Publications by authors named "Kevin Mortimer"

86 Publications

Task-shifting to improve asthma education for Malawian children: a qualitative analysis.

Hum Resour Health 2021 Mar 2;19(1):28. Epub 2021 Mar 2.

Lung Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre 3, Malawi.

Background: Asthma education, a key component of long-term asthma management, is challenging in resource-limited settings with shortages of clinical staff. Task-shifting educational roles to lay (non-clinical) staff is a potential solution. We conducted a randomised controlled trial of an enhanced asthma care intervention for children in Malawi, which included reallocation of asthma education tasks to lay-educators. In this qualitative sub-study, we explored the experiences of asthmatic children, their families and lay-educators, to assess the acceptability, facilitators and barriers, and perceived value of the task-shifting asthma education intervention.

Methods: We conducted six focus group discussions, including 15 children and 28 carers, and individual interviews with four lay-educators and a senior nurse. Translated transcripts were coded independently by three researchers and key themes identified.

Results: Prior to the intervention, participants reported challenges in asthma care including the busy and sometimes hostile clinical environment, lack of access to information and the erratic supply of medication. The education sessions were well received: participants reported greater understanding of asthma and their treatment and confidence to manage symptoms. The lay-educators appreciated pre-intervention training, written guidelines, and access to clinical support. Low education levels among carers presented challenges, requiring an open, non-critical and individualised approach.

Discussion: Asthma education can be successfully delivered by lay-educators with adequate training, supervision and support, with benefits to the patients, their families and the community. Wider implementation could help address human resource shortages and support progress towards Universal Health Coverage. Trial registration The RCT was registered in the Pan African Clinical Trials Registry: PACTR201807211617031.
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http://dx.doi.org/10.1186/s12960-021-00576-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927223PMC
March 2021

Improving lung health in low-income and middle-income countries: from challenges to solutions.

Lancet 2021 Mar 22;397(10277):928-940. Epub 2021 Feb 22.

Global Asthma Network (GAN), Auckland, New Zealand; International Union Against Tuberculosis and Lung Diseases, Paris, France; Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; UNSW Medicine, Sydney, NSW, Australia.

Low-income and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs), including asthma, chronic obstructive pulmonary disease, bronchiectasis, and post-tuberculosis lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases (NCDs), and contribute to complex multi-morbidity, with major consequences for the lives and livelihoods of those affected. The relevance of CRDs to health and socioeconomic wellbeing is expected to increase in the decades ahead, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of NCDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals by 2030. In this Review, we focus on CRDs in LMICs. We discuss the early life origins of CRDs; challenges in their prevention, diagnosis, and management in LMICs; and pathways to solutions to achieve true universal health coverage.
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http://dx.doi.org/10.1016/S0140-6736(21)00458-XDOI Listing
March 2021

An enhanced care package to improve asthma management in Malawian children: a randomised controlled trial.

Thorax 2021 Jan 21. Epub 2021 Jan 21.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.

Background: Shortages of clinical staff make chronic asthma care challenging in low-income countries. We evaluated an outpatient asthma care package for children, including task-shifting of asthma management roles.

Methods: We conducted a non-blinded individually randomised controlled trial at a tertiary-level government hospital in Blantyre, Malawi. Children aged 6-15 years diagnosed with asthma were recruited from outpatient clinic, stratified by Childhood Asthma Control Test (cACT) score and allocated 1:1 from a concealed file, accessed during electronic questionnaire completion. The intervention, delivered by non-physicians, comprised clinical assessment, optimisation of inhaled treatment, individualised asthma education. The control group received standard care from outpatient physicians. Primary outcome for intention-to-treat analysis was change in cACT score at 3 months. Secondary outcomes included asthma exacerbations requiring emergency healthcare and school absence.

Findings: Between September 2018 and December 2019, 120 children (59 intervention; 61 control) were recruited; 65.8% males, with mean (SD) age 9.8 (2.8) years, mean (SD) baseline cACT 20.3 (2.6). At 3 months, intervention children (n=56) had a greater mean (SD) change in cACT score from baseline (2.7 (2.8) vs 0.6 (2.8)) compared with standard care participants (n=59); a difference of 2.1 points (95% CI: 1.1 to 3.1, p<0.001). Fewer intervention children attended emergency healthcare (7.3% vs 25.4%, p=0.02) and missed school (20.0% vs 62.7%, p<0.001) compared with standard care children.

Interpretation: The intervention resulted in decreased asthma symptoms and exacerbations. Wider scale-up could present substantial benefits for asthmatic patients in resource-limited settings.

Trial Registration Number: PACTR201807211617031.
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http://dx.doi.org/10.1136/thoraxjnl-2020-216065DOI Listing
January 2021

The long term effect of pulmonary tuberculosis on income and employment in a low income, urban setting.

Thorax 2020 Dec 18. Epub 2020 Dec 18.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.

Background: Mitigating the socioeconomic impact of tuberculosis (TB) is key to the WHO End TB Strategy. However, little known about socioeconomic well-being beyond TB-treatment completion. In this mixed-methods study, we describe socioeconomic outcomes after TB-disease in urban Blantyre, Malawi, and explore pathways and barriers to financial recovery.

Methods: Adults ≥15 years successfully completing treatment for a first episode of pulmonary TB under the National TB Control Programme were prospectively followed up for 12 months. Socioeconomic, income, occupation, health seeking and cost data were collected. Determinants and impacts of ongoing financial hardship were explored through illness narrative interviews with purposively selected participants.

