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Alupo P, Baluku J, Bongomin F, Siddharthan T, Katagira W, Ddungu A, Hurst JR, van Boven JFM, Worodria W, Kirenga BJ. Overcoming challenges of managing chronic obstructive pulmonary disease in low- and middle-income countries. Expert Rev Respir Med 2024:1-10. [PMID: 39268898 DOI: 10.1080/17476348.2024.2398639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/24/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) ranks among the top three global causes of death, with 90% of fatalities concentrated in low- and middle-income countries (LMICs). The projected rise in COPD burden, especially in LMICs, emphasizes the need to address the challenges for effective control and reversal of this trend. We aimed to provide an overview, and propose potential solutions to these challenges. AREAS COVERED We highlight the challenges faced in managing COPD in LMICs and put forward the potential approaches to mitigate the same. EXPERT OPINION In LMICs, the effective management of COPD encounters numerous barriers. These include limited access to critical diagnostic services, inadequately trained healthcare personnel, shortages of inhaler medications, oxygen therapy, insufficient access to vaccines, and pulmonary rehabilitation programs. Compounding the above challenges is the late presentation due to misdiagnosis by health workers, and limited access to vital diagnostics. Moreover, the pharmacological armamentarium for optimal COPD therapy, notably inhaled therapies, face constraints in both access and affordability. We propose multi-level and multifaceted interventions to address the urgent need for enhanced respiratory care, human resource capacity building, relevant diagnostic approaches, increased access to medications, government, regional and global efforts to achieve optimal COPD management in LMICs.
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Affiliation(s)
- Patricia Alupo
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, Netherlands
| | - Joseph Baluku
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Pulmonology, Kirruddu National Referral Hospital, Kampala, Uganda
| | - Felix Bongomin
- Department of medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Department of Internal Medicine, Gulu Regional referral Hospital, Gulu, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, FL, USA
| | - Winceslaus Katagira
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ahmed Ddungu
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, Netherlands
| | - William Worodria
- Mulago National Referral Hospital, Ministry of Health, Kampala, Uganda
| | - Bruce J Kirenga
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Ozoh OB, Ndimande N, Amaral AFS, Lesosky M, Mbonigaba J, Stolbrink M, Zurba L, Ayo-Olagunju T, Kayembe-Kitenge T, Lakoh S, Mocumbi A, Mohammed J, Nantanda R, Nunes E, Ouédraogo AR, Owusu S, Sibomana JP, Masekela R, Mortimer K. Chronic respiratory disease observatory for Africa (CHEST-Africa): study protocol for the prevalence, determinants and economic impacts of asthma and COPD in Africa. BMJ Open Respir Res 2024; 11:e002416. [PMID: 39019625 PMCID: PMC11256067 DOI: 10.1136/bmjresp-2024-002416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/07/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Contemporary data on the burden of chronic respiratory diseases in sub-Saharan Africa is limited. More so, their economic burden is not well described. This study aims to establish a chronic respiratory disease observatory for Africa. Specific study aims are (1) to describe the prevalence and determinants of asthma with a target to screen up to 4000 children and adolescents across four African cities; (2) to determine the prevalence and determinants of chronic obstructive pulmonary disease (COPD) with a target to screen up to 3000 adults (≥18 years) across five African cities; (3) to describe the disease burden by assessing the frequency and severity of symptoms and exacerbations, medication use, emergency healthcare utilisation and hospitalisation; and (4) to assess the economic burden and affordability of the medicines for these diseases. METHODS AND ANALYSIS Surveys will be conducted in schools to identify children and adolescents with asthma using the Global Asthma Network screening questionnaire in Ghana, Nigeria, the Democratic Republic of Congo, and Uganda. Community surveys will be conducted among adults using an adapted version of the Burden of Obstructive Lung Disease Questionnaire to identify persons with COPD symptoms in Nigeria, Burkina Faso, Mozambique, Rwanda, and Sierra Leone. Fractional exhaled nitric oxide and pre-bronchodilator and post-bronchodilator spirometry will be done for children with asthma or asthma symptoms and for all adult participants. Children and adults with respiratory symptoms or diagnoses will complete the health economic questionnaires. Statistical analysis will involve descriptive and analytical statistics to determine outcomes. ETHICS AND DISSEMINATION Ethical approval has been obtained from participating institutions. This study's results will inform deliberations at the United Nations General Assembly high-level meeting on non-communicable diseases in 2025. The results will be shared through academic conferences and journals and communicated to the schools and the communities.
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Affiliation(s)
- Obianuju B Ozoh
- Department of Medicine, University of Lagos College of Medicine, Lagos, Nigeria
- Department of Paediatrics and Child Health, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Nqobile Ndimande
- Department of Paediatrics and Child Health, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | | | | | | | - Marie Stolbrink
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Tony Kayembe-Kitenge
- Higher Institute of Medical Techniques of Lubumbashi, Lubumbashi, Congo (the Democratic Republic of the)
- Lubumbashi University Hospital, Lubumbashi, Congo (the Democratic Republic of the)
| | | | - Ana Mocumbi
- Department of Medicine, University Eduardo Mondlane, Maputo, Mozambique
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Jibril Mohammed
- Department of Physiotherapy, Faculty of Allied Health Sciences Bayero University Kano, Kano, Nigeria
| | | | - Elizabete Nunes
- Department of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Sandra Owusu
- Department of Child Health, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Refiloe Masekela
- Department of Paediatrics and Child Health, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Kevin Mortimer
- Department of Paediatrics and Child Health, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Swarnakar R, Dhar R. Call to action: Addressing asthma diagnosis and treatment gaps in India. Lung India 2024; 41:209-216. [PMID: 38687232 PMCID: PMC11093140 DOI: 10.4103/lungindia.lungindia_518_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/22/2023] [Accepted: 12/31/2023] [Indexed: 05/02/2024] Open
Abstract
In comparison to the worldwide burden of asthma, although India contributes to 13% of the total asthma prevalence, it has a threefold higher mortality rate and more than twofold higher DALYs, indicating a substantial gap in asthma diagnosis and treatment. Asthma causes significant suffering, affecting people's quality of life and draining the country's resources; therefore, we must devise ways and means to fill these gaps. The most successful and cost-efficient strategy to battle asthma is to form strong partnerships between patients, the general public, the government, the pharmaceutical industry and non-governmental organisations. This necessitates a comprehensive approach that involves raising awareness, developing universally applicable recommendations, increasing access to high-quality asthma care, and other measures. The purpose of this article was to review the existing scenario of asthma management in India and the factors that contribute to it and devise unique and all-encompassing strategies to fill these gaps.
