BACKGROUND: Allergic rhinitis (AR) affects 5% to 40% of the general population. In developing countries, AR is poorly documented and tracked due to a lack of appropriate diagnostic tools. OBJECTIVE: 1) To validate a questionnaire standardised in industrialised countries to ascertain AR, the Score For Allergic Rhinitis (SFAR), in developing countries; 2) to better understand AR prevalence previously reported from developing countries by comparing results from the SFAR and the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires. METHODS: Six African countries were selected for their climates. In each country, 70 individuals with and 30 without nasal symptoms filled out the SFAR and the ISAAC questionnaires. Skin prick tests (SPTs) for allergens were performed by the physician if necessary. RESULTS: The SFAR presented a close match with the gold standard (the physician's diagnosis of AR backed up by SPT where necessary) in terms of various performance parameters. In particular, it showed high sensitivity (0.84) and specificity (0.81). Compared to the ISAAC questionnaire, the SFAR had greater sensitivity and equal specificity. CONCLUSIONS: In the absence of a medical visit, the SFAR is a useful standardised screening instrument for the collection of information needed for the identification of AR in developing countries.

A multinational study of treatment failures in asthma management.

SETTING: Emergency rooms. OBJECTIVE: To assess quality of care and its determinants for asthma patients before emergency room treatment. DESIGN: Consecutive patients with acute severe asthma attending emergency rooms were questioned about the severity of their disease and treatment in the previous 4 weeks. Prescriptions of inhaled corticosteroids were recorded. Other outcomes included self-reported adherence to treatment and loss of work. RESULTS: Thirteen centres in 11 countries recruited 1156 patients. Only 36% of patients with persistent asthma had been prescribed an adequate dose of inhaled corticosteroids. This percentage improved in those receiving regular care from the same doctor (OR 2.86, 95%CI 1.38-5.96), and was at least as good for the 10% of patients receiving 'private' health care (OR 3.08, 95%CI 1.69-5.62). Forty-four per cent of patients had health insurance covering some asthma medications. These patients were more likely to be receiving adequate inhaled corticosteroids (OR 1.74, 95%CI 1.17-2.58), and reported better adherence than those without insurance (OR 3.00, 95%CI 1.64-5.50). Of those on adequate inhaled corticosteroids, 18% had lost work in each of the 4 previous weeks compared with 59% among those more than one treatment step below the recommended dose. CONCLUSIONS: Access to adequate treatment is critical for better management of asthma.