Albuterol nebulizer use in Bahrain and the burning oil wells of Kuwait.

Bahrain is an archipelago with a total area of 693.15 |km.sup.2~, and an estimated population of 516,444. It is located in the Arabian Gulf 320 km southeast of the oil wells of Kuwait. According to a source in the Bahrain Civil Aviation Affairs' Meteorological Service, smoke from the burning oil wells of Kuwait was noticed in the skies of Bahrain for at least 70 percent of the time between the later part of February through the end of July 1991 (1, 2). On those days where smoke was observed, it was at the surface for 44 percent of the time (2). In addition to a drop in the temperature and humidity, the agricultural crop was severely affected (2, 3, 4, 5, 6). Lastly, the level of dust particles contributing to air pollution was reported to have increased after the outbreak of the Desert Storm Operation (7).

Having heard all of these reports, one wonders if the smoke from the burning oil wells of Kuwait had any effect on the health of the people living in Bahrain. Many conferences were organized to study this question. The conclusion heard in many instances was that the air pollution recorded in Bahrain was lower than that found in many western industrialized countries. This by itself is not reassuring. In Japan, for instance, the level of nitrogen oxide in the air is high, and considered to be an important health hazard (8). In the United Kingdom and the U.S., the incidence and the mortality rate for asthma are increasing (9, 10). A recent study from the U.S. has shown that respiratory symptoms still occur because of air pollution (11). Furthermore, some researchers found that asthmatic subjects may experience significant changes in pulmonary function, even when exposed to sulfuric acid levels that are much lower than the permissible exposure limit (12).

This study examines the incidence of albuterol nebulizer prescriptions in Bahrain between the beginning of January and the end of August from 1989 to 1992. Such data may help to determine whether asthmatics were affected by the SBOWK.

Methods

The procedure books in four health centres --Muharraq, Nai'm, Hoora, and Sheikh Sabah-- were reviewed for the period between January 1 and August 31 for three consecutive years beginning in 1989. The frequency of administering albuterol nebulizer per month was noted (Table 1). The number of medical encounters per month for the same health centres within the period specified also was determined.

Results

The number of albuterol (Ventolin |R~) nebulizer prescriptions per month, per thousand medical encounter for the period mentioned above are displayed in Figure 1. The number of medical encounters per month in the four considered health centres and the aforementioned period are shown in Figure 2. This load represents around 20 percent of the patients examined in Bahrain.

Although the data for the three years are not independent, the denominator (total number of visits per month) is large, and the difference in the use of albuterol nebulizer was compared for every month using the |X.sup.2~ test. The difference in the number of albuterol nebulizer prescriptions per thousand medical visits, between 1989 and 1991, is highly significant (p |is less than~ 0.001) in all the months considered. Such difference was not noticed when one compares 1989 and 1990.

Discussion

When compared to the previous two years, an increase in albuterol nebulizer use during the year 1991 is noted. The increase may be attributed to more than one factor. Of those mentioned, psychological factors, weather changes, air pollution and exercise all could be contributing factors.

Observation of the black smoke in the sky may of itself cause stress, which in turn may precipitate an asthmatic attack (13, 14). The highest rate of Ventolin nebulizer prescriptions was seen in January 1991. This was before the oil wells in Kuwait were set on fire. There could be more than one explanation for this: psychological stresses due to the war (hearing the sound of sirens, supersonic military aircraft, explosion of Patriot and SCUD missiles, etc.), in addition to staying in sealed rooms with poor ventilation, higher risk of passive smoking and contracting upper respiratory tract infections, all may precipitate a hyperreactive airway reaction.

Asthmatics are more vulnerable than the general population with respect to the hazards of air pollution (11, 12, 13). Burning fossil fuels produces sulfur dioxide and nitrogen dioxide. Nitrogen oxides are primary precursors of oxidants such as ozone. All of these agents are implicated in chronic bronchitis (13, 15, 16). Furthermore, the sulfates, nitrates and organic particles produced by burning fossil fuel are less than 2.5 microns. Such particles, when inhaled, mostly deposit in the terminal bronchioles and alveoli (15).

Table 1
Frequency of Ventolin nebulizer use and number of medical
encounters in four health centres from January to August
1989-1991
         1989            1990             1991
      V(*)   ME(**)    V      ME        V      ME
Jan    610   37,983   687   35,688   1,107   34,572
Feb    435   32,642   641   34,207     855   35,439
Mar    540   36,155   732   39,461   1,084   40,415
Apr    474   37,995   498   34,145     831   41,271
May    539   45,042   522   42,861     811   42,509
Jun    392   37,294   445   36,254     655   36,275
Jul    386   38,108   416   35,841     689   42,854
Aug    431   39,158   538   38,454     649   30,783
* Ventolin; ** Medical encounters

Knowing the concentration of the various air pollutants may assist in determining whether psychological factors were responsible for the increase in the use of Ventolin nebulizer. For example, if there was an increase in the concentration of air pollutants to levels that are not acceptable to patients with respiratory problems, then the increase in the use of albuterol nebulizer would probably be due to the smoke from the burning oil wells of Kuwait. An effort to obtain air pollution levels in Bahrain after the oil wells of Kuwait were set on fire was made; unfortunately such information was not available.

As mentioned earlier, the smoke from the burning oil wells of Kuwait resulted in a drop in the temperature and humidity. This may have encouraged people, including asthmatics, to undertake outdoor exercises more than the usual. The lower temperature and humidity and the stress of exercise are well known to exacerbate asthma (13, 14, 17, 18).

There was little physician turnover in the four selected health centres during the three-year period of the study: only four new physicians joined the health centres, which are usually served by 86 doctors. In spite of this, one cannot exclude the possibility of a change in the doctors' prescription patterns, which may result in an increase in albuterol nebulizer use.

Finally, the total number of medical encounters did not increase markedly during the year 1991, which may account for the higher rate of Ventolin nebulizer use.

Conclusion

There was a definite increase in the use of albuterol nebulizer in Bahrain between the beginning of March and the end of August 1991. Whether this is due to the direct effect of the smoke from the burning oil wells of Kuwait remains to be determined. For this conclusion, more research of air pollution during this same period needs to be examined. It will also be helpful to observe the pattern of Ventolin nebulizer use in the four health centres considered in this article, during the next few years after the burning oil wells are extinguished.

References

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2. Chad, I. (1991), Smoke makes July coolest in 77 years, Gulf Daily News XIV (139):1.

3. Bahrain Civil Aviation Affairs' Meteorological Service (1991), Monthly Weather Summary, Feb-Aug.

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16. F.E. Speizer (1991), Environmental lung diseases. In: Wilson, Braunwald, Isselbacher, Petersdorf, Martin, Fauci, Root (eds.), Harrison's principles of internal medicine, International edition, McGraw-Hill, New York, NY. Pp. 1056-1063.

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Basem Roberto Saab, M.D., Asst. Professor, Department of Family Medicine, American University of Beirut, 850 Third Ave., New York, NY 10022.