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Allergies are on the rise in Africa, but there aren’t enough specialists to treat them

Many conditions are going undiagnosed the answer is to boost immunology awareness in Africa say researchers

At the doctor © istock.com/aBeya1
At the doctor © istock.com/aBeya1

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Allergy and immunology in Africa: Challenges and unmet needs

Yehia M. El-Gamal, MD, PhD, FAAAAI, Elham M. Hossny, MD, PhD, FAAAAI, Zeinab A. El-Sayed, MD, PhD, Shereen M. Reda, MD, PhD
The Journal of Allergy and Clinical Immunology, Volume 140, November 2017, Pages 1240–1243

Many parents expose their babies and young children to bacteria and dirt to help stave off illness and allergies in the future; this is thought to work by teaching their immune systems to fight off invaders. According to the hygiene hypothesis, a lack of exposure might shift the balance of the immune system.

But what, then, is the explanation for the huge increase in allergies in Africa, where exposure to bacteria and allergens is higher than most other areas? An Atlas Award-winning study in The Journal of Allergy and Clinical Immunology aimed to explore this question, and the authors have some suggestions for dealing with the rise in allergies.

Across Africa, many communities are faced daily with sewage-contaminated water supplies, unsanitary living conditions and parasite infestations. But rather than strengthening their immune responses, allergic disease is on the rise. What little data there is suggests allergies and asthma are getting more prevalent and more severe; statistics from Cape Town, Nairobi, the urban Ivory Coast and other areas reveal asthma rates of 18-20 percent, which is comparable to rates seen in the West.

Dr. Elham Hossny, Professor of Pediatrics at the Children’s Hospital, Ain Shams University in Egypt and one of the authors of the study, described the puzzle:

This tremendous increase in allergy in Africa cannot simply be explained by the change in public hygiene, as there are many pre-hygiene situations across the continent with sewage contaminated water supply, helminth infestations, bare footedness and poor housing, and still there is growing prevalence of allergic disease. This may argue against the hygiene hypothesis in our country.

People in Africa can be exposed to many risk factors that can trigger severe asthma and allergic reactions, including foods, animals and birds, house dust mites, mold spores, stinging insects and aeroallergens like smoke and pollen. But because it was assumed the rates of allergy were low across the continent, there is very little data showing just how big the problem is. Take food allergy, for example. It has been perceived as being rare in Africa, but the available data suggest that it is underdiagnosed.

Helminth infestation, which is common in Africa, is also a noteworthy example, said Dr. Hossny:

According to the hygiene hypothesis, effective deworming may enhance allergy risk. Helminth parasites are believed to induce regulatory immune responses that dampen atopic responses, but this remains unclear. Despite the increased rates of infestations, allergic diseases are growing in frequency with rates that match those in many developed countries, and this again stands against the hygiene hypothesis on our continent.

The rise in allergies alone would provide enough of a challenge, but the increase in diseases that compromise the immune system, such as HIV and primary immunodeficiency diseases (PIDs) is exacerbating the problem. The rate of new HIV infections in high-prevalence areas across Africa is still very high, and although only 2,500 patients have been diagnosed with PIDs, the number is estimated to be more like 988,000.

Since the data and diagnoses do not reflect the real situation, the support will not be forthcoming. Dr. Hossny and her colleagues highlight an urgent need to establish PID registries, stem cell transplantation facilities and neonatal screening programs, and to boost the study and practice of allergy and immunology in Africa. She explained:

We need to deliver a message to the policy makers in Africa and in everywhere in the world to help us promote our specialty and support our patients and perform the required research at a global standard. In order for African allergists and immunologists to provide better care for their patients and to be able to perform cutting-edge research in the field, they need to be empowered by motivated governments, dedicated funds, and compassionate scientific partnerships.

All of these vital solutions will require dedication and funding – something Dr. Hossny and her colleagues are seeking in collaboration with researchers and healthcare providers.

I look forward to cooperating with other African countries in establishing registries for the prevailing allergy immunology disorders, and to be able to exchange knowledge and expertise with each other. This will allow for pushing towards considering allergy and immunodeficiency among the healthcare priorities in the African continent.