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Affiliation(s)
- Rajesh Swarnakar
- Department of Pulmonology, Getwell Hospital and Research Institute, Nagpur, Maharashtra, India
| | - Raja Dhar
- Department of Pulmonary, Sleep and Critical Care Medicine, Calcutta Medical Research Institute and Hospital, Kolkata, West Bengal, India
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Alupo P, Mugenyi L, Katagira W, Kayongo A, Nalunjogi J, Siddharthan T, Hurst JR, Kirenga B, Jones R. Characteristics and phenotypes of a COPD cohort from referral hospital clinics in Uganda. BMJ Open Respir Res 2024; 11:e001816. [PMID: 38490695 PMCID: PMC10946361 DOI: 10.1136/bmjresp-2023-001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition with varied clinical and pathophysiological characteristics. Although there is increasing evidence that COPD in low-income and middle-income countries may have different clinical characteristics from that in high-income countries, little is known about COPD phenotypes in these settings. We describe the clinical characteristics and risk factor profile of a COPD population in Uganda. METHODS We cross sectionally analysed the baseline clinical characteristics of 323 patients with COPD aged 30 years and above who were attending 2 national referral outpatient facilities in Kampala, Uganda between July 2019 and March 2021. Logistic regression was used to determine factors associated with spirometric disease severity. RESULTS The median age was 62 years; 51.1% females; 93.5% scored COPD Assessment Test >10; 63.8% modified medical research council (mMRC) >2; 71.8% had wheezing; 16.7% HIV positive; 20.4% had a history of pulmonary tuberculosis (TB); 50% with blood eosinophilic count >3%, 51.7% had 3 or more exacerbations in the past year. Greater severity by Global initiative for Chronic Obstructive Lung Disease (GOLD) stage was inversely related to age (aOR=0.95, 95% CI 0.92 to 0.97), and obesity compared with underweight (aOR=0.25, 95% CI 0.07 to 0.82). Regarding clinical factors, more severe airflow obstruction was associated with SPO2 <93% (aOR=3.79, 95% CI 2.05 to 7.00), mMRC ≥2 (aOR=2.21, 95% CI 1.08 to 4.53), and a history of severe exacerbations (aOR=2.64, 95% CI 1.32 to 5.26). CONCLUSION Patients with COPD in this population had specific characteristics and risk factor profiles including HIV and TB meriting tailored preventative approaches. Further studies are needed to better understand the pathophysiological mechanisms at play and the therapeutic implications of these findings.
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Affiliation(s)
- Patricia Alupo
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Levicatus Mugenyi
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Statistics Department, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Winceslaus Katagira
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Alex Kayongo
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joanitah Nalunjogi
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary, Critical care and Sleep medicine, University of Miami School of Medicine, Miami, Florida, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Bruce Kirenga
- Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Bongomin F, Kwizera R, Namusobya M, van Rhijn N, Andia-Biraro I, Kirenga BJ, Meya DB, Denning DW. Re-estimation of the burden of serious fungal diseases in Uganda. Ther Adv Infect Dis 2024; 11:20499361241228345. [PMID: 38328511 PMCID: PMC10848809 DOI: 10.1177/20499361241228345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background It is of utmost importance to monitor any change in the epidemiology of fungal diseases that may arise from a change in the number of the at-risk population or the availability of local data. Objective We sought to update the 2015 publication on the incidence and prevalence of serious fungal diseases in Uganda. Methods Using the Leading International Fungal Education methodology, we reviewed published data on fungal diseases and drivers of fungal diseases in Uganda. Regional or global data were used where there were no Ugandan data. Results With a population of ~45 million, we estimate the annual burden of serious fungal diseases at 4,099,357 cases (about 9%). We estimated the burden of candidiasis as follows: recurrent Candida vaginitis (656,340 cases), oral candidiasis (29,057 cases), and esophageal candidiasis (74,686 cases) in HIV-infected people. Cryptococcal meningitis annual incidence is estimated at 5553 cases, Pneumocystis pneumonia at 4604 cases in adults and 2100 cases in children. For aspergillosis syndromes, invasive aspergillosis annual incidence (3607 cases), chronic pulmonary aspergillosis (26,765 annual cases and 63,574 5-year-period prevalent cases), and prevalence of allergic bronchopulmonary aspergillosis at 75,931 cases, and severe asthma with fungal sensitization at 100,228 cases. Tinea capitis is common with 3,047,989 prevalent cases. For other mycoses, we estimate the annual incidence of histoplasmosis to be 646 cases and mucormycosis at 9 cases. Conclusion Serious fungal diseases affect nearly 9% of Ugandans every year. Tuberculosis and HIV remain the most important predisposition to acute fungal infection necessitating accelerated preventive, diagnostic, and therapeutic interventions for the management of these diseases.
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Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard Kwizera
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Namusobya
- Department of Clinical Epidemiology and Biostatistics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Norman van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Bruce J. Kirenga
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W. Denning
- Manchester Fungal Infection Group, CTF Building, The University of Manchester, Grafton Street, Manchester M13 9NT, UK
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Smith LJE, Bhugra R, Kelani RY, Smith J. Towards net zero: asthma care. BMJ 2023; 381:e072328. [PMID: 37336559 DOI: 10.1136/bmj-2022-072328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
| | - Ruhi Bhugra
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | | | - James Smith
- Public Health Education Group, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Kirenga BJ, Alupo P, van Gemert F, Jones R. Implication of the Global Initiative for Chronic Obstructive Lung Disease 2023 report for resource-limited settings: tracing the G in the GOLD. Eur Respir J 2023; 61:2300484. [PMID: 37321612 PMCID: PMC10269374 DOI: 10.1183/13993003.00484-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 06/17/2023]
Abstract
The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report provides a very useful synthesis of available scientific evidence to guide COPD management, research and prevention, as always [1, 2]. Important changes include the revision of the definition of the condition and the replacement of groups C and D with E, which highlights the importance of exacerbations in COPD [2]. COPD guidelines still have blind spots for low-resource settings. If GOLD is truly to be considered a global report on COPD, more attention will need to be paid to practical solutions in global settings. https://bit.ly/3zusjOd
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Affiliation(s)
- Bruce J Kirenga
- Makerere University Lung Institute, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Frederik van Gemert
- Department of Health Sciences, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, Groningen, The Netherlands
| | - Rupert Jones
- Research and Knowledge Exchange, Plymouth Marjon University, Plymouth, UK
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Ouédraogo AR, Boncoungou K, Ouédraogo JCRP, Ouédraogo GA, Kiendrebeogo JA, Sourabie A, Maiga S, Kafando S, Ouédraogo G, Badoum G, Ouédraogo M. [Availability and affordability of diagnosis and treatment for asthma and COPD in Ouagadougou, Burkina Faso]. Rev Mal Respir 2023; 40:382-390. [PMID: 37062632 DOI: 10.1016/j.rmr.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/14/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Chronic respiratory diseases, particularly asthma and Chronic Obstructive Pulmonary Disease (COPD), pose a significant threat to public health. This study aims to determine the accessibility and affordability of means of diagnosis and treatment. METHODS This was a cross-sectional study covering the period from August to December 2021 in Ouagadougou, Burkina Faso. This study involved 107 health centers and 135 pharmacies. The World Health Organization/Health Action International definition was used as a benchmark for accessibility to medicines. RESULTS Out of 107 health centers, 29 (27.1%) had a spirometer. The average cost of spirometry represented 19.88 days of salary for a patient paid at the minimum wage. The most widely available drugs were salbutamol in a pressurized metered dose inhaler (pMDI) (88.1%) and prednisone 20mg tablet (87.4%). No disease-modifying drug was available in public pharmacies. Affordable drugs were salbutamol 4mg tablet and aminophylline 100mg tablet. CONCLUSION The means of diagnosis and treatment of asthma and COPD are insufficiently available, especially in the public sector, which is characterized by a nearly total absence of basic treatment.