Results: 405 participants were recruited from February 2016 to April 2017. Median age was 35 years (IQR: 28-41), 67.9% (275/405) were male, and 60.6% (244/405) were HIV-positive. Employment and incomes were lowest at TB-treatment completion, with limited recovery in the following year: fewer people were in paid work (63.0% (232/368) vs 72.4% (293/405), p=0.006), median incomes were lower (US$44.13 (IQR: US$0-US$106.15) vs US$72.20 (IQR: US$26.71-US$173.29), p<0.001), and more patients were living in poverty (earning
Conclusions: TB-affected households remain economically vulnerable even after TB-treatment completion, with limited recovery in income and employment, persistent financial strain requiring dissaving, and ongoing school interruptions. Measures of the economic impact of TB disease should include the post-TB period. Interventions to protect the long-term health and livelihoods of TB survivors must be explored.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982936PMC
December 2020

Cohort profile: The Chikwawa lung health cohort; a population-based observational non-communicable respiratory disease study of adults in Malawi.

PLoS One 2020 12;15(11):e0242226. Epub 2020 Nov 12.

Liverpool School of Tropical Medicine, Liverpool, United Kingdom.

Purpose: The aim of this article is to provide a detailed description of the Chikwawa lung health cohort which was established in rural Malawi to prospectively determine the prevalence and causes of lung disease amongst the general population of adults living in a low-income rural setting in Sub-Saharan Africa.

Participants: A total of 1481 participants were randomly identified and recruited in 2014 for the baseline study. We collected data on demographic, socio-economic status, respiratory symptoms and potentially relevant exposures such as smoking, household fuels, environmental exposures, occupational history/exposures, dietary intake, healthcare utilization, cost (medication, outpatient visits and inpatient admissions) and productivity losses. Spirometry was performed to assess lung function. At baseline, 56.9% of the participants were female, mean age was 43.8 (SD:17.8) and mean body mass index (BMI) was 21.6 Kg/m2 (SD: 3.46).

Findings To Date: The cohort has reported the prevalence of chronic respiratory symptoms (13.6%, 95% confidence interval [CI], 11.9-15.4), spirometric obstruction (8.7%, 95% CI, 7.0-10.7), and spirometric restriction (34.8%, 95% CI, 31.7-38.0). Additionally, an annual decline in forced expiratory volume in one second [FEV1] of 30.9mL/year (95% CI: 21.6 to 40.1) and forced vital capacity [FVC] by 38.3 mL/year (95% CI: 28.5 to 48.1) has been reported.

Future Plans: The ongoing phases of follow-up will determine the annual rate of decline in lung function as measured through spirometry and the development of airflow obstruction and restriction, and relate these to morbidity, mortality and economic cost of airflow obstruction and restriction. Population-based mathematical models will be developed driven by the empirical data from the cohort and national population data for Malawi to assess the effects of interventions and programmes to address the lung burden in Malawi. The present follow-up study started in 2019.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242226PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660567PMC
January 2021

Prevalence and Population Attributable Risk for Chronic Airflow Obstruction in a Large Multinational Study.

Am J Respir Crit Care Med 2020 Nov 10. Epub 2020 Nov 10.

Oregon Health Sciences University, Medicine / Pulmonary & Critical Care, Portland, Oregon, United States.

The Global Burden of Disease programme identified smoking, and ambient and household air pollution as the main drivers of death and disability from Chronic Obstructive Pulmonary Disease (COPD). To estimate the attributable risk of chronic airflow obstruction (CAO), a quantifiable characteristic of COPD, due to several risk factors. The Burden of Obstructive Lung Disease study is a cross-sectional study of adults, aged≥40, in a globally distributed sample of 41 urban and rural sites. Based on data from 28,459 participants, we estimated the prevalence of CAO, defined as a post-bronchodilator one-second forced expiratory volume to forced vital capacity ratio < lower limit of normal, and the relative risks associated with different risk factors. Local RR were estimated using a Bayesian hierarchical model borrowing information from across sites. From these RR and the prevalence of risk factors, we estimated local Population Attributable Risks (PAR). Mean prevalence of CAO was 11.2% in men and 8.6% in women. Mean PAR for smoking was 5.1% in men and 2.2% in women. The next most influential risk factors were poor education levels, working in a dusty job for ≥10 years, low body mass index (BMI), and a history of tuberculosis. The risk of CAO attributable to the different risk factors varied across sites. While smoking remains the most important risk factor for CAO, in some areas poor education, low BMI and passive smoking are of greater importance. Dusty occupations and tuberculosis are important risk factors at some sites.
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http://dx.doi.org/10.1164/rccm.202005-1990OCDOI Listing
November 2020

Participant compensation in global health research: a case study.

Int Health 2020 Nov;12(6):524-532

Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK.

Background: Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct.

Methods: We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field.

Results: Attention to careful researcher-participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of 'ethics dumping'.

Conclusions: We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.
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http://dx.doi.org/10.1093/inthealth/ihaa064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651450PMC
November 2020

Adverse health effects associated with household air pollution: a systematic review, meta-analysis, and burden estimation study.

Lancet Glob Health 2020 11;8(11):e1427-e1434

Department of Non-communicable Disease, London School of Hygiene & Tropical Medicine, London, UK. Electronic address:

Background: 3 billion people worldwide rely on polluting fuels and technologies for domestic cooking and heating. We estimate the global, regional, and national health burden associated with exposure to household air pollution.