A conversation with Dr. Elham Hossny

Allergies are on the rise in Africa, but with not enough specialists to treat them, and a parallel increase in immune deficiency diseases, the continent faces a big challenge. We talked to author Dr. Elham Hossny, Professor of Pediatrics at the Children’s Hospital, Ain Shams University in Egypt to find out what the problem is, and what can be done to solve it Listen now.

In this podcast Dr. Elham Hossny talks about dealing with the increase in allergies and immune deficiency diseases in Africa.

What's the problem with allergies in Africa?

Allergy and immune deficiency represent a significant sector of the healthcare burden in Africa. There are few allergy immunology specialists because of the prevailing healthcare infrastructure and the lack of recognition of allergy as a clinical specialty. The lack of immunological expertise across the continent is highlighted by the limited publication output from our countries.

Many African countries are currently affected by conflict and fragility, which poses an indirect impact on healthcare proficiency. The volatile situations, particularly in North Africa since 2012, has an indirect impact on that vulnerability to allergy and adversely affected the levels of patients' asthma control. Also, the social and political unrest has potential serious implications on HIV control, on human immune deficiency virus, in the form of disrupted implementation of prevention and advocacy programs and interference with service delivery.

Why did you decide to look at this in your article?

Being motivated by the expanding burden of allergy immune deficiency in our continent, the coauthors and I tried to outline the challenges and unmet needs that have to be faced. We were hoping to draw the attention to the growing needs of our patients and to the necessity of properly designed local cutting-edge research in the field of allergy immunology. Actually, we were seeking for help and suggestions from other centers.

What are your main findings?

We observed considerable variations in the prevalence of wheeze, allergy and rhinoconjunctivitis and eczema between countries and between centers within the same country. Published data on the nature and prevalence of asthma from Africa are scarce, but there is a trend toward increase in rate and severity. Moreover, the reporting on food allergy is inadequate, so that there are not enough systematic reviews and meta-analyses. But the available data suggests that food allergy is underdiagnosed in Africa.

Concerning HIV, the prevalence of new infections remains unacceptably high. While the annual number of new HIV infections in sub-Saharan Africa have declined lately, new HIV infections in the Middle East and North Africa region have increased. However, the current prevalence of 0.1 percent is still among the lowest globally. The reported patterns and spectrum of PID differ from one center to others, and in the primary immune deficiency diseases. It differs from one center to another in countries due to lack of national registries.

How do you suggest addressing these problems, and who is responsible?

In order for African allergists and immunologists to provide better care for their patients and to be able to perform cutting-edge research in the field, they need to be empowered by motivated governments, dedicated funds, and compassionate scientific partnerships. There is an urgent need for the establishment of PID registries for primary immune deficiency, stem cell transplantation facilities and neonatal screening programs. All these, of course, need funds and need more dedication.

How do you see this situation being different in the future?

I'm always optimistic. The coauthors and I hope that the improved visibility of this article will draw global attention towards promoting the specialty of allergy and clinical immunology in Africa, which is optimistically termed the continent of the future. Indeed, the emerging allergy and immunology training programs and scientific societies will produce more efficient and dedicated physicians and this way improve the kind of service provided to our patients. So our goal is to actually promote the specialty through new training programs everywhere and scientific societies that deal with allergy and clinical immunology.

What's next for your work?

I intend to perform multi-center studies on the prevalence of some emergent conditions in my country. The pediatric allergy immunology unit that I'm currently directing has been chosen by the World Allergy Organization as a Center of Excellence recently, and our fellows in training are engaged in research aimed at screening for allergic autoimmune and immune deficiency disorders. The ultimate objective is to set the stage for effective control and prevention programs that fit with the local economic and social circumstances in our continent.

About The Journal of Allergy and Clinical Immunology

The Journal of Allergy and Clinical Immunology publishes high-impact, cutting-edge clinical and translational research papers for allergists, immunologists, dermatologists, gastroenterologists, and other physicians and researchers interested in allergic diseases and clinical immunology. Articles cover topics such as asthma, food allergy, atopic dermatitis, eczema, biologics, primary immune deficiencies and other allergic and immunologic diseases, and include clinical trials and mechanistic studies that report on novel therapies and other discoveries that will ultimately improve the diagnosis and management of patients.

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