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Affiliation(s)
- A R Ouédraogo
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso; Service de pneumologie, CHU de Tengandogo, Ouagadougou, Burkina Faso.
| | - K Boncoungou
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso; Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - J C R P Ouédraogo
- Département MEPHATRA-PH, institut de recherche en sciences de la santé (IRSS), Ouagadougou, Burkina Faso
| | - G A Ouédraogo
- Service de pneumologie, centre hospitalier universitaire régional de Ouahigouya, Ouagadougou, Burkina Faso
| | - J A Kiendrebeogo
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso
| | - A Sourabie
- Service de pneumologie, CHU de Souro-Sanou, Bobo-Dioulasso, Burkina Faso
| | - S Maiga
- Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - S Kafando
- Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - G Ouédraogo
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso; Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - G Badoum
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso; Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - M Ouédraogo
- Unité de formation et de recherche en sciences de la santé, université Joseph-Ki-Zerbo, Ouagadougou, Burkina Faso; Service de pneumologie, CHU de Yalgado Ouedraogo, Ouagadougou, Burkina Faso
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Stolbrink M, Thomson H, Hadfield RM, Ozoh OB, Nantanda R, Jayasooriya S, Allwood B, Halpin DMG, Salvi S, de Oca MM, Mortimer K, Rylance S. The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review. Lancet Glob Health 2022; 10:e1423-e1442. [PMID: 36113528 PMCID: PMC9638033 DOI: 10.1016/s2214-109x(22)00330-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Asthma and chronic obstructive pulmonary disease (COPD) cause a considerable burden of morbidity and mortality in low-income and middle-income countries (LMICs). Access to safe, effective, quality-assured, and affordable essential medicines is variable. We aimed to review the existing literature relating to the availability, cost, and affordability of WHO's essential medicines for asthma and COPD in LMICs. METHODS A systematic review of the literature was done by searching seven databases to identify research articles published between Jan 1, 2010, and June 30, 2022. Studies on named essential medicines for asthma and COPD in LMICs were included and review articles were excluded. Two authors (MS and HT) screened and extracted data independently, and assessed bias using Joanna Briggs Institute appraisal tools. The main outcome measures were availability (WHO target of 80%), cost (compared with median price ratio [MPR]), and affordability (number of days of work of the lowest paid government worker). The study was registered with PROSPERO, CRD42021281069. FINDINGS Of 4742 studies identified, 29 met the inclusion criteria providing data from 60 LMICs. All studies had a low risk of bias. Six of 58 countries met the 80% availability target for short-acting beta-agonists (SABAs), three of 48 countries for inhaled corticosteroids (ICSs), and zero of four for inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) combination inhalers. Costs were reported by 12 studies: the range of MPRs was 1·1-351 for SABAs, 2·6-340 for ICSs, and 24 for ICS-LABAs in the single study reporting this. Affordability was calculated in ten studies: SABA inhalers typically cost around 1-4 days' wages, ICSs 2-7 days, and ICS-LABAs at least 6 days. The included studies showed heterogeneity. INTERPRETATION Essential medicines for treating asthma and COPD were largely unavailable and unaffordable in LMICs. This was particularly true for inhalers containing corticosteroids. FUNDING WHO and Wellcome Trust.
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Affiliation(s)
- Marie Stolbrink
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa.
| | | | - Ruth M Hadfield
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia; Global Initiative for Chronic Obstructive Lung Disease, Deer Park, IL, USA
| | - Obianuju B Ozoh
- Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Rebecca Nantanda
- Makerere University Lung Institute, College of Health Sciences Kampala, Kampala, Uganda
| | - Shamanthi Jayasooriya
- British Thoracic Society Global Health Group, London, UK; University of Sheffield, Sheffield, UK
| | - Brian Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa; Tygerberg Hospital, Cape Town, South Africa
| | - David M G Halpin
- Global Initiative for Chronic Obstructive Lung Disease, Deer Park, IL, USA; University of Exeter Medical School, Exeter, UK
| | - Sundeep Salvi
- Global Initiative for Chronic Obstructive Lung Disease, Deer Park, IL, USA; Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Maria Montes de Oca
- Global Initiative for Chronic Obstructive Lung Disease, Deer Park, IL, USA; Universidad Central de Venezuela, Caracas, Venezuela; Centro Medico de Caracas Hospital, Caracas, Venezuela
| | - Kevin Mortimer
- The International Union Against Tuberculosis and Lung Disease, Paris, France; Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sarah Rylance
- Noncommunicable Disease Management Unit, WHO, Geneva, Switzerland
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Access to essential respiratory medications remains elusive in LMICs. THE LANCET GLOBAL HEALTH 2022; 10:e1365-e1366. [DOI: 10.1016/s2214-109x(22)00370-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/08/2022] [Indexed: 11/22/2022] Open
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Magwenzi P, Rusakaniko S, Sibanda EN, Gumbo FZ. Challenges in the diagnosis of asthma in children, what are the solutions? A scoping review of 3 countries in sub Saharan Africa. Respir Res 2022; 23:254. [PMID: 36123720 PMCID: PMC9487077 DOI: 10.1186/s12931-022-02170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/09/2022] [Indexed: 08/29/2023] Open
Abstract
Background Asthma is the commonest chronic respiratory tract disease in children. In low-income countries, challenges exist in asthma diagnosis. In surveys done in children, the prevalence of ‘asthma’ defined by symptoms is high compared to ‘doctor diagnosed asthma’. The questions answered by this review are (i) What challenges have been experienced in the diagnosis of asthma in children? (ii) What solutions will address these challenges? Methods The Arksey and O’Malley’s framework for scoping reviews was used for the study methodology, while the PRISMA-ScR checklist guided the reporting process. Electronic databases: PubMed Central, EMBASE and Google Scholar were searched. Primary quantitative and qualitative studies and reviews from 2010 to 2021, from Nigeria, South Africa and Uganda written in English or translated to English, which answered the study questions were included. The author, title, country, study type, methods, purpose, findings and references were captured onto a predefined data collection table. The ‘Preview, Question, Read, Summarise’ system was used and a narrative report was used to summarise the findings. Results A total of 28 studies were included. The causes of under-diagnosis of asthma include lack of community knowledge and perception of asthma, poor accessibility to health care, strained health systems, lack of diagnostic tests including spirometry, low levels of knowledge among health-care workers and lack of or non-implementation of asthma guidelines. Strategies to improve asthma diagnosis will include community and school based education programmes, revision of asthma diagnostic terms, guideline development and implementation and health systems strengthening. Conclusion This scoping review provides research evidence for policy makers and health-workers involved in the care of asthmatic children on challenges faced in asthma diagnosis and strategies to improve asthma diagnosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02170-y.
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Affiliation(s)
- P Magwenzi
- Child and Adolescent Health Unit, Faculty of Medical Sciences, University of Zimbabwe, P O Box A178, Avondale, Harare, Zimbabwe.
| | - S Rusakaniko
- Family Medicine, Global and Public Health Unit, Faculty of Medical Sciences, University of Zimbabwe, P O Box A178, Avondale, Harare, Zimbabwe
| | - E N Sibanda
- Asthma, Allergy and Immune Dysfunction Clinic, 113, Kwame Nkrumah Avenue, Harare, Zimbabwe
| | - F Z Gumbo
- Child and Adolescent Health Unit, Faculty of Medical Sciences, University of Zimbabwe, P O Box A178, Avondale, Harare, Zimbabwe
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Mulupi S, Ayakaka I, Tolhurst R, Kozak N, Shayo EH, Abdalla E, Osman R, Egere U, Mpagama SG, Chinouya M, Chikaphupha KR, ElSony A, Meme H, Oronje R, Ntinginya NE, Obasi A, Taegtmeyer M. What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries. BMJ Open 2022; 12:e052105. [PMID: 35906045 PMCID: PMC9345041 DOI: 10.1136/bmjopen-2021-052105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda. STUDY DESIGN Qualitative descriptive study. SETTINGS Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries. PARTICIPANTS We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach. RESULTS We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease. CONCLUSION Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.
