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Alupo P, Katagira W, Mukunya D, Okimat P, Tejwani V, Kayongo A, Nalunjogi J, Robertson NM, Jones R, Hurst JR, Kirenga B, Siddharthan T. The Neutrophil-to-Lymphocyte Ratio as a Predictor of Acute Exacerbations Among Patients With COPD in Uganda. Chronic Obstr Pulm Dis 2024; 11:187-195. [PMID: 38237091 DOI: 10.15326/jcopdf.2023.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Background The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive biomarker that potentially predicts acute exacerbations of chronic obstructive pulmonary disease (AECOPDs). We evaluated the association of baseline NLR and respiratory hospitalization risk within one year among chronic obstructive pulmonary disease (COPD) patients in Uganda, a low- and middle-income country. Methods A total of 312 COPD patients were followed for one year. Clinical characteristics and exacerbation rates were collected. Poisson regression with robust variance estimators was used to measure the association between NLR and hospital admissions due to COPD exacerbations. Receiver-operator characteristic (ROC) curves and the area under the curve were used to assess the ability of NLR to predict AECOPDs. Results The median (Q 1, Q 3) age was 64 years (53, 71). Females comprised 50.96% (n=159) of the cohort, and 71.2% (n=222) of participants had moderate or severe COPD. A total of 9.9% (n=31) of participants experienced a COPD exacerbation during the period of follow-up. At baseline, the median (Q 1, Q 3) NLR ratio among participants who experienced an exacerbation was 1.46 (0.92, 2.33) compared to 1.03 (0.72,1.42) among those who did not experience one during the follow-up period (p=0.002). Using Youden and Liu's methods, the optimal NLR cutoff for predicting COPD exacerbation was 1.17. This cutoff resulted in a ROC curve area of 0.64 (95% confidence interval: 0.56, 0.73). Conclusion The NLR could be used as a risk predictor, in low- and middle-income countries, for hospital admissions due to COPD exacerbations. A cutoff of 1.17 was an independent predictor of hospitalization due to acute exacerbations of COPD within one year.
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Affiliation(s)
| | | | - David Mukunya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Okimat
- Soroti District Local Government, Soroti, Uganda
| | - Vickram Tejwani
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Alex Kayongo
- Makerere University Lung Institute, Kampala, Uganda
| | | | - Nicole M Robertson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rupert Jones
- Makerere University Lung Institute, Kampala, Uganda
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Bruce Kirenga
- Makerere University Lung Institute, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, Florida, United States
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Pollard SL, Siddharthan T, Hossen S, Rykiel NA, Flores-Flores O, Alupo P, Quaderi S, Ascencio I, Barber JA, Chandyo R, Das SK, Gianella G, Kirenga B, Grunstra K, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Shrestha L, Soares MO, Wosu AC, Hurst JR, Checkley W. Chronic Obstructive Pulmonary Disease Self-Management in Three Low- and Middle-Income Countries: A Pilot Randomized Trial. Am J Respir Crit Care Med 2023; 208:1052-1062. [PMID: 37698443 PMCID: PMC10867931 DOI: 10.1164/rccm.202303-0505oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/11/2023] [Indexed: 09/13/2023] Open
Abstract
Objectives: Chronic obstructive pulmonary disease (COPD) disproportionately affects low- and middle-income countries. Health systems are ill prepared to manage the increase in COPD cases. Methods: We performed a pilot effectiveness-implementation randomized field trial of a community health worker (CHW)-supported, 1-year self-management intervention in individuals with COPD grades B-D. The study took place in low-resource settings of Nepal, Peru, and Uganda. The primary outcome was the St. George's Respiratory Questionnaire (SGRQ) score at 1 year. We evaluated differences in moderate to severe exacerbations, all-cause hospitalizations, and the EuroQol score (EQ-5D-3 L) at 12 months. Measurements and Main Results: We randomly assigned 239 participants (119 control arm, 120 intervention arm) with grades B-D COPD to a multicomponent, CHW-supported intervention or standard of care and COPD education. Twenty-five participants (21%) died or were lost to follow-up in the control arm compared with 11 (9%) in the intervention arm. At 12 months, there was no difference in mean total SGRQ score between the intervention and control arms (34.7 vs. 34.0 points; adjusted mean difference, 1.0; 95% confidence interval, -4.2, 6.1; P = 0.71). The intervention arm had a higher proportion of hospitalizations than the control arm (10% vs. 5.2%; adjusted odds ratio, 2.2; 95% confidence interval, 0.8, 7.5; P = 0.15) at 12 months. Conclusions: A CHW-based intervention to support self-management of acute exacerbations of COPD in three resource-poor settings did not result in differences in SGRQ scores at 1 year. Fidelity was high, and intervention engagement was moderate. Although these results cannot differentiate between a failed intervention or implementation, they nonetheless suggest that we need to revisit our strategy. Clinical trial registered with www.clinicaltrials.gov (NCT03359915).
