Prioritising primary care respiratory research needs: results from the 2020 International Primary Care Respiratory Group (IPCRG) global e-Delphi exercise.

Respiratory diseases remain a significant cause of global morbidity and mortality and primary care plays a central role in their prevention, diagnosis and management. An e-Delphi process was employed to identify and prioritise the current respiratory research needs of primary care health professionals worldwide. One hundred and twelve community-based physicians, nurses and other healthcare professionals from 27 high-, middle- and low-income countries suggested 608 initial research questions, reduced after evidence review by 27 academic experts to 176 questions covering diagnosis, management, monitoring, self-management and prognosis of asthma, COPD and other respiratory conditions (including infections, lung cancer, tobacco control, sleep apnoea). Forty-nine questions reached 80% consensus for importance. Cross-cutting themes identified were: a need for more effective training of primary care clinicians; evidence and guidelines specifically relevant to primary care, adaption for local and low-resource settings; empowerment of patients to improve self-management; and the role of the multidisciplinary healthcare team.

Previous tuberculosis disease as a risk factor for chronic obstructive pulmonary disease: a cross-sectional analysis of multicountry, population-based studies.

BACKGROUND: Risk factors for COPD in high-income settings are well understood; however, less attention has been paid to contributors of COPD in low-income and middle-income countries (LMICs) such as pulmonary tuberculosis. We sought to study the association between previous tuberculosis disease and COPD by using pooled population-based cross-sectional data in 13 geographically diverse, low-resource settings. METHODS: We pooled six cohorts in 13 different LMIC settings, 6 countries and 3 continents to study the relationship between self-reported previous tuberculosis disease and lung function outcomes including COPD (defined as a postbronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) below the lower limit of normal). Multivariable regressions with random effects were used to examine the association between previous tuberculosis disease and lung function outcomes. RESULTS: We analysed data for 12 396 participants (median age 54.0 years, 51.5% male); 332 (2.7%) of the participants had previous tuberculosis disease. Overall prevalence of COPD was 8.8% (range 1.7%-15.5% across sites). COPD was four times more common among those with previous tuberculosis disease (25.7% vs 8.3% without previous tuberculosis disease, p<0.001). The adjusted odds of having COPD was 3.78 times higher (95% CI 2.87 to 4.98) for participants with previous tuberculosis disease than those without a history of tuberculosis disease. The attributable fraction of COPD due to previous tuberculosis disease in the study sample was 6.9% (95% CI 4.8% to 9.6%). Participants with previous tuberculosis disease also had lower prebronchodilator Z-scores for FEV1 (-0.70, 95% CI -0.84 to -0.55), FVC (-0.44, 95% CI -0.59 to -0.29) and the FEV1:FVC ratio (-0.63, 95% CI -0.76 to -0.51) when compared with those without previous tuberculosis disease. CONCLUSIONS: Previous tuberculosis disease is a significant and under-recognised risk factor for COPD and poor lung function in LMICs. Better tuberculosis control will also likely reduce the global burden of COPD.

Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care.

INTRODUCTION: Low- and middle-income countries (LMICs) bear a high proportion of the global morbidity and mortality caused by COPD. Increased exposure to risk factors throughout life (e.g. malnutrition, indoor and outdoor air pollution, and smoking) is associated with higher COPD prevalence in LMICs and the lack of treatment availability increases avoidable harm. AREAS COVERED: This review covers the epidemiology and burden of COPD in LMICs, and challenges and recommendations related to health-care systems, prevention, diagnosis, and treatment. Main challenges are related to under-resourced health-care systems (such as limited availability of spirometry, rehabilitation, and medicines). Lack of policy and practical local guidelines on COPD diagnosis and management further contribute to the low diagnostic and treatment rates. In the absence of, or limited number of respiratory specialists, primary care practitioners (general practitioners, nurses, pharmacists, physiotherapists, and community health workers) play an even more pivotal role in COPD management in LMICs. EXPERT OPINION: Raising awareness on COPD, educating health-care workers, patients, and communities on cost-effective preventive measures as well as improving availability, affordability and proper use of diagnostic and pharmacological and non-pharmacologic treatment in primary care are the key interventions needed to improve COPD prevention, diagnosis, and care in LMICs.

Publisher Correction: Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study.

