Abstract
Background:
There is a dearth of epidemiologic studies on allergic diseases in children in the Philippines.
Objective:
This study aimed to describe the prevalence, characteristics, and management of allergic disease consultations among pediatric patients who visited urban, rural, and remote primary care health facilities.
Methods:
This was a cross-sectional study involving all pediatric patients less than 19 years old who sought consultation in the primary care facilities in the urban, rural, and remote sites from May 1, 2019, to April 30, 2022. Data from each pediatric consult were encoded in real time into the electronic health record (EHR) by healthcare workers in the primary care sites. The Philippine Primary Care Studies data management team extracted from the EHR the month and year of consultation, frequency of consults, demographic factors including age, sex, and location, and clinical factors including chief complaint, diagnosis, management, and family history of allergic disease of the study participants.
Results:
There were 20,380 pediatric patients who consulted in the 3 primary care sites over the 3-year study period from May 1, 2019, to April 30, 2022, of which 546 (2.7%) had an allergic condition. The most common allergic condition across the sites was asthma at 74.9%, followed by atopic dermatitis (13.2%) and allergic contact dermatitis (8.1%). The average number of consults per patient was 1.2 (standard deviation: 0.7). Significant variation in the pharmacologic management of the various allergic conditions was observed across the sites.
Conclusion:
The prevalence of allergic conditions among pediatric patients consulting in the 3 primary care sites was 2.7%, although this is likely an underestimate due to missed diagnosis especially for mild or asymptomatic disease, and lack of confirmatory testing in the primary care setting. Underutilization of first-line medications and overutilization of nonessential drugs were more apparent in the rural and remote sites.
Keywords: Asthma, hypersensitivity, pediatrics, Philippines, primary health care
1. Introduction
The burden of disease of allergic disease conditions, including allergic rhinitis, asthma, atopic dermatitis, and food allergy, has dramatically increased in the past decades. Children are most affected by the increase in prevalence of allergic conditions [1]. The global incident cases of childhood atopic dermatitis increased by 39.4%, while the global incident cases of childhood asthma increased by 7.07% from 1990 to 2019 [2]. Among children in industrialized countries, the prevalence of childhood allergic rhinitis increased by 2% to 3% over the last 3 decades [1, 3]. Worldwide, it is estimated that 15% to 30% of children have allergic rhinitis, 9% to 11% of children have asthma, 6% have atopic dermatitis, and 4% of children have food allergy [1, 4–6]. The global prevalence of urticaria remained relatively unchanged in the past 3 decades, affecting 1.1% of the global population [7].
There is geographical variation in the burden of allergic diseases. The highest number of asthma incident cases was observed in Eastern Africa, while Southeast Asia had incidences lower than the global average [2]. Food allergies are more prevalent in Western countries in general, although a higher prevalence of shellfish allergy is observed in Southeast Asia [4]. Urbanization is also hypothesized to affect the incidence of allergic diseases. Urban residence, with greater exposure to environmental pollutants, a sedentary lifestyle, higher antibiotic use, and a Western diet, has been associated with a higher prevalence of allergic conditions [8, 9].
There is a dearth of epidemiologic studies on allergic diseases in children in the Philippines. A 2024 study reported that 1.6% of children consulting in a Philippine primary care clinic were diagnosed with asthma over a 1-year study period [10]. A 2006 study using the National Nutrition and Health Survey data reported a 9.2% prevalence of asthma based on wheezing symptoms among Filipino children [11]. Investigation into the disparities in the burden of allergic diseases across different settings is needed. This information is crucial for the institution of appropriate public health policies, creation of effective interventional and educational programs, and proper allocation of health resources.
The Philippine Primary Care Studies (PPCS) program was launched in 2016. This program pilot tested and assessed the effect of interventions intended to strengthen the Philippine primary care health system. The interventions were implemented in an urban, rural, and remote site. The interventions included health financing, development of an electronic health record (EHR) system, augmentation and training of health human resources, and community engagement. The urban site was the health facility at the state university in Quezon City, Metro Manila, which provided healthcare services to its employees. The rural site was a fourth-class municipality in the province of Bataan. The remote site was also a fourth-class municipality in the province of Sorsogon and is considered a geographically isolated and disadvantaged area. The interventions were implemented in the urban site in the year 2016 and in the rural and remote sites in the year 2019. Full funding was available in the first year of implementation. Only residual funds were available for the second year, while funding was already depleted by the third year [12].
