DIAGNOSTIC CHALLENGES OF
ASTHMA AND RESPIRATORY
INFECTIONS IN UNDER-FIVES
The Uganda Experience
Rebecca Nantanda
Department of Paediatrics and Child Health/ Lung
Institute-Makerere University
Aims of presentation
1. Understand and appreciate the challenges of
diagnosing asthma and ARI in U-5s
2. Discuss the role of multidisciplinary teams in
overcoming the challenges
– Over diagnosis of bacterial pneumonia
– Under-diagnosis of asthma
Asthma prevalence in U-5s
Author/Year
Age group Sample size
(months)
Prevalence
(%)
India
Sachdev et.al.
2001
6-59
200
54%
Pakistan
Hazir et.al 2004
1-59
1622
49%
103
79%
Haiti
2-59
Heffelfinger ,2002
Magnitude of asthma and pneumonia among children
with acute respiratory symptoms (N=614)
Others included PTB and PJP
Christensen et al (2010) found a prevalence of 6% -physician diagnosed asthma
How were the diagnoses made?
• Study definitions were based on international
guidelines with some modifications
• Diagnostic criteria based on clinical, laboratory
and radiological findings, and response to
treatment
• Pragmatic definition ‘asthma syndrome’ to
include children with asthma and bronchiolitis
Concept of medical diagnosis
Considering combinations of and symptoms or
symptom
complexes
in
conjunction
with
combination of diseases or disease complexes in
order to make fully informed assessments and
astute, analytical judgments (Ledley & Lusted 1959)
The complexity of making a diagnosis
community
Health
system
Disease
Caretaker
Clinician
Diagnostic challenges in asthma:
The disease
• Heterogeneous
– Diverse clinical spectrum of symptoms
• Exact cause remains unknown
• Diagnosis is clinical-no gold standard /standard definition
– Type and
– Severity and frequency of symptoms
Diagnostic tests
Hallmark features
• Inflammation
• Hyper-responsiveness
– No objective measures
in
U-5s
Symptom overlap: pneumonia, bronchiolitis
Natural
Pneumonia
Bronchiolitis
Acute onset
Acute onset
Asthma
Chronic
history
Symptoms
Fever, cough
difficulty
in
breathing,
Acute
1st
wheezing,
wheezing,
+/-
flu/cold,
difficulty
in
cough,
breathing
during exacerbations
fast breathing, chest in drawing
fast breathing, chest in drawing
fast breathing, chest in drawing
+/- auscultatory wheeze,
prolonged expiration,
prolonged expiration, +/- reduced air
+/- reduced air entry
+/- reduced air entry
entry
auscultatory wheeze
cases
,
recurrent episodes of cough, with
flu/cold +/- fever, cough
episode of wheeze
Very severe
recurrent
exacerbations
difficulty in breathing, wheeze
Signs
or
auscultatory wheeze
severe respiratory distress
severe respiratory distress
severe respiratory distress
inability to breastfeed/drink
inability to breastfeed/drink
absent auscultatory wheeze
cyanosis
cyanosis
inability to breastfeed/drink
lethargy
lethargy
cyanosis, lethargy,
Asthma and wheezing disorders
• Episodic Viral
wheeze
• Transient wheezers
• Late onset wheezers
• Multiple trigger
wheeze
• Persistent wheezers
Caretakers’/Community perceptions
of asthma
• Understanding asthma symptoms
– Wheeze (whistling, coffee machine, sleeping cat, etc.)
– Cough-at what point is cough a cause for concern to the
caretaker?
– What is recurrent cough?
• Myths and stigma associated with diagnosis of asthma
• Myths and perceptions about the treatment- inhalers are
addictive, they are for severe diseases, etc.