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Affiliation(s)
- Stephen Mulupi
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Irene Ayakaka
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Lung Institute, Makerere University, Kampala, Uganda
| | - Rachel Tolhurst
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicole Kozak
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Health Systems and Policy Research Unit, REACH Trust Malawi, Lilongwe, Malawi
| | - Elizabeth Henry Shayo
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- National Institute of Medical Research, Mbeya, United Republic of Tanzania
| | | | - Rashid Osman
- Lung Health Department, Epi-Lab, Khartoum, Sudan
| | - Uzochukwu Egere
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stellah G Mpagama
- Medical Department, Kibong'oto Infectious Diseases Hospital/Kilimanjaro Christian Medical University, Kilimanjaro, United Republic of Tanzania
| | - Martha Chinouya
- Education Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Asma ElSony
- Lung Health Department, Epi-Lab, Khartoum, Sudan
| | - Helen Meme
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Rose Oronje
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research (NIMR), Mbeya Medical Research Centre, Mbeya, Tanzania, United Republic of
| | - Angela Obasi
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- AXESS Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Miriam Taegtmeyer
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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13
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Woodcock A, Beeh KM, Sagara H, Aumônier S, Addo-Yobo E, Khan J, Vestbo J, Tope H. The environmental impact of inhaled therapy: making informed treatment choices. Eur Respir J 2022; 60:2102106. [PMID: 34916263 PMCID: PMC9301054 DOI: 10.1183/13993003.02106-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/22/2021] [Indexed: 12/03/2022]
Abstract
When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.
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Affiliation(s)
- Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Kai M Beeh
- Insaf Respiratory Research Institute, Wiesbaden, Germany
| | - Hironori Sagara
- Dept of Medicine, Division of Respiratory Medicine and Allergology, Showa University, Tokyo, Japan
| | | | - Emmanuel Addo-Yobo
- Dept of Child Health, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Javaid Khan
- Section of Pulmonary and Critical Care Medicine, The Aga Khan University, Karachi, Pakistan
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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14
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Medication availability and economic barriers to adherence in asthma and COPD patients in low-resource settings. NPJ Prim Care Respir Med 2022; 32:20. [PMID: 35637220 PMCID: PMC9151780 DOI: 10.1038/s41533-022-00281-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/05/2022] [Indexed: 11/08/2022] Open
Abstract
Inhaled medication is essential to control asthma and COPD, but availability and proper adherence are challenges in low-middle income countries (LMIC). Data on medication availability and adherence in Central Asia are lacking. We aimed to investigate the availability of respiratory medication and the extent of financially driven non-adherence in patients with COPD and asthma in Kyrgyzstan. A cross-sectional study was conducted in two regions of Kyrgyzstan. Patients with a physician- and spirometry confirmed diagnosis of asthma and/or COPD were included. The main outcomes were (1) availability of respiratory medication in hospitals and pharmacies, assessed by a survey, and (2) medication adherence, assessed by the Test of Adherence to Inhalers (TAI). Logistic regression analyses were used to identify predictors for adherence. Of the 300 participants (COPD: 264; asthma: 36), 68.9% were buying respiratory medication out-of-pocket. Of all patients visiting the hospital, almost half reported medication not being available. In pharmacies, this was 8%. Poor adherence prevailed over intermediate and good adherence (80.7% vs. 12.0% and 7.3%, respectively). Deliberate and erratic non-adherence behavior patterns were the most frequent (89.7% and 88.0%), followed by an unconscious non-adherent behavioral pattern (31.3%). In total, 68.3% reported a financial reason as a barrier to proper adherence. Low BMI was the only factor significantly associated with good adherence. In this LMIC population, poor medication availability was common and 80% were poorly adherent. Erratic and deliberate non-adherent behaviors were the most common pattern and financial barriers play a role in over two-thirds of the population.
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15
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Siddharthan T, Robertson NM, Rykiel NA, Underhill LJ, Rahman N, Kafle S, Mohan S, Padalkar R, McKeown S, Flores-Flores O, Quaderi SA, Alupo P, Kalyesubula R, Kirenga B, Luo J, Cárdenas MK, Gianella G, Miranda JJ, Checkley W, Hurst JR, Pollard SL. Availability, affordability and access to essential medications for asthma and chronic obstructive pulmonary disease in three low- and middle-income country settings. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001309. [PMID: 36962898 PMCID: PMC10021856 DOI: 10.1371/journal.pgph.0001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Despite the rising burden of chronic respiratory disease globally, and although many respiratory medications are included in the World Health Organization Essential Medications List (WHO-EML), there is limited information concerning the availability and affordability of treatment drugs for respiratory conditions in low- and middle-income countries (LMICs). METHODS All public and private pharmacies in catchment areas of the Global Excellence in COPD outcomes (GECo) study sites in Bhaktapur, Nepal, Lima, Peru, and Nakaseke, Uganda, were approached in 2017-2019 to assess pricing and availability of medications for the management of asthma and COPD. RESULTS We surveyed all 63 pharmacies in respective study areas in Nepal (95.2% private), 104 pharmacies in Peru (94.2% private) and 53 pharmacies in Uganda (98.1% private). The availability of any medication for respiratory disease was higher in private (93.3%) compared to public (73.3%) pharmacies. Salbutamol (WHO-EML) monotherapy in any formulation was the most commonly available respiratory medication among the three sites (93.7% Nepal, 86.5% Peru and 79.2% Uganda) while beclomethasone (WHO-EML) was only available in Peru (33.7%) and Nepal (22%). LABA-LAMA combination therapy was only available in Nepal (14.3% of pharmacies surveyed). The monthly treatment cost of respiratory medications was lowest in Nepal according to several cost metrics: the overall monthly cost, the median price ratio comparing medication costs to international reference prices at time of survey in dollars, and in terms of days' wages of the lowest-paid government worker. For the treatment of intermittent asthma, defined as 100 mcg Salbutamol/Albuterol inhaler, days' wages ranged from 0.47 days in Nepal and Peru to 3.33 days in Uganda. CONCLUSION The availability and pricing of respiratory medications varied across LMIC settings, with medications for acute care of respiratory diseases being more widely available than those for long-term management.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, University of Miami, Miami, Florida, United States of America
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nicole M Robertson
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- University of Kentucky School of Medicine, Louisville, Kentucky, United States of America
| | - Natalie A Rykiel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Lindsay J Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nihaal Rahman
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sujan Kafle
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Roma Padalkar
- Rowan University School of Osteopathic Medicine, Glassboro, New Jersey, United States of America
| | - Sarah McKeown
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Oscar Flores-Flores
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
| | | | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | | | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Jing Luo
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Gonzalo Gianella
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John R Hurst
- Respiratory Medicine, University College London, London, United Kingdom
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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16
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Yang X, Zhang T, Zhang Y, Chen H, Sang S. Global burden of COPD attributable to ambient PM2.5 in 204 countries and territories, 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 796:148819. [PMID: 34265615 DOI: 10.1016/j.scitotenv.2021.148819] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 06/13/2023]
Abstract
The global spatiotemporal pattern of the COPD burden attributable to ambient PM2.5 is unknown in the context of the continuing increase in exposure to ambient PM2.5. Data on COPD burden attributable to ambient PM2.5 from 1990 to 2019 were retrieved from the Global Burden of Disease Study 2019. Cases and age-standardized rates of COPD mortality (ASMR) and disability-adjusted life years (ASDR) were estimated by age, sex, region, and country. The estimated annual percentage change (EAPC) was calculated to quantify the secular trends of ASMR and ASDR from 1990 to 2019. Globally, the number of COPD deaths and DALYs attributable to ambient PM2.5 both increased by over 90% from 1990 to 2019, but ASMR and ASDR both slightly decreased, with EAPC of -0.58 (95% CI: -0.72, -0.44) and -0.40 (95% CI: -0.51, -0.29), respectively. Most COPD deaths and DALYs attributable to PM2.5 occurred in the middle sociodemographic index (SDI) region, but the fastest growth of ASMR and ASDR occurred in the low SDI region, with EAPCs of 2.41 (95% CI: 2.23, 2.59) and 2.34 (95% CI: 2.16, 2.52), respectively. East Asia and South Asia were the high-risk areas of COPD deaths and DALYs attributable to PM2.5, among which China and India were the countries with the heaviest burden. COPD deaths and DALYs attributable to PM2.5 mainly occurred in individuals 70-89 years old and 60-84 years old, respectively. The age-specific rates of mortality and DALYs had a rapid increase in low and low-middle SDI regions from 1990 to 2019. The ASMR or ASDR had a reverse V-shaped relationship with SDI. In summary, the ambient PM2.5-attributable COPD burden is socioeconomic- and age-dependent, and it mediates the heterogeneity of spatial and temporal distribution. Low- and middle-income countries endure the highest ambient PM2.5-attributable COPD burden due to the high exposure to PM2.5 and poor availability and affordability of medicines and diagnostic tests.
