Prevalence of Asthma among University Students and Workers in Khartoum State, Sudan

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1 Prevalence of Asthma among University Students and Workers in Khartoum State, Sudan Azza O Alawad 1, Khalil A.KH.H 2, Tarig H Merghani 3 1 Department of Physiology, Faculty of Medicine, University of Al-Neelain; Sudan 2 Department of Biochemistry, Faculty of Medicine, University of Al-Neelain; Sudan 3 Department of Physiology, Faculty of Medicine, University of Khartoum; Sudan. Correspondence to Azza Ossman Alawad; azzaosman2@hotmail.com ABSTRACT Introduction: The prevalence of asthma is increasing worldwide; however, there is paucity of data regarding this in the Sudan. The purpose of this study is to estimate prevalence of asthma among university students and workers in Khartoum State, Sudan. Methods: A random sample of 1200 university student and workers, aged 18 to 77 with a male to female ratio of 1:1.3, was selected randomly from two universities in Khartoum State, Sudan. Prevalence of asthma was assessed using a modified International Study of Asthma and Allergy (ISAAC) questionnaire. Measurements of lung function were done for those who showed positive findings. Results: A previous diagnosis of asthma was found in 7.4% of participants, wheeze during the last 12 months was found in 6.5% whereas other asthma symptoms like early morning breathlessness, shortness of breath without exercise and interrupted sleep by cough were found in 5.6%, 6.2% and 5.9% respectively. A high correlation was found between previous diagnosis of asthma and recent wheeze. Reversibility test was positive in only 14% of those with known history of asthma. Conclusion: Prevalence of asthma among university students and workers in Khartoum state was found to be 7.4%, with high correlation with recent wheeze during the last 12 months. INTRODUCTION In 1997, an international consensus report on the diagnosis and treatment of asthma, supervised by the Department of Health and Human Services of the United States defined asthma as a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular mast cells, eosinophils, T-lymphocytes, macrophages, neutrophils and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or the early morning. These episodes are associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial responsiveness to a variety of stimuli (1). In epidemiological studies asthma can be defined simply as airway hyperresponsiveness plus recent wheeze, in the last 12 months prior to study (2). The prevalence of asthma is increasing worldwide (3). About 300 million subjects are currently having asthma (4). It affects both sexes and almost all ages. The male to female ratio is about 1.5 in children, 1.0 in late adolescence and less than 1.0 in adults, when more females have symptoms. The cause of this international increase in asthma prevalence is unclear but it may be due to increased environmental pollution or dietary factors. Despite the worldwide increases, there remains large difference in the prevalence of asthma between populations, with higher rate of wheezing illness in affluent countries like Australia and lower rates of prevalence in poor countries; however, in many countries, the prevalence of asthma is about 10 to 15% of the general population. In the Sudan, the prevalence in adults is approaching 10% in Northern Sudan (5). Prevalence among Sudanese children was found to be significantly associated with many factors including male gender, urban residence, history of atopy, parental asthma and parental smoking (6). Asthma is multifactorial in origin arising from a complex interaction of genetic and environmental factors. It seems likely that airway inflammation occurs when genetically susceptible