Methods: For the systematic review and meta-analysis, we systematically searched four databases for studies published from database inception to April 2, 2020, that evaluated the risk of adverse cardiorespiratory, paediatric, and maternal outcomes from exposure to household air pollution, compared with no exposure. We used a random-effects model to calculate disease-specific relative risk (RR) meta-estimates. Household air pollution exposure was defined as use of polluting fuels (coal, wood, charcoal, agricultural wastes, animal dung, or kerosene) for household cooking or heating. Temporal trends in mortality and disease burden associated with household air pollution, as measured by disability-adjusted life-years (DALYs), were estimated from 2000 to 2017 using exposure prevalence data from 183 of 193 UN member states. 95% CIs were estimated by propagating uncertainty from the RR meta-estimates, prevalence of household air pollution exposure, and disease-specific mortality and burden estimates using a simulation-based approach. This study is registered with PROSPERO, CRD42019125060.

Findings: 476 studies (15·5 million participants) from 123 nations (99 [80%] of which were classified as low-income and middle-income) met the inclusion criteria. Household air pollution was positively associated with asthma (RR 1·23, 95% CI 1·11-1·36), acute respiratory infection in both adults (1·53, 1·22-1·93) and children (1·39, 1·29-1·49), chronic obstructive pulmonary disease (1·70, 1·47-1·97), lung cancer (1·69, 1·44-1·98), and tuberculosis (1·26, 1·08-1·48); cerebrovascular disease (1·09, 1·04-1·14) and ischaemic heart disease (1·10, 1·09-1·11); and low birthweight (1·36, 1·19-1·55) and stillbirth (1·22, 1·06-1·41); as well as with under-5 (1·25, 1·18-1·33), respiratory (1·19, 1·18-1·20), and cardiovascular (1·07, 1·04-1·11) mortality. Household air pollution was associated with 1·8 million (95% CI 1·1-2·7) deaths and 60·9 million (34·6-93·3) DALYs in 2017, with the burden overwhelmingly experienced in low-income and middle-income countries (LMICs; 60·8 million [34·6-92·9] DALYs) compared with high-income countries (0·09 million [0·01-0·40] DALYs). From 2000, mortality associated with household air pollution had reduced by 36% (95% CI 29-43) and disease burden by 30% (25-36), with the greatest reductions observed in higher-income nations.

Interpretation: The burden of cardiorespiratory, paediatric, and maternal diseases associated with household air pollution has declined worldwide but remains high in the world's poorest regions. Urgent integrated health and energy strategies are needed to reduce the adverse health impact of household air pollution, especially in LMICs.

Funding: British Heart Foundation, Wellcome Trust.
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http://dx.doi.org/10.1016/S2214-109X(20)30343-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564377PMC
November 2020

Measuring Air Quality for Advocacy in Africa (MA3): Feasibility and Practicality of Longitudinal Ambient PM Measurement Using Low-Cost Sensors.

Int J Environ Res Public Health 2020 10 3;17(19). Epub 2020 Oct 3.

Institute for Social Marketing and Health, University of Stirling, Stirling FK9 4LA, UK.

Ambient air pollution in urban cities in sub-Saharan Africa (SSA) is an important public health problem with models and limited monitoring data indicating high concentrations of pollutants such as fine particulate matter (PM). On most global air quality index maps, however, information about ambient pollution from SSA is scarce. We evaluated the feasibility and practicality of longitudinal measurements of ambient PM using low-cost air quality sensors (Purple Air-II-SD) across thirteen locations in seven countries in SSA. Devices were used to gather data over a 30-day period with the aim of assessing the efficiency of its data recovery rate and identifying challenges experienced by users in each location. The median data recovery rate was 94% (range: 72% to 100%). The mean 24 h concentration measured across all sites was 38 µg/m with the highest PM period average concentration of 91 µg/m measured in Kampala, Uganda and lowest concentrations of 15 µg/m measured in Faraja, The Gambia. Kampala in Uganda and Nnewi in Nigeria recorded the longest periods with concentrations >250µg/m. Power outages, SD memory card issues, internet connectivity problems and device safety concerns were important challenges experienced when using Purple Air-II-SD sensors. Despite some operational challenges, this study demonstrated that it is reasonably practicable and feasible to establish a network of low-cost devices to provide data on local PM concentrations in SSA countries. Such data are crucially needed to raise public, societal and policymaker awareness about air pollution across SSA.
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http://dx.doi.org/10.3390/ijerph17197243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579047PMC
October 2020

Diagnostic accuracy of combined thoracic and cardiac sonography for the diagnosis of pulmonary embolism: A systematic review and meta-analysis.

PLoS One 2020 28;15(9):e0235940. Epub 2020 Sep 28.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.

Objectives: Computed tomography pulmonary angiography (CTPA) is the diagnostic standard for pulmonary embolism (PE), but is unavailable in many low resource settings. We evaluated the evidence for point of care ultrasound as an alternative diagnostic.

Methods: Using a PROSPERO-registered, protocol-driven strategy (https://www.crd.york.ac.uk/PROSPERO, ID = CRD42018099925), we searched MEDLINE, EMBASE, and CINHAL for observational and clinical trials of cardiopulmonary ultrasound (CPUS) for PE. We included English-language studies of adult patients with acute breathlessness, reported according to PRISMA guidelines published in the last two decades (January 2000 to February 2020). The primary outcome was diagnostic accuracy of CPUS compared to reference standard CTPA for detection of PE in acutely breathless adults.

Results: We identified 260 unique publications of which twelve met all inclusion criteria. Of these, seven studies (N = 3872) were suitable for inclusion in our meta-analysis for diagnostic accuracy (two using CTPA and five using clinically derived diagnosis criterion). Meta-analysis of data demonstrated that using cardiopulmonary ultrasound (CPUS) was 91% sensitive and 81% specific for pulmonary embolism diagnosis compared to diagnostic standard CTPA. When compared to clinically derived diagnosis criterion, CPUS was 52% sensitive and 92% specific for PE diagnosis. We observed substantial heterogeneity across studies meeting inclusion criteria (I2 = 73.5%).

