Collision of communicable and non-communicable disease epidemics-the case of HIV and COPD

In this issue of The Lancet Global Health, Jean Joel Bigna and colleagues report the results of their systematic review and meta-analysis of studies of chronic obstructive pulmonary disease (COPD) in people with HIV.1 COPD is one of the most common non-communicable diseases that, as a group, are the leading causes of morbidity and mortality worldwide.2 HIV is one of the principal infectious causes for morbidity and mortality globally.3 Although typically thought of as a problem of high-income countries, most of the burden of non-communicable diseases is seen in low-income and middle-income countries (LMICs), where they drive and perpetuate poverty

Amoxicillin is associated with a lower risk of further antibiotic prescriptions for lower respiratory tract infections in primary care - A database analysis spanning over 30 years.

Antibiotic prescriptions for lower respiratory tract infections occur commonly in primary care but there is uncertainty about the most effective initial treatment strategy. Both increasing antimicrobial resistance and awareness of preventable harm from medicines make resolving this uncertainty a priority. Pragmatic, real-life epidemiological investigations are needed to inform future interventional studies. In this cross-sectional database study we analysed antibiotic prescriptions for non-pneumonic, lower respiratory tract infections (LRTI) in primary care as captured in the Optimum Care Database from 1984 to 2017. The primary outcome was a second antibiotic prescription for a LRTI code within 14 days of index prescription, the secondary outcome further antibiotic prescription for any indication. Only individuals without chronic respiratory diseases were included. We conducted univariable analysis to identify factors associated with repeat prescriptions and generate hypotheses for forthcoming projects. We analysed 367,188 index prescriptions for LRTI. Amoxicillin was the commonest used index drug (65.1%). In 6% a second antibiotic course coded for a further LRTI was prescribed (11.2% without this coding restriction). Further antibiotic prescriptions for LRTI were significantly associated with older age, previous smoking, seven day index courses and not using amoxicillin initially. The largest effect size was seen when amoxicillin was not used as index drug (odds ratio (OR) 1.15, p < 0.001). This would support current prescribing practice for amoxicillin as index drug in those without respiratory disease. Prospective studies are needed to explore the observed differences

Antibiotic Choice and Duration Associate with Repeat Prescriptions in Infective Asthma Exacerbations

Background: Patients with asthma who present with lower respiratory tract infections (LRTIs) often receive antibiotics. There is uncertainty about the need for and consequences of antibiotic administration. Objective: To describe the demographic characteristics of and antibiotic prescriptions for adult patients with asthma with LRTI and investigate factors associated with repeat antibiotic courses. Methods: We analyzed prescriptions of antibiotics for LRTIs in UK primary care from 2010 to 2015 using the Optimum Care Database. The primary outcome was a second antibiotic prescription for an LRTI code within 14 days of index prescription, as a proxy of initial treatment failure. A model for repeat prescriptions was derived using univariable and multivariable logistic regression analyses. Results: We assessed 28,289 cases with complete data sets, 6.5% of which received a second antibiotic course. Amoxicillin and clarithromycin respectively were used most commonly as index and second agents. The most frequent course length was 7 days for both index and repeat prescriptions. Multivariable analysis demonstrated that age, index antibiotic and duration, smoking status, location, and number of consultations and oral steroid courses in the previous year were significantly associated with repeat prescriptions. The derived model predicted the binary outcome adequately (Cox-Snell R2, 0.012; area under curve, 0.62; 95% CI, 0.61-0.63). Comorbidities, vaccinations, asthma treatment, and number of exacerbations were significant only in the univariable analysis. Conclusions: The current index prescribing preference of 7 days of amoxicillin correlated to fewer repeat courses. Baseline asthma treatment was not associated with risk of further prescriptions. Antibiotic administration in older patients with a smoking history could be a target for future studies

Supplemental oxygen in Queen Elizabeth Central Hospital Malawi: a prospective cohort study of patients admitted to medical wards