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Affiliation(s)
- Xiaorong Yang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China; Clinical Research Center of Shandong University, Jinan, Shandong, People's Republic of China
| | - Tongchao Zhang
- Department of Epidemiology and Health Statistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Yuan Zhang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China; Clinical Research Center of Shandong University, Jinan, Shandong, People's Republic of China
| | - Hao Chen
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China; Clinical Research Center of Shandong University, Jinan, Shandong, People's Republic of China
| | - Shaowei Sang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, People's Republic of China; Clinical Research Center of Shandong University, Jinan, Shandong, People's Republic of China; Department of Epidemiology and Health Statistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China.
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17
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Skevaki C, Ngocho JS, Amour C, Schmid-Grendelmeier P, Mmbaga BT, Renz H. Epidemiology and management of asthma and atopic dermatitis in Sub-Saharan Africa. J Allergy Clin Immunol 2021; 148:1378-1386. [PMID: 34715154 DOI: 10.1016/j.jaci.2021.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
Abstract
Sub-Saharan Africa (SSA) is currently undergoing a transformation process of unprecedented magnitude owing to economic development and urbanization. This process is paralleled by a dramatic increase in prevalence and incidence of noncommunicable diseases. In this article we analyze the current situation with regard to 1 group of the earliest noncommunicable diseases in a person's life, namely, allergies and asthma. This article provides an update on the epidemiology, availability, and access to management strategies by patients experiencing bronchial asthma or atopic dermatitis in SSA. Despite all of the progress, there is still a tremendous need to support education and training, transfer of resources, and cooperation with pharmaceutical and diagnostic companies to achieve adequate treatment and sustainability in SSA with regard to allergy, asthma, and eczema management.
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Affiliation(s)
- Chrysanthi Skevaki
- Institute of Laboratory Medicine, Universities of Giessen and Marburg Lung Center, Philipps Universität Marburg, Member of the German Center for Lung Research, Marburg, Germany
| | - James S Ngocho
- Department of Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Caroline Amour
- Department of Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Blandina T Mmbaga
- Department of Pediatric and Child Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania; Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Harald Renz
- Institute of Laboratory Medicine, Universities of Giessen and Marburg Lung Center, Philipps Universität Marburg, Member of the German Center for Lung Research, Marburg, Germany; Department of Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania; Department of Clinical Immunology and Allergology, Laboratory of Immunopathology, Sechenov University, Moscow, Russia.
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18
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Rossaki FM, Hurst JR, van Gemert F, Kirenga BJ, Williams S, Khoo EM, Tsiligianni I, Tabyshova A, van Boven JF. Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care. Expert Rev Respir Med 2021; 15:1563-1577. [PMID: 34595990 DOI: 10.1080/17476348.2021.1985762] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Foteini M Rossaki
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (Griac), Groningen, The Netherlands
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frederik van Gemert
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (Griac), Groningen, The Netherlands
| | - Bruce J Kirenga
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Siân Williams
- International Primary Care Respiratory Group, London, UK
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Aizhamal Tabyshova
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (Griac), Groningen, The Netherlands.,Pulmonology Department, National Center of Cardiology and Internal Medicine Named after M.m. Mirrakhimov, Bishkek, Kyrgyzstan
| | - Job Fm van Boven
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (Griac), Groningen, The Netherlands
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19
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Schnieders E, Ünal E, Winkler V, Dambach P, Louis VR, Horstick O, Neuhann F, Deckert A. Performance of alternative COPD case-finding tools: a systematic review and meta-analysis. Eur Respir Rev 2021; 30:200350. [PMID: 34039672 PMCID: PMC9488779 DOI: 10.1183/16000617.0350-2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/20/2021] [Indexed: 11/05/2022] Open
Abstract
RATIONALE Guidelines recommend pre-/post-bronchodilator spirometry for diagnosing COPD, but resource constraints limit the availability of spirometry in primary care in low- and middle-income countries. Although spirometry is the diagnostic gold standard, we shall assess alternative tools for settings without spirometry. METHODS A systematic literature review and meta-analysis was conducted, utilising Cochrane, CINAHL, Google Scholar, PubMed and Web of Science (search cut-off was May 01, 2020). Published studies comparing the accuracy of diagnostic tools for COPD with post-bronchodilator spirometry were considered. Studies without sensitivity/specificity data, without a separate validation sample and outside of primary care were excluded. Sensitivity, specificity and area under the curve (AUC) were assessed. RESULTS Of 7578 studies, 24 were included (14 635 participants). Hand devices yielded a larger AUC than questionnaires. The meta-analysis included 17 studies and the overall AUC of micro-spirometers (0.84, 95% CI 0.80-0.89) was larger when compared to the COPD population screener (COPD-PS) questionnaire (0.77, 95% CI 0.63-0.85) and the COPD diagnostic questionnaire (CDQ) (0.72, 95% CI 0.64-0.78). However, only the difference between micro-spirometers and the CDQ was significant. CONCLUSIONS The CDQ and the COPD-PS questionnaire were approximately equally accurate tools. Questionnaires ensured testing of symptomatic patients, but micro-spirometers were more accurate. A combination could increase accuracy but was not evaluated in the meta-analysis.