Conclusions: Cardiopulmonary ultrasound may be useful in areas where CTPA is unavailable or unsuitable. Interpretation is limited by study heterogeneity. Further methodologically rigorous studies comparing CPUS and CTPA are important to inform clinical practice.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235940PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521742PMC
October 2020

Exploring perspectives on chronic obstructive pulmonary disease in people who smoke heroin: a qualitative study.

BJGP Open 2020 Aug 25;4(3). Epub 2020 Aug 25.

Royal Liverpool and Broadgreen University Hospitals, Liverpool, UK.

Background: Smoking rather than injecting heroin has become more common over the last 20 years. Although there is an increasing body of evidence describing high levels of chronic obstructive pulmonary disease (COPD) in people who smoke heroin, there is limited evidence documenting the impact of the long-term condition on this population group.

Aim: This study aimed to describe the experiences of people who smoke heroin with COPD in Liverpool, UK.

Design & Setting: Participants were purposefully sampled for this qualitative study. They included adults enrolled in an opioid replacement clinic run by Addaction in Liverpool, who had already engaged with spirometry testing for COPD as part of a previous study.

Method: Semi-structured interviews were performed with participants with spirometrically confirmed COPD in opioid replacement clinics. Data were analysed using a framework analysis approach.

Results: Sixteen potential participants were invited to take part in the study, of which 10 agreed and were interviewed. Three themes common to all interviews were identified: functional measures of lung health that impacted on their activities of daily living; inhaler and medication perceptions with erratic use that was not concordant with their prescription; and the impact of difficulties accessing care.

Conclusion: These findings, along with previous studies highlighting the prevalence of COPD in this population, warrant efforts to integrate community COPD and opioid replacement services to improve outcomes for this vulnerable population.
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http://dx.doi.org/10.3399/bjgpopen20X101055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465580PMC
August 2020

Pneumonia and Exposure to Household Air Pollution in Children Under the Age of 5 Years in Rural Malawi: Findings From the Cooking and Pneumonia Study.

Chest 2020 Aug 18;158(2):501-511. Epub 2020 Apr 18.

University of California, Berkeley, CA; University of California, San Francisco, San Francisco, CA.

Background: Exposure to household air pollution is associated with an increased risk of pneumonia in children in low- and middle-income countries; however, exposure-response data are limited, and there are uncertainties around the extent to which biomass-fueled cookstoves can reduce these exposures.

Research Question: What is the association between exposure to household air pollution and pneumonia in children under the age of 5 years in rural Malawi and what are the effects of a biomass-fueled cookstove intervention on personal exposure to household air pollution?

Study Design And Methods: We measured personal exposure to carbon monoxide (CO; 48 hours of continuous measurement and transcutaneous carboxyhemoglobin) every 6 months in children who participated in a cluster-randomized controlled trial of a cleaner burning biomass-fueled cookstove intervention to prevent pneumonia in children under the age of 5 years in rural Malawi (the Cooking And Pneumonia Study). Exposure-response and multivariable analyses were done.

Results: We recruited 1805 (928 intervention; 877 control) children (mean age, 25.6 months; 50.6% female). We found no evidence of an association between exposure to CO (incident rate ratio, 1.0; 95% CI, 0.967 to 1.014; P = .53) or carboxyhemoglobin (incident rate ratio, 1.00; 95% CI, 0.993 to 1.003; P = .41) in children who experienced pneumonia vs those who did not. Median exposure to CO in the intervention and control groups was was 0.34 (interquartile range, 0.15 to 0.81) and 0.37 parts per million (interquartile range, 0.15 toa 0.97), respectively. The group difference in means was 0.46 (95% CI, -0.95 to 0.012; P = .06).

Interpretation: Exposure to CO in our population was low with no association seen between exposure to CO and pneumonia incidence and no effect of the Cooking And Pneumonia Study intervention on these exposures. These findings suggest that CO may not be an appropriate measure of household air pollution exposure in settings such as rural Malawi and that there is a need to develop ways to measure particulate matter exposures directly in young children instead.

Clinical Trial Registration: ISRCTN59448623.
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http://dx.doi.org/10.1016/j.chest.2020.03.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417377PMC
August 2020

Patient outcomes associated with post-tuberculosis lung damage in Malawi: a prospective cohort study.

Thorax 2020 03 26;75(3):269-278. Epub 2020 Feb 26.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.

Background: Post-tuberculosis lung damage (PTLD) is a recognised consequence of pulmonary TB (pTB). However, little is known about its prevalence, patterns and associated outcomes, especially in sub-Saharan Africa and HIV-positive adults.

Methods: Adult (≥15 years) survivors of a first episode of pTB in Blantyre, Malawi, completed the St George's Respiratory Questionnaire, 6-minute walk test, spirometry and high-resolution CT (HRCT) chest imaging at TB treatment completion. Symptom, spirometry, health seeking, TB-retreatment and mortality data were collected prospectively to 1 year. Risk factors for persistent symptoms, pulmonary function decline and respiratory-related health-seeking were identified through multivariable regression modelling.

Results: Between February 2016 and April 2017, 405 participants were recruited. Median age was 35 years (IQR: 28 to 41), 77.3% (313/405) had had microbiologically proven pTB, and 60.3% (244/403) were HIV-positive. At pTB treatment completion, 60.7% (246/405) reported respiratory symptoms, 34.2% (125/365) had abnormal spirometry, 44.2% (170/385) had bronchiectasis ≥1 lobe and 9.4% (36/385) had ≥1 destroyed lobe on HRCT imaging. At 1 year, 30.7% (113/368) reported respiratory symptoms, 19.3% (59/305) and 14.1% (43/305) of patients had experienced declines in FEV or FVC of ≥100 mL, 16.3% (62/380) had reported ≥1 acute respiratory event and 12.2% (45/368) had symptoms affecting their ability to work.