This study aimed to describe the prevalence, characteristics, and management of allergic disease conditions among children who consulted in an urban, rural, and remote primary care health facility. Specifically, this study aimed to: (1) determine the prevalence of pediatric allergic diseases in primary care clinics, including allergic rhinitis, asthma, atopic dermatitis, food allergy, and urticaria, (2) describe the demographic and clinical characteristics of children with allergic diseases, and (3) describe the management of pediatric allergic diseases in the primary care sites.
2. Methodology
2.1. Study design
This was a cross-sectional study involving retrospective review of the EHR records in the PPCS primary care sites. The EHR system was started in October 2016 at the urban site, April 2019 at the rural site, and May 2019 at the remote site [13]. This study involved the EHR records of the 3 sites over a 3-year time period, from May 1, 2019, to April 30, 2022.
2.2. Study site
The urban site is the health service of a tertiary university that provides primary care services to 15,051 faculty members, employees, their dependents, and students.
The rural site had 1 Rural Health Unit and 14 Barangay Health Stations (or community health stations), which provided primary care to its adult and pediatric residents. The rural site had 35,298 residents. There were no private clinics in this municipality. The remote site had 1 Rural Health Unit and 7 Barangay Health Stations, which similarly provided primary care to its adult and pediatric residents. The site has 22,884 residents. Although there are 2 private clinics in this municipality, most of the primary care consults were through the Rural Health Unit or Barangay Health Stations. Primary care services for children included well-child visits for preventive and immunization services and consultation for sick children [14].
2.3. Study participants
The records of all pediatric patients less than 19 years old who sought consultation in the primary care facilities in the urban, rural, and remote sites from May 1, 2019, to April 30, 2022, were reviewed. All patients with a diagnosis of atopic dermatitis (International Classification of Diseases [ICD] code L20), allergic rhinitis (ICD code J30), asthma (ICD code J45), food allergy (ICD code Z91.01), urticaria (ICD code L50), drug allergy (ICD code Z88), or allergic contact dermatitis (ICD code L23) were included.
2.4. Data collection and processing
Data from each pediatric consult were encoded in real time into the EHR by healthcare workers in the primary care sites. The PPCS data management team extracted from the EHR the month and year of consultation, frequency of consults, demographic factors including age, sex, and location, and clinical factors including chief complaint, diagnosis, management, and family history of allergic disease of the study participants.
The data were cleaned and processed using Microsoft Excel. In case of missing data, it was encoded as “not reported.” The unit of the study in reporting the prevalence of allergic conditions is the patient, such that a patient with multiple allergic conditions was counted as one when computing for prevalence. The number of patients with multiple allergic diagnoses was reported. For the variables chief complaint, severity classification, pharmacologic management, and nonpharmacologic management, each consult was counted separately since these variables may change for each consult.
2.5. Data analysis
The data were presented using descriptive statistics. Categorical variables were reported using frequencies and percentages, while continuous variables were reported as mean and standard deviation (SD) if normally distributed, or median and interquartile range if not normally distributed. GraphPad Prism version 8 (GraphPad Software, Inc, San Diego, CA, USA ) was used to create the appropriate graphs. Prevalence of pediatric allergic disease in the primary care clinics was computed as the number of patients diagnosed to have an allergic condition divided by the total number of pediatric patients who consulted within the 3-year study period.
2.6. Ethics
We obtained informed consent for the involvement of PPCS-related research from all patients who consulted at the PPCS sites. The study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2015-489-01, Review Panel Chair Dr. Virginia De Jesus, approved February 4, 2022) with address at Room 126, National Institutes of Health, University of the Philippines Manila, 623 Pedro Gil Street, Ermita, Manila, Philippines. The participants in this study gave informed consent for the use of their data for research purposes. Anonymized data were extracted to protect the study participants’ privacy and confidentiality. Data were stored in a password-protected laptop accessible only to the study investigators and will be destroyed 3 years after study completion.
3. Results
There were 20,380 unique pediatric patients who made 36,801 consults in the 3 primary care sites over the 3-year study period. Of the 20,380 patients, 546 (2.7%) had an allergic condition. In the urban site, 33 out of 2,274 pediatric patients (1.5%) had an allergic condition. In the rural site, 281 out of 11,545 pediatric patients (2.4%) had an allergic condition. In the remote site, 232 out of 6,561 pediatric patients (3.5%) had an allergic condition.