Most patients with chronic respiratory disease live in low-resource settings, where evidence is scarcest. In Kyrgyzstan and Vietnam, we studied the implementation of a Ugandan programme empowering communities to take action against biomass and tobacco smoke. Together with local stakeholders, we co-created a train-the-trainer implementation design and integrated the programme into existing local health infrastructures. Feasibility and acceptability, evaluated by the modified Conceptual Framework for Implementation Fidelity, were high: we reached ~15,000 Kyrgyz and ~10,000 Vietnamese citizens within budget (~€11,000/country). The right engaged stakeholders, high compatibility with local contexts and flexibility facilitated programme success. Scores on lung health awareness questionnaires increased significantly to an excellent level among all target groups. Behaviour change was moderately successful in Vietnam and highly successful in Kyrgyzstan. We conclude that contextualising the awareness programme to diverse low-resource settings can be feasible, acceptable and effective, and increase its sustainability. This paper provides guidance to translate lung health interventions to new contexts globally.

Training needs for Ugandan primary care health workers in management of respiratory diseases: a cross sectional survey.

BACKGROUND: Respiratory diseases are among the leading causes of morbidity and mortality in Uganda, but there is little attention and capacity for management of chronic respiratory diseases in the health programmes. This survey assessed gaps in knowledge and skills among healthcare workers in managing respiratory illnesses. METHODS: A cross sectional study was conducted among primary care health workers, specialist physicians and healthcare planners to assess gaps in knowledge and skills and, training needs in managing respiratory illnesses. The perspectives of patients with respiratory diseases were also sought. Data were collected using questionnaires, patient panel discussions and review of pre-service training curricula for clinicians and nurses. Survey Monkey was used to collect data and descriptive statistical analysis was undertaken for quantitative data, while thematic content analysis techniques were utilized to analyze qualitative data. RESULTS: A total of 104 respondents participated in the survey and of these, 76.9% (80/104) were primary care health workers, 16.3% (17/104) specialist clinicians and 6.7% (7/104) healthcare planners. Over 90% of the respondents indicated that more than half of the patients in their clinics presented with respiratory symptoms. More than half (52%) of the primary care health workers were not comfortable in managing chronic respiratory diseases like asthma and COPD. Only 4% of them were comfortable performing procedures like pulse oximetry, nebulization, and interpreting x-rays. Majority (75%) of the primary care health workers had received in-service training but only 4% of the sessions focused on respiratory diseases. The pre-service training curricula included a wide scope of respiratory diseases, but the actual training had not sufficiently prepared health workers to manage respiratory diseases. The patients were unsatisfied with the care in primary care and reported that they were often treated for the wrong illnesses. CONCLUSIONS: Respiratory illnesses contribute significantly to the burden of diseases in primary care facilities in Uganda. Management of patients with respiratory diseases remains a challenge partially because of inadequate knowledge and skills of the primary care health workers. A training programme to improve the competences of health workers in respiratory medicine is highly recommended.

Lack of an Association Between Household Air Pollution Exposure and Previous Pulmonary Tuberculosis.

CONTEXT: Observational studies investigating household air pollution (HAP) exposure to biomass fuel smoke as a risk factor for pulmonary tuberculosis have reported inconsistent results. OBJECTIVE: To evaluate the association between HAP exposure and the prevalence of self-reported previous pulmonary tuberculosis. DESIGN: We analyzed pooled data including 12,592 individuals from five population-based studies conducted in Latin America, East Africa, and Southeast Asia from 2010 to 2015. We used multivariable logistic regression to model the association between HAP exposure and self-reported previous pulmonary tuberculosis adjusted for age, sex, tobacco smoking, body mass index, secondary education, site and country of residence. RESULTS: Mean age was 54.6 years (range of mean age across settings 43.8-59.6 years) and 48.6% were women (range of % women 38.3-54.5%). The proportion of participants reporting HAP exposure was 38.8% (range in % HAP exposure 0.48-99.4%). Prevalence of previous pulmonary tuberculosis was 2.7% (range of prevalence 0.6-6.9%). While participants with previous pulmonary tuberculosis had a lower pre-bronchodilator FEV1 (mean - 0.7 SDs, 95% CI - 0.92 to - 0.57), FVC (- 0.52 SDs, 95% CI - 0.69 to - 0.33) and FEV1/FVC (- 0.59 SDs, 95% CI - 0.76 to - 0.43) as compared to those who did not, we did not find an association between HAP exposure and previous pulmonary tuberculosis (adjusted odds ratio = 0.86; 95% CI 0.56-1.32). CONCLUSIONS: There was no association between HAP exposure and self-reported previous pulmonary tuberculosis in five population-based studies conducted worldwide.

