Pediatric asthma in the Philippines: risk factors, barriers, and steps forward across the child's life stages.

This 2023, the Global Initiative for Asthma (GINA) selected ‘Asthma Care for All’ as the theme for World Asthma Day, underscoring the disproportionately high asthma prevalence, morbidity, and mortality in low- and middle-income countries (LMICs). This burden especially impacts children and adolescents worldwide, in whom asthma remains the most common chronic disease and a top cause of disability-adjusted life years.1Serebrisky D. Wiznia A. Pediatric asthma: a global epidemic.Ann Global Health. 2019; 85: 6Crossref PubMed Scopus (100) Google Scholar Pediatric asthma remains a serious public health issue in the Philippines, a LMIC in Southeast Asia where nearly 1 in 10 children have asthma – a figure that is likely an underestimation.2Alava H.D. Dans L. Sumpaico M. Castor M.A. de Leon J. Prevalence of asthma among Filipino children 0-19 years old based on National Nutrition and Health Survey (NNHeS).Philipp J Pediatr. 2006; 55https://www.herdin.ph/index.php/herdin-journals?view=research&cid=77601Date accessed: April 11, 2023Google Scholar We examine the social determinants and systemic barriers that underlie the substantial burden of pediatric asthma in the Philippines across a child's life course, and highlight steps forward. A child's risk for asthma development begins in utero. Maternal asthma and allergic rhinitis are important risk factors that cannot be discounted.3Collier C.H. Risnes K. Norwitz E.R. Bracken M.B. Illuzzi J.L. Maternal infection in pregnancy and risk of asthma in offspring.Matern Child Health J. 2013; 17: 1940-1950Crossref PubMed Scopus (30) Google Scholar Beyond genetics, foetomaternal events also influence the risk of asthma later in life. Adverse peripartum events such as premature rupture of membranes and preterm birth have been associated with an increased risk of childhood asthma development and hospitalisation.3Collier C.H. Risnes K. Norwitz E.R. Bracken M.B. Illuzzi J.L. Maternal infection in pregnancy and risk of asthma in offspring.Matern Child Health J. 2013; 17: 1940-1950Crossref PubMed Scopus (30) Google Scholar,4Resuscitation of preterm infants in the Philippines: a national survey of resources and practice.ADC Fetal Neonat Ed. 2019; https://fn.bmj.com/content/105/2/209Date accessed: April 13, 2023Google Scholar The Philippines currently ranks 8th highest in the number of preterm births,4Resuscitation of preterm infants in the Philippines: a national survey of resources and practice.ADC Fetal Neonat Ed. 2019; https://fn.bmj.com/content/105/2/209Date accessed: April 13, 2023Google Scholar with up to 6% of pregnant people without access to professional prenatal care.5Tantengco O.A.G. Ornos E.D.B. Trends in health insurance and antenatal care coverage in the Philippines.J Public Health. 2023; 45: e146-e147Crossref Scopus (1) Google Scholar The maternal environment also creates a foundation for respiratory complications in their child, as the passage of air pollutants and aeroallergens into the foetal circulation via the placenta sensitises the foetal immune system and promotes asthma development.6Gonzalez-Barcala F.-J. Pertega S. Sampedro M. et al.Impact of parental smoking on childhood asthma.J Pediatr. 2013; 89: 294-299Crossref Scopus (24) Google Scholar In 2015, 23.8% of Filipinos were smokers, exposing many pregnant women, even non-smokers themselves, to tobacco smoke. Threats to asthma development in neonates include being male, receiving early exposure to ventilator-assisted breathing and antibiotics, and low vitamin D levels.7Wang C.-M. Yang S.-T. Yang C.-C. et al.Maternal and neonatal risk factors of asthma in children: nationwide population based study.J Microbiol Immunol Infect. 2023; 56: 182-191Crossref PubMed Scopus (1) Google Scholar The infant is exposed to additional risk factors once out of the uterine environment. Although risk factors for asthma during infancy are myriad, early environmental exposures represent a major determinant. Children remain vulnerable to the ill effects of air pollution because they inhale a higher volume of air per body weight than adults. A growing body of evidence suggests that early life exposure to tobacco smoke (e.g., through parental smoking) and ambient air pollutants may contribute to pediatric asthma incidence.6Gonzalez-Barcala F.-J. Pertega S. Sampedro M. et al.Impact of parental smoking on childhood asthma.J Pediatr. 