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Affiliation(s)
- Elena Schnieders
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Elyesa Ünal
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Volker Winkler
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Dambach
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Valérie R Louis
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Olaf Horstick
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Neuhann
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
- School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Andreas Deckert
- Research to Practice Group, HIGH - Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
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20
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Jenkins CR, Wen FQ, Martin A, Barnes PJ, Celli B, Zhong NS, Zheng JP, Scaria A, Di Tanna GL, Bradbury T, Berend N. The effect of low-dose corticosteroids and theophylline on the risk of acute exacerbations of COPD: the TASCS randomised controlled trial. Eur Respir J 2021; 57:13993003.03338-2020. [PMID: 33334939 DOI: 10.1183/13993003.03338-2020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/21/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The highest burden of chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries. Low-cost oral medications, if effective, could enable affordable, accessible COPD treatment. METHODS In this randomised, three-arm, double-blind, double-dummy, placebo-controlled study conducted in 37 centres in China, symptomatic patients with moderate to very severe COPD were randomised 1:1:1 to placebo twice daily plus placebo once daily, low-dose theophylline 100 mg twice daily plus placebo once daily or low-dose theophylline 100 mg twice daily plus low-dose oral prednisone 5 mg once daily for 48 weeks. The primary end-point was annualised exacerbation rate. RESULTS 1670 subjects were randomised and 1242 completed the study (1142 with acceptable data at week 48). Subjects (75.7% male) had a mean age of 64.4 years, with mean±sd baseline post-bronchodilator forced expiratory volume in 1 s (FEV1) 1.1±0.4 L (42.2% predicted) and St George's Respiratory Questionnaire (SGRQ) score 45.8±20.1. There were negligible differences between annualised exacerbation rates across the three treatments: 0.89 (95% CI 0.78-1.02) on theophylline plus prednisone, 0.86 (95% CI 0.75-0.99) on theophylline plus placebo and 1.00 (95% CI 0.87-1.14) on placebo. The rate ratio for theophylline plus prednisone versus pooled theophylline plus placebo and placebo was 0.96 (95% CI 0.83-1.12), for theophylline plus placebo versus placebo was 0.87 (95% CI 0.73-1.03; p=0.101) and for theophylline plus prednisone versus placebo was 0.90 (95% CI 0.76-1.06; p=0.201). Secondary outcomes of hospitalisations, FEV1, SGRQ and COPD Assessment Test score showed no statistically significant difference between treatment arms. Serious adverse events other than exacerbations were <2% and did not differ between treatment arms. CONCLUSIONS Low-dose theophylline alone or in combination with prednisone did not reduce exacerbation rates or clinically important secondary end-points compared with placebo.
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Affiliation(s)
- Christine R Jenkins
- The George Institute for Global Health, Sydney, Australia .,Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Fu-Qiang Wen
- West China Hospital, Sichuan University, Chengdu, China
| | - Allison Martin
- The George Institute for Global Health, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Bartolome Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Nan-Shan Zhong
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin-Ping Zheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Anish Scaria
- The George Institute for Global Health, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Gian-Luca Di Tanna
- The George Institute for Global Health, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Thomas Bradbury
- The George Institute for Global Health, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Norbert Berend
- The George Institute for Global Health, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia
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21
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Bernabé-Ortiz A, Zafra-Tanaka JH, Moscoso-Porras M, Sampath R, Vetter B, Miranda JJ, Beran D. Diagnostics and monitoring tools for noncommunicable diseases: a missing component in the global response. Global Health 2021; 17:26. [PMID: 33750391 PMCID: PMC7941936 DOI: 10.1186/s12992-021-00676-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/25/2021] [Indexed: 11/15/2022] Open
Abstract
A key component of any health system is the capacity to accurately diagnose individuals. One of the six building blocks of a health system as defined by the World Health Organization (WHO) includes diagnostic tools. The WHO's Noncommunicable Disease Global Action Plan includes addressing the lack of diagnostics for noncommunicable diseases, through multi-stakeholder collaborations to develop new technologies that are affordable, safe, effective and quality controlled, and improving laboratory and diagnostic capacity and human resources. Many challenges exist beyond price and availability for the current tools included in the Package of Essential Noncommunicable Disease Interventions (PEN) for cardiovascular disease, diabetes and chronic respiratory diseases. These include temperature stability, adaptability to various settings (e.g. at high altitude), need for training in order to perform and interpret the test, the need for maintenance and calibration, and for Blood Glucose Meters non-compatible meters and test strips. To date the issues surrounding access to diagnostic and monitoring tools for noncommunicable diseases have not been addressed in much detail. The aim of this Commentary is to present the current landscape and challenges with regards to guidance from the WHO on diagnostic tools using the WHO REASSURED criteria, which define a set of key characteristics for diagnostic tests and tools. These criteria have been used for communicable diseases, but so far have not been used for noncommunicable diseases. Diagnostic tools have played an important role in addressing many communicable diseases, such as HIV, TB and neglected tropical diseases. Clearly more attention with regards to diagnostics for noncommunicable diseases as a key component of the health system is needed.
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Affiliation(s)
- Antonio Bernabé-Ortiz
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jessica H. Zafra-Tanaka
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Miguel Moscoso-Porras
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Beatrice Vetter
- Foundation for Innovative and New Diagnostics, Geneva, Switzerland
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, UNSW, Sydney, Australia
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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22
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Plum C, Stolbrink M, Zurba L, Bissell K, Ozoh BO, Mortimer K. Availability of diagnostic services and essential medicines for non-communicable respiratory diseases in African countries. Int J Tuberc Lung Dis 2021; 25:120-125. [PMID: 33656423 PMCID: PMC7987206 DOI: 10.5588/ijtld.20.0762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND: The global burden of disease due to asthma and chronic obstructive pulmonary disease (COPD) is substantial and particularly great in low- and middle-income countries, including many African countries. Management is affected by availability of diagnostic tests and essential medicines. The study aimed to explore the availability of spirometry services and essential medicines for asthma and COPD in African countries.METHOD: Questionnaires were delivered to healthcare workers at the annual meeting of the Pan African Thoracic Society Methods in Epidemiology and Clinical Research (PATS MECOR) and International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA). Data were analysed using simple descriptive statistics.RESULTS: A total of 37 questionnaires representing 13 African countries were returned. Spirometry availability was 73.0%. The most common reasons for non-availability were lack of knowledge of the utility of the test. Within the study sample, 33.3% faced sporadic availability due to maintenance issues. Essential medicines availability ranged from 37.8% for inhaled corticosteroid-long-acting beta-agonist inhalers to 100% for prednisolone 5 mg tablets, mainly due to supply chain problems.CONCLUSION: There is varied availability of spirometry and WHO essential medicines for COPD and asthma in African countries. Strategies are needed to improve access to basic effective care for people with non-communicable lung disease in Africa.
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Affiliation(s)
- C Plum
- Liverpool School of Tropical Medicine, Liverpool
| | - M Stolbrink
- Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - L Zurba
- Education for Health Africa, Durban, South Africa
| | - K Bissell
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - B O Ozoh
- College of Medicine, University of Lagos, Lagos, Nigeria
| | - K Mortimer
- Liverpool School of Tropical Medicine, Liverpool
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23
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Ozoh OB, Eze JN, Garba BI, Ojo OO, Okorie EM, Yiltok E, Okoli CV, Hammangabdo A, Beran D. Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria. Trop Med Int Health 2020; 26:54-65. [PMID: 32985028 DOI: 10.1111/tmi.13497] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE(S) To determine the availability and affordability of asthma and COPD medicines across Nigeria. METHODS This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in ≥ 80% of surveyed pharmacies. Unaffordability was defined as paying> 1 day's wage (> US$1.68) for a standard 30-day supply of the medicine. RESULTS The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5 days. CONCLUSIONS There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.