Conclusions: PTLD is a common and under-recognised consequence of pTB that is disabling for patients and associated with adverse outcomes beyond pTB treatment completion. Increased efforts to prevent PTLD and guidelines for management of established disease are urgently needed. Low-cost clinical interventions to improve patient outcomes must be evaluated.
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http://dx.doi.org/10.1136/thoraxjnl-2019-213808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063395PMC
March 2020

Non-communicable respiratory disease and air pollution exposure in Malawi: a prospective cohort study.

Thorax 2020 03 20;75(3):220-226. Epub 2020 Feb 20.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK

Rationale: There are no population-based studies from sub-Saharan Africa describing longitudinal lung function in adults.

Objectives: To explore the lung function trajectories and their determinants, including the effects of air pollution exposures and the cleaner-burning biomass-fuelled cookstove intervention of the Cooking and Pneumonia Study (CAPS), in adults living in rural Malawi.

Methods: We assessed respiratory symptoms and exposures, spirometry and measured 48-hour personal exposure to fine particulate matter (PM) and carbon monoxide (CO), on three occasions over 3 years. Longitudinal data were analysed using mixed-effects modelling by maximum likelihood estimation.

Measurements And Main Results: We recruited 1481 adults, mean (SD) age 43.8 (17.8) years, including 523 participants from CAPS households (271 intervention; 252 controls), and collected multiple spirometry and air pollution measurements for 654 (44%) and 929 (63%), respectively. Compared with Global Lung Function Initiative African-American reference ranges, mean (SD) FEV (forced expiratory volume in 1 s) and FVC (forced vital capacity) z-scores were -0.38 (1.14) and -0.19 (1.09). FEV and FVC were determined by age, sex, height, previous TB and body mass index, with FEV declining by 30.9 mL/year (95% CI: 21.6 to 40.1) and FVC by 38.3 mL/year (95% CI: 28.5 to 48.1). There was decreased exposure to PM in those with access to a cookstove but no effect on lung function.

Conclusions: We did not observe accelerated lung function decline in this cohort of Malawian adults, compared with that reported in healthy, non-smoking populations from high-income countries; this suggests that the lung function deficits we measured in adulthood may have origins in early life.
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http://dx.doi.org/10.1136/thoraxjnl-2019-213941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063402PMC
March 2020

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

Chest 2020 03 22;157(3):558-565. Epub 2019 Nov 22.

Royal Liverpool and Broadgreen University Hospitals, Liverpool, England.

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 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 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.
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http://dx.doi.org/10.1016/j.chest.2019.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078587PMC
March 2020

The long shadow post-tuberculosis.

Lancet Infect Dis 2019 11;19(11):1170-1171

Liverpool School of Tropical Medicine, Liverpool, UK.

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http://dx.doi.org/10.1016/S1473-3099(19)30564-XDOI Listing
November 2019

Exercise and pulmonary rehabilitation for people with chronic lung disease in LMICs: challenges and opportunities.

Lancet Respir Med 2019 12 16;7(12):1002-1004. Epub 2019 Oct 16.

Liverpool School of Tropical Medicine, Liverpool, UK.

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http://dx.doi.org/10.1016/S2213-2600(19)30364-9DOI Listing
December 2019

Lung health and exposure to air pollution in Malawian children (CAPS): a cross-sectional study.

Thorax 2019 11 29;74(11):1070-1077. Epub 2019 Aug 29.

Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK

Background: Non-communicable lung disease and exposure to air pollution are major problems in sub-Saharan Africa. A high burden of chronic respiratory symptoms, spirometric abnormalities and air pollution exposures has been found in Malawian adults; whether the same would be true in children is unknown.

Methods: This cross-sectional study of children aged 6-8 years, in rural Malawi, included households from communities participating in the Cooking and Pneumonia Study (CAPS), a trial of cleaner-burning biomass-fuelled cookstoves. We assessed; chronic respiratory symptoms, anthropometry, spirometric abnormalities (using Global Lung Initiative equations) and personal carbon monoxide (CO) exposure. Prevalence estimates were calculated, and multivariable analyses were done.

Results: We recruited 804 children (mean age 7.1 years, 51.9% female), including 476 (260 intervention; 216 control) from CAPS households. Chronic respiratory symptoms (mainly cough (8.0%) and wheeze (7.1%)) were reported by 16.6% of children. Average height-for-age and weight-for-age z-scores were -1.04 and -1.10, respectively. Spirometric abnormalities (7.1% low forced vital capacity (FVC); 6.3% obstruction) were seen in 13.0% of children. Maximum CO exposure and carboxyhaemoglobin levels (COHb) exceeded WHO guidelines in 50.1% and 68.5% of children, respectively. Children from CAPS intervention households had lower COHb (median 3.50% vs 4.85%, p=0.006) and higher FVC z-scores (-0.22 vs -0.44, p=0.05) than controls.

Conclusion: The substantial burden of chronic respiratory symptoms, abnormal spirometry and air pollution exposures in children in rural Malawi is concerning; effective prevention and control strategies are needed. Our finding of potential benefit in CAPS intervention households calls for further research into clean-air interventions to maximise healthy lung development in children.
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http://dx.doi.org/10.1136/thoraxjnl-2018-212945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860406PMC
November 2019

Temporarily quadrupling the dose of inhaled steroid to prevent asthma exacerbations: FAST.