Across the sites, the most common allergic condition was asthma at 74.9%. This was followed by atopic dermatitis (13.2%) and allergic contact dermatitis (8.1%) (Table 1). There were 22 patients with multiple allergic conditions (4.0%), the most common of which was asthma with allergic rhinitis affecting 12 patients.
Table 1.
Frequency distribution of allergic conditions among pediatric patients in the primary care sites
| Disease | Urban site (n = 33), n (%) | Rural site (n = 281*), n (%) | Remote site (n = 232†), n (%) | Overall (N = 546), n (%) |
|---|---|---|---|---|
| Asthma | 25 (75.8) | 169 (60.1) | 215 (92.7) | 409 (74.9) |
| Atopic dermatitis | 3 (9.1) | 66 (23.5) | 3 (1.3) | 72 (13.2) |
| Allergic contact dermatitis | 4 (12.1) | 31 (11.0) | 8 (3.4) | 43 (7.9) |
| Urticaria | 0 | 18 (6.4) | 8 (3.4) | 26 (4.8) |
| Allergic rhinitis | 0 | 11 (3.9) | 2 (0.9) | 13 (2.4) |
| Drug allergy | 1 (3.0) | 2 (0.7) | 1 (0.4) | 4 (0.7) |
| Food allergy | 0 | 2 (0.7) | 0 | 2 (0.4) |
| Anaphylaxis | 0 | 1 (0.4) | 0 | 1 (0.2) |
15 patients had multiple allergic conditions, with 14 having 2 allergic conditions and 1 having 3 allergic conditions.
5 patients had 2 allergic conditions.
The 546 unique pediatric patients diagnosed with an allergic condition made a total of 666 consults over the 3-year period. The highest number of pediatric consults for allergic conditions was recorded in year 1, with 492 consults across the 3 sites. There were only 129 consults in year 2, and 45 consults in year 3 (Fig. 1).
Figure 1.
Number of pediatric allergic consults per year across urban, rural, and remote Philippine primary care sites.
Figure 2 shows the number of monthly pediatric allergy consults per month in each of the sites. The highest number of consults across the sites was recorded in February (79 consults, 12%), September (77 consults, 12%), and January (73 consults, 11%). The lowest number of consults was recorded in April (21 consults, 3%) and December (28 consults, 4%).
Figure 2.
Monthly number of pediatric allergic consults in the urban, rural, and remote Philippine primary care sites.
Overall, the mean age of patients was 5 years (SD: 5.0). The patients in the urban site were older (mean 9 years, SD: 6.1) compared with the rural (mean 6.3 years, SD: 5.2) and remote sites (mean 5.9 years, SD: 4.6). There were slightly more males (56.2%) compared with females. The most common chief complaints were cough (48.9%) and colds (30.8%). The most common concomitant diagnoses were lower respiratory tract infections (17.8%) and upper respiratory tract infections (16.3%). The majority of the patients (83.3%) did not have a family history of allergic disease. The average number of consults per patient was 1.2 (SD: 0.7). The demographic and clinical characteristics of the 546 pediatric patients with allergic conditions are detailed in Supplementary Table 1, https://links.lww.com/PA9/A71.
3.1. Asthma
There were 409 patients diagnosed with asthma, with a total of 503 consults. The majority of patients were from the remote site (215 patients or 52.6%). The average age of the patients in the urban site was higher (9.8 years) compared with the rural (6.7 years) and remote (6.0 years) sites. There were more males (59.4%) with asthma across the sites. The average number of consults per patient was 1.3 times (SD 0.7). The most common chief complaint across all sites was cough (57.2%), followed by colds (36.0%) (Supplementary Table 2, https://links.lww.com/PA9/A71). In the rural site, 40.8% of patients were recorded to be in exacerbation compared with 24.2% in the remote site and 18.5% in the urban site. The majority of the patients (59.2%) did not have their severity classification recorded in the EHR.
There were 11 patients in the rural site with other concomitant allergic conditions, including allergic rhinitis (9 patients), atopic dermatitis (1 patient), and allergic rhinitis with urticaria (1 patient). In the remote site, 5 patients had other concomitant allergic conditions, including allergic rhinitis (2 patients), atopic dermatitis (1 patient), and urticaria (2 patients).
