Towards regional progress: APSR 2022 Big Five Lung Diseases Workshop

Background: In conjunction with the Annual Scientific Congress of the APSR held in Seoul, South Korea in November 2022, a workshop was held which brought together representatives from the APSR, Union APR, WHO SEARO and WHO WPRO. The input was sought from successful national groups that would address issues relating to Asthma, COPD, Lung Cancer, Tuberculosis and non-TB infections (the ‘Big Five’), with a focus on broad applicability including to lower-middle income countries. Objective: Recognizing that a strategic objective of each organization was to expand or create new relationships with other regional organizations with like intent, the objective of the workshop was to bring together their somewhat differing resources and different ways of functioning and use their overlapping memberships, to help set a pathway for developing the best way forward to tackle the biggest challenges in respiratory medicine in our region. Methodology: On the day, 10 oral presentations were made. Working in groups, the workshop participants discussed the presentations and rated the approaches taken in terms of “Acceptability, Feasibility, Scalability and Affordability on one axis and ‘Potential Impact’ on the other axis, with each parameter given a rating out of 10. After the workshop, presenters were invited to submit a summary of their presentation, reflecting on feedback. Four additional poster presentations were provided but these were not broadly discussed. The workshop was the culmination of contributions from a wide range of expert representatives: Governance Group: Ral Antic (Union APR), Kwun Fong (APSR), Kalpeshsinh Rahevar (WHO WPRO) and Rohit Sarin (NITRD). Steering Group: Elizabeth Cadena (Union APR), Lenora Canizares-Fernandez (PCCP, Union APR), David Lam (APSR), Asif Mujtaba Mahmud (Bangladesh LF), Akihiro Ohkado (Union APR), Camilo Roa (Union APR), Jann-Yuan Wang (Union APR), Manami Yanagawa (WHO WPRO), Maria Victoria Restituta Diezmo-Marbibi (San JuanDe Dios Hospital, Vaccination Centre of Asian Hospital). Chairs and Facilitators: Masayuki Hanaoka (APSR), Yoichi Nakanishi (APSR), Chul-Gyu Yoo (APSR), Ral Antic (Union APR), Lenora Canizares-Fernandez (PCCP, Union APR), Maria Victoria Restituta Diezmo-Marbibi (San JuanDe Dios Hospital, Vaccination Centre of Asian Hospital), Asif Mujtaba Mahmud (Bangladesh LF), Kyung Hyun Oh (WHO WPRO), Chin Kook Rhee (APSR), Mohammad Abdus Shakur Khan (Bangaldesh LF), Erlina Burhan (APSR), Guy Marks (UNION Global), Elizabeth Cadena (Union APR), Henry Marshall (APSR), Karen Collishaw (ATS), Akihiro Ohkado (Union APR), Carlos Robalo Cordeiro (ERS), Patricia Rivera (ATS), Gregory P Downey (ATS), Camilo Roa (Union APR), Yoko Shibata (APSR), Jann-Yuan Wang (Union APR) Peter AB Wark (University of Newcastle) and Heather Zar (FIRS). Welcome: Ki-Suck Jung (APSR), Closing: Yoshiosuke Fukuchi (APSR). Sameera Ansari, Hassan Hosseinzadeh, Sarah Dennis, Nicholas Zwar (Australia) COPD is often under-recognized in primary care and complicated by the presence of comorbidities, which further impacts the quality of life. Most prior self-management support programs for COPD have had a single-disease focus, and mainly addressed biomedical outcomes. Furthermore, such programs have excluded people with more severe COPD and certain comorbidities. The Activating Primary Care COPD Patients with Multimorbidity (APCOM) program, is a self-management support program aimed to improve patient activation, COPD-related quality of life, COPD knowledge, inhaler device technique and self-management capacity of their multimorbidity. The program was delivered to patients by their practice nurses (PNs) in Sydney, Australia. The program was tailored according to individual needs, preferences and values; this involved active participation of patients in decision-making regarding their own health. The PNs were trained in 1-day workshops with knowledge and skills on tailoring and delivering the program to patients in three one-to-one sessions. The APCOM program had a holistic approach and considered the implications of patients' comorbidities towards their COPD. Components of the program included biomedical as well as psychosocial aspects of coping with COPD and comorbidities, which are essential for self-management support of chronic disease. At 6 months follow-up, there was an average increase of 7.16 points in the Patient Activation Measure, which was both statistically (p < 0.001) and clinically significant. The average increase of 1.75 points in patients' COPD knowledge was statistically significant (p < 0.001). There was a statistically (p = 0.012) as well as clinically significant improvement in patients' COPD-related quality of life, with an increase of 2.45 points in the COPD Assessment Test. There was also a significant improvement (p = 0.001) in the accuracy of patients' inhaler device technique, with 20 patients performing the technique correctly at 6 months follow-up compared to five patients at baseline. Qualitative interviews were held with 10 PNs, 7 General Practitioners (GPs) and 12 patients. The PNs felt that participating in the program improved their confidence and skills for COPD