Effects and acceptability of implementing improved cookstoves and heaters to reduce household air pollution: a FRESH AIR study.

The objective was to evaluate the effectiveness and acceptability of locally tailored implementation of improved cookstoves/heaters in low- and middle-income countries. This interventional implementation study among 649 adults and children living in rural communities in Uganda, Vietnam and Kyrgyzstan, was performed after situational analyses and awareness programmes. Outcomes included household air pollution (PM2.5 and CO), self-reported respiratory symptoms (with CCQ and MRC-breathlessness scale), chest infections, school absence and intervention acceptability. Measurements were conducted at baseline, 2 and 6-12 months after implementing improved cookstoves/heaters. Mean PM2.5 values decrease by 31% (to 95.1 µg/m3) in Uganda (95%CI 71.5-126.6), by 32% (to 31.1 µg/m3) in Vietnam (95%CI 24.5-39.5) and by 65% (to 32.4 µg/m3) in Kyrgyzstan (95%CI 25.7-40.8), but all remain above the WHO guidelines. CO-levels remain below the WHO guidelines. After intervention, symptoms and infections diminish significantly in Uganda and Kyrgyzstan, and to a smaller extent in Vietnam. Quantitative assessment indicates high acceptance of the new cookstoves/heaters. In conclusion, locally tailored implementation of improved cookstoves/heaters is acceptable and has considerable effects on respiratory symptoms and indoor pollution, yet mean PM2.5 levels remain above WHO recommendations.

The complications of treating chronic obstructive pulmonary disease in low income countries of sub-Saharan Africa.

INTRODUCTION: In most low and middle-income countries, chronic obstructive pulmonary disease (COPD) is on the rise. Areas covered: Unfortunately, COPD is a neglected disease in these countries. Taking sub-Saharan Africa as an example, in rural areas, COPD is even unknown regarding public awareness and public health planning. Programs for the management of COPD are poorly developed, and the quality of care is often of a low standard. Inhaled medication is often not available or not affordable. Tobacco smoking is the most common encountered risk factor for COPD. However, in sub-Saharan Africa, household air pollution is another major risk factor for the development of COPD. Communities are also exposed to a variety of other risk factors, such as low birth weight, malnutrition, severe childhood respiratory infections, occupational exposures, outdoor pollution, human-immunodeficiency virus and tuberculosis. All these factors contribute to the high burden of poor respiratory health in sub-Saharan Africa. Expert commentary: A silent growing epidemic of COPD seems to be unravelling. Therefore, prevention and intervention programs must involve all the stakeholders and start as early as possible. More research is needed to describe, define and inform treatment approaches, and natural history of biomass-related COPD.

Socio-economic factors, gender and smoking as determinants of COPD in a low-income country of sub-Saharan Africa: FRESH AIR Uganda.

In Uganda, biomass smoke seems to be the largest risk factor for the development of COPD, but socio-economic factors and gender may have a role. Therefore, more in-depth research is needed to understand the risk factors. The aim of this study was to investigate the impact of socio-economic factors and gender differences on the COPD prevalence in Uganda. The population comprised 588 randomly selected participants (>30 years) who previously completed the FRESH AIR Uganda study. In this post hoc analysis, the impact of several socio-economic characteristics, gender and smoking on the prevalence of COPD was assessed using a logistic regression model. The main risk factors associated with COPD were non-Bantu ethnicity (odds ratio (OR) 1.73, 95% confidence interval (CI) 1.06-2.82, P=0.030), biomass fuel use for heating (OR 1.76, 95% CI 1.03-3.00, P=0.038), former smoker (OR 1.87, 95% CI 0.97-3.60, P=0.063) and being unmarried (OR 0.087, 95% CI 0.93-2.95, P=0.087). A substantial difference in the prevalence of COPD was seen between the two ethnic groups: non-Bantu 20% and Bantu 12.9%. Additional analysis between these two groups showed significant differences in socio-economic circumstances: non-Bantu people smoked more (57.7% vs 10.7%), lived in tobacco-growing areas (72% vs 14.8%) and were less educated (28.5% vs 12.9% had no education). With regard to gender, men with COPD were unmarried (OR 3.09, 95% CI 1.25-7.61, P=0.015) and used more biomass fuel for heating (OR 2.15, 95% CI 1.02-4.54, P=0.045), and women with COPD were former smokers (OR 3.35, 95% CI 1.22-9.22, P=0.019). Only a few socio-economic factors (i.e., smoking, biomass fuel use for heating, marital status and non-Bantu ethnicity) have been found to be associated with COPD. This applied for gender differences as well (i.e., for men, marital status and biomass fuel for heating, and for women being a former smoker). More research is needed to clarify the complexity of the different risk factors.