The most common pharmacologic treatment in the urban site is inhaled short-acting beta-agonist combined with short-acting muscarinic antagonist (SABA/SAMA, 37.0%), followed by inhaled SABA (33.3%). Of the 25 patients with asthma in the urban site, 5 (25%) were prescribed inhaled corticosteroids (ICS). In the rural site, the most common prescribed medication was antihistamines (62.9%), followed by inhaled SABA (63.0%) and oral antibiotics (55.5%). ICS was prescribed in only 5.9% of patients (10 out of 169). In the remote site, the most common prescribed medication was oral corticosteroids (52.1%), followed by oral SABA (44.2%) and inhaled SABA/SAMA (37.7%). ICS was prescribed in only 0.9% of patients (2 out of 215).
Most consults did not have nonpharmacologic management plans recorded in the EHR. The most common nonpharmacological advice was to increase fluid intake, followed by steam therapy (Table 2).
Table 2.
Severity and management of consults for pediatric asthma
| Parameters | Urban site (n = 27), n (%) | Rural site (n = 211), n (%) | Remote site (n = 265), n (%) | Overall (N = 503), n (%) |
|---|---|---|---|---|
| Severity classification | ||||
| In exacerbation | 5 (18.5) | 86 (40.8) | 64 (24.2) | 155 (30.8) |
| Not reported | 22 (81.5) | 125 (59.2) | 151 (57.0) | 298 (59.2) |
| Pharmacologic management | ||||
| Inhaled SABA | 9 (33.3) | 133 (63.0) | 47 (17.7) | 189 (37.6) |
| Inhaled SABA/SAMA | 10 (37.0) | 39 (18.5) | 100 (37.7) | 149 (29.6) |
| ICS | 4 (14.8) | 1 (0.5) | 0 | 5 (1.0) |
| ICS/LABA | 1 (3.7) | 12 (5.7) | 3 (1.1) | 16 (3.2) |
| Oral corticosteroids | 0 | 21 (10.0) | 138 (52.1) | 159 (31.6) |
| Oral SABA | 2 (7.4) | 54 (25.6) | 117 (44.2) | 173 (34.4) |
| LRA | 2 (7.4) | 41 (19.4) | 31 (11.7) | 74 (14.7) |
| Antihistamine | 5 (18.5) | 137 (64.9) | 51 (19.2) | 193 (38.4) |
| Antibiotic | 4 (14.8) | 117 (55.5) | 90 (34.0) | 211 (41.9) |
| Mucolytic | 7 (25.9) | 14 (6.6) | 7 (2.6) | 28 (5.6) |
| Herbal medications | 3 (11.1) | 11 (5.2) | 20 (7.5) | 34 (6.8) |
| Decongestant | 1 (3.7) | 0 | 0 | 1 (0.2) |
| Sodium chloride spray | 1 (3.7) | 2 (0.9) | 8 (3.0) | 11 (2.2) |
| Antipyretic | 0 | 47 (22.3) | 97 (36.6) | 144 (28.6) |
| Expectorant | 0 | 23 (10.9) | 1 (0.4) | 24 (4.8) |
| Vitamins | 0 | 30 (14.2) | 34 (12.8) | 64 (12.7) |
| Nonpharmacologic management | ||||
| Increased fluid intake | 3 (11.1) | 1 (0.5) | 5 (18.9) | 9 (1.8) |
| Steam therapy | 1 (3.7) | 1 (0.5) | 0 | 2 (0.4) |
| Dietary restriction | 1 (3.7) | 0 | 0 | 1 (0.2) |
| Smoking cessation | 0 | 0 | 1 (0.4) | 1 (0.2) |
ICS, inhaled corticosteroids; LABA, long-acting beta-agonist; LRA, leukotriene receptor antagonist; n, number of consults; SABA, short-acting beta-agonist; SAMA, short-acting muscarinic antagonist.
3.2. Allergic rhinitis
There were 13 patients diagnosed with allergic rhinitis, with 11 patients coming from the rural site (84.6%) and 2 patients from the remote site (15.4%). There were no patients diagnosed with allergic rhinitis in the urban site. The average age of patients is higher in the rural site (9.9 years) compared with the remote site (3.5 years). There was a male predilection observed (61.5%). Only 1 patient in the rural site and 1 patient in the remote site had a follow-up consultation. The rest of the patients consulted only once in the 3-year period. Ten out of the 11 patients (90.9%) in the rural site and both patients in the remote site had concomitant asthma.
The most common chief complaint in the rural site was asthma attack (41.7%), followed by a request for a medical certificate (25.0%) and cough (16.7%). In the remote site, the most common chief complaint was cough (100%), followed by colds (66.7%). All patients did not have the severity classification of their allergic rhinitis recorded in the EHR.
