1
|
Al Akoury N, Spinardi J, Haridy H, Molefe-Osman N, Mphahlele N, Mendoza CF, Yang J, Aruffo E, Kyaw MH, Yarnoff B. Modeling the potential public health impact of different vaccination strategies with an adapted vaccine in South Africa. Expert Rev Vaccines 2024; 23:750-760. [PMID: 39176448 DOI: 10.1080/14760584.2024.2396091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/13/2024] [Accepted: 08/20/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND COVID-19 vaccines adapted to newly emerging circulating variants are necessary to better protect the population due to the evolving nature of the SARS-CoV-2 virus. RESEARCH DESIGN AND METHODS The South African population was stratified by age and risk (defined by comorbidities such as diabetes, obesity, smoking, cancer, and asthma), and HIV status. The outcomes of different vaccination strategies based on age, risk, and HIV status were estimated using a Markov-decision tree model based on age-specific inputs derived from the literature and South African surveillance data. RESULTS Vaccinating older adults and those with comorbidities was estimated to avert 111,179 infections 18,281 hospitalizations, and 3,868 deaths, resulting in savings of ZAR 1,260 million (USD 67 million) and ZAR 3,205 million (USD 170 million) in direct and indirect costs, respectively. Similar results were obtained when considering strategies targeting older adults and the HIV population. Expanding vaccination to 75% of the standard-risk population prevented more infections (401%), hospitalizations (167%), and deaths (67%) and increased the direct (232%) and indirect (455%) cost savings compared to the base case. CONCLUSIONS Implementing widespread vaccination strategies that utilize a vaccine adapted to the prevailing circulating variant in South Africa would result in significant public health and economic gains.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Elena Aruffo
- Modeling & Simulation, Evidera Inc, Bethseda, MD, USA
| | - Moe H Kyaw
- Access and Value, Pfizer Inc, New York, NY, USA
| | - Ben Yarnoff
- Modeling & Simulation, Evidera Inc, Bethseda, MD, USA
| |
Collapse
|
2
|
Nkhoma KB, Farrant L, Mzimkulu O, Hunter J, Higginson I, Gao W, Maddocks M, Gwyther L, Harding R. High Prevalence and Burden of Physical and Psychological Symptoms in a Chronic Obstructive Pulmonary Disease Population in Primary Care Settings in South Africa. Int J Chron Obstruct Pulmon Dis 2023; 18:1665-1679. [PMID: 37554921 PMCID: PMC10404593 DOI: 10.2147/copd.s395834] [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: 11/17/2022] [Accepted: 04/30/2023] [Indexed: 08/10/2023] Open
Abstract
Background Many deaths globally are attributable to non-communicable disease, and four-fifths of these deaths are in low- and middle-income countries. Globally, COPD is currently the third leading cause of mortality. Research Question 1) To determine the prevalence and burden of symptoms and concerns, and 2) determine predicting factors of symptom burden among patients with COPD. Methods A cross-sectional survey was conducted at eight primary care sites in Western Cape. We collected socio-demographic data (age, gender, smoking status, number of missed doses of prescribed medication in the last seven days) and clinical data (PEF and KPS). The Memorial Symptom Assessment Scale (MSAS), the Medical Outcomes Study, Social Support Survey (MOS-SSS), the London Chest Activity of Daily Living Scale (LCADLS) and the COPD Assessment Test (CAT) (impairment on person's life) were administered to patients. We conducted ordered logistic regression analysis to assess factors associated with the burden of symptoms. MSAS subscales: 1) Global symptom distress index, 2) physical symptom distress and 3) psychological symptom distress were dependent outcomes. We constructed three ordinal logistic regression models for each of the three subscales. Covariates were MOS-SSS, LCADLS, CAT, demographic and clinical variables. Results We recruited n=387 patients, mean age 59.5 years, 53.0% female. In multivariate analysis, each of the three models (ie, global, psychological and physical symptom distress) was positively associated with impairment on person's life p<0.001, difficulty to perform activities of daily living p<0.001, and low social support p<0.001. Old age was associated with lower global symptom distress (p=0.004), psychological and (0.014) physical distress (0.005). Missing 1 or more doses of medication was associated with higher levels of global (0.004) and physical (0.005) symptom distress. Interpretation The high prevalence and burden of physical and psychological symptoms provides strong evidence of the need for integrating person-centred assessment and management of symptoms in primary care settings.