Background: Oxygen is designated an essential drug by the World Health Organisation, and reduces mortality in hypoxic patients. In low-resource settings the provision of oxygen seldom meets its demand. This study explores predictors and observed time-course of hypoxaemia in order to help inform needs assessments for oxygen in hospitals in low- and middle-income countries. Methods: : A prospective cohort study of adults with hypoxaemia admitted to medical wards of a teaching hospital in Malawi between February and March 2020. Vital signs and oxygen therapy were recorded daily. We analysed outcomes (death, discharge from hospital or ongoing inpatient care at 14 days after admission) using Kaplan-Meier and Cox regression time-to-event analysis. Results: : 33 patients were recruited with median age 45 years (IQR 33-61). 13 (39%) were female. Median pre-treatment oxygen saturations were 84% (IQR 76-87%). Oxygen delivery devices were often shared with other patients (n=10, 33%) and the flow rate was often unknown (n=14, 47%), mostly because of broken equipment (n=8, 57%). Median duration of oxygen therapy was 3 days (IQR 1-7). Death occurred in 16 (49%). Hazard ratios for short oxygen therapy were reduced in patients who had a chest radiograph performed (HR 0.08, 95% CI 0.02–0.30), in ex-smokers (HR 0.01, 95% CI 0.00-0.22) and in never smokers (HR 0.03, 95% CI 0.00 – 0.78). Conclusions: : Delivering oxygen therapy in lower-middle income countries is challenging; broken equipment and shared delivery devices prevented titration of flow rates. Patients were relatively young and at a high risk of death. Patients with a chest radiograph received oxygen for longer than those without. This hypothesis generating study can be used to build a more comprehensive understanding of oxygen supply need at the hospital level

Screening Heroin Smokers Attending Community Drug Clinics for Change in Lung Function:A Cohort Study

Background: Heroin smokers have high rates of COPD, respiratory morbidity, hospital admission, and mortality. We assessed the natural history of symptoms and lung function in this population over time. Methods: A cohort of heroin smokers with COPD was followed for 18 to 24 months. At baseline and follow-up, respiratory symptoms were measured by the Medical Research Council Dyspnea Scale (MRC) and the COPD Assessment Tool (CAT), and postbronchodilator spirometry was performed. Frequency of health-care-seeking episodes was extracted from routine health records. Parametric, nonparametric, and linear regression models were used to analyze the change in symptoms and lung function over time. Results: Of 372 participants originally recruited, 161 were assessed at follow-up (mean age, 51.0 ± 5.3 years; 74 women [46%]) and 106 participants completed postbronchodilator spirometry. All participants were current or previous heroin smokers, and 122 (75.8%) had smoked crack. Symptoms increased over time (MRC score increased by 0.48 points per year, P <.001; CAT score increased by 1.60 points per year, P <.001). FEV 1 declined annually by 90 ± 190 mL (P <.001). This deterioration was not associated with change in tobacco or heroin smoking status or use of inhaled medications. Conclusions: Heroin smokers experience a high and increasing burden of chronic respiratory symptoms and a decline in FEV 1 that exceeds the normal age-related decline observed among tobacco smokers with COPD and healthy nonsmokers. Targeted COPD diagnostic and treatment services hosted within opiate substitution services could benefit this vulnerable, relatively inaccessible, and underserved group of people

Pulmonary hypertension in adults completing tuberculosis treatment

Background Pulmonary hypertension (PH) after tuberculosis (TB) is typically not included among the chronic lung diseases causing PH (group 3 PH), with few data available to support the inclusion. Objectives To determine the prevalence of PH in an adult population completing TB treatment. Methods. This single-centre, cross-sectional study only included patients with their first documented episode of TB, and who were in the second half of treatment or had recently completed treatment. PH was assessed using transthoracic echocardiography. Questionnaires were also completed and spirometry and a 6-minute walk test were performed. Results One hundred patients were enrolled, with a mean age of 37.1 years, of whom 58% were male and 46% HIV positive. The median time since initiation of TB treatment was 22 weeks. The mean (standard deviation) measured right ventricular systolic pressure (RVSP) was 23.6 (6.24) mmHg. One participant had PH (defined as RVSP ≥40 mmHg; 95% confidence interval (CI) 0.0 - 3.0) and a further 3 had possible PH (RVSP ≥35 and &lt;40 mmHg), with a combined PH prevalence of 4% (95% CI 0.2 - 7.8). Airflow obstruction on spirometry was found in 13.3% of 98 patients, while 25.5% had a reduced forced vital capacity. There was no association between RVSP or PH/possible PH and sex, age, HIV status, systemic hypertension, spirometry measurements or 6-minute walking distance. Smoking status was associated with RVSP, but not with the presence of PH/possible PH. Conclusion There was a significant prevalence of PH in this preliminary study of predominantly young patients completing treatment for a first episode of TB. Larger and more detailed studies are warranted

Health Risks Associated with Occupational Exposure to Ambient Air Pollution in Commercial Drivers: a Systematic Review