management, and also enabled better rapport with patients and GPs. The main challenges included scheduling of sessions, making contact for monthly follow-ups and complications presented by patients' comorbidities. The GPs perceived the program to be significant and beneficial to patients, and felt that PNs were better suited to delivering self-management education. The patients perceived the program as a positive and worthwhile experience; they felt more aware of COPD and its implications; thereby, they were able to better cope with stressors due to multimorbidity. Participating general practices were each provided a recompense of AUD350 for identifying and inviting eligible patients; AUD60 was provided for every hour of the PNs' time towards training and delivery of the APCOM program. Patients' visits to their practice for the program were free-of-cost as they were PN consultations; any GP consultations were billed through Medicare. Patients were provided a recompense of AUD100 for their time towards visiting the practice five times during the program. For the interviews, PNs and GPs were provided AUD50, and patients were provided AUD30. The APCOM program is currently being upscaled as a large-scale randomized controlled trial in general practices across Australia (protocol can be found at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12622000568718). Given the dearth of primary care nurses in low- and middle-income country (LMIC)/developing health systems, community health workers could be trained to deliver this model of care. Consultations with primary care providers and consumers are needed to tailor the model of care to make it suitable to the country context. Funding support, perhaps from country governments and/or aid agencies, is vital for implementation, evaluation and sustainability of the program. There was strong enthusiasm for the approach taken, with high scores in the domains of acceptability and feasibility but some concerns were raised about costs in other countries and the capacity to provide the level of required training to nurses, and the availability of spirometry. Rosalyn Hernandez-Sebastian, Mario Augusto Lorman L. Goco (Philippines) In many parts of the world, government health services are hindered by budgetary constraints, manpower shortages, logistical challenges to reach the areas concerned or a combination of these factors. The havoc of the Covid-19 pandemic only highlighted the shortages of public health services in these disadvantaged areas. The island province of Oriental Mindoro in the Philippines has a public primary care health system with an average public doctor-to-people ratio of 1:29,000. Massive health operations such as the Covid-19 vaccinations proved to be challenging, especially in the earlier part of the pandemic. The Oriental Mindoro Medical Society (OMMS), a component society of the Philippine Medical Association, is a volunteer non-government organization of private and public physicians in the province. One of its core objectives is the upliftment of the public health status of our community through advocacy campaigns and specialized health services catering to indigent/disadvantaged groups in our community. The Oriental Mindoro Medical Society provided augmentation in the government vaccinations efforts in different locations in the province since August 2021. It provided local manpower assistance and logistical resources including incentive packs for vaccines, especially for the elderly and indigenous people. Done in close coordination with the Provincial Health Office and the local chapter of Philippine Nurses Association, volunteer physicians, off-duty nurses, volunteer support staff were fielded to different strategic vaccination areas such as public gymnasiums, local school buildings, mountain villages of indigenous tribes, provincial jails and shopping malls. OMMS has engaged in 26 mass vaccination activities all over the province from August 2021 to 2022 contributing to the 85% Covid-19 vaccination coverage in the province as of November 2022. As a non-government organization doing volunteer work, the OMMS finds its own funding at no cost to the government. This strategy of harnessing local volunteerism efforts directed towards attaining government goals is applied in another OMMS project with the local government—The Active TB Case Finding Project, a one-stop shop for patient education, diagnosis and management of pulmonary tuberculosis in pre-determined high-burden areas. OMMS augments government efforts in providing free chest radiographs, on-the-spot interpretation of tests and medical advice of complicated cases—significantly cutting down turn-around time from TB diagnosis to initiation of treatment. What is needed is close communication and cooperation between the local government unit and the volunteer organizations such that the volunteer work is concerted, needs-based and accounted for. The issues of sustainability and regularity, inherent in volunteer work, are noted as limitations. This strategy of maximizing local volunteerism efforts is attuned with the 2022 State of the World's Volunteerism Report of the United Nations as it states ‘volunteerism is a powerful force, and an important