Collapse
Affiliation(s)
- Kennedy B Nkhoma
- Cicely Saunders Institute of Palliative Care Policy and Rehabilitation, King’s College London, London, UK
| | - Lindsay Farrant
- Division of Interdisciplinary Palliative Care & Medicine, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Olona Mzimkulu
- Division of Interdisciplinary Palliative Care & Medicine, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joy Hunter
- Division of Interdisciplinary Palliative Care & Medicine, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Irene Higginson
- Cicely Saunders Institute of Palliative Care Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Division of Interdisciplinary Palliative Care & Medicine, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care Policy and Rehabilitation, King’s College London, London, UK
| | - Liz Gwyther
- Division of Interdisciplinary Palliative Care & Medicine, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care Policy and Rehabilitation, King’s College London, London, UK
| |
Collapse
|
3
|
The characteristics and costs of severe theophylline toxicity in a tertiary critical care unit in Eastern Cape Province, South Africa. S Afr Med J 2022; 112:866-870. [DOI: 10.7196/samj.2022.v112i11.16453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background. Severe theophylline toxicity requiring haemodialysis accounts for approximately one-third of drug toxicity cases admitted to the Livingstone Tertiary Hospital (LTH) intensive care unit (ICU) in Gqeberha, South Africa, imposing a significant resource burden.
Objectives. To investigate the characteristics and burden of severe theophylline toxicity in an Eastern Cape Province tertiary hospital adult ICU.
Methods. A retrospective review of all severe theophylline toxicity admissions to the ICU from 1 January 2013 to 31 December 2018 was conducted. Demographic and clinical data were captured and analysed. The National Department of Health 2019 fees schedule was used to calculate costs based on duration of ICU stay and number of haemodialysis sessions received.
Results. Of the 57 patients included in the study, 84% were cases of deliberate self-harm. The majority were aged <40 years (77%) and female (79%). The mean (standard deviation (SD)) initial serum theophylline level was 612 (269) µmol/L. Complications included convulsions (n=12; 21%), arrhythmias (n=9; 16%), need for mechanical ventilation (n=7; 12%) and death (n=4; 7%). The main risk factors for these complications were age ≥30 years, an inappropriately normal or elevated initial serum potassium level, an elevated serum creatinine kinase level and an elevated initial serum theophylline level. Receiver operator characteristic curve analysis assessing the initial serum theophylline level as a discriminator for life-threatening complications produced an area under the curve of 0.71 for serum theophylline >400 µmol/L (sensitivity 88%, specificity 12%). All the 4 patients who died had an initial serum theophylline level >1 000 µmol/L. The mean (SD) cost per admission amounted to ZAR16 897 (10 718), with a mean of one 4-hour dialysis session per admission.
Conclusion. Severe theophylline toxicity, usually in the context of deliberate self-harm, is a preventable yet life-threatening toxicity encountered at LTH. Demographic risk factors include young females from certain areas in and around Gqeberha. Risk factors for complications include older age, paradoxically normal or elevated serum potassium levels, elevated serum creatinine kinase levels and an initial serum theophylline level >400 µmol/L. Patients with these clinical features should be closely monitored and treated timeously at an appropriate level of care. The need for ICU admission and dialysis, both limited resources, makes the treatment of severe theophylline toxicity costly. Further studies of the underlying psychosocial drivers, local prescribing practices and preventive interventions related to severe theophylline toxicity are required.
