The implementation of electronic medical recording system (CERNER) in primary health care setting in Qatar starting 2016 provided the opportunity to study the utilization of these services and provide some epidemiologic insights into one of the important health problems in pediatrics.
In this cross sectional study, electronic health records for children aged 5 to 12 years in which a diagnosis of Asthma was tagged were extracted during a two years period (2016–2017). The seasonal pattern was analyzed after aggregating the two years data to reduce the random variation component between the two years. The peak of clinical encounters of asthma cases increased by Oct and Nov more than 50% compared to the average monthly count. This pattern was endorsed by analyzing the encounters as a proportion out of total clinic workload for the same months. In November the contribution of Asthma clinical encounters to total clinic workload is increased by an almost a half compared to the monthly average of 8.5%. The seasonal pattern for Asthma has important impact on the health care system. Hospital admissions as well as emergency department (ED) visits for asthma exacerbations would differ among school-age children who lived in locations with different climates and these differences have important therapeutic implications .
Seasonal variations in the frequency of asthma exacerbations during childhood occur worldwide. Among preschool and older children, most of the seasonal information available has been derived from studies of children who lived in the United States, Canada, the United Kingdom, and northern Europe [14, 15]. These studies reported an increase in wheezing attacks that are most pronounced during the fall months. Some studies also reported an increase in exacerbations in the spring [14, 16]. It is not clear, however, whether seasonal patterns for attacks of wheezing are the same among children who live in different geographic regions where climates and environmental conditions vary. Several articles proposed that viral infections account for the increased frequency of asthma exacerbations in the fall when children return to school [17,18,19,20]. Other studies indicate that exposure to environmental allergens, which vary in intensity at different times of the year may provide an explanation for this peak [14, 15]. Huang S-J, et al., concluded in their study that 70% of the children with asthma in Taiwan had airway hyper-responsiveness methacholine, which varied among seasons. Children with a higher total serum IgE level may be more seasonally dependent, particularly in summer . A frequency of attacks was observed during the summer months in all the locations. Seasonal peaks for asthma exacerbations varied among the children who lived in geographic locations with different climates, and were not restricted to the beginning of the school year .
Environmental pollution may also contributed to seasonal variation of Asthma clinical encounters. According to the article from Doha news, the capital of Qatar “Doha” is ranked by the World Health Organization among the world’s most polluted cities. Unfortunately, official Air Quality monitoring in Qatar is not available. But from this article, the Qatar Environment and Energy Research Institute is working, since 2013, on setting up the official Air Quality Monitoring System in Doha and still waiting for the official data to be published .
A school-based asthma trial conducted by the University of Rochester School of Medicine and Dentistry, Rochester, NY, USA recommend that children with persistent asthma have at least 2 preventive asthma visits per year . Analysis of Asthma encounters in PHCC showed around a quarter of cases achieved only one visit to the health center during the whole study period. This may point out to a possible wrong diagnosis, since no pulmonary function test is done to establish the diagnosis in PHCC clinics. The GINA guidelines  clearly require the pulmonary function test to establish the diagnosis. Another possibility is a perceived low satisfaction from the patient or his parents with the health care service or its timing. Slightly more than a quarter of Asthmatic cases visited the clinics more than 5 times during the two years period, which obviously exceed the recommended frequency of visits per year and places an added burden on the clinical staff workload. Some of these asthmatics had more than 10 consultations (clinical encounters) during the study period. In addition, those with a short average duration between successive visits (4 weeks or shorter) constituted more than a quarter (27.7%) of total registered cases with Asthma. Such a frequent visit and / or short duration between successive visits may be attributed to inadequate therapeutic control or preventive strategy for Asthma. Non adherence to recommended clinical practice guidelines by physicians or lack of compliance with prescribed medications from patients are probable causes behind these findings.
An estimate for the age specific prevalence rate of Asthma during 2016–2017 was based on knowing the count of registered Asthma cases in a specific age group divided by the count of registered clients in the same age group by the end of 2017. This approach may suffer from a non-measurable amount and direction of bias, since the population of Qatar is a dynamic one with a noticeable amount of expatriates coming in and leaving out the country constantly. In addition, the private sector and secondary health care providers attract some of Asthma cases especially in the pediatric ages. Nevertheless having an estimate is better than guessing. The prevalence rate of asthma in PHCC pediatric clients was 6.1%. This rate was higher (10.2%) in younger children (5–6 years old) and decrease with advancing age to reach its lower value of 4.1% in teenagers (10–12 years old). More over the rate is higher in boys (7.6%) compared to girls (4.6%). These findings were previously reflected in a cross sectional study in Qatar in 2004  . Other studies from the Middle East showed that the prevalence of asthma is lower than many developed countries such as the UK (25.9%), Spain (12.8%), Australia (31%) and Turkey (17.8%). However, it is higher than some developing countries like Tibet area in China (1.1%), India (4.9%) and Taiwan (6%). In addition, studies in the Middle East showed that the prevalence of asthma is higher among younger boys. However, the difference decreases between the two sexes in early adolescence  . This male gender predilection to Asthma was raised in other studies from Japan, Turkey, Nigeria, South Korea, and India .
In a systematic review Pearce et al. reported that the negative age trend for the prevalence of Asthma shown in the current study was also reported in 5 countries including Iran and Oman . In that paper, they reported that across 35 countries of the world, the prevalence of asthma in 21 countries (60%) is higher in the older age group and in nine countries (25.7%) is higher in the younger age group. It was reported in 10 countries (25.7%) that the difference was insignificant. Overall, in the Middle East, the prevalence of asthma is higher in the 13–14 years age group .
The 2016 GINA report was intended to provide an advice on diagnosis and treatment of asthma and make it more personalized and responsive to individual patient’s needs. The “new” definition of asthma was suggested to describe its heterogeneous nature. The report emphasized the importance of confirming the diagnosis of asthma using lung function test to minimize both under and over-treatment. In addition, it highlighted a comprehensive approach to asthma management that acknowledges the foundational role of inhaled corticosteroid therapy. The framework for individualizing patient care addressed common problems such as incorrect inhaler technique and poor adherence; a continuum of care for worsening asthma, starting with early self-management and progressing to acute care management .
The use of steroids in management of Asthma was recorded at least once in only 22.7% of cases in the current study. This percentage is very low, especially if we consider that management of asthma patients is complicated by non-adherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk and therefore as a reason for more frequent visits to the health centers . Referring to the GINA advice on using steroids, the current study showed that physicians in primary care are resistant to the idea of using preventive steroids medication for cases with Asthma. Only those with very frequent visits (> 5 per year) would be deemed eligible for using steroid by their managing physician. It is interesting to observe that even for those cases with very frequent visits, still a quarter had never used a steroid medication.
It is expected that Asthma is over diagnosed in the present study, since pulmonary function tests are not available in primary health care setting. In addition, the calculation of prevalence rate may suffer from bias because using the registered cases as the population at risk is not an accurate representation for catchment area and some of the Asthma cases prefer to receive care in hospitals.