Acute asthmatic attacks in Bahrain in the wake of the Gulf War: a follow-up.

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Introduction

Bahrain is an archipelago located within the Arabian Gulf with a total area of 693.5 [km.sup.2] and an estimated population of 516,444. This nation lies 320 km to the South-East of Kuwait. Medical services are provided by a well-developed, free-of-charge government health system and a small private sector. There are 19 easily accessible government health care centers which act as referral centers for the largest segment of the population. In these centers, patients with acute asthmatic attacks are treated by albuterol (Ventolin[R]) inhalation via a nebulizer.

[TABULAR DATA FOR TABLE 1 OMITTED]

The health effects of smoke from the burning oil wells of Kuwait (SBOWK) in the wake of the 1991 Operation Desert Storm have been well-documented (1, 2, 3). Most prominent among these effects are respiratory conditions. SBOWK has been drifting to all neighboring nations. It was even noticed 2,000 km away from the source area (4). Thus, the Bahraini population was exposed to, and may have been adversely affected by, this drifting smoke. Earlier data indicated a substantial increase in the use of Ventolin[R] nebulizer in Bahrain between 1990 and 1991 (5). This paper analyzes trends after 1991 to determine whether the increase in nebulizer use continued in the years following the extinction of burning wells.

Methods

Monthly data on medical encounters at four health centers in Bahrain were reviewed for the period between January 1 and August 31 for two consecutive years (1992 1993). Monthly frequencies of Ventolin[R] nebulizer use per 100 medical encounters were computed. Monthly frequencies were compared to those reported in the three preceding years (5). Variances from the 1991 baseline data were tested for significance using [[Chi].sup.2] (df = 1). Corresponding p-values are presented with results.

Results

The monthly frequencies of medical encounters ending in Ventolin[R] nebulizer use are presented in Table 1. A total of 331,095 encounters were recorded for 1992, and 335,620 for 1993. There was no clear periodicity to Ventolin[R] use within each single year. While in 1992 use reached a maximum in May, in 1993 usage started at the highest levels in January and decreased steadily throughout the year. Overall, cumulative annual frequencies of medical encounters ending in a Ventolin[R] prescription have been increasing steadily. Frequencies were 2.9% in 1992 and 3.8% in 1993. Frequencies in 1992 and 1993 were significantly higher than previously reported in 1991 (p[less than]0.01). Trends since 1989 are presented in Figure 1.

Discussion

A significant increase in Ventolin[R] nebulizer use in Bahrain was found in 1991 following the burning of oil wells in Kuwait in the wake of Operation Desert Storm. The frequency of such use reported during the following two years (1992-1993) significantly increased from the 1991 level. No changes intervened in the process of diagnosing asthma in the health centers reviewed, thus eliminating the possibility of an artificial increase due to changes in medical practice.

Sulfur dioxide is mainly produced by the burning of coal, oil, pulp, and by paper mills. Particulate matter refers to any smoke, dust, droplets, or dirt occurring as a result of natural events or human activity. Of concern is exposure to a high concentration of particulate matter size 10 and less ([PM.sub.10]), because such particles can reach the terminal bronchioles and alveoli (6). Reasons for the increase in nebulizer use in 1991 are well-understood. Exposure to high levels of sulfur dioxide results in bronchospasm in persons without reactive airway disease (RAD), and exacerbates this condition in persons with RAD (6). United Nations agencies reported an increase above permissible levels of S[O.sub.2] in the air of the Gulf region between April and July 1991 (7). Exposure to high concentrations of [PM.sub.10] results in a 1.5 to 2.1-fold increase in the rate of asthma, and a 6.2-fold increase in the use of asthma medication (6, 8). Exposure to high levels of [PM.sub.10] was observed in the aforementioned period (2, 7).

The continued increase in nebulizer use after the extinction of the Kuwaiti fires may be attributed to a number of factors. Studies have shown that people exposed to outdoor pollution may be at higher risk of developing chronic obstructive pulmonary disease later in life (9, 10). Exposure to high levels of air pollutants in 1991 may therefore have resulted in physiological changes within the bronchial tree, leading to chronic respiratory problems. Increasing trends in nebulizer use may indicate that asthmagenic particles produced by burning fossil fuel may still be deposited in the Bahraini environment. No toxicological data were available from Bahrain to confirm the persistence of such particles. It is also possible that increased asthma incidence, as indicated by increased Ventolin[R] use in Bahrain, may be the local reflection of similar increases in asthma in some developed countries (11, 12).

Data were limited in that they did not indicate the proportion of return visits included in monthly accounts, but it may be assumed that the same proportion of return visits persisted throughout the period reviewed. At any rate, some increase in nebulizer use was demonstrated. The appropriate preventive approach to such an increase must be established based on a clear understanding of the predominant pathological mechanisms involved. Continued monitoring of Ventolin[R] use in the coming years may help determine whether increases in Bahrain were specifically due to war-related pollution. If such is the case, nebulizer use should normally decrease over longer periods of observation. In the opposite case, global reasons may he more strongly implicated.

Conclusion

After the extinction of the oil wells of Kuwait, there was a significant increase in the use of Ventolin[R] nebulizer in Bahrain. This trend is similar to that reported in many countries. A delayed effect of pollutants emitted by the burning wells cannot be ruled out.

Acknowledgement

We are grateful to Professor May Jurdi from the Dept. of Environmental Health, Faculty of Health Sciences, American University of Beirut for her comments on this paper.

REFERENCES

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Corresponding author: Dr. Basem Roberto Saab, Department of Family Medicine, American University of Beirut, 850 3rd Ave., New York, NY 10022.