The State of Ambient Air Quality in Two Ugandan Cities: A Pilot Cross-Sectional Spatial Assessment.

Air pollution is one of the leading global public health risks but its magnitude in many developing countries' cities is not known. We aimed to measure the concentration of particulate matter with aerodynamic diameter <2.5 µm (PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3) pollutants in two Ugandan cities (Kampala and Jinja). PM2.5, O3, temperature and humidity were measured with real-time monitors, while NO2 and SO2 were measured with diffusion tubes. We found that the mean concentrations of the air pollutants PM2.5, NO2, SO2 and O3 were 132.1 µg/m3, 24.9 µg/m3, 3.7 µg/m3 and 11.4 µg/m3, respectively. The mean PM2.5 concentration is 5.3 times the World Health Organization (WHO) cut-off limits while the NO2, SO2 and O3 concentrations are below WHO cut-off limits. PM2.5 levels were higher in Kampala than in Jinja (138.6 µg/m3 vs. 99.3 µg/m3) and at industrial than residential sites (152.6 µg/m3 vs. 120.5 µg/m3) but residential sites with unpaved roads also had high PM2.5 concentrations (152.6 µg/m3). In conclusion, air pollutant concentrations in Kampala and Jinja in Uganda are dangerously high. Long-term studies are needed to characterize air pollution levels during all seasons, to assess related public health impacts, and explore mitigation approaches.

The minimal clinically important difference of the Control of Allergic Rhinitis and Asthma Test (CARAT): cross-cultural validation and relation with pollen counts.

BACKGROUND: The Control of Allergic Rhinitis and Asthma Test (CARAT) monitors control of asthma and allergic rhinitis. AIMS: To determine the CARAT's minimal clinically important difference (MCID) and to evaluate the psychometric properties of the Dutch CARAT. METHODS: CARAT was applied in three measurements at 1-month intervals. Patients diagnosed with asthma and/or rhinitis were approached. MCID was evaluated using Global Rating of Change (GRC) and standard error of measurement (s.e.m.). Cronbach's alpha was used to evaluate internal consistency. Spearman's correlation coefficients were calculated between CARAT, the Asthma Control Questionnaire (ACQ5) and the Visual Analog Scale (VAS) on airway symptoms to determine construct and longitudinal validity. Test-retest reliability was evaluated with intra-class correlation coefficient (ICC). Changes in pollen counts were compared with delta CARAT and ACQ5 scores. RESULTS: A total of 92 patients were included. The MCID of the CARAT was 3.50 based on GRC scores; the s.e.m. was 2.83. Cronbach's alpha was 0.82. Correlation coefficients between CARAT and ACQ5 and VAS questions ranged from 0.64 to 0.76 (P < 0.01). Longitudinally, correlation coefficients between delta CARAT scores and delta ACQ5 and VAS scores ranged from 0.41 to 0.67 (P < 0.01). Test-retest reliability showed an ICC of 0.81 (P < 0.01) and 0.80 (P < 0.01). Correlations with pollen counts were higher for CARAT than for ACQ5. CONCLUSIONS: This is the first investigation of the MCID of the CARAT. The CARAT uses a whole-point scale, which suggests that the MCID is 4 points. The CARAT is a valid and reliable tool that is also applicable in the Dutch population.

Prevalence of chronic obstructive pulmonary disease and associated risk factors in Uganda (FRESH AIR Uganda): a prospective cross-sectional observational study.