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Affiliation(s)
- Suzanne L. Pollard
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Shakir Hossen
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Natalie A. Rykiel
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Unidad de Investigación Biomédica, A. B. PRISMA, Lima, Perú
- Facultad de Ciencias de la Salud, Universidad Cientifica del Sur, Lima, Peru
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | | | | | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | | | - Santa K. Das
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Kelli Grunstra
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - J. Jaime Miranda
- Centro de Excelencia en enfermedades crónicas CRONICAS, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | | | | | | | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | | | - William Checkley
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
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Mohan A, Alupo P, Martinez FJ, Mendes RG, Zhang J, Hurst JR. Respiratory Health and Cities. Am J Respir Crit Care Med 2023; 208:371-373. [PMID: 37343298 PMCID: PMC10449068 DOI: 10.1164/rccm.202304-0759vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/21/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, New York
| | - Renata G. Mendes
- Department of Physical Therapy, Federal University of São Carlos, São Carlos, Brazil
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College of Fudan University, Shanghai, China; and
| | - John R. Hurst
- University College London (UCL) Respiratory, UCL, London, United Kingdom
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Florman KE, Siddharthan T, Pollard SL, Alupo P, Barber JA, Chandyo RK, Flores-Flores O, Kirenga B, Mendes RG, Miranda JJ, Mohan S, Ricciardi F, Rykiel NA, Sharma AK, Wosu AC, Checkley W, Hurst JR. Unmet Diagnostic and Therapeutic Opportunities for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Countries. Am J Respir Crit Care Med 2023; 208:442-450. [PMID: 37369142 PMCID: PMC10449073 DOI: 10.1164/rccm.202302-0289oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/27/2023] [Indexed: 06/29/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is a prevalent and burdensome condition in low- and middle-income countries (LMICs). Challenges to better care include more effective diagnosis and access to affordable interventions. There are no previous reports describing therapeutic needs of populations with COPD in LMICs who were identified through screening. Objectives: To describe unmet therapeutic need in screening-detected COPD in LMIC settings. Methods: We compared interventions recommended by the international Global Initiative for Chronic Obstructive Lung Disease COPD strategy document, with that received in 1,000 people with COPD identified by population screening at three LMIC sites in Nepal, Peru, and Uganda. We calculated costs using data on the availability and affordability of medicines. Measurement and Main Results: The greatest unmet need for nonpharmacological interventions was for education and vaccinations (applicable to all), pulmonary rehabilitation (49%), smoking cessation (30%), and advice on biomass smoke exposure (26%). Ninety-five percent of the cases were previously undiagnosed, and few were receiving therapy (4.5% had short-acting β-agonists). Only three of 47 people (6%) with a previous COPD diagnosis had access to drugs consistent with recommendations. None of those with more severe COPD were accessing appropriate maintenance inhalers. Even when available, maintenance treatments were unaffordable, with 30 days of treatment costing more than a low-skilled worker's daily average wage. Conclusions: We found a significant missed opportunity to reduce the burden of COPD in LMIC settings, with most cases undiagnosed. Although there is unmet need in developing novel therapies, in LMICs where the burden is greatest, better diagnosis combined with access to affordable interventions could translate to immediate benefit.