Collapse
|
4
|
Feldman C, Dlamini S, Richards GA, Black J, Butler ILC, Cutland C, Hefer E, Hodkinson B, Kok A, Manga P, Meiring S, Molaudzi M, Moosa MYS, Parker S, Peter J, van Vuuren C, Verburgh E, Watermeyer G. A comprehensive overview of pneumococcal vaccination recommendations for adults in South Africa, 2022. J Thorac Dis 2022; 14:4150-4172. [PMID: 36389298 PMCID: PMC9641319 DOI: 10.21037/jtd-22-287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/28/2022] [Indexed: 09/08/2024]
Abstract
Pneumococcal infections remain a common global cause of significant morbidity and mortality. The first recommendations for adult pneumococcal vaccination, published in South Africa in 1999, contained information only on the 23-valent polysaccharide vaccine (PPV23). With the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) for use in adults and the perceived uncertainty that most clinicians had regarding use of these vaccines in adults, these vaccine recommendations were updated in 2022. A Working Group, which consisted of individuals in various fields of medical practice in South Africa, who were from different areas of the country, and included clinicians from both the public and private sectors, was assembled to revise the recommendations. The expertise of the participants varied widely, dependent on their training and specialty, and encompassed different organ systems, disease conditions, and/or practice types. Each participant was allocated a different section, based on their expertise, for which they were required to do an extensive review of the current literature and write their section. The entire working group then reviewed the complete document several times, following additional comments and recommendations. This update contains recommendations for the use of both PPV23 and PCV13, either alone, or in sequence, both in vaccine naïve and in previously vaccinated individuals. It includes both age and risk categories, and encompasses the elderly (≥65 years), as well as younger adults (<65 years) with comorbid conditions or with high-risk conditions and/or immunocompromise. It is hoped that this review and its associated vaccine recommendations will clarify for clinicians, from all spheres of practice in South Africa, how, where, and when pneumococcal vaccines should be used in adults, with the ultimate goal of significantly increasing the appropriate use of these vaccines, in order to decrease the substantial morbidity and mortality associated with pneumococcal infections in adults in South Africa. Furthermore, it is hoped that this review of local epidemiological data and the manner in which this information was interpreted in the development of these local vaccine recommendations, could be used as an example for other regions of the world, to tailor their recommendations to locally available epidemiological data.
Collapse
Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Guy A. Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John Black
- Department of Internal Medicine, Walter Sisulu University, Gqeberha, South Africa
| | - India L. C. Butler
- Division of Geriatric Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clare Cutland
- African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eric Hefer
- General Practitioner in Private Practice, Forest Town, Johannesburg, South Africa
| | - Bridget Hodkinson
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Adri Kok
- Private Practice Physician and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pravin Manga
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Mahomed-Yunus S. Moosa
- Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Salim Parker
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department Internal Medicine, University of the Free State and Department of Internal Medicine, 3 Military Hospital, Bloemfontein, South Africa
| | - Estelle Verburgh
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gill Watermeyer
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Position statement on endoscopic lung volume reduction in South Africa: 2022 update. Afr J Thorac Crit Care Med 2022; 28:10.7196/AJTCCM.2022.v28i2.249. [PMID: 35919923 PMCID: PMC9315962 DOI: 10.7196/ajtccm.2022.v28i2.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) remains one of the most common causes of morbidity and mortality in South Africa. Endoscopic lung volume reduction (ELVR) was first proposed by the South African Thoracic Society (SATS) for the treatment of advanced emphysema in 2015. Since the original statement was published, there has been a growing body of evidence that a certain well-defined sub-group of patients with advanced emphysema may benefit from ELVR, to the point where the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines and the United Kingdom National Institute for Health and Care Excellence (NICE) advocate the use of endoscopic valves based on level A evidence. Patients aged 40 - 75 years with severe dyspnoea (COPD Assessment Test score ≥10) despite maximal medical therapy and pulmonary rehabilitation, with forced expiratory volume in one second (FEV1) 20 - 50%, hyperinflation with residual volume (RV) >175% or RV/total lung capacity (TLC) >55% and a six-minute walking distance (6MWD) of 100 - 450 m (post-rehabilitation) should be referred for evaluation for ELVR, provided no contraindications (e.g. severe pulmonary hypertension) are present. Further evaluation should focus on the extent of parenchymal tissue destruction on high-resolution computed tomography (HRCT) of the lungs and interlobar collateral ventilation (CV) to identify a potential target lobe. Commercially available radiology software packages and/or an endobronchial catheter system can aid in this assessment. The aim of this statement is to provide the South African medical practitioner and healthcare funders with an overview of the practical aspects and current evidence for the judicious use of the valves and other ELVR modalities which may become available in the country.