The most common pharmacologic treatment in the rural site is antihistamines and inhaled SABA (33.3%). In the remote site, the most common prescribed medication was inhaled SABA/SAMA (100%). No patients were prescribed intranasal corticosteroids. All patients did not have any nonpharmacologic management plans recorded in the EHR (Supplementary Table 3, https://links.lww.com/PA9/A71).
3.3. Atopic dermatitis
There were 72 patients diagnosed with atopic dermatitis, with the majority of patients coming from the rural site (66 of 72, 91.7%). The average age of patients is higher in the urban site (10 years) compared with the rural site (4.7 years) and the remote site, where all patients were infants 1-year old and below. There was no sex predilection observed (Supplementary Table 4, https://links.lww.com/PA9/A71). Only 2 patients in the rural site had a follow-up consultation. The rest of the patients consulted only once in the 3-year period.
The most common chief complaint across all sites was rashes (50%). In the rural and remote sites, the second most common chief complaint was wounds or ulcerations. All patients did not have the severity classification of their atopic dermatitis recorded in the EHR.
The most common pharmacologic treatment across all sites was oral antihistamine. Oral antibiotics were prescribed in 45.6% of consults in the rural site and 66.7% in the remote site. Topical antipruritic drugs (calamine-containing preparations) were prescribed in 30.9% of consults in the rural site, but not prescribed in the urban and remote sites. Topical corticosteroids were prescribed in 33.3% of consults in the urban and remote sites and in 25% of consults in the rural site. Topical calcineurin inhibitors were prescribed to a patient in the urban site, but not prescribed in the rural and remote sites. The most common nonpharmacologic management was advice on skin care (including use of mild soap and moisturizers) (Table 3).
Table 3.
Chief complaint and management of consults for pediatric atopic dermatitis
| Parameters | Urban site (n = 3), n (%) | Rural site (n = 68), n (%) | Remote site (n = 3), n (%) | Overall (N = 74), n (%) |
|---|---|---|---|---|
| Chief complaint | ||||
| Rashes | 2 (66.7) | 33 (48.5) | 2 (66.7) | 37 (50.0) |
| Wounds/ulcers | 0 | 7 (10.3) | 1 (33.3) | 8 (10.8) |
| Colds | 0 | 6 (8.8) | 0 | 6 (8.1) |
| Pruritus | 1 (33.3) | 4 (5.9) | 1 (33.3) | 6 (8.1) |
| Cough | 0 | 5 (7.4) | 0 | 5 (6.8) |
| Skin irritation | 0 | 2 (2.9) | 0 | 2 (2.7) |
| Furuncle | 0 | 1 (1.5) | 0 | 1 (1.4) |
| Skin allergy | 0 | 1 (1.5) | 0 | 1 (1.4) |
| Pharmacologic management | ||||
| Oral antihistamine | 2 (66.7) | 41 (60.3) | 3 (100.0) | 46 (62.2) |
| Oral antibiotic | 0 | 31 (45.6) | 2 (66.7) | 33 (44.6) |
| Vitamins | 0 | 20 (29.4) | 2 (66.7) | 22 (29.7) |
| Topical antipruritic | 0 | 21 (30.9) | 0 | 21 (28.4) |
| TCS | 1 (33.3) | 17 (25.0) | 1 (33.3) | 19 (25.7) |
| Topical antibiotics | 0 | 15 (22.1) | 0 | 15 (20.3) |
| Antipyretic | 0 | 5 (7.4) | 0 | 5 (6.8) |
| TCI | 1 (33.3) | 0 | 0 | 1 (1.4) |
| LRA | 1 (33.3) | 0 | 0 | 1 (1.4) |
| Topical scabicide | 0 | 1 (1.5) | 0 | 1 (1.4) |
| Nonpharmacologic management | ||||
| Skin care | 1 (33.3) | 1 (1.5) | 2 (66.7) | 4 (5.4) |
| Avoidance of irritants | 1 (33.3) | 1 (1.5) | 0 | 2 (2.7) |
| Wound care | 0 | 1 (1.5) | 0 | 1 (1.4) |
| Diet change | 0 | 1 (1.5) | 0 | 1 (1.4) |
LRA, leukotriene receptor antagonist; n, number of consults; TCI, topical calcineurin inhibitors; TCS, topical corticosteroids.