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Affiliation(s)
- Katia E.H. Florman
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Oscar Flores-Flores
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
- Facultad de Ciencias de la Salud, Universidad Cientíifica del Sur, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, Sao Carlos, Brazil
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases and
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; and
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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6
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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7
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Kayongo A, Bartolomaeus TUP, Birkner T, Markó L, Löber U, Kigozi E, Atugonza C, Munana R, Mawanda D, Sekibira R, Uwimaana E, Alupo P, Kalyesubula R, Knauf F, Siddharthan T, Bagaya BS, Kateete DP, Joloba ML, Sewankambo NK, Jjingo D, Kirenga B, Checkley W, Forslund SK. Sputum Microbiome and Chronic Obstructive Pulmonary Disease in a Rural Ugandan Cohort of Well-Controlled HIV Infection. Microbiol Spectr 2023; 11:e0213921. [PMID: 36790203 PMCID: PMC10100697 DOI: 10.1128/spectrum.02139-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/23/2023] [Indexed: 02/16/2023] Open
Abstract
Sub-Saharan Africa has increased morbidity and mortality related to chronic obstructive pulmonary disease (COPD). COPD among people living with HIV (PLWH) has not been well studied in this region, where HIV/AIDS is endemic. Increasing evidence suggests that respiratory microbial composition plays a role in COPD severity. Therefore, we aimed to investigate microbiome patterns and associations among PLWH with COPD in Sub-Saharan Africa. We conducted a cross-sectional study of 200 adults stratified by HIV and COPD in rural Uganda. Induced sputum samples were collected as an easy-to-obtain proxy for the lower respiratory tract microbiota. We performed 16S rRNA gene sequencing and used PICRUSt2 (version 2.2.3) to infer the functional profiles of the microbial community. We used a statistical tool to detect changes in specific taxa that searches and adjusts for confounding factors such as antiretroviral therapy (ART), age, sex, and other participant characteristics. We could cluster the microbial community into three community types whose distribution was shown to be significantly impacted by HIV. Some genera, e.g., Veillonella, Actinomyces, Atopobium, and Filifactor, were significantly enriched in HIV-infected individuals, while the COPD status was significantly associated with Gammaproteobacteria and Selenomonas abundance. Furthermore, reduced bacterial richness and significant enrichment in Campylobacter were associated with HIV-COPD comorbidity. Functional prediction using PICRUSt2 revealed a significant depletion in glutamate degradation capacity pathways in HIV-positive patients. A comparison of our findings with an HIV cohort from the United Kingdom revealed significant differences in the sputum microbiome composition, irrespective of viral suppression. IMPORTANCE Even with ART available, HIV-infected individuals are at high risk of suffering comorbidities, as shown by the high prevalence of noninfectious lung diseases in the HIV population. Recent studies have suggested a role for the respiratory microbiota in driving chronic lung inflammation. The respiratory microbiota was significantly altered among PLWH, with disease persisting up to 3 years post-ART initiation and HIV suppression. The community structure and diversity of the sputum microbiota in COPD are associated with disease severity and clinical outcomes, both in stable COPD and during exacerbations. Therefore, a better understanding of the sputum microbiome among PLWH could improve COPD prognostic and risk stratification strategies. In this study, we observed that in a virologically suppressed HIV cohort in rural Uganda, we could show differences in sputum microbiota stratified by HIV and COPD, reduced bacterial richness, and significant enrichment in Campylobacter associated with HIV-COPD comorbidity.
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Affiliation(s)
- Alex Kayongo
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Theda Ulrike Patricia Bartolomaeus
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Till Birkner
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Lajos Markó
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Ulrike Löber
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Edgar Kigozi
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Carolyne Atugonza
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Richard Munana
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Mawanda
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rogers Sekibira
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Esther Uwimaana
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Patricia Alupo
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert Kalyesubula
- African Community Center for Social Sustainability (ACCESS), Department of Research, Nakaseke, Uganda
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Trishul Siddharthan
- University of Miami, School of Medicine, Division of pulmonary and critical care medicine, Miami, Florida, USA
| | - Bernard S. Bagaya
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - David P. Kateete
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Moses L. Joloba
- Makerere University, College of Health Sciences, Department of Immunology and Molecular Biology, Kampala, Uganda
| | - Nelson K. Sewankambo
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - Daudi Jjingo
- Makerere University, College of Computing and Information Sciences, Department of Computer Science, Kampala, Uganda
- African Center of Excellence in Bioinformatics and Data Science, Infectious Diseases Institute, Kampala, Uganda
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University, College of Health Sciences, Department of Medicine, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sofia K. Forslund