Collapse
|
6
|
Guidelines for the management of asthma in adults and adolescents: Position statement of the South African Thoracic Society - 2021 update. Afr J Thorac Crit Care Med 2022; 27. [PMID: 35118373 PMCID: PMC8802209 DOI: 10.7196/ajtccm.2021.v27i4.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma prevalence is increasing worldwide, and surveys indicate that most patients in developed and developing countries, including
South Africa, do not receive optimal care and are therefore not well controlled. Standard management guidelines adapted to in-country
realities are important to support optimal care. The South African Thoracic Society (SATS) first published a guideline for the management
of chronic persistent asthma in 1992, which has subsequently been revised several times.
The main aim of the present document was to revise and update SATS’ statement on the suggested management of chronic asthma, based
on the need to promote optimal care and control of asthma, together with the incorporation of new concepts and drug developments. This
revised document reinforces optimal care and incorporates the following primary objectives to achieve the recent advances in asthma care:
continued emphasis on the use of inhaled corticosteroids (ICS) as the foundation of asthma treatment to reduce the reliance on short-acting beta-2 agonist (SABA) monotherapy for asthma symptoms to incorporate the evidence and strategy for the use of the combination of an ICS and formoterol for acute symptom relief (instead of
a SABA) to incorporate the evidence and strategy for the use of as-needed ICS-long-acting beta agonists (LABA) for patients with infrequent
symptoms or ‘mild’ asthma to incorporate the evidence and strategy for the use of a long-acting muscarinic antagonist (LAMA) in combination with ICS-LABA; and to incorporate the evidence and strategy for the use of and management with a biologic therapy in severe asthma.
Collapse
|
7
|
Goolam Mahomed T, Peters RPH, Allam M, Ismail A, Mtshali S, Goolam Mahomed A, Ueckermann V, Kock MM, Ehlers MM. Lung microbiome of stable and exacerbated COPD patients in Tshwane, South Africa. Sci Rep 2021; 11:19758. [PMID: 34611216 PMCID: PMC8492659 DOI: 10.1038/s41598-021-99127-w] [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: 01/27/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is characterised by the occurrence of exacerbations triggered by infections. The aim of this study was to determine the composition of the lung microbiome and lung virome in patients with COPD in an African setting and to compare their composition between the stable and exacerbated states. Twenty-four adult COPD patients were recruited from three hospitals. Sputum was collected and bacterial DNA was extracted. Targeted metagenomics was performed to determine the microbiome composition. Viral DNA and RNA were extracted from selected samples followed by cDNA conversion. Shotgun metagenomics sequencing was performed on pooled DNA and RNA. The most abundant phyla across all samples were Firmicutes and Proteobacteria. The following genera were most prevalent: Haemophilus and Streptococcus. There were no considerable differences for alpha and beta diversity measures between the disease states. However, a difference in the abundances between disease states was observed for: (i) Serratia (3% lower abundance in exacerbated state), (ii) Granulicatella (2.2% higher abundance in exacerbated state), (iii) Haemophilus (5.7% higher abundance in exacerbated state) and (iv) Veillonella (2.5% higher abundance in exacerbated state). Virome analysis showed a high abundance of the BeAn 58058 virus, a member of the Poxviridae family, in all six samples (90% to 94%). This study is among the first to report lung microbiome composition in COPD patients from Africa. In this small sample set, no differences in alpha or beta diversity between stable and exacerbated disease state was observed, but an unexpectedly high frequency of BeAn 58058 virus was observed. These observations highlight the need for further research of the lung microbiome of COPD patients in African settings.