The Clinician
• Knowledge, skills and conviction about asthma in
U-5s
• Overlap in signs and symptoms with other
diseases: pneumonia, bronchiolitis, common cold
• Hesitancy/discomfort to inform caretakers about
a diagnosis of asthma
• Treatment options – low availability of asthma
medicines
The Health System
Diagnostics for pneumonia
– Lacking
– Not always available
– Long turn over time of
results
Referral mechanisms for
suspected asthma
• Availability of drugs
• Records (HMIS)
• Chronic care
• Lack of country
guidelines
Skilled human resources
–
–
–
–
WHO: Hospital Care for Sick
Children
Integrated Management of
Childhood Illnesses (IMCI)
Uganda Clinical Guidelines
GINA
Diagnostic challenges for pneumonia
No simple, reliable way to establish aetiology
– Bacteremia in only 5-20%
– Virus are more common cause than bacteria
– 14-35% are virus alone & 8-40% are mixed
infections
– 20-60% unidentified
– Virus in nasopharyngeal specimen - does
not mean that it is the cause
Diagnostics for pneumonia
• Chest X-ray is gold standard for diagnosis of
pneumonia - Unreliable
• Other tests – Lung punctures, CRP, PCR,
Calcitonin
• No rapid point of care test available
• Clinical signs & symptoms are MOST commonly
used for diagnosis
Co-morbidities
Combination
Prevalence (%)
1
Asthma-Pneumonia
20
2
Pneumonia-Malaria
30
3
Asthma-Pneumonia-Malaria
18
4
Asthma-Malaria
25
Addressing the challenges (LMIC, HIC)
• History, history, and a good history
– descriptive and pragmatic approach
• Effective communication - clear,
understandable, culturally-sensitive
• Patient-centered care
• Monitor treatment trials
Addressing the challenges: Uganda
• Awareness campaigns about asthma in U-5s
– Health workers
– Policy makers
– General population
• Research (FRESHAIR-H2020)
– Health worker practices in diagnosis of respiratory
diseases in primary care settings
– Local concepts and treatments for respiratory diseases
• Policy and guidelines on asthma in children-availability
of medicines, improved diagnosis
Future perspectives
• The role of asthma predictive indices in LIC
• Advances in lung function testing: spirometry
• Primary prevention: aetiology of asthma
• Co-morbidities
The role of multidisciplinary teams
Multidisciplinary teams are the cornerstone for
effective childhood asthma care




Nurses
Clinician
Pharmacists
Social worker
Caretaker
School teachers
Need for research in models for paediatric asthma
care applicable to resource-limited settings
?? Paediatric HIV care and treatment programmes
References
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27(4): p. 538-48.
2. Hart, M.K. and M.W. Millard, Approaches to chronic disease management for asthma and chronic obstructive pulmonary
disease: strategies through the continuum of care. Proc (Bayl Univ Med Cent), 2010. 23(3): p. 223-9.
3. Hazir, T., et al., Assessment and management of children aged 1-59 months presenting with wheeze, fast breathing, and/or
lower chest indrawing; results of a multicentre descriptive study in Pakistan. Arch Dis Child, 2004. 89(11): p. 1049-54.
4. Heffelfinger, J.D., et al., Evaluation of children with recurrent pneumonia diagnosed by World Health Organization criteria.
Pediatr Infect Dis J, 2002. 21(2): p. 108-12.
5. Ledley, R. S., & Lusted, L. B. (1959). Reasoning foundations of medical diagnosis; symbolic logic, probability, and value
theory aid our understanding of how physicians reason. Science, 130(3366), 9-21.
6.
Nantanda, R., et al., Asthma and pneumonia among children less than five years with acute respiratory
symptoms in Mulago Hospital, Uganda: evidence of under-diagnosis of asthma. PLoS One, 2013. 8(11): p.
e81562.
7.
Ostergaard, M.S., et al., Childhood asthma in low income countries: an invisible killer? Prim Care Respir J,
2012. 21(2): p. 214-9.
8.
Pavord, I.D., A. Bush, and S. Holgate, Asthma diagnosis: addressing the challenges. Lancet Respir Med,
2015. 3(5): p. 339-41.
9.
Sachdev, H.P., S.C. Mahajan, and A. Garg, Improving antibiotic and bronchodilator prescription in children
presenting with difficult breathing: experience from an urban hospital in India. Indian Pediatr, 2001. 38(8):
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