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Experimental and Clinical Research Center, A Cooperation of Charité - Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- European Molecular Biology Laboratory, Structural and Computational Biology Unit, Heidelberg, Germany
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8
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Jackson P, Padalkar R, Katagira W, Mortimer K, Rykiel NA, Robertson NM, Pollard SL, Alupo P, Checkley W, Kirenga B, Siddharthan T. Development and validation of an interstitial lung disease exposure questionnaire for sub-Saharan Africa. ERJ Open Res 2022; 8:00205-2022. [PMID: 36578631 PMCID: PMC9792102 DOI: 10.1183/23120541.00205-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023] Open
Abstract
Background American Thoracic Society/European Respiratory Society guidelines recommend context-specific exposure assessments to diagnose interstitial lung disease (ILD). In sub-Saharan Africa, ILD diagnoses are rare, and locally validated ILD exposure questionnaires are not used. Methods A physician-administered ILD exposure questionnaire was developed using a four-step mixed-methods modified Delphi approach. First, ILD questionnaires from high-income countries and data from Pneumotox were reviewed, compiled and face-validated. Second, a local pilot group of ILD experts ranked item relevance using a Likert scale and suggested additions. Third, the questionnaire format and pilot rankings were addressed in a focus group discussion that was analysed using grounded theory. Finally, following focus group discussion modifications, the resulting items (with three duplicate item groups for evaluation of internal consistency) were ranked for importance by members of the Pan-African Thoracic Society (PATS). Results Face validation resulted in 82 items in four categories: "Smoking and Drugs", "Environmental Exposures", "Occupations" and "Medications". Pilot group (n=10) ranking revealed 27 outliers and 30 novel suggestions. Focus group (n=12) discussion resulted in 10 item deletions, 14 additions and 22 re-wordings; themes included desire for extensive questionnaires and stigma sensitivity. Final validation involved 58 PATS members (mean±sd age 46±10.6 years, 76% male, from 17 countries) ranking 84 items derived from previous steps and three duplicate question groups. The questionnaire was internally consistent (Cronbach's α >0.80) and ultimately included 73 items. Conclusion This mixed-methods study included experts from 17 countries in sub-Saharan Africa and successfully developed a 73-item ILD exposure questionnaire for sub-Saharan Africa. African pulmonary experts valued region-specific additions and ranked several items from existing ILD questionnaires as unimportant.
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Affiliation(s)
- Peter Jackson
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA,Corresponding author: Peter Jackson ()
| | - Roma Padalkar
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | | | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, University of Miami, Miami, FL, USA
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9
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Swank Z, Gross A, Mahmud H, Gharai LR, Perelas A, Siddharthan T, Katagira W, Alupo P, Kirenga B, Jackson P. Development and implementation of a transnational multi-disciplinary discussion for diagnosis of interstitial lung disease. Int J Tuberc Lung Dis 2022; 26:784-786. [PMID: 35898129 DOI: 10.5588/ijtld.22.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Z Swank
- Division of Pulmonary and Critical Care, Richmond, VA
| | - A Gross
- Division of Pulmonary and Critical Care, Richmond, VA
| | - H Mahmud
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - L R Gharai
- Division of Radiology, Virginia Commonwealth University, Richmond, VA
| | - A Perelas
- Division of Pulmonary and Critical Care, Richmond, VA
| | - T Siddharthan
- Division of Pulmonary and Critical Care, University of Miami Miller School of Medicine, Miami, FL, USA
| | - W Katagira
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - P Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - B Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - P Jackson
- Division of Pulmonary and Critical Care, Richmond, VA
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10
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Siddharthan T, Pollard SL, Quaderi SA, Rykiel NA, Wosu AC, Alupo P, Barber JA, Cárdenas MK, Chandyo RK, Flores-Flores O, Kirenga B, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Das SK, Shrestha L, Soares MO, Checkley W, Hurst JR. Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings. JAMA 2022; 327:151-160. [PMID: 35015039 PMCID: PMC8753498 DOI: 10.1001/jama.2021.23065] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. OBJECTIVE To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. EXPOSURES Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. MAIN OUTCOMES AND MEASURES The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. CONCLUSIONS AND RELEVANCE This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Now with the National Institutes of Health, Bethesda, Maryland
| | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Nepal
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Biomedical Research Unit, A.BPRISMA, Lima, Peru
- Centro de Investigación del Envejecimiento (CIEN), Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Santa Kumar Das
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Laxman Shrestha
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Marta O. Soares
- Centre for Health Economics, University of York, York, United Kingdom
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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11