Health Technol Assess 2018 12;22(70):1-82

Respiratory Medicine, Nottingham NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK.

Background: Asthma exacerbations affect the quality of life of patients with asthma and have a major effect on the overall costs of asthma care. An asthma self-management plan that advises the temporary quadrupling of inhaled corticosteroid dose may prevent asthma exacerbations, but this needs to be confirmed before being adopted widely.

Objectives: To compare the clinical effectiveness and cost-effectiveness of an asthma self-management plan that advises patients to temporarily quadruple the dose of inhaled corticosteroid when asthma control starts to deteriorate with a standard self-management plan.

Design: A multicentre, parallel-group, pragmatic randomised trial, with follow-up for 12 months.

Setting: Primary and secondary care across 207 sites in the UK.

Participants: Asthma patients aged ≥ 16 years treated with an inhaled corticosteroid who had experienced at least one exacerbation in the previous 12 months.

Interventions: Participants were randomised (1 : 1) to a usual-care self-management plan or to a modified self-management plan that advised a temporary quadrupling of the inhaled corticosteroid at the point of asthma deterioration, both of which were actively implemented and supported by local research staff.

Primary Outcome: The primary outcome of 'time to first asthma exacerbation' was defined as the need for systemic corticosteroids (for at least 3 consecutive days) and/or unscheduled health-care consultations for asthma (i.e. reaching zone 3 or 4 of the Asthma UK self-management plan).

Results: A total of 1922 participants were randomised: the primary analysis included 938 participants (97%) in the usual-care group and 933 participants (97%) in the modified self-management group. The number of participants having at least one exacerbation of asthma in the year after randomisation was 484 (51.6%) in the usual-care group and 420 (45.0%) in the modified self-management group [adjusted hazard ratio 0.81, 95% confidence interval (CI) 0.71 to 0.92;  = 0.002]. There were fewer serious adverse events reported in the modified self-management group than in the usual-care group (11 vs. 32, respectively). Eight and six events of pneumonia, lower respiratory tract infections or influenza were reported in the usual-care group and the modified self-management group, respectively. Health-care-related costs were lower in the modified self-management group. The modified self-management group was £24 (bootstrapped 95% CI -£122 to £71) less costly than usual care, with a greater quality-adjusted life-year gain of 0.02 (bootstrapped 95% CI -0.005 to 0.04). Therefore, the modified self-management group was 'dominant', with a 94-95% probability of being cost-effective at the £20,000-30,000 threshold.

Limitations: As the Fourfold Asthma STudy (FAST) was an open-label pragmatic trial, the possibility of treatment bias that may have affected the participants in the modified self-management group cannot be ruled out. Poorer than expected completion of participant diary cards, particularly within the usual-care self-management group, could have led to a null bias, underestimating the true effect of the intervention.

Conclusions: An asthma self-management plan that advises patients to temporarily quadruple their dose of inhaled corticosteroid at the point of asthma symptoms worsening does reduce clinically important asthma exacerbations. In addition, the plan is cost-effective compared with the usual-care self-management plan.

Future Work: To effectively implement asthma self-management plans that advise a temporary quadrupling of inhaled steroid at asthma deterioration into routine practice.

Trial Registration: Current Controlled Trials ISRCTN15441965.

Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in ; Vol. 22, No. 70. See the NIHR Journals Library website for further project information.
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http://dx.doi.org/10.3310/hta22700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307366PMC
December 2018

Household Air Pollution Is Associated with Chronic Cough but Not Hemoptysis after Completion of Pulmonary Tuberculosis Treatment in Adults, Rural Eastern Democratic Republic of Congo.

Int J Environ Res Public Health 2018 11 15;15(11). Epub 2018 Nov 15.

Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven, 300 Leuven, Belgium.

Little is known about the respiratory health damage related to household air pollution (HAP) in survivors of pulmonary tuberculosis (PTB). In a population-based cross-sectional study, we determined the prevalence and associated predictors of chronic cough and hemoptysis in 441 randomly selected PTB survivors living in 13 remote health zones with high TB burden in the South Kivu province of the Democratic Republic of Congo (DRC). Trained community and health-care workers administered a validated questionnaire. In a multivariate logistic regression, chronic cough was independently associated with HAP (adjusted odds ratios (aOR) 2.10, 95% CI: 1.10⁻4.00) and PTB treatment >6 months (aOR 3.80, 95% CI: 1.62⁻8.96). Among women, chronic cough was associated with cooking ≥3 h daily (aOR 2.74, 95% CI: 1.25⁻6.07) and with HAP (aOR 3.93, 95% CI: 1.15⁻13.43). Independent predictors of hemoptysis were PTB retreatment (aOR 3.04, 95% CI: 1.04⁻5.09) and ignorance of treatment outcome (aOR 2.24, 95% CI: 1.09⁻4.58) but not HAP (aOR 1.86, 95% CI: 0.61⁻5.62). Exposure to HAP proved a major risk factor for chronic cough in PTB survivors, especially in women. This factor is amenable to intervention.
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http://dx.doi.org/10.3390/ijerph15112563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6265859PMC
November 2018

Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 2: Air Pollution and Organ Systems.

Chest 2019 02 9;155(2):417-426. Epub 2018 Nov 9.

School of Earth, Society, and Environment, Department of Atmospheric Sciences, University of Illinois, Urbana, IL.