Collapse
Affiliation(s)
- T Goolam Mahomed
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - R P H Peters
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
- Foundation for Professional Development, Research Unit, East London, South Africa
| | - M Allam
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - A Ismail
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - S Mtshali
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | | | - V Ueckermann
- Department of Internal Medicine, University of Pretoria, Pretoria, South Africa
| | - M M Kock
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
- Department of Medical Microbiology, Tshwane Academic Division, National Health Laboratory Service, Johannesburg, South Africa
| | - M M Ehlers
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.
- Department of Medical Microbiology, Tshwane Academic Division, National Health Laboratory Service, Johannesburg, South Africa.
| |
Collapse
|
8
|
Lion-Cachet HC, Musonda JMM, Omole OB. Severe asthma in South Africa: A literature review and management approach for primary care. S Afr Fam Pract (2004) 2021; 63:e1-e10. [PMID: 33567835 PMCID: PMC8378165 DOI: 10.4102/safp.v63i1.5179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/15/2020] [Accepted: 09/19/2020] [Indexed: 11/01/2022] Open
Abstract
Severe asthma in South Africa (SA) is underappreciated, especially in the primary care setting. This study highlights the epidemiological context of severe asthma as a phenotypic variant. Primary care practitioners, as first-contact medical providers, need grounding in the management of severe asthma based on the precision of diagnosis and negotiated along the 10-point strategy. The underdiagnosis and undertreatment of asthma ought to inform educational programmes and research in this country.
Collapse
Affiliation(s)
- Huibrecht C Lion-Cachet
- Department of Family Medicine and Primary Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg.
| | | | | |
Collapse
|
9
|
Irusen EM, Malange T. Pharmacotherapy of chronic obstructive pulmonary disease: Therapeutic considerations with a focus on inhaled corticosteroids. S Afr Fam Pract (2004) 2020; 62:e1-e6. [PMID: 33314947 PMCID: PMC8378153 DOI: 10.4102/safp.v62i1.5198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/01/2022] Open
Abstract
International and national guidelines on chronic obstructive pulmonary disease (COPD) emphasise bronchodilators as first-line therapy. However, in considering them the 'foundation' of treatment, attention has shifted from the fact that COPD is fundamentally an inflammatory disease. The mainstay ought to be anti-inflammatory medication, and inhaled corticosteroids (ICS) are the best agents we have presently. There was initial scepticism about their role, but ICS were subsequently shown to have numerous anti-inflammatory effects. They are synergistic with bronchodilators at a molecular and clinical level and unequivocally improve dyspnoea, quality of life, exacerbation frequency and, more recently, mortality. These benefits are most apparent in the COPD eosinophilic phenotype. These beneficial effects have been met with some reservations because of the predisposition to pneumonia of ICS. This must be seen in context: over 90% of COPD patients in all clinical trials do not get pneumonia. The fact that patients with COPD are predisposed to pneumonia because of the disease itself is disregarded; this is a crucial omission as this constitutes the baseline incidence of about 3%. When one allows for this, then in the clinical reports, the excess risk of pneumonia ranges from zero to a maximum of 3%. Equally, some of the systemic effects attributed to ICS fail to appreciate that the disease, smoking and older age are risk factors in themselves, and ICS do not aggravate these. Chronic obstructive pulmonary disease has considerable impact on respiratory reserve and is associated with increasing morbidity; optimal outcomes are best achieved with long-acting bronchodilators and ICS co-prescription.
Collapse
Affiliation(s)
- Elvis M Irusen
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and, Tygerberg Hospital, Cape Town.
| | | |
Collapse
|