3.4. Allergic contact dermatitis
There were 43 patients diagnosed with allergic contact dermatitis, with the majority of patients coming from the rural site (31 of 43, 72.1%). The average age of patients is higher in the urban site (11.8 years) compared with the rural (6.1 years) and remote (5.9 years) sites. There was a slight female predilection observed (53.4%). All patients consulted only once during the 3-year period.
The most common chief complaint was skin rash for the urban site (100%) and the remote site (62.5%). In the rural site, the most common chief complaint was pruritus (38.7%), followed by wounds (22.6%). There were 2 patients in the rural site where the suspected trigger was identified (cosmetics and food). No identified trigger was recorded in the EHR for the rest of the patients.
The most common pharmacologic treatment across all sites was oral antihistamine. Oral antibiotics were prescribed in 32.3% of consults, and topical antibiotics were prescribed in 22.6% of consults in the rural site. Oral corticosteroids were prescribed in 37.5% in the remote site, but not in the urban and rural sites. The most common nonpharmacologic management was advice on skin care (use of mild soap) (Supplementary Table 5, https://links.lww.com/PA9/A71).
3.5. Urticaria
There were 28 patients diagnosed with urticaria, with 18 patients coming from the rural site (69.2%) and 8 patients from the remote site (30.8%). There were no patients diagnosed with urticaria in the urban site. The overall average age of patients is 7.8 years (SD: 5.4), with female predilection. All patients consulted only once in the 3-year period.
The most common chief complaint across both sites was rashes (61.5%), followed by pruritus (19.2%). The majority of patients (61.5%) had acute urticaria, while the remaining patients could not be classified due to inadequate data in the EHR. The majority of patients (76.9%) did not have the suspected trigger recorded in the EHR. There were 3 patients whose urticaria was attributed to food (shrimp, chicken/fish, and eggs/chicken). Two patients in the remote site had urticaria attributed to cold/heat, while one patient in the rural site developed urticaria after intake of an unnamed drug.
The most common pharmacologic treatment in both sites was oral antihistamine. Most consults did not have nonpharmacologic management plans recorded in the EHR (Supplementary Table 6, https://links.lww.com/PA9/A71).
3.6. Drug allergy
There were only 4 patients with drug allergies. One patient from the urban site was a 13-year-old female with a reported history of allergy to penicillin. Two patients were from the rural site. There was an 8-year-old female with a reported history of allergy to penicillin who consulted due to a pruritic skin rash. She was prescribed clarithromycin. The other patient was a 17-year-old female who consulted due to erythema after intake of an unnamed medication the night prior. She was diagnosed with urticaria and prescribed antihistamines and oral corticosteroids. One patient from the remote site was a 9-month-old male, consulting due to cough, cold, fever, and rashes after the first dose of a measles-containing vaccine. He was diagnosed to have allergy to vaccines and prescribed antihistamine, paracetamol, and vitamins. All patients did not have follow-up consultation in the 3-year period.
3.7. Food allergy
There were only 2 patients with food allergy, both from the rural site. One patient was a 16-year-old female who developed anaphylaxis after eating shrimp. She was prescribed antihistamines and oral corticosteroids. The second patient was a 2-year-old male who consulted due to skin rashes. He was diagnosed to have urticaria, probably secondary to chicken and fish. He was prescribed antihistamines and topical steroids and was advised to avoid eating chicken and fish. Both patients did not have follow-up consultation in the 3-year period.
4. Discussion
From the years 2019 to 2022, only 2.7% of all pediatric patients who consulted in the 3 primary care sites were identified to have an allergic condition. The lowest proportion of patients with an allergic condition was observed in the urban site (1.5%), while the highest was observed in the remote site (3.5%).
The low prevalence of allergic conditions in primary care clinics in this study may be due to missed diagnosis of allergic conditions, particularly if the patients had mild or asymptomatic allergic disease at the time of consultation or if the parents/patients feel that the condition is not bothersome enough to warrant consultation. A study in Japan reported that among children 1 year of age, 16.8% of parents reported eczema in their children, but only 4% received a clinical diagnosis from a physician [15]. Similarly, a study in Puerto Rico reported that physicians missed >75% of allergic rhinitis diagnoses among children without asthma and missed >85% of allergic rhinitis diagnoses among children with asthma. The missed diagnosis leads to poor control of allergic conditions, leading to reduced quality of life and a higher risk of complications from these allergic diseases [16]. As can be observed in our study, the majority of patients had severe or complicated disease at the time of consultation. Almost a third of patients with asthma had exacerbation at the time of consultation. The highest proportion of patients in exacerbation was observed in the rural site, followed by the remote site, which reflects poorer disease control compared with the urban site. Oral antibiotics were prescribed in 66.7% of patients with atopic dermatitis in the remote site and 45.6% of patients in the rural site, compared with none in the urban site. This suggests the presence of secondary bacterial infection complicating the atopic dermatitis among patients in the remote and rural site. Similarly, among patients with allergic contact dermatitis, 32.3% in the rural site and 12.5% in the remote site were prescribed oral antibiotics compared with none in the urban site.
