NOML’s First Screening and Clinic in a Third-World Country
Medical Message by: Gerald W. Staton, Jr. MD. and Debra L. Staton
Date: April 4, 2012
Not One More Life (NOML) was begun by LeRoy Graham, MD for the purpose of improving the identification and treatment of patients in underserved areas and populations who suffer from obstructive lung disease. Over the last several years, screening and clinics have been performed across several cities in the United States.
During a medical mission trip to Manila, Philippines, the first NOML screenings/clinics in a third-world country were held. On arrival at one of the sites, we were told that an asthmatic child in that area had died the night before from a severe asthma attack, highlighting the need for better asthma treatment in this setting.
Gerald Staton MD and Debra Staton, were invited by a Missions to the World team to join them on a medical missions trip to Manila, Philippines, traveling in February, 2012. NOML provided a portable spirometer to be used for the lung function testing. Debra was trained by Mike Stader, one of the NOML staff, on the use of the spirometer in the January, 2012 clinic and a screening in the Atlanta area in January.
Donated respiratory drugs were obtained by Dr. Graham from GSK and by Dr. Staton thru MAP.
Clinics were held in multiple sites and settings in the provinces outside Manila. In each clinic, after triage, each patient was seen by a provider (MD, PA, or nurse).
The patients who were to be screened with spirometry were chosen by the providers based on their symptoms and prior medical problems.
Spirometry was performed by Debra Staton, with the help of a Philippino interpreter. Due to the need for rapid turnaround of the testing, the first good spirometry test was used as the result and no attempt was made to perform the usual three tests.
If the patients were determined to have either asthma or COPD, the drugs that should be provided were determined by Dr. Staton or the Pediatrician. The patients were instructed by the provider and one of the team members on the use of the medications and the technique for the use of the inhalers.
A total of 28 patients had spirometry. There were 16 females and 12 males, with an average age of 46.1 years; 6 were under the age of 18 and 10 were 60 or older.
Two patients, age 8 and 65 years old, were not able to complete the test. The average FVC% predicted for the remaining 26 patients was 89.7% with a range of 49 to 138%. The average FEV1% predicted was 67% with a range of 30 to 112% and the average FEV1/FVC ratio was 63.6% with a range of 39 to 93%. The average PEFR% predicted was 56.5% with a range of 26 to 112 %.
Only one patient had normal spirometry. Thirteen patients had obstructive defects and 7 patients had obstruction and a reduced FVC indicating either combined restriction or air trapping. A total of 20 of 28 patients had evidence of airway obstruction. Five patients had restrictive defects only.
Of the six children that were tested, one could not complete the test and the remaining 5 all had obstruction, 4 of the 5 moderate to severe.
Of the 10 patients 60 years old and older, one was not able to complete the test. Four patients had obstruction, 2 had restriction, and 3 had obstruction and a reduced FVC. The degree of obstruction in the 7 patients with obstruction was severe in 2 and moderate in 2.
None of the patients that had a history of lung disease, mostly asthma, were on controller medications. Some were taking salbutamol either orally or by nebulizer on an as needed basis.
The patients with airway obstruction were treated based on standard guidelines. All patients received a short acting beta agonist MDI (albuterol). The patients who were cigarette smokers and had airway obstruction were diagnosed with COPD and received salmeterol 50/fluticasone 250 discus one inhalation twice a day. The patients that were felt to have asthma either received a low dose inhaled steroid (several types were available) two inhalations twice a day if deemed to be mild, or salmeterol 50/fluticasone 100 discus one inhalation twice a day if moderate or severe. A few patients were given a nebulizer treatment in the clinic and a few were given a short burst of prednisone.
With the help of a Philippino interpreter, all patients were given some asthma or COPD education including recommendations for smoking cessation and the patients were given instruction on the use of the inhaler devices.
Among the Philippino patients that were chosen by the providers to have spirometry, almost all were abnormal, and most had airway obstruction, often severe. And no patient, even with a history of airway disease, was receiving controller medication; most of the patients with a history of asthma were receiving rescue medication.
Because of the need to keep the patient flow moving in the high volume setting that we were in, the first good spirometry effort was used as the value. For this reason, the accuracy of the spirometry data is somewhat compromised.
Filipino children living in the US have an increased prevalence of asthma (http://www.ncbi.nlm.nih.gov/pubmed/16882779). Studies of adults in the Philippines found a prevalence of asthma of 17-22% (http://healthypinoy.com/health/guidelines/asthma/12-asthma-common-philippines.html).
In the Philippines, about 50% of the male population smoke and COPD is the seventh greatest cause of death (http://www.tobacco.org/news/77577.html). The prevalence of COPD is estimated at 6.3% (http://chestjournal.chestpubs.org/content/133/2/517.full).
The hope is that the patients have now been educated on the proper treatment of their lung disease and that they will have improvement in their lung symptoms while on controller medication for the one to two months of treatment that we were able to provide. At that point, the patients will hopefully be motivated to seek out controller medications that they can afford.