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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 Glob 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] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Siddharthan T, Pollard SL, Jackson P, Robertson NM, Wosu AC, Rahman N, Padalkar R, Sekitoleko I, Namazzi E, Alupo P, Hurst JR, Kalyesubula R, Dowdy D, Wise R, Barnes PJ, Checkley W, Kirenga B. Effectiveness of low-dose theophylline for the management of biomass-associated COPD (LODOT-BCOPD): study protocol for a randomized controlled trial. Trials 2021; 22:213. [PMID: 33726828 PMCID: PMC7962083 DOI: 10.1186/s13063-021-05163-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND COPD is a leading cause of death globally, with the majority of morbidity and mortality occurring in low- and middle-income country (LMIC) settings. While tobacco-smoke exposure is the most important risk factor for COPD in high-income settings, household air pollution from biomass smoke combustion is a leading risk factor for COPD in LMICs. Despite the high burden of biomass smoke-related COPD, few studies have evaluated the efficacy of pharmacotherapy in this context. Currently recommended inhaler-based therapy for COPD is neither available nor affordable in most resource-limited settings. Low-dose theophylline is an oral, once-a-day therapy, long used in high-income countries (HICs), which has been proposed for the management of COPD in LMICs in the absence of inhaled steroids and/or bronchodilators. The Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD) trial investigates the clinical efficacy and cost-effectiveness of low-dose theophylline for the management of biomass-related COPD in a low-income setting. METHODS LODOT-BCOPD is a randomized, double-blind, placebo-controlled trial to test the efficacy of low-dose theophylline in improving respiratory symptoms in 110 participants with moderate to severe COPD in Central Uganda. The inclusion criteria are as follows: (1) age 40 to 80 years, (2) full-time resident of the study area, (3) daily biomass exposure, (4) post-bronchodilator FEV1/FVC below the 5th percentile of the Global Lung Initiative mixed ethnic reference population, and (5) GOLD Grade B-D COPD. Participants will be randomly assigned to receive once daily low-dose theophylline (200 mg ER, Unicontin-E) or placebo for 52 weeks. All participants will receive education about self-management of COPD and rescue salbutamol inhalers. We will measure health status using the St. George's Respiratory Questionnaire (SGRQ) and quality of life using the EuroQol-5D (EQ-5D) at baseline and every 6 months. In addition, we will assess household air pollution levels, serum inflammatory biomarkers (fibrinogen, hs-CRP), and theophylline levels at baseline, 1 month, and 6 months. The primary outcome is change in SGRQ score at 12 months. Lastly, we will assess the cost-effectiveness of the intervention by calculating quality-adjusted life years (QALYs) from the EQ-5D. TRIAL REGISTRATION ClinicalTrials.gov NCT03984188 . Registered on June 12, 2019 TRIAL ACRONYM: Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD).
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA. .,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter Jackson
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, USA
| | - Nicole M Robertson
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Adaeze C Wosu
- Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Nihaal Rahman
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Roma Padalkar
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Isaac Sekitoleko
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Esther Namazzi
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Patricia Alupo
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Robert Kalyesubula
- Department of Physiology, Makerere College of Health Sciences, Kampala, Uganda.,African Community Center for Social Sustainability, Nakaseke, Uganda
| | - David Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Robert Wise
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter J Barnes
- National Health and Lung Institute, Imperial College, London, UK
| | - William Checkley
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
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13
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Alupo P, Wosu AC, Mahofa A, Mugenyi L, Semakula D, Katagira W, Kirenga B. Incidence and predictors of COPD mortality in Uganda: A 2-year prospective cohort study. PLoS One 2021; 16:e0246850. [PMID: 33571315 PMCID: PMC7877567 DOI: 10.1371/journal.pone.0246850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Data is lacking on outcomes among COPD patients in sub-Saharan Africa. The objective of the study was to assess the incidence and predictors of mortality among COPD patients enrolled in the Uganda Registry for Asthma and COPD. RESEARCH QUESTION What is the Incidence and predictors of mortality among COPD patients in Uganda? STUDY DESIGN AND METHODS Individuals with a diagnosis of COPD at six hospitals in Uganda were enrolled into the registry, and followed every six months. Mortality was ascertained through post-mortem reports and verbal autopsies. Mortality rates (MR), mortality rate ratios (MRR), and hazard ratios (HR) were computed to assess associations between socio-demographic, behavioural, and clinical characteristics at enrolment into the registry and mortality up to two years after. RESULTS We enrolled 296 COPD patients. Median age was 60 years, and 51·3% were male. The overall mortality rate was 95·90 deaths/1000 person-years. COPD severity by post-bronchodilator FEV1 was the strongest risk factor for mortality. Compared to stage 1, adjusted hazard ratios were as follows for stage 4: 9·86 (95%CI: 1·70-57·14, p = 0·011), stage 3: 6·16 (95%CI: 1·25-30·32, p = 0·025), and stage 2: 1·76 (95%CI: 0·33-9·48, p = 0·51). Underweight patients had a higher incidence of mortality compared to normal weight patients (MRR: 3·47 (95%CI: 1·45-8·31, p = 0·0026). CONCLUSION Among COPD patients in Uganda, two-year mortality is high, and disease severity at baseline was the strongest risk factor for mortality. Our findings suggest the need for early, accurate, diagnosis and management of COPD, to potentially improve survival.
