Executive summary of the multicenter survey on the prevalence and risk factors of chronic respiratory diseases in patients presenting to primary care centers and emergency rooms in Syria
1Tishreen university, WHO-EMRO collaborating center for CRD, Lattakia, Syria; 2Unit 700 Epidemiology, National Institute of Health and Medical Research (INSERM), Paris, France; 3Ministry of Health, Damascus, Syria; 4University of Aleppo, Aleppo, Syria; 5Hopital Al-Assad, Lattakia, Syria; 6NCDnet (Global Noncommunicable Disease Network), WHO-EMRO (Eastern Mediterranean Region), Geneva, Switzerland; 7Global Alliance against Chronic Respiratory Diseases (GARD), WHO, Geneva, Switzerland; 8WHO collaborating center for asthma and Rhinitis, Montpellier, France; 9University of Damascus, Damascus, Syria; 10University of Homs, Homs, Syria
J Thorac Dis 2012;4(2):203-205. DOI: 10.3978/j.issn.2072-1439.2011.11.07
In 2009-2010, Tishreen University and the Health Ministry conducted a multi-center Survey on the Prevalence and risk factors of chronic respiratory diseases (CRD) and co-morbidities in patients presenting to primary care centers, general outpatients clinics and Emergency rooms in hospitals. In collaboration with WHO-Global alliance against chronic respiratory diseases (GARD), www.who.int/gard, the protocol of this survey has been established tested and validated by the WHO-GARD experts (1
). This survey is the first multi-center survey on CRD in primary care in the Eastern Mediterranean Region. The strongest point is the use of lung function measurement for diagnosis of CRD (2
Primary care centers should play a big role in CRD management, because they are widespread in the most remote regions through the Syrian Arab Republic, and they are the sites for WHO programs (3
). Primary care plays a critical role in health system in Europe and USA (2
). In developing countries, some patients present to Emergency rooms for acute exacerbation of their CRD, neglecting their long-term treatment and follow up, for this reason we included ER in our survey (7
Taking this in consideration, we wanted to investigate the following questions, to provide a tool for evidence bases health strategy for CRD: track the prevalence of CRD and co-morbid chronic diseases (hypertension, cardiac diseases, diabetes, and cancer) in patients presenting to primary care centers and ER; determine risk factors; evaluate the knowledge of primary care doctors in CRD diagnosis and management.
Improve teaching and training curriculum in Universities, through a new approach on long term management of CRD and co- morbidities, taking in consideration risk factors, follow up, and patient education.
Improve Ministry of Health (MOH) programs on CRD and co-morbid chronic diseases, by evidence-based strategies, in elaborating training, Educational materials, and leaflets. Also for prevention strategies.
Patients six years and older, presenting to primary care health centers of MOH and ministry of Education were surveyed. Patients presenting to Emergency rooms and Outpatients General Clinics in hospitals of MOH, higher education, Military Health were also surveyed. Data analysis by SPSS has been done. Results
were presented in tables. Association between chronic respiratory
symptoms, diseases, risk factors and FEV1 <80% predicted, or
FEV1/FVC <70% is considered as significant if P<0.05.
Strong argument for the validity of our study is that the
protocol has been tested in other countries and results published
). Another strong point is that we did spirometry to measure
the true prevalence of obstruction and asthma (2
trained GPs or nurses performed spirometry (8
). None of our
patients had spirometry done before.
We surveyed 22 centers in Lattakia, Tartous, Damascus, Aleppo,
Homs, Hama. 1599 patients in total, 51% are women. Median
age for women (30.87±17.84), and for men (32.08±20.37).
Age categories are: 37.7% (6-20) years, 34.13% (20-44) years
old, 18.17%>44 years. 73.3% in dispensaries, 19% in emergency
rooms and 7.45% in outpatient clinics. 30% are unemployed,
30% are illiterates, 23% have dusty job. Obesity with BMI >30 in
14%, 17.5% in women. Smoking cigarettes in 23.24%, it goes to
47.42% in patients >44 years. Men smokers in 34.24%, women
in 13.4%. Narguile smokers in 11.11%, 9.42% for in women.
Of notice is that 4.7% of 6-20 years old smoke Narguile. So we
should emphasize on these public health priorities, especially in
youth and women.
Respiratory symptoms reported by patients: 35.5% have
respiratory complaint. Chronic cough in 36.8%, chronic sputum
31.68 %, dyspnea in 14.75%.
FEV1 <80% predicted in 36.23%.
Reversibility in 27.88% as seen in asthma.
FEV1/FVC <70% in 16.67% confirming COPD. It is
15% in women, while Doctor in the primary care center
reported 3.39% COPD. This point to the burden of
COPD in primary care, and to the lack of knowledge
and the need of training doctors in health centers,
hospitals and ER.
Mean FEV1, which is the marker of severity of COPD
correlates with age, it is 70.77% in patients >44 years
old. This highlights the burden of COPD.
in 13.12%, but wheezing in 31% (9
reversibility in 27% (6
), this point to the under- diagnosis of
asthma, and the need for training.