part of the fabric of society… and yet its potential to contribute to the achievement of sustainable development that delivers to all is yet to be realized’. The plan scored highly in regards to potential impact relative to cost in this setting, but its acceptability and feasibility might be a limitation in other jurisdictions where volunteerism is not so well established. Watchara Boonsawat, Uraiwan Zaeoue, Sunee Lertsinudom. (Thailand) The Thai national asthma guideline was first implemented in 1994 and was updated periodically following updated GINA guidelines. Despite the implementation of the asthma guideline, asthma control in Thailand is still sub-optimal. National Health Security Office (NHSO) performed a national asthma audit in 2007 and found that only 1.08 percent of asthmatic patients were measuring peak flow and inhaled corticosteroid was prescribed in only 10.9% of patients. These indicated the failure of asthma guideline implementation and improvement is urgently needed. We have developed the Easy Asthma Clinic (EAC) Network as a model to enhance the implementation of GINA guidelines in Thailand since 2004. The Easy Asthma Clinic is run by GPs in general hospitals. In the clinic, we simplified asthma guidelines and organized the system to facilitate teamwork, and emphasized the role of nurses and pharmacists to help doctors. We also developed an online web database for registering and monitoring patients. To set up the Easy Asthma Clinic, each hospital sent three personnel, a doctor, pharmacist and nurse, to attend a 1-day workshop. The workshop provided information on the diagnosis and treatment of asthma, peak flow measurement and interpretation, inhaler technique and type of medications and how to use the web database. After setting up EAC in the district hospitals the quality of asthma care improved a lot. The patients received asthma control assessment by questionnaire and peak flow measurement. More than 80% of the patients in the EAC received controllers (ICS, ICS/LABA). The EAC multidisciplinary team get more expertise in managing asthma. Asthma admissions and ER visits decreased dramatically after setting up the Easy Asthma Clinic and was reported in local journals. Each hospital has their own database of their asthma patients for monitoring their performance. The Easy Asthma clinic is easy to do in small rural hospitals and very effective in the management of asthma. Encouraged by early success, in 2009 NHSO supported 500 hospitals to set up Easy Asthma Clinics and launched a national 5-year project to improve asthma management using the Easy Asthma Clinic model in 2010. This resulted in much improvement in asthma care and asthma admissions were reduced by 25% in 5-year period. Now there are 1171 EAC in Thailand, most of them are small district hospitals, and 419,038 asthmatic patients are registered in the clinics. The cost of setting up the EAC is minimal. To set up EAC we need only 1-day workshop for doctors nurses and pharmacists. The only equipment required in the each EAC is a peak flow meter. The Easy Asthma Clinic runs by GPs in general hospitals. It is easy to set up and easy to implement. The approach was rated highly in all domains of acceptability, feasibility and impact. Costs were thought reasonable although the availability of a pharmacist and spirometry was raised as a potential limitation in some settings, the program actually uses peak flow meters so spirometry was not a major concern. Shih-Yu Chen, NTUH COPD team (Taiwan) Inappropriate peak inspiratory flow rate (PIFR) is a common critical error in inhaler manipulation. We applied PIFR-guided inhalation therapy to solve this problem. PIFR-guided inhalation therapy includes PIFR assessment and PIFR-guided inhaler education. The In-Check Dial G16 (Clement-Clarke International Ltd., Harlow, United Kingdom) was used to measure PIFR under simulated-resistance of the prescribed inhaler. Patients, in sitting position, were asked to perform three inspiratory manoeuvres through In-Check Dial G16. The optimal PIFR for dry powder inhalers (DPIs) ranges from 30 to 90 L/min and 20–60 L/min for a soft mist inhaler (SMI) or a pressurized metered dose inhaler (pMDI). If the highest PIFR observed was insufficient for a prescribed inhaler, the PIFR against a lower resistance was measured. The PIFR results were given as feedback to the primary physicians immediately for reconsideration of the current prescription. If the PIFR observed was excessive, the patient will be taught to decrease the inspiratory forces. Patients were required to return to the case manager for a reassessment of PIFR and repeatedly assessed during two subsequent clinical visits to make sure of its optimization. The implementation of this model of care showed several positive outcomes. Firstly, there is an improved physician and patient rapport. Many doctors expressed that they understood the patient better when giving PIFR-guided inhalation therapy. Through the interaction, patients generally got more familiar with the inhaler prescribed and would gradually build confidence in their prescription. Secondly, the model helps to avoid wasting of inhalers at de novo prescription. Through the PIFR screen at different resistances and the introduction of devices, patients get to know each device well and would be able to decide which device suits them. Finally, there is an improved clinical outcome among patients with COPD. A study of patients receiving PIFR-guided inhalation therapy in comparison to patients receiving sorely conventional inhaler education found that there was a significant reduction in the incidence of severe acute exacerbation (11.9% vs. 21.1%, relative risk 0.56, p < 0.05) and decreased probability of severe acute exacerbation in 1 year (Chen et al., Front Pharmacol. 