2 individuals are exposed to certain environmental factors. The exact processes underlying asthma may vary from patient to patient. However, in many cases the most important environmental factors are the intensity, timing and mode of exposure to aeroallergens which stimulate the production of IgE. Asthmatics in the Sudan are found to be sensitive to cockroach allergens, cat allergens, Betulaceae trees allergens and the house dust mite (7). Additional environmental factors include the concurrent exposure to co-factors such as cigarette smoke, atmospheric pollutants and respiratory tract infections (8). The pathophysiologic hallmark of asthma is a reduction in airway diameter brought about by contraction of smooth muscle, vascular congestion, edema of the bronchial wall and thick tenacious secretions (1). These result in an increase in airway resistance, decreased forced expiratory volumes and flow rates and hyperinflation of the lungs and chest. They result also in increased work of breathing, changes in elastic recoil of the lung, abnormal distribution of both ventilation and perfusion and alteration in arterial blood gases. Therefore all aspects of lung function are compromised during an acute attack of asthma (9). There are two peaks of onset of asthma: in childhood and in middle life. Childhood asthma, also called extrinsic asthma, generally occurs in atopic individuals who show positive skin reactions to common inhaled allergens and increased levels of IgE in their serum. They may complain of other allergic disorders such as allergic rhinitis and eczema. A family history of these disorders and of early onset asthma is common. On the other hand, asthma arising in adult life (late onset asthma or intrinsic asthma) may represent reactivation of childhood asthma or it may arise for the first time in adulthood. Here it may not be associated with atopic allergy. Asthma occurring in the workplace (occupational asthma) is an important cause of ill health. Wide ranges of organic and inorganic materials have been implicated as etiological factors (10). Withdrawal from exposure often leads to some clinical improvement. However, it is quite common for occupational asthma to persist in certain patients despite cessation of exposure (11). Despite efforts of many Sudanese researchers; there is paucity of data regarding all these aspects of asthma prevalence in the Sudan. The aim of this study is to estimate the percentage of asthmatics among university students and workers using a questionnaire as tool of diagnosis. MATERIALS AND METHODS Study area and population: This is a descriptive, cross-sectional study. It has been carried out in two universities in Khartoum State: University of Science and Technology in Omdurman and El- Zaeem El-Azhri University in Khartoum Bahri. A total of 1200 Sudanese adults were selected randomly to participate in the study. The sample size was calculated using Epi Info, with expectation of 10% prevalence (+2) and confidence level of 99. Inclusion criteria were adult subject (male or female), age 18 years old or above and living in Khartoum state. Exclusion criteria were age less than 18 years and not living in Khartoum state. Data collection: An anonymous questionnaire, modified from the questionnaire of the International Study of Asthma and Allergy (ISAAC), was distributed to university students, workers, and employees, by random choices from lists of names. The questionnaire requires information about subject s age, gender, marital status, previous diagnosis of asthma, symptoms of asthma in the last 12 months (e.g. wheeze, cough breathlessness and sleep disturbance), symptoms of allergic rhinitis in the last 12 months (e.g. sneezing, nasal discharge and nasal obstruction), symptoms of eczema in the last 12 months (itchy skin eruption), triggering factors and sources of indoor or outdoor air pollution, smoking and past medical history. It was filled with assistance from the investigator. Those who gave positive responses indicating asthma were selected for lung function tests. Statistical analysis: The data obtained by questionnaire and the lung function testing were analyzed using SPSS Version The chi square test was used to test distribution of categorical variables. Statistical significance was accepted when P value equals or less than Ethical consideration: Agreement was obtained from the authorities of the universities. Informed consents were taken from all participants before filling the questionnaire. All procedures were in accordance to Helsinki Declaration (12). 22

3 RESULTS Age & sex distribution of the sample Females constitute 56.9% of the sample whereas males constitute 43.1% (fig 1). Most of the subjects (91%) were students distributed in the age group years old (table 1). Others were employees or workers. mal e 43.1% fem al e 56.9% Figure 1: Gender Distribution in the Study Group Table 1: Age Distribution in the Study Group Age group No. % Total Asthma in the study group Previous diagnosis of asthma and prevalence of asthma symptoms during the last 12 months (wheeze, early morning breathlessness, shortness of breath without exercise and interrupted sleep by cough) were found in 7.4%, 6.5%, 5.6%, 6.2% and 5.9% respectively (table 2). Wheeze during the last 12 months was found in 84.6% of those with a previous diagnosis of asthma and 15.4% of those who were not known to be asthmatics, correlation= 0.78 (fig 2). Asthma symptoms were more common in females (64%) than males (36%). Table 2: Indicators of asthma in the Study Group, n=1200 Indicator of asthma No. % Previous diagnosis Wheeze Early morning breathlessness Shortness of breath without exercise Interrupted sleep by cough

4 Percent Percent Wheeze 20 no 0 no yes yes Occurrence of Asthma (Spearman correlation = 0.78). Figure 2: Presence of Wheeze during the Last Twelve Months in Relation to Previous Diagnosis of Asthma male female Sex distribution among subjects with asthma symptoms Figure 3: Gender Distribution among Subjects Who Had Asthma Symptoms in the Study Group