There was seasonal variation in the number of consults, with the majority of consults recorded in the months of January, February, and September. This finding is similar to international literature reporting seasonality of allergic conditions due to fluctuating temperature and humidity, changes in aeroallergen concentrations, and seasonality of respiratory infections. A study in Korea reported that asthma consults peaked in the winter (December to March) and spring (April to June) and allergic rhinitis consults peaked in September, while atopic dermatitis consults peaked from May to August [17]. A 2021 study reported that the peak expiratory flow rate among children with asthma was significantly reduced in April, August, October, and December, increasing the risk for asthma exacerbations [18].
Allergic diseases are chronic, relapsing diseases that need long-term care. Poor disease control leads to negative health consequences, including poor sleep, suboptimal growth, poor academic performance, and poor quality of life [19]. Based on the Global Initiative for Asthma (GINA) guidelines, children in exacerbation should be followed up within 1 to 2 days, and then at 1 to 2 months. Once asthma has been well controlled for 2 to 3 months, continued follow-up is still needed to step down the pharmacologic treatment [20]. In this study, the majority of patients had only 1 consult over the 3-year period, with the average number of consults at 1.2. The reason for the limited follow-up consults in this study is likely multifactorial, including parents’ beliefs that the disease has been resolved or that the symptoms are mild and do not need medical care, the lack of time to bring the children to the primary care facilities due to competing work and home responsibilities, and lack of patient satisfaction with the primary care facility services. The utility of telemedicine in monitoring allergic diseases has been reported in international literature. Telemedicine has been shown to have great potential in improving access to health care services, reducing the cost of consultations, and improving personal and public health [21]. Although telemedicine was also offered in the 3 study sites, some barriers were identified that deterred its full potential, including the need for infrastructural support for communication technology, building healthcare worker capacities in managing online platforms, and insufficient staffing to support telemedicine services. These barriers were most apparent in the remote site [22].
Variation in the management of allergic patients across sites was apparent in this study. The GINA guidelines recommend the use of oral corticosteroids only for asthmatic patients in acute exacerbation due to its adverse effects [20]. In this study, a large proportion of patients in the remote site were prescribed oral corticosteroids (52.1%) compared with the rural site (10%) and none in the urban site, despite the higher proportion of patients in exacerbation in the rural site (40.8%) compared with the remote site (24.2%). Oral SABA use was also higher in the remote site (44.2%) compared with the rural (25.6%) and urban site (7.4%). Antihistamine prescription was higher in the rural site (64.9%) than in the remote site (19.2%) and the urban site (18.5%). In the GINA guidelines, oral SABA and antihistamines are not recommended for the management of asthma. ICS and ICS/LABA medications, which are the recommended first-line medications based on the GINA guidelines, were prescribed more often in the urban site compared with the rural and remote sites [20]. It is also notable that across the 3 sites, mucolytics were prescribed more often than the first-line medications (ICS-containing drugs). In the rural and remote sites, oral corticosteroids, leukotriene receptor antagonists, antihistamines, antibiotics, and vitamins were also prescribed more often than ICS. Expectorants were also prescribed more often than ICS in the rural site, while herbal-containing medications were prescribed more often than ICS in the remote site.
International guidelines on atopic dermatitis recommend the use of topical corticosteroids or topical calcineurin inhibitors in addition to the use of emollients as first-line treatment [23, 24]. In this study, oral antihistamines were prescribed more frequently than topical corticosteroids or topical calcineurin inhibitors in all sites. Vitamins were also prescribed more frequently in the rural and remote site; topical antipruritic agents (calamine-containing preparations) and topical antibiotics were prescribed more frequently in the rural site compared with topical corticosteroids or topical calcineurin inhibitors.