As for co-morbidities: hypertension in 9.6%, diabetes in 7.8%,
cardiac ischemia in 3.88%, cardiac failure in 2.61%, allergic
rhinitis in 5.64%, Cancer in 1.4%, Tuberculosis in2.75%.
Risk factors associated with abnormal FEV1 (FEV1 <80%
predicted): active and passive smoking, illiteracy, body mass
index, P=0.0001. It is important to stress on the impact of passive
smoking of both cigarette and Narguile on FEV1 reduction.
FEV1/FVC <70% in 29% of illiterate, in 22% of patients
presenting to ER, but only in 12% of patients presenting to
primary health care centers.
Respiratory symptoms are associated with FEV1 <80%,
Hypertension, heart failure and diabetes are associated with
FEV1 <80%, P=0.0001.
General practitioner diagnosis, after reviewing the form and
lung function results (GPs Form):
Asthma is diagnosed in 13%, while 24% of not
diagnosed as asthmatics reported to have wheezing
ever, the same for reversibility, which points to the
Another important issue is 56% of asthma patients have
FEV1 <80% at baseline, 25% of asthma patients have
FEV1/FVC <70% after bronchdilators, which points to
poor control and inadequate treatment.
There is association between diagnosed asthma, dusty
jobs, smoking, FEV1, and symptoms: P=0.0001.
If we consider current prescription for asthma: Inhaled
corticosteroids (ICS), which are the gold standard for
long term treatment are more prescribed for asthma
patients P=0.001 but still under prescribed, although
available on the market, listed as WHO essential drug,
and included in WHO programs. Oral corticosteroids
(OCS) are over prescribed 46%, which could be
avoided if, ICS prescribed more often. There is over
prescription of antibiotics in 59%. All those highlights
the need for training for GPs and students.
For COPD: Smoking, degree of education, obesity, and
age are risk factors for COPD. P=0.001. ICS are over
prescribed in 84%, while no need for it and very costly,
OCS in 64.29% exposing the patient to undesirable
effects. We need to improve knowledge about COPD in
primary care and ER.
CRD are public health priority (11
), our recommendations
are evidence based. Our results showed that in 35.49% patients
presenting to primary care centers and ER have chronic
respiratory problem. We trained health care workers in PHC and
ER how to perform correct lung function measurement (expire
forcibly, the most deeply, and all air in the lungs), and how to do
Our results seems coherent, proof is the association of FEV1
<80% with age, smoking P=0.0001, this points to the accuracy in
filling in the questionnaire and in performing lung functions (we
discarded 200 non conform lung functions).
Accordingly our recommendations (considering the WHO-NCD action plan and GARD action plan) (11,12) are
Training courses in primary health care centers and
emergency rooms on: how to perform Spirometry,
peak flow and oxymetrie, which is the gold standard
for COPD diagnosis. And on how to evaluate asthma
control, and confirm its diagnosis by reversibility test.
Need for training materials and modules to be
elaborated on the essential to know on CRD according
to evidence based needs, for primary care and ER, to be
used for CME.
Consider co-morbidities: hypertension, ischemic heart
diseases, and hear failure, diabetes and cancer. Sharing
the same risk factors (eg: smoking), or co-existing and
impacting on treatment (eg: diabetes).
Widespread awareness and education for CRD in the
Considering the existence of illiterates, need for photos
and video for patients education and community
COPD exists as well in women, we should emphasis in
women in our programs.
Building on existing national WHO programs:
Package of essentials needs for non communicable
diseases interventions at primary care (PEN-WHO),
and the Practical Approach to Lung Health (PAL),
we recommend to refer patients suffering chronic
respiratory symptoms of low peak flow rate for
spirometry testing in central primary care centers or
We recommend including outpatients clinics in
hospitals in WHO primary care programs.
Elaborate guidelines for ER, and to include it in
Strategic partnership between health sectors: MOH,
universities, school health and military services, and
then cope with medical syndicates and associations and
Encourage multi-center national surveys for CRD, for
evidence based health outcomes (13
Foundation of referral tertiary care clinics for difficult
Include our results in the biannual 2012- 2013 WHO plan of
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Cite this article as: Mohammad Y, Shaaban R, Yassine F, Allouch J, Daaboul
N, Bassam A, Mohammad A, Taha D, Sabba S, Dyban G, Al-Sheih K, Balleh H,
Ibrahim M, Al Khaer H, Dayoub M, Halloum R, Fadhil I, Abbas A, KHouri A,
Khaltaev N, Bousquet J, Khaddouj M, Suleiman I, Meri M, Bakir M, Naem A,
Said H, Al-Dmeirawi F, Myhoub H, Dib G. Executive summary of the multicenter
survey on the prevalence and risk factors of chronic respiratory diseases in
patients presenting to primary care centers and emergency rooms in Syria. J
Thorac Dis 2012;4(2):203-205. doi: 10.3978/j.issn.2072-1439.2011.11.07