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Affiliation(s)
- Patricia Alupo
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adaeze C. Wosu
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland, United States of America
| | - Abdallah Mahofa
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Levicatus Mugenyi
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Semakula
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Winceslaus Katagira
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bruce Kirenga
- Makerere University 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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14
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Tabyshova A, Hurst JR, Soriano JB, Checkley W, Wan-Chun Huang E, Trofor AC, Flores-Flores O, Alupo P, Gianella G, Ferdous T, Meharg D, Alison J, Correia de Sousa J, Postma MJ, Chavannes NH, van Boven JFM. Gaps in COPD Guidelines of Low- and Middle-Income Countries: A Systematic Scoping Review. Chest 2021; 159:575-584. [PMID: 33038390 PMCID: PMC7856534 DOI: 10.1016/j.chest.2020.09.260] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/19/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Guidelines are critical for facilitating cost-effective COPD care. Development and implementation in low-and middle-income countries (LMICs) is challenging. To guide future strategy, an overview of current global COPD guidelines is required. RESEARCH QUESTION We systematically reviewed national COPD guidelines, focusing on worldwide availability and identification of potential development, content, context, and quality gaps that may hamper effective implementation. STUDY DESIGN AND METHODS Scoping review of national COPD management guidelines. We assessed: (1) global guideline coverage; (2) guideline information (authors, target audience, dissemination plans); (3) content (prevention, diagnosis, treatments); (4) ethical, legal, and socio-economic aspects; and (5) compliance with the eight Institute of Medicine (IOM) guideline standards. LMICs guidelines were compared with those from high-income countries (HICs). RESULTS Of the 61 national COPD guidelines identified, 30 were from LMICs. Guidelines did not cover 1.93 billion (30.2%) people living in LMICs, whereas only 0.02 billion (1.9%) in HICs were without national guidelines. Compared with HICs, LMIC guidelines targeted fewer health-care professional groups and less often addressed case finding and co-morbidities. More than 90% of all guidelines included smoking cessation advice. Air pollution reduction strategies were less frequently mentioned in both LMICs (47%) and HICs (42%). LMIC guidelines fulfilled on average 3.37 (42%) of IOM standards, compared with 5.29 (66%) in HICs (P < .05). LMICs scored significantly lower compared with HICs regarding conflicts of interest management, updates, articulation of recommendations, and funding transparency (all, P < .05). INTERPRETATION Several development, content, context, and quality gaps exist in COPD guidelines from LMICs that may hamper effective implementation. Overall, COPD guidelines in LMICs should be more widely available and should be transparently developed and updated. Guidelines may be further enhanced by better inclusion of local risk factors, case findings, and co-morbidity management, preferably tailored to available financial and staff resources.
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Affiliation(s)
- Aizhamal Tabyshova
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pulmonary Diseases, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - John R Hurst
- UCL Respiratory, University College London, United Kingdom
| | - Joan B Soriano
- Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD
| | - Erick Wan-Chun Huang
- Woolcock Institute of Medical Research, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia; Division of Thoracic Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Antigona C Trofor
- University of Medicine and Pharmacy 'Grigore T. Popa' Iasi (UMF Iasi), Iasi, Romania
| | - Oscar Flores-Flores
- Biomedical Research Unit, A.B. PRISMA, Lima, Peru; Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru; and the Universidad Cientifica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - Patricia Alupo
- Department of Medicine, Makerere Lung Institute, Kampala, Uganda
| | - Gonzalo Gianella
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - David Meharg
- University of Sydney, Faculty of Medicine and Health, Australia
| | - Jennifer Alison
- University of Sydney, Faculty of Medicine and Health, Australia
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga Portugal; ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Maarten J Postma
- University of Groningen, University Medical Center Groningen, Department of Health Sciences, Unit of Global Health, Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, the Netherlands.