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Affiliation(s)
- Obianuju B Ozoh
- Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria.,Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Joy N Eze
- Department of Pediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital Ituku Ozalla, Enugu, Nigeria
| | - Bilkisu I Garba
- Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Oluwafemi O Ojo
- Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Esther Yiltok
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | - Chinyere V Okoli
- Department of Paediatrics, Nyanya General Hospital, Abuja, Nigeria
| | - Ahmed Hammangabdo
- Department of Medicine, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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24
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Cazzola M, Matera MG. The effect of doxofylline in asthma and COPD. Respir Med 2020; 164:105904. [PMID: 32094104 DOI: 10.1016/j.rmed.2020.105904] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
Abstract
Theophylline is still one of the most widely prescribed drugs for the treatment of asthma and COPD in developing countries because the majority of asthma and COPD medicines are largely unavailable and also because it is a cheap option. In any case, its anti-inflammatory effects and capacity to reverse corticosteroid resistance deserve consideration, but it can induce numerous side effects and drug-drug interactions and frequently requires measurement of drug levels in plasma. In order to overcome the problems posed by theophylline, other xanthines have been developed. Doxofylline is a newer generation xanthine with both bronchodilating and anti-inflammatory activities and for this reason it has been called "novofylline". It differs substantially from theophylline at the pharmacological level. Clinical studies have shown substantial differences between doxofylline and theophylline. In particular, efficacy/safety profile of doxofylline is better than that of theophylline.
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Affiliation(s)
- Mario Cazzola
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Italy.
| | - Maria Gabriella Matera
- Chair of Pharmacology, Department of Experimental Medicine, University of Campania, Naples, Italy
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25
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Mpairwe H, Tumwesige P, Namutebi M, Nnaluwooza M, Katongole T, Tumusiime J, Apule B, Onen C, Mukasa M, Kahwa J, Webb EL, Pearce N, Elliott AM. Asthma control and management among schoolchildren in urban Uganda: results from a cross-sectional study. Wellcome Open Res 2019; 4:168. [PMID: 32656365 PMCID: PMC7327727 DOI: 10.12688/wellcomeopenres.15460.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Children from low- and middle-income countries have poor asthma control, mainly because of poor management. The extent of this problem in Uganda is not well known, but such information would be useful to guide policy and practice. We therefore conducted a cross-sectional study among schoolchildren with asthma in urban Uganda, to assess the level of asthma control and management. Methods: Schoolchildren aged 5-17 years were enrolled, asthma was diagnosed by the study medical team. Asthma control was assessed using the Asthma Control Test and the childhood Asthma Control Test. Data on previous asthma management was obtained using interviewer-led questionnaires. Data were analysed using multiple linear and multiple logistic regression. Results: We enrolled 561 children with asthma, of whom only 56% had ever had an asthma diagnosis. We categorised asthma as well-controlled (55.5%), partly-controlled (29.5%) and poorly-controlled (15.0%). Poor asthma control was associated with increasing age (adjusted regression coefficient [95% confidence interval], p-value: -1.07 [-1.20, -0.94], p<0.0001), concurrent allergic rhinitis (-1.33 [-2.28, -0.38], p=0.006), and city residence in early life (-1.99 [-3.69, -0.29], p=0.06). Regular use of inhaled asthma medication in the last 12 months was very low; 18.1% for salbutamol and 6.7% for inhaled corticosteroids. The main barriers to inhaled asthma medication use were lack of prescription (47.6%) and inaccurate diagnosis (38.8%). Increased inhaler use was associated with tertiary education of the fathers (adjusted odds ratio [95% confidence interval], p-value: 5.19 [2.39-11.28], p<0.0001), city residence in early life (4.66 [1.79-12.43], 0.002) and an asthma diagnosis prior to enrolment (11.39 [6.35-20.43], p<0.0001). Conclusions: This study confirms that children with asthma in Uganda generally have inadequate asthma control, which is attributable to poor asthma management. This could be improved through re-training of medical workers and patient education, and by increasing availability and affordability of essential asthma medications.
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Affiliation(s)
- Harriet Mpairwe
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Pius Tumwesige
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Milly Namutebi
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Marble Nnaluwooza
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Tonny Katongole
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Josephine Tumusiime
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Barbara Apule
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Caroline Onen
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Mike Mukasa
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Joseph Kahwa
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda
| | - Emily L Webb
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Neil Pearce
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Alison M Elliott
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Box 49, Entebbe, Uganda.,London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
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26
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Ozoh OB, Ayuk AC, Ukwaja KN, Desalu OO, Olufemi O, Aderibigbe SA, Egbagbe E, Oridota OE, Dede SK, Shopeyin A, Babashani M. Asthma management and control in Nigeria: the asthma insight and reality Nigeria (AIRNIG) study. Expert Rev Respir Med 2019; 13:917-927. [PMID: 31365287 DOI: 10.1080/17476348.2019.1651201] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The state of asthma management and asthma control at the population level in Nigeria is unknown. We aimed to determine the level of asthma control and asthma management practices in Nigeria. Methods: A cross-sectional population-based study of 405 participants with current asthma (physician-diagnosed with use of asthma medication or asthma symptoms in the preceding 12 months). We determined the level of asthma control, self-perception of asthma control, health-care use, missed work/school, and medication use. Results: Asthma was controlled in 6.2% of the participants. Night-time awakening and limitation in activity in the preceding 4 weeks were reported by 77.5% and 78.3%, respectively, 56.3% and 14.1% missed work/school and had emergency room visits, respectively, and 11.6% and 38.8% used inhaled corticosteroid and short-acting beta-2 agonist, respectively, in the preceding year. About a third (34.3%) had spirometry ever performed and 46.7% had training on inhaler technique. Nearly 90% with uncontrolled asthma had self-perception of asthma control between somewhat and completely controlled. Conclusion: The level of asthma control in Nigeria is poor with a high burden of asthma symptoms and limitation in activities. This calls for a broad-based approach for the improvement in asthma care that encompasses education and access to medications.
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Affiliation(s)
- Obianuju B Ozoh
- Department of Medicine, College of Medicine, University of Lagos , Lagos State , Nigeria.,Department of Medicine, Lagos University Teaching Hospital , Lagos State , Nigeria
| | - Adaeze C Ayuk
- Department of Paediatrics, College of Medicine, University of Nigeria Teaching Hospital , Enugu State , Nigeria
| | - Kingsley N Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital Abakiliki , Ebonyi State , Nigeria
| | - Olufemi O Desalu
- Department of Medicine, College of Health Sciences, University of Ilorin , Kwara State , Nigeria
| | - Olajumoke Olufemi
- Department of Community Medicine, Lagos University Teaching Hospital , Lagos State , Nigeria
| | - Sunday A Aderibigbe
- Department of Public Health, College of Medicine, University of Ilorin , Kwara State , Nigeria
| | - Eruke Egbagbe
- Department of Medicine, College of Medicine, University of Benin , Edo State , Nigeria
| | - Olufela E Oridota
- Department of Community Medicine, Lagos University Teaching Hospital , Lagos State , Nigeria.,Department of Community Medicine and Child Health, College of Medicine, University of Lagos , Lagos State , Nigeria
| | - Sandra K Dede
- Department of Medicine, Lagos University Teaching Hospital , Lagos State , Nigeria
| | - Azeezat Shopeyin
- Department of Community Medicine, Lagos University Teaching Hospital , Lagos State , Nigeria
| | - Musa Babashani
- Department of Medicine, College of Medicine, Aminu Kano University , Kano State , Nigeria
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27
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Kibirige D, Sanya RE, Nantanda R, Worodria W, Kirenga B. Availability and affordability of medicines and diagnostic tests recommended for management of asthma and chronic obstructive pulmonary disease in sub-Saharan Africa: a systematic review. Allergy Asthma Clin Immunol 2019; 15:14. [PMID: 30899279 PMCID: PMC6407228 DOI: 10.1186/s13223-019-0329-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 02/20/2019] [Indexed: 01/02/2023] Open
Abstract
Background Early accurate diagnosis and sustainable availability of affordable medicines and diagnostic tests is fundamental in optimal management of asthma and chronic obstructive pulmonary disease (COPD). We systematically reviewed original research articles about availability and affordability of medicines and diagnostic tests recommended for management of asthma and COPD in sub-Saharan Africa (SSA). Methods We searched PubMed, Scopus and African Journal Online for original research articles conducted in SSA between 2000 and March 2018 containing information about availability and affordability of any recommended medicine and diagnostic test for asthma and COPD. Results The search yielded 9 eligible research articles. Availability of short-acting beta agonists (SABA), inhaled corticosteroids (ICS) and short acting anti-muscarinic agents (SAMA) ranged between 19.9-100%, 0-45.5% and 0-14.3% respectively. Combination of ICS-long acting beta agonists (LABA) were available in 0-14.3% of facilities surveyed. There was absence of inhaled long acting anti-muscarinic agents (LAMA) and LAMA/LABA combinations. Spirometry and peak expiratory flow devices were available in 24.4-29.4% and 6.7-53.6% respectively. Affordability of SABA and ICS varied greatly, ranging from < 2 to 107 days' wages while ICS-LABA combinations, SAMA and oral theophylline plus leukotriene receptor antagonists cost 6.4-17.1, 13.7 and 6.9 days' wages respectively. Conclusion Availability and affordability of medicines and diagnostics recommended for the management of asthma and COPD is a big challenge in SSA. Research about this subject in this region is still limited. More robustly performed studies are required to further understand the magnitude of inequity in access to these medicines and diagnostic tests in SSA and also to formulate simple pragmatic solutions to address this challenge.