Introduction: Ambient air pollution is major global health problem and commercial drivers are particularly exposed to it. No systematic assessment of the health risks associated with occupational exposure to ambient air pollution in this population has been carried out. Methods: We conducted a systematic review using a protocol-driven strategy. Papers published from inception to 20th April 2018 in MEDLINE, EMBASE, CINAHL, African journals online, Cochrane library, ISRCTN and WHO ICTRP databases were screened for inclusion by two independent reviewers. Original articles with at least an available abstract in English or French were included. Results: The initial search retrieved 1454 published articles of which 20 articles were included. 3 Studies reported a significant difference in white blood cells (106/L) among commercial motorcyclists compared to rural inhabitants (5.041&plusmn;1.209 vs 5.900&plusmn;1.213,p=0.001), an increased risk of lung cancer (RR=1.6, 95%CI 1.5-1.8) in bus drivers and an increased standardized mortality ratio (SMR) in bus drivers from Hodgkin&rsquo;s lymphoma (SMR 2.17, 95%CI 1.19-3.87) compared to white collar workers. Other studies also found that drivers had more oxidative DNA damage and chromosome breaks. 4 papers failed to demonstrate that the drivers were more exposed to air pollution than the controls. 3 other studies also reported no significant difference in lung function parameters and respiratory symptoms. The genetic polymorphisms of detoxifying enzymes were not also homogeneously distributed compared to the controls. Conclusion: There is some evidence that occupational exposure to ambient air pollution among commercial drivers is associated with adverse health outcomes but the existing literature is limited with few studies of small sample size, methodological weaknesses and contradictory findings. Further research is recommended

The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review.

Asthma and chronic obstructive pulmonary disease (COPD) cause a considerable burden of morbidity and mortality in low-income and middle-income countries (LMICs). Access to safe, effective, quality-assured, and affordable essential medicines is variable. We aimed to review the existing literature relating to the availability, cost, and affordability of WHO's essential medicines for asthma and COPD in LMICs. A systematic review of the literature was done by searching seven databases to identify research articles published between Jan 1, 2010, and June 30, 2022. Studies on named essential medicines for asthma and COPD in LMICs were included and review articles were excluded. Two authors (MS and HT) screened and extracted data independently, and assessed bias using Joanna Briggs Institute appraisal tools. The main outcome measures were availability (WHO target of 80%), cost (compared with median price ratio [MPR]), and affordability (number of days of work of the lowest paid government worker). The study was registered with PROSPERO, CRD42021281069. Of 4742 studies identified, 29 met the inclusion criteria providing data from 60 LMICs. All studies had a low risk of bias. Six of 58 countries met the 80% availability target for short-acting beta-agonists (SABAs), three of 48 countries for inhaled corticosteroids (ICSs), and zero of four for inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) combination inhalers. Costs were reported by 12 studies: the range of MPRs was 1·1-351 for SABAs, 2·6-340 for ICSs, and 24 for ICS-LABAs in the single study reporting this. Affordability was calculated in ten studies: SABA inhalers typically cost around 1-4 days' wages, ICSs 2-7 days, and ICS-LABAs at least 6 days. The included studies showed heterogeneity. Essential medicines for treating asthma and COPD were largely unavailable and unaffordable in LMICs. This was particularly true for inhalers containing corticosteroids. WHO and Wellcome Trust

Persistent chronic respiratory symptoms despite TB cure is poorly correlated with lung function

BACKGROUND: Persistent respiratory symptoms and lung function deficits are common after patients with TB. We aimed to define the burden of post-TB lung disease (PTLD) and assess associations between symptoms and impairment in two high TB incidence communities. METHODS: This was a cross-sectional survey of adults in Cape Town, South Africa who completed TB treatment 1–5 years previously. Questionnaires, spirometry and 6-minute walking distance (6MWD) were used to assess relationships between outcome measures and associated factors. RESULTS: Of the 145 participants recruited (mean age: 42 years, range: 18–75; 55 [38%] women), 55 (38%) had airflow obstruction and 84 (58%) had low forced vital capacity (FVC); the mean 6MWD was 463 m (range: 240–723). Respiratory symptoms were common: chronic cough (n = 27, 19%), wheeze (n = 61, 42%) and dyspnoea (modified MRC dyspnoea score 3 or 4: n = 36, 25%). There was poor correlation between FVC or obstruction and 6MWD. Only low body mass index showed consistent association with outcomes on multivariable analyses. Only 19 (13%) participants had a diagnosis of respiratory disease, and 16 (11%) currently received inhalers. CONCLUSION: There was substantial burden of symptoms and physiological impairment in this “cured” population, but poor correlation between objective outcome measures, highlighting deficits in our understanding of PTLD