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15
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Siddharthan T, Wosu AC, Pollard SL, Hossen S, Alupo P, Shade T, Kalyesubula R, Quaderi S, Wise RA, Hurst JR, Kirenga B, Checkley W. A Novel Case-Finding Instrument for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Country Settings. Int J Chron Obstruct Pulmon Dis 2020; 15:2769-2777. [PMID: 33173289 PMCID: PMC7648534 DOI: 10.2147/copd.s268076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
Background Low- and middle-income countries (LMICs) account for >90% of deaths and illness episodes related to COPD; however, this condition is commonly underdiagnosed in these settings. Case-finding instruments for COPD may improve diagnosis and identify individuals that need treatment, but few have been validated in resource-limited settings. Methods We conducted a population-based cross-sectional study in Uganda to assess the diagnostic accuracy of a respiratory symptom, exposure and functional questionnaire in combination with peak expiratory flow for COPD diagnosis using post-bronchodilator FEV1/FVC z-score below the 5th percentile as the gold standard. We included locally relevant exposure questions and statistical learning techniques to identify the most important risk factors for COPD. We used 80% of the data to develop the case-finding instrument and validated it in the remaining 20%. We evaluated for calibration and discrimination using standard approaches. The final score, COLA (COPD in LMICs Assessment), included seven questions, age and pre-bronchodilator peak expiratory flow. Results We analyzed data from 1,173 participants (average age 47 years, 46.9% male, 4.5% with COPD) with acceptable and reproducible spirometry. The seven questions yielded a cross-validated area-under-the-curve [AUC] of 0.68 (95% CI 0.61-0.75) with higher scores conferring greater odds of COPD. The inclusion of peak expiratory flow and age improved prediction in a validation sample (AUC=0.83, 95% CI 0.78-0.88) with a positive predictive value of 50% and a negative predictive value of 96%. The final instrument (COLA) included seven questions, age and pre-bronchodilator peak expiratory flow. Conclusion COLA predicted COPD in urban and rural settings in Uganda has high calibration and discrimination, and could serve as a simple, low-cost screening tool in resource-limited settings.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Adaeze C Wosu
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Alupo
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Timothy Shade
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Kalyesubula
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Robert A Wise
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Bruce Kirenga
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - On behalf of LiNK Cohort Study Investigators
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
- UCL Respiratory, University College London, London, UK
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16
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Jackson P, Siddharthan T, Moughames E, Rykiel N, Padalkar R, Katagira W, Alupo P, Kirenga B. DEVELOPMENT AND VALIDATION OF AN INTERSTITIAL LUNG DISEASE EXPOSURE QUESTIONNAIRE IN SUB-SAHARAN AFRICA. Chest 2020. [DOI: 10.1016/j.chest.2020.08.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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17
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Nagourney EM, Robertson NM, Rykiel N, Siddharthan T, Alupo P, Encarnacion M, Kirenga BJ, Kalyesubula R, Quaderi SA, Hurst JR, Checkley W, Pollard SL. Illness representations of chronic obstructive pulmonary disease (COPD) to inform health education strategies and research design-learning from rural Uganda. Health Educ Res 2020; 35:258-269. [PMID: 32702133 PMCID: PMC7787214 DOI: 10.1093/her/cyaa016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
More than 90% of chronic obstructive pulmonary disease (COPD)-related deaths occur in low- and middle-income countries; however, few studies have examined the illness experiences of individuals living with and providing treatment for COPD in these settings. This study characterizes illness representations for COPD in Nakaseke, Uganda from the perspectives of health care providers, village health teams and community members (CMs) with COPD. We conducted 40 in-depth, semi-structured interviews (16 health care providers, 12 village health teams and 12 CMs, aged 25-80 years). Interviews were analyzed using inductive coding, and the Illness Representations Model guided our analysis. Stakeholder groups showed concordance in identifying causal mechanisms of COPD, but showed disagreement in reasons for care seeking behaviors and treatment preferences. CMs did not use a distinct label to differentiate COPD from other respiratory illnesses, and described both the physical and social consequences of COPD. Local representations can inform development of adapted educational and self-management tools for COPD.