2013; 89: 294-299Crossref Scopus (24) Google Scholar,8To T. Zhu J. Stieb D. et al.Early life exposure to air pollution and incidence of childhood asthma, allergic rhinitis and eczema.Eur Respir J. 2020; 55https://doi.org/10.1183/13993003.00913-2019Crossref Scopus (71) Google Scholar An estimated 12.37% of the Philippine population, over 13 million people, resides in the National Capital region, where fine particulate matter (PM2.5) can reach 58.4 μg/m3, nearly twelve times the WHO global air quality limit of 5 μg/m3.9Highlights of the National Capital Region (NCR) population 2020 census of population and housing (2020 CPH). Philippine statistics Authority, 2020https://psa.gov.ph/content/highlights-national-capital-region-ncr-population-2020-census-population-and-housing-2020Date accessed: April 11, 2023Google Scholar,10Tantengco O.A.G. Guinto R.R. Tackling air pollution in the Philippines.Lancet Planet Health. 2022; 6e300Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Additionally, approximately 80 percent of children with asthma develop symptoms by age 5; however, the disease is frequently mis- and underdiagnosed, especially in infants and toddlers.11Diagnosis and management of asthma in children.BMJ Paediatr Open. 2022; https://bmjpaedsopen.bmj.com/content/6/1/e001277Date accessed: April 13, 2023Google Scholar Viral-induced wheezing, a similar presentation to asthma, is common in respiratory syncytial virus (RSV), which surged in its incidence in the country just last year.12DOH bares surge in RSV cases; 200 children in PH affected. Inquirer News, 2022https://newsinfo.inquirer.net/1689572/doh-bares-surge-in-rsv-cases-200-children-in-ph-affectedDate accessed: April 18, 2023Google Scholar Thus, recurrence of symptoms and bronchodilator trials become key in diagnosing the disease. In the Philippines, inadequate diagnosis of asthma is only compounded by the limited accessibility of diagnostic tests that objectively confirm expiratory airflow limitation. Pulmonary function tests can cost from between 2000 PHP (∼36.8 USD) and 8000 PHP (∼147.4 USD), which is roughly a week's salary at minimum wage.13PFT test price in Philippines pulmonary function test – medical pinas. 2022https://medicalpinas.com/pft-test-price-in-philippines-pulmonary-function-test/Date accessed: April 18, 2023Google Scholar,14Daily minimum wage rates. Department of Labor and Employment National Wages Productivity Commission | NWPC.https://nwpc.dole.gov.ph/Date: 2022Date accessed: April 18, 2023Google Scholar Beyond influencing childhood asthma development, tobacco smoke exposure also contributes substantially to the risk of exacerbation among asthmatics.15Merianos A.L. Jandarov R.A. Mahabee-Gittens E.M. Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents.J Asthma. 2019; 56: 369-379Crossref PubMed Scopus (11) Google Scholar Although Philippine law prohibits tobacco use, sale, and promotion among minors and in schools, the Global Youth Tobacco Survey of 2019 found that among 13–15 year olds in the Philippines, 18.3% of boys and 6.9% of girls are current tobacco users.16Republic Act No. 9211 | GOVPH. Official gazette of the republic of the Philippines. 2003https://www.officialgazette.gov.ph/2003/06/23/republic-act-no-9211/Date accessed: April 6, 2023Google Scholar,17Global Tobacco Surveillance SystemGlobal Youth tobacco Survey fact sheet, Philippines.2019Google Scholar On-campus smoking was observed by 62%, and 11% had been offered tobacco promotion products.15Merianos A.L. Jandarov R.A. Mahabee-Gittens E.M. Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents.J Asthma. 2019; 56: 369-379Crossref PubMed Scopus (11) Google Scholar Meanwhile, only 57.6% of respondents reported being taught in school about the dangers of tobacco use.15Merianos A.L. Jandarov R.A. Mahabee-Gittens E.M. Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents.J Asthma. 2019; 56: 369-379Crossref PubMed Scopus (11) Google Scholar These imply that regulations surrounding tobacco access, exposure, and education for Filipino children remain poor. Local practice guidelines on asthma are frequently published; however, dissemination of updated information to rural areas represents a challenge to adequate asthma control, leading to inappropriate prescription practices. Although short-acting B2 agonist (SABA) inhaler dependence increases the risk for exacerbation, hospitalisation, and mortality, a nationwide study found that over 10% of Filipino asthma patients over age 12 are over-prescribed SABA canisters.18Diaz D.V. Nicodemus L.A. Parena-Santiago E.L. et al.Short-acting β2-agonist prescription patterns in patients with asthma in the Philippines: results from SABINA III.Acta Med Philipp. 