BACKGROUND: In sub-Saharan Africa, little is known about the damage to respiratory health caused by biomass smoke and tobacco smoke. We assessed the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in a rural region of Uganda. METHODS: We did this prospective observational cross-sectional study in rural Masindi, Uganda. We randomly selected people above the age of 30 years from 30 villages. Trained local health-care workers asked validated questionnaires and administered spirometry to participants. We defined COPD as FEV1:FVC less than the lower limit of normal. We calculated prevalence of COPD and tested its association with risk factors. FINDINGS: Between April 13, and Aug 14, 2012, we invited 620 people to participate, of whom 588 provided acceptable spirometry and were analysed. Mean age was 45 years (SD 13·7); 297 (51%) were women. 546 (93%) were exposed to biomass smoke. The prevalence of COPD was 16·2% (15·4% in men, 16·8% in women). Prevalence was highest in people aged 30-39 years (17 [38%] of 45 men, 20 [40%] of 50 women). 20 (44%) of 45 men with COPD were current smokers (mean age 40 years, SD 7·5), 11 (24%) were former smokers (mean age 49 years, SD 11·0); four [8%] of 50 women were current smokers (mean age 52 years, SD 18·1), nine (18%) were former smokers (mean age 64 years, SD 16·2). Mean Clinical COPD Questionnaire score was 0·81 (SD 0·78), mean Medical Research Council dyspnoea score was 1·33 (SD 0·65); 28 (30%) of 95 patients had had one or more exacerbations past 12 months. COPD was associated with wheeze (odds ratio 2·17, 95% CI 1·09-4·34; p=0·028) and being a former smoker (1·96, 1·07-3·59; p=0·029). INTERPRETATION: In this rural district of Uganda, COPD starts early in life. Major risk factors were biomass smoke for both sexes and tobacco smoke for men. In addition to high smoking prevalence in men, biomass smoke could be a major health threat to men and women in rural areas of Uganda. FUNDING: International Primary Care Respiratory Group.

A woman with breathlessness: a practical approach to diagnosis and management.

Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are to be identified and managed. Distinguishing between heart failure and COPD is a particular challenge as symptoms and signs overlap. In low and middle income countries additional priorities are the detection of infections such as tuberculosis and human immunodeficiency virus (HIV). Clinicians need to be alert to the possibility of atypical presentations (such as pain-free variants of angina) and less common conditions (including chronic thromboembolic pulmonary hypertension) in order not to overlook important potentially treatable conditions.

Impact of chronic respiratory symptoms in a rural area of sub-Saharan Africa: an in-depth qualitative study in the Masindi district of Uganda.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), once regarded as a disease of developed countries, is now recognised as a common disease in low- and middle-income countries. No studies have been performed to examine how the community in resource poor settings of a rural area in sub-Saharan Africa lives with chronic respiratory symptoms. AIMS: To explore beliefs and attitudes concerning health (particularly respiratory illnesses), use of biomass fuels, tobacco smoking, and the use of health services. METHODS: A qualitative study was undertaken in a rural area of Masindi district in Uganda, using focus group discussions with 10-15 members of the community in 10 randomly selected villages. RESULTS: Respiratory symptoms were common among men, women, and children. In several communities respiratory symptoms were stigmatised and often associated with tuberculosis. Almost all the households used firewood for cooking and the majority cooked indoors without any ventilation. The extent of exposure to tobacco and biomass fuel smoke was largely determined by their cultural tradition and gender, tribal origin and socioeconomic factors. Many people were unaware of the damage to respiratory health caused by these risk factors, notably the disproportionate effect of biomass smoke in women and children. CONCLUSIONS: The knowledge of chronic respiratory diseases, particularly COPD, is poor in the rural community in sub-Saharan Africa. The lack of knowledge has created different beliefs and attitudes concerning respiratory symptoms. Few people are aware of the relation between smoke and respiratory health, leading to extensive exposure to mostly biomass-related smoke.

The impact of asthma and COPD in sub-Saharan Africa.

BACKGROUND: Many countries in sub-Saharan Africa have the highest risk of developing chronic diseases and are the least able to cope with them. AIMS: To assess the current knowledge of the prevalence and impact of asthma and chronic obstructive pulmonary disease (COPD) in sub- Saharan Africa. METHODS: A literature search was conducted using Medline (1995-2010) and Google Scholar. RESULTS: Eleven studies of the prevalence of asthma in sub-Saharan Africa were identified, all of which showed a consistent increase, particularly in urban regions. The data on asthma show a wide variation (5.7-20.3%), with the highest prevalence in 'westernised' urban areas. Only two studies of the prevalence of COPD in sub-Saharan Africa have been performed. Nevertheless, COPD has become an increasing health problem in sub-Saharan Africa due to tobacco smoking and exposure to biomass fuels. In most countries of sub-Saharan Africa, 90% of the rural households depend on biomass fuel for cooking and heating, affecting young children (acute lower respiratory infections) and women (COPD). This is the cause of significant mortality and morbidity in the region. CONCLUSIONS: Asthma and COPD in sub-Saharan Africa are under-recognised, under-diagnosed, under-treated, and insufficiently prevented. A major priority is to increase the awareness of asthma and COPD and their risk factors, particularly the damage caused by biomass fuel. Surveys are needed to provide local healthcare workers with the possibility of controlling asthma and COPD.