5 DISCUSSION The percentage of females in this study (56.9%) was higher than that of males (43.1%). This is consistent with the observation that the number of females is higher than males in most universities in Khartoum. On the other hand most subjects in the study were within the younger age groups (18-27 years old) because most subjects in the study were students. Many studies were conducted to estimate asthma prevalence in the Sudan. Prevalence among adults in Northern Sudan was estimated recently (5). It was found to be approaching 10%. In Khartoum, prevalence of wheeze and symptoms of severe asthma in 13 to 14 years old children were estimated few years ago in a large international study of asthma and allergy in childhood ISAAC (13). Wheeze was found in 12.5% of children and severe asthma symptoms were found in 5.5%. Comparable results were obtained in the past in Elgadarif (14). In this study, recent wheeze was found in 6.5% of adult subjects in the study group. This percentage is very near to the percent of those with a known previous diagnosis of asthma who were 7.4% of all subjects in the study group. Statistical analysis showed high correlation between recent wheeze and previous diagnosis of asthma in the study group (correlation = 0.78). It is well known that prevalence of asthma in epidemiological surveys can be determined by recent wheeze in the last twelve months prior to study (2). Therefore, our results confirm that recent wheeze is a useful indicator of asthma diagnosis. In addition to those who had wheeze during the last 12 months, equivalent proportions of patients complained of other asthma symptoms like shortness of breath without exercise, early morning breathlessness and cough at night causing sleep interruption. The majority of the subjects who had these symptoms were females. This is consistent with the prevalence of asthma worldwide where asthma in children is more common in males whereas in adults it is more common in females (15). Reversibility test is an important tool for confirmation of asthma diagnosis. Although past history of asthma diagnosis was already established in 7.4% of subjects in the study group, only 17% of these showed positive reversibility test. This finding is expected since the majority of these patients were asymptomatic at the time of the study. Conclusion: This study showed that the prevalence of asthma among university students and workers is 7.4%. Recent wheeze in the last twelve months has high correlation with diagnosis of asthma. REFERENCES 1. National asthma Education and Prevention Program. Expert Panel Report 2. Guidelines for the Diagnosis and Management of Asthma. NIH publication No Bethesda, MD:US Dept of Health and Human Services, Toelle BG, Peat JK, Salome CM, Mellis CM, Woolcock AJ. Toward a definition of asthma for epidemiology. Am Rev Respir Dis 1992; 146(3): Upton MN, McConnachie A, Mc Sharry C, Hart CL, Smith GD, Gillis CR, Watt GC. Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the midspan family study surveys of parents and offspring. BMJ 2000; 321(7253): Masoli M, Fabian D, Holt S, Beasley R, et al. Global Initiative for Asthma (GINA) program: the global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy 2004;59: Magzoub A, Elsoni A, Musa OA. Prevalence of asthma symptoms in adult university students and workers in Dongola, North Sudan. TB, HIV and Lung Health Conference. Berlin Germany 13 November PC Mohamed EA, Habour A, Musa OA. Childhood asthma: risk factors and control of the disease. Chest, oct Abstract. 7. Abdel Razag AE, Musa OA. Validation of the score for allergic rhinitis diagnosis (SFAR) and correlation of allergic rhinitis and asthma. MSc thesis (2004), Dept. of Physiology, University of Gezira (un-published data). 8. Duff AL, Platts, Mills TA. Allergens and Asthma. Pediatr Clin North Am 1992; 39: Ganong WF. Review of medical physiology. 22 nd ed. McGraw-Hill Companies, Inc p Chan, Yeung M, Malo JL. Occupational Asthma. N Engl J Med 1995; 333: Weatheral DJ, L:edingham JG, Warrell DA (1996). Oxford textbook of medicine; 3 rd Ed; 2: Oxford University Press Inc., Ne. 12. World Medical Association Medical Ethics Committee. Updating the WMA Declaration of Helsinki. Wld Med J 1999; 45:11-13.

6 13. Ait-Khalid N, Odihambo J, Pearce N, Adjoh KS, Maesano IA, Benhabyles B, Camara L, Catteau C, Asma ES, Hypolite IE, Musa OA, Jerray M, Khaldi F, Sow O, Tijani O, Zar HJ, Melaku K, Kuaban C, Voyi K (2007). International Study of Asthma and Allergy (ISAAC) in Childhood Phase III: Prevalence of symptoms of asthma, rhinitis and eczema in 13 to 14 year old children in Africa. Allergy 2007 DOI: /j Bashir AA, Musa OA. Normal spirometric values in Sudanese and their clinical applications. PhD thesis Dept. of Physiology, University of Gezira (un-published data). 15. Strachan DP, Butland BK, Anderson HR. Incidence and prognosis of asthma and wheezing illness from early childhood to age 33 in a national British cohort. BMJ 1996; 312: 1195.

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