2020; https://doi.org/10.47895/amp.vi0.4816Crossref Google Scholar Local data currently remains unavailable for younger children. Furthermore, combination ICS-formoterol inhalers remain expensive and therefore unavailable in most local health centers that provide free medications. Low health literacy among caregivers may also be a factor, as misperceptions that asthma is an acute (vs chronic) disease may contribute to dismissal of intermittent symptoms and poor inhaler adherence. Overall, these factors may contribute to poor asthma control in the pediatric population, with implications for school absenteeism and costs borne by families.11Diagnosis and management of asthma in children.BMJ Paediatr Open. 2022; https://bmjpaedsopen.bmj.com/content/6/1/e001277Date accessed: April 13, 2023Google Scholar Healthcare workers, especially at the primary care level, should be trained to detect various asthma presentations in children, correctly prescribe inhaled corticosteroids with SABA, and educate families on 1) proper nebulisation and inhaler technique, and 2) environmental modification.18Diaz D.V. Nicodemus L.A. Parena-Santiago E.L. et al.Short-acting β2-agonist prescription patterns in patients with asthma in the Philippines: results from SABINA III.Acta Med Philipp. 2020; https://doi.org/10.47895/amp.vi0.4816Crossref Google Scholar Educating adult caregivers and family members, who primarily control the child's environment, is especially essential to reduce harmful environmental exposures (e.g., tobacco smoke, aeroallergens) that predispose to asthma development and precipitate exacerbations. Programs directed at counseling men on smoking cessation not only decrease second-hand smoke exposure for their families but also provide opportunities for positive involvement with their children.19Bottorff J.L. Sarbit G. Oliffe J.L. Caperchione C.M. Wilson D. Huisken A. Strategies for supporting smoking cessation among indigenous fathers: a qualitative participatory study.Am J Men's Health. 2018; 131557988318806438PubMed Google Scholar This could be a particularly useful strategy in the Philippines where childcare is still traditionally the women's role, and the majority of smokers are men.17Global Tobacco Surveillance SystemGlobal Youth tobacco Survey fact sheet, Philippines.2019Google Scholar Notably, such programs should be culturally sensitive, involving stakeholders directly to maximise opportunities for success. The smoking cessation program of the Indigenous Father of Canada has seen success with this approach, by involving community members as facilitators, leaders, and guest speakers. By the end of the program, 28% of the fathers involved were abstinent, and 43% had reduced their smoking.19Bottorff J.L. Sarbit G. Oliffe J.L. Caperchione C.M. Wilson D. Huisken A. Strategies for supporting smoking cessation among indigenous fathers: a qualitative participatory study.Am J Men's Health. 2018; 131557988318806438PubMed Google Scholar Public health policy also represents a crucial area for intervention. The Universal Health Care Law, passed in 2019, is a key opportunity to realise access to timely asthma diagnosis and appropriate management. This can begin with expanding national health financing to broaden access to spirometry and essential asthma medications. The Catalão, Goias city of Brazil has increased their asthma control rate to 62%, compared to the national average of 9%, by creating a holistic asthma program that not only facilitated interaction among multiple stakeholders, including the municipal government, healthcare personnel, and patients, but also provided free medications.20Silva Segundo G.R. Ribeiro J.L. A successful asthma treatment program in Brazil.Am J Publ Health. 2013; 103: e1-e2Crossref PubMed Scopus (1) Google Scholar Leveraging policy is also critical to control environmental risk factors. The Philippine Clean Air Act of 1999 (RA 8749) regulates major causes of air pollution, such as motor vehicles, industrial emissions, and fuel sources.21R.A. 8749.https://lawphil.net/statutes/repacts/ra1999/ra_8749_1999.htmlDate accessed: April 11, 2023Google Scholar Recently enacted tax reforms on both traditional and heatless tobacco products and e-cigarettes may decrease their affordability; however, further work is needed to curb adolescent access to such products, given their rising popularity. Although we presented each issue concomitantly with a particular lifestage, their effects are often non-linear and far-reaching. Similarly, however, any intervention targeting this population may deliver positive effects spanning decades and even generations. It is our hope that shedding light on environmental and systems barriers to pediatric asthma control in the Philippines galvanises public health policy changes that positively impact patients, especially in other LMICs confronted with parallel challenges.