Although air pollution is well known to be harmful to the lung and airways, it can also damage most other organ systems of the body. It is estimated that about 500,000 lung cancer deaths and 1.6 million COPD deaths can be attributed to air pollution, but air pollution may also account for 19% of all cardiovascular deaths and 21% of all stroke deaths. Air pollution has been linked to other malignancies, such as bladder cancer and childhood leukemia. Lung development in childhood is stymied with exposure to air pollutants, and poor lung development in children predicts lung impairment in adults. Air pollution is associated with reduced cognitive function and increased risk of dementia. Particulate matter in the air (particulate matter with an aerodynamic diameter < 2.5 μm) is associated with delayed psychomotor development and lower child intelligence. Studies link air pollution with diabetes mellitus prevalence, morbidity, and mortality. Pollution affects the immune system and is associated with allergic rhinitis, allergic sensitization, and autoimmunity. It is also associated with osteoporosis and bone fractures, conjunctivitis, dry eye disease, blepharitis, inflammatory bowel disease, increased intravascular coagulation, and decreased glomerular filtration rate. Atopic and urticarial skin disease, acne, and skin aging are linked to air pollution. Air pollution is controllable and, therefore, many of these adverse health effects can be prevented.
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http://dx.doi.org/10.1016/j.chest.2018.10.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904854PMC
February 2019

Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 1: The Damaging Effects of Air Pollution.

Chest 2019 02 9;155(2):409-416. Epub 2018 Nov 9.

School of Earth, Society, and Environment, Department of Atmospheric Sciences, University of Illinois, Urbana, IL.

Air pollution poses a great environmental risk to health. Outdoor fine particulate matter (particulate matter with an aerodynamic diameter < 2.5 μm) exposure is the fifth leading risk factor for death in the world, accounting for 4.2 million deaths and > 103 million disability-adjusted life years lost according to the Global Burden of Disease Report. The World Health Organization attributes 3.8 million additional deaths to indoor air pollution. Air pollution can harm acutely, usually manifested by respiratory or cardiac symptoms, as well as chronically, potentially affecting every organ in the body. It can cause, complicate, or exacerbate many adverse health conditions. Tissue damage may result directly from pollutant toxicity because fine and ultrafine particles can gain access to organs, or indirectly through systemic inflammatory processes. Susceptibility is partly under genetic and epigenetic regulation. Although air pollution affects people of all regions, ages, and social groups, it is likely to cause greater illness in those with heavy exposure and greater susceptibility. Persons are more vulnerable to air pollution if they have other illnesses or less social support. Harmful effects occur on a continuum of dosage and even at levels below air quality standards previously considered to be safe.
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http://dx.doi.org/10.1016/j.chest.2018.10.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904855PMC
February 2019

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

Int J Environ Res Public Health 2018 09 18;15(9). Epub 2018 Sep 18.

Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.

Ambient air pollution is a major global health problem and commercial drivers are particularly exposed to it. As no systematic assessment of the health risks associated with occupational exposure to ambient air pollution in this population had yet been carried out, we conducted a systematic review using a protocol-driven strategy. Papers published from inception to April 20, 2018 in MEDLINE, EMBASE, CINAHL, African journals online, the Cochrane library, ISRCTN WHO ICTRP, and the Web of Science and Scopus databases were screened for inclusion by two independent reviewers. Original articles with at least an available abstract in English or French were included. The initial search retrieved 1454 published articles of which 20 articles were included. Three studies reported a significant difference in white blood cells (10⁶/L) among commercial motorcyclists compared to rural inhabitants (5.041 ± 1.209 vs. 5.900 ± 1.213, = 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'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. Four papers failed to demonstrate that the drivers were more exposed to air pollution than the controls. Three other studies also reported no significant difference in lung function parameters and respiratory symptoms. The genetic polymorphisms of detoxifying enzymes were also not homogeneously distributed compared to the controls. 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 on small sample size, methodological weaknesses, and contradictory findings-thus, further research is recommended.
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http://dx.doi.org/10.3390/ijerph15092039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163743PMC
September 2018

The Early Recognition and Management of Sepsis in Sub-Saharan African Adults: A Systematic Review and Meta-Analysis.

Int J Environ Res Public Health 2018 09 15;15(9). Epub 2018 Sep 15.

Department of Clinical Sciences, Liverpool School of Tropical Medicine and Aintree University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK.

Sepsis is a common cause of morbidity and mortality in sub-Saharan African adults. Standardised management pathways have been documented to improve the survival of adults with sepsis from high-resource settings. Our aim was to assess the current evidence base for early sepsis interventions (recognition, empirical antibiotics, and resuscitation) in resource-poor settings of sub-Saharan Africa. We searched MEDLINE, EMBASE and CINHAL Plus databases to identify interventional studies for the early recognition and management of sepsis in sub-Saharan Africa (1 January 2000 to 1 August 2018) using a protocol-driven search strategy: adults, protocolised care pathway, and sub-Saharan Africa. We identified 725 publications of which three met criteria for final selection. Meta-analysis from two randomised controlled trials demonstrated that mortality was increased by 'early goal-directed therapy' interventions that increased fluid resuscitation (R.R. 1.26, 95% C.I. 1.00⁻1.58, = 0.045; ² 53%). The third observational cohort study demonstrated improved survival after implementation of protocolised management for sepsis (mortality 33.0% vs. 45.7%, = 0.005). No study incorporated standardised protocols for empirical antibiotic administration. High rates of pneumonia and mycobacteraemia were reported. There has been little research into the early recognition and management of sepsis in sub-Saharan Africa. Interventional trials of early goal-directed therapy have, to date, increased mortality. There is an urgent need to develop effective strategies to improve outcomes for adults with sepsis in sub-Saharan Africa.
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http://dx.doi.org/10.3390/ijerph15092017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164025PMC
September 2018

The Cooking and Pneumonia Study (CAPS) in Malawi: A Cross-Sectional Assessment of Carbon Monoxide Exposure and Carboxyhemoglobin Levels in Children under 5 Years Old.