Underutilization of first-line drugs and overutilization of nonessential drugs were more apparent in the rural and remote sites compared with the urban site. Possible reasons for this include variation in providers’ knowledge and attitudes toward clinical practice guidelines, poor accessibility and high cost of medications, fear of side effects, and the acceptability and ease of administration of certain medication routes to patients (eg, oral medications compared with inhaled medications) [25]. System-level factors such as the pharmaceutical industry influence and limited access to diagnostic facilities may also be contributory [26]. The results in this study may be useful for clinical practice guideline developers in the Philippines as they choose the priority topics for guideline development and decide which clinical questions should be included in the guidelines. Furthermore, clinical decision support tools may also be useful in guiding healthcare professionals on the recommended management for these allergic conditions. Given the step-wise approach in management for allergic conditions, with the recommended treatment varying per severity classification and the rapid advancements in scientific evidence on the recommended treatment, access to clinical decision support tools may be a valuable resource to ensure that the management of patients follows the latest recommendations.
Key components of allergy management, aside from pharmacologic treatment, are patient education and the identification and avoidance of triggers [27]. In this study, the majority of the patients did not have nonpharmacologic management recorded in the EHR. Tests to identify triggers, such as skin testing, specific IgE levels, and oral challenge to food or drugs, were also not done. This is expected since these tests are often provided by specialists or specialized laboratories who are often not available in the primary care setting. This highlights the importance of integrated care pathways where primary care providers can refer patients in need of more specialized services in an efficient manner.
There are several limitations to this study. First, this study covers only 3 selected sites where the PPCS interventions were instituted. Results of this study may not be generalizable to the national population. Second, the data collected in this study rely on the accuracy and completeness of patient records. The diagnosis in the EHR was encoded in real time by the physician at the primary care sites. Commonly used objective tests for allergic conditions, such as skin prick tests and serum IgE levels, are not available in the primary care setting. Thus, misdiagnosis and underdiagnosis of allergic conditions in the study population are possible, especially for patients with mild or asymptomatic disease. Thus, the results of this study are likely an underestimate of the true burden of disease of allergic conditions among children. Future studies where standardized criteria for diagnosis of the allergic conditions are set by the investigators are needed to better estimate the prevalence and burden of disease. Third, the severity classification of the allergic conditions was not reported in the EHR, and there was a low average number of follow-up consults. Since the management of most allergic conditions has a step-wise approach, it is difficult to draw conclusions in terms of the quality of care and long-term disease control received by the study population. Moreover, qualitative studies to explore providers’ knowledge, attitudes, and practices and patients’ preferences and experiences are needed to contextualize the results observed in this study. Finally, there are several external factors that affected the results. The COVID-19 pandemic changed the health landscape of the Philippines, leading to alterations in the provision of healthcare services and increasing hesitancy among patients to seek consultation in fear of contracting the disease. Funding for the PPCS interventions also declined over time, with the first year of implementation receiving full funding, the second year of implementation having just partial funding, and the third year of implementation having no funds left. The number of patient consults generally declined over time with the decline in funding, as is observed in this study, with the highest number of consults observed from 2019 to 2020 and a sharp decline afterwards.
5. Conclusion
The prevalence of allergic conditions among pediatric patients consulting in the 3 primary care sites was 2.7%, although this is likely an underestimate due to missed diagnosis, especially for mild or asymptomatic disease, and lack of confirmatory testing in the primary care setting. The most common allergic condition across the 3 sites was asthma. Pharmacologic management varied across sites. The majority of the patients did not have severity classification and nonpharmacologic management plans recorded in the EHR. Underutilization of first-line medications and overutilization of nonessential drugs were more apparent in the rural and remote sites.
Acknowledgements
The authors would like to thank the field staff in the University of the Philippines Diliman, Samal, Bataan, and Bulusan, Sorsogon. The study was funded by the Philippine Department of Health (DOH), the Philippine Health Insurance Corporation (PhilHealth), the Emerging Interdisciplinary Research Program (EIDR), the Center for Integrative and Development Studies (CIDS), and the Philippine Council for Health Research and Development (PCHRD).
Conflicts of interest
The authors declare no conflicts of interest.
Author contributions
CSCT-L, LFD, and AMLD did the conceptualization and development of the methodology. CSCT-L, RMGF, JFF, and MBF performed the data analysis. CSCT-L, RMGF, and JFF wrote the original draft. All authors were involved in review and editing of the final draft.
Supplementary Material
Footnotes
Supplementary material can be found via https://journals.lww.com/apallergy
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