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Affiliation(s)
- Davis Kibirige
- Department of Medicine, Uganda Martyrs Hospital Lubaga, P.O.BOX 14130, Kampala, Uganda.,2Non-communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Richard E Sanya
- 2Non-communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Rebecca Nantanda
- 3Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda.,4Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - William Worodria
- Division of Pulmonology, Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Bruce Kirenga
- 3Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Division of Pulmonology, Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
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28
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Mehanni S, Jha D, Kumar A, Choudhury N, Dangal B, Deukmedjian G, Dhungana SK, Gauchan B, Gupta TK, Halliday S, Kalaunee SP, Mahar R, Poudel S, Raut A, Schwarz R, Singh DR, Thapa A, Thapa R, Wong L, Maru D, Schwarz D. Implementing a quality improvement initiative for the management of chronic obstructive pulmonary disease in rural Nepal. BMJ Open Qual 2019; 8:e000408. [PMID: 31259269 PMCID: PMC6567951 DOI: 10.1136/bmjoq-2018-000408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 12/14/2018] [Accepted: 12/27/2018] [Indexed: 12/01/2022] Open
Abstract
Background Chronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity. Design Using international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback. Results The rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative. Conclusion This case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.
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Affiliation(s)
- Stephen Mehanni
- Possible, Kathmandu, Nepal.,Health Equity Action Leadership Initiative, University of California San Francisco, San Francisco, California, USA.,Gallup Indian Medical Center, Gallup, New Mexico, USA
| | - Dhiraj Jha
- Possible, Kathmandu, Nepal.,Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Anirudh Kumar
- Possible, Kathmandu, Nepal.,Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Grace Deukmedjian
- Possible, Kathmandu, Nepal.,Health Equity Action Leadership Initiative, University of California San Francisco, San Francisco, California, USA.,Department of Pediatrics, Natividad Medical Center, Salinas, California, USA
| | | | - Bikash Gauchan
- Possible, Kathmandu, Nepal.,Health Equity Action Leadership Initiative, University of California San Francisco, San Francisco, California, USA
| | | | - Scott Halliday
- Possible, Kathmandu, Nepal.,Henry M. Jackson School of International Studies, University of Washington, Seattle, Washington, USA
| | - S P Kalaunee
- Possible, Kathmandu, Nepal.,College of Business and Leadership, Eastern University, St. Davids, Pennsylvania, USA
| | | | | | | | - Ryan Schwarz
- Possible, Kathmandu, Nepal.,Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dipendra Raman Singh
- Public Health Monitoring and Evaluation Division, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | | | | | - Lena Wong
- Possible, Kathmandu, Nepal.,Health Equity Action Leadership Initiative, University of California San Francisco, San Francisco, California, USA.,Tuba City Indian Medical Center, Tuba City, Arizona, USA
| | - Duncan Maru
- Possible, Kathmandu, Nepal.,Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dan Schwarz
- Possible, Kathmandu, Nepal.,Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts, USA
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29
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Masekela R, Zurba L, Gray D. Dealing with Access to Spirometry in Africa: A Commentary on Challenges and Solutions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 16:E62. [PMID: 30591644 PMCID: PMC6339263 DOI: 10.3390/ijerph16010062] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 11/16/2022]
Abstract
Spirometry is an important tool in the surveillance, epidemiology, diagnosis, and management of respiratory disease, yet its accessibility is currently limited in Africa where the burden of respiratory diseases is amongst the highest globally. The reasons for limited access to spirometry in Africa include poor access to training and skilled technicians, limited availability of equipment, consumables, and technical support, and lack of human and financial resources. The Pan African Thoracic Society, working together with regional African thoracic societies and key research initiatives in Africa, have made progress in training and education, but a lot of work is still needed to meet the challenges faced. Accurately defining these challenges of access to high quality spirometry, development of local, standardised, and context-specific training and quality assurance tools; development of appropriate reference standards and innovative approaches to addressing the challenges of access to equipment, consumables and technical support are needed. Training and research collaborations that include regional thoracic societies, health system leaders, the Pan African Thoracic Society and international role players in the field are key to maximising available intellectual and financial resources. Hence ensuring that access to high quality spirometry measures that are used effectively in tackling the burden of respiratory disease in Africa.
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Affiliation(s)
- Refiloe Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban 4013, South Africa.
| | - Lindsay Zurba
- Education for Health Africa, Durban 4302, South Africa.
| | - Diane Gray
- Department of Paediatrics and Child Health and MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town 7700, South Africa.
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van Gemert FA, Kirenga BJ, Gebremariam TH, Nyale G, de Jong C, van der Molen T. The complications of treating chronic obstructive pulmonary disease in low income countries of sub-Saharan Africa. Expert Rev Respir Med 2018; 12:227-237. [PMID: 29298106 DOI: 10.1080/17476348.2018.1423964] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Frederik A van Gemert
- a Groningen Research Institute for asthma and COPD (GRIAC) , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands.,b Makerere University Lung Institute (MLI), Mulago Hospital , Kampala , Uganda
| | - Bruce J Kirenga
- a Groningen Research Institute for asthma and COPD (GRIAC) , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands.,b Makerere University Lung Institute (MLI), Mulago Hospital , Kampala , Uganda.,c Department of Medicine , Makerere University , Kampala , Uganda
| | - Tewodros Haile Gebremariam
- d Department of Internal Medicine, Division of Pulmonary & Critical Care Medicine , Addis Ababa University, College of Health Science , Addis Ababa , Ethiopia
| | - George Nyale
- e Respiratory and Infectious Disease Unit , Kenyatta National Referral & Teaching Hospital , Nairobi , Kenya.,f Kenya Association of Physicians for Tuberculosis and other Lung Disease (KAPTLD) , Nairobi , Kenya
| | - Corina de Jong
- a Groningen Research Institute for asthma and COPD (GRIAC) , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Thys van der Molen
- a Groningen Research Institute for asthma and COPD (GRIAC) , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands.,b Makerere University Lung Institute (MLI), Mulago Hospital , Kampala , Uganda
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