Int J Environ Res Public Health 2018 09 5;15(9). Epub 2018 Sep 5.

Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.

Household air pollution is estimated to cause half a million deaths from pneumonia in children worldwide. The Cooking and Pneumonia Study (CAPS) was conducted to determine whether the use of cleaner-burning biomass-fueled cookstoves would reduce household air pollution and thereby the incidence of pneumonia in young children in rural Malawi. Here we report a cross-sectional assessment of carbon monoxide (CO) exposure and carboxyhemoglobin (COHgB) levels at recruitment to CAPS. Mean (SD; range) 48-h CO exposure of 1928 participating children was 0.90 (2.3; 0⁻49) ppm and mean (SD; range) COHgB level was 5.8% (3.3; 0⁻20.3). Higher mean CO and COHgB levels were associated with location (Chikhwawa versus Chilumba) (OR 3.55 (1.73⁻7.26)); (OR 2.77 (1.08⁻7.08)). Correlation between mean CO and COHgB was poor (Spearman's ρ = 0.09, < 0.001). The finding of high COHgB levels in young children in rural Malawi that are at levels at which adverse neurodevelopmental and cognitive effects occur is of concern. Effective approaches for reducing exposure to CO and other constituents of air pollution in rural sub-Saharan African settings are urgently needed.
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http://dx.doi.org/10.3390/ijerph15091936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163876PMC
September 2018

Noncommunicable Respiratory Disease and Air Pollution Exposure in Malawi (CAPS). A Cross-Sectional Study.

Am J Respir Crit Care Med 2019 03;199(5):613-621

1 Liverpool School of Tropical Medicine, Liverpool, United Kingdom.

Rationale: Noncommunicable respiratory diseases and exposure to air pollution are thought to be important contributors to morbidity and mortality in sub-Saharan African adults.

Objectives: We set out to explore the prevalence and determinants of noncommunicable respiratory disease among adults living in Chikhwawa District, Malawi.

Methods: We performed a cross-sectional study among adults in communities participating in a randomized controlled trial of a cleaner-burning biomass-fueled cookstove intervention (CAPS [Cooking and Pneumonia Study]) in rural Malawi. We assessed chronic respiratory symptoms, spirometric abnormalities, and personal exposure to air pollution (particulate matter <2.5 μm in aerodynamic diameter [PM] and carbon monoxide [CO]). Weighted prevalence estimates were calculated; multivariable and intention-to-treat analyses were done.

Measurements And Main Results: One thousand four hundred eighty-one participants (mean [SD] age, 43.8 [17.8] yr; 57% female) were recruited. The prevalence of chronic respiratory symptoms, spirometric obstruction, and restriction were 13.6% (95% confidence interval [CI], 11.9-15.4), 8.7% (95% CI, 7.0-10.7), and 34.8% (95% CI, 31.7-38.0), respectively. Median 48-hour personal PM and CO exposures were 71.0 μg/m (interquartile range [IQR], 44.6-119.2) and 1.23 ppm (IQR, 0.79-1.93), respectively. Chronic respiratory symptoms were associated with current/ex-smoking (odds ratio [OR], 1.59; 95% CI, 1.05-2.39), previous tuberculosis (OR, 2.50; 95% CI, 1.04-15.58), and CO exposure (OR, 1.46; 95% CI, 1.04-2.05). Exposure to PM was not associated with any demographic, clinical, or spirometric characteristics. There was no effect of the CAPS intervention on any of the secondary trial outcomes.

Conclusions: The burden of chronic respiratory symptoms, abnormal spirometry, and air pollution exposures in adults in rural Malawi is of considerable potential public health importance. We found little evidence that air pollution exposures were associated with chronic respiratory symptoms or spirometric abnormalities and no evidence that the CAPS intervention had effects on the secondary trial outcomes. More effective prevention and control strategies for noncommunicable respiratory disease in sub-Saharan Africa are needed. Clinical trial registered with www.isrctn.com (ISRCTN 59448623).
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http://dx.doi.org/10.1164/rccm.201805-0936OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396863PMC
March 2019

Questionnaires for Lung Health in Africa across the Life Course.

Int J Environ Res Public Health 2018 07 31;15(8). Epub 2018 Jul 31.

Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.

Respiratory infections remain a leading cause of morbidity and mortality in many low and middle-income countries but non-communicable disease rates are rising fast. Prevalence studies have been primarily symptom-focused, with tools developed in countries in the Global North such as the United States and the United Kingdom. Systematic study in sub-Saharan African populations is necessary to accurately reflect disease risk factors present in these populations. We present tools for such studies, developed as part of the International Multidisciplinary Programme to Address Lung Health and TB in Africa ('IMPALA'), which includes lay representatives. At a preliminary meeting, the adequacy and suitability of existing tools was discussed and a new questionnaire set proposed. Individual questionnaires were developed, and an expert panel considered content and criterion validity. Questionnaires underwent a cross-cultural adaptation process, incorporating translation and contextual 'sense-checking', through the use of pre-established lay focus groups in Malawi, before consensus-approval by project collaborators. The complete set of research questionnaires, providing information on lung health symptoms and a relevant range of potential risk factors for lung disease, is now available online. In developing the tools, cultural and contextual insights were important, as were translational considerations. The process benefitted from a foundation in expert knowledge, starting with validated tools and internationally respected research groups, and from a coordinated collaborative approach. We present and discuss a newly devised, contextually appropriate set of questionnaires for non-communicable lung disease research in Africa that are now available in open access for all to use.
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http://dx.doi.org/10.3390/ijerph15081615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121394PMC
July 2018