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Affiliation(s)
- Emily M Nagourney
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Nicole M Robertson
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Natalie Rykiel
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Patricia Alupo
- College of Health Sciences Lung Institute, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Marysol Encarnacion
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Bruce J Kirenga
- College of Health Sciences Lung Institute, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Robert Kalyesubula
- Department of Physiology, College of Health Sciences, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Shumonta A Quaderi
- UCL Respiratory, University College London, Gower Street, London, WC1E 6BT, UK
| | - John R Hurst
- UCL Respiratory, University College London, Gower Street, London, WC1E 6BT, UK
| | - William Checkley
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Suzanne L Pollard
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
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18
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Kalyesubula R, Mutyaba I, Rabin T, Andia-Biraro I, Alupo P, Kimuli I, Nabirye S, Kagimu M, Mayanja-Kizza H, Rastegar A, Kamya MR. Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study. PLoS One 2019; 14:e0216060. [PMID: 31086371 PMCID: PMC6516645 DOI: 10.1371/journal.pone.0216060] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda. METHODS AND RESULTS The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections. CONCLUSION Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.
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Affiliation(s)
- Robert Kalyesubula
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Innocent Mutyaba
- Department of Medicine, Uganda Cancer Institute, Kampala, Uganda
| | - Tracy Rabin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Irene Andia-Biraro
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patricia Alupo
- Department of Medicine, Makerere Lung Institute, Kampala, Uganda
| | - Ivan Kimuli
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Stella Nabirye
- Directorate of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Magid Kagimu
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Asghar Rastegar
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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19
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Alupo P, Ssekitoleko R, Rabin T, Kalyesubula R, Kimuli I, Bodnar BE. Improving inpatient medication adherence using attendant education in a tertiary care hospital in Uganda. Int J Qual Health Care 2017; 29:587-592. [PMID: 28934403 PMCID: PMC5890877 DOI: 10.1093/intqhc/mzx075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 05/19/2017] [Accepted: 06/05/2017] [Indexed: 11/13/2022] Open
Abstract
QUALITY PROBLEM Although widely utilized in resource-rich health care systems, the use of quality improvement (QI) techniques is less common in resource-limited environments. Uganda is a resource-limited country in Sub-Saharan Africa that faces many challenges with health care delivery. These challenges include understaffing, inconsistent drug availability and inefficient systems that limit the provision of clinical care. INITIAL ASSESSMENT Poor adherence to prescribed inpatient medications was identified as a key shortcoming of clinical care on the internal medicine wards of Mulago National Referral Hospital, Kampala, Uganda. Baseline data collection revealed a pre-intervention median inpatient medication adherence rate of 46.5% on the study ward. Deficiencies were also identified in attendant (lay caretaker) education, and prescriber and pharmacy metrics. CHOICE OF SOLUTION A QI team led by a resident doctor and consisting of a QI nurse, a pharmacist and a ward nurse supervisor used standard QI techniques to address this issue. IMPLEMENTATION Plan-Do-Study-Act cycle interventions focused on attendant involvement and education, physician prescription practices and improving pharmacy communication with clinicians and attendants. EVALUATION Significant improvements were seen with an increase in overall medication adherence from a pre-intervention baseline median of 46.5% to a post-intervention median of 92%. Attendant education proved to be the most effective intervention, though resource and staffing limitations made institutionalization of these changes difficult. LESSONS LEARNED QI methods may be the way forward for optimizing health care delivery in resource-limited settings like Uganda. Institutionalization of these methods remains a challenge due to shortage of staff and other resource limitations.
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Affiliation(s)
- Patricia Alupo
- School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Mulago Hill, Kampala, Uganda
| | - Richard Ssekitoleko
- School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Mulago Hill, Kampala, Uganda
| | - Tracy Rabin
- School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, USA
| | - Robert Kalyesubula
- School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Mulago Hill, Kampala, Uganda
| | - Ivan Kimuli
- School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Mulago Hill, Kampala, Uganda
| | - Benjamin E. Bodnar
- School of Medicine, Johns Hopkins University, 733 N Broadway, Baltimore, 21205 MD, USA
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