2021; 12:704316). A In-Check dial G16 (Clement-Clarke International Ltd., Harlow, United Kingdom) costs £38. An adaptor, with a one-way valve, costs £0.13. Patients can safely breathe through one In-Check dial G16 by changing single-use adaptors. The In-Check dial G16 is easy to clean by simple washing. This model of care is non-invasive, easy to be performed and is feasible both in local clinic and hospital settings. It was felt that the real-world impact of this approach would be low to moderate, and there was concern that the approach would not be available easily outside of hospital settings. In some areas, the cost of the ‘optimized’ inhaler may still be prohibitive. In other areas, MDI plus spacer may simply be suitable. Landy Lan, Dawei Yang (China) Early detection and treatment for lung cancer is critical to reducing mortality and lowering overall healthcare costs. In current clinical practice, low-dose computed tomography (LDCT) is an effective tool for identifying lung nodules and potential lung cancer. Widespread implementation of lung cancer screening has led to an increase in identification of nodules, as high as up to 51% of screened patients. However, many patients need multiple investigations and invasive procedures to confirm their final diagnosis, and invasive procedures that yield a benign diagnosis may have limited clinical use and can put patients at risk. In addition, multiple investigations may delay care for malignant diseases. In general, as little as 1%–12% of nodules ultimately were confirmed as malignant and hence there is an unmet clinical need to develop a more effective approach to ensure patient safety through routine and effective use of clinical risk models. An integrated clinical care team at Zhongshan Hospital, Fudan University investigated the combination of clinical biomarkers and CT results to develop a novel diagnosis model. The First Affiliated Hospital of Sun Yat-Sen University further recognized the opportunity to maximize patient care with enhanced patient safety through this diagnostic pathway to determine the likelihood of malignancy, while reducing unnecessary invasive procedures. The clinical implementation of a nodule risk model (lung cancer biomarker panel [LCBP] with LDCT) increased the possibilities of malignant nodules diagnosis and significantly increased patient safety by mitigating the need for invasive procedures in patients with benign nodules, providing more opportunities of earlier treatment of malignant nodules and a better outcome. Implementation of a nodule risk model can be used to evaluate the likelihood of malignancy before surgery. CT results, in combination with clinical data and laboratory tumour markers LCBP can be used in a preoperative risk assessment tool with high pretest probability, particularly for high-risk patients. Among the biomarkers, ProGRP (progastrin-releasing peptide), CEA (carcinoembryonic antigen), SCC (squamous cell carcinoma antigen) and CYRFRA21-1 (cytokeratin 19 fragment) showed high performance in the evaluation of patients with lung nodules. Moreover, the combination of LCBP with clinical parameters (patient age, history, smoking status, nodule size, etc.) can significantly increase the clinical efficacy of CT screening for determining malignancy as an non-invasive procedures. The clinical implementation of the nodule risk model reduced the unnecessary invasive procedures and surgeries for patients with benign tumours. These lead to the cost saving of ¥5032.48 ($717 USD) and ¥59,589.61 ($8490 USD) per patient, respectively. The LCBP model has been recommended by China Lung Cancer Screening Expert Consensus and the China Alliance Against Lung Cancer (CAALC). The potential for advanced screening augmented by biomarkers was clearly something that may be of benefit in future but it was felt this particular approach needed more validation, and at this time was beyond the budget of most health systems, including those in developed economies. GM Monsur Habib (Bangladesh) As a consequence of the sociodemographic and epidemiological transitional impact prevalence of Chronic Respiratory Diseases (CRDs) is rising along with the existing infectious diseases, imposing a double burden on the healthcare system of LMICs. We are well equipped and skilled in chasing respiratory infections, but not with CRDs equally. We need further structured evidence-based coping strategies for these challenges. The approach should include understanding our local context, searching for global evidence-based recommendations and adapting deliverable strategies. Despite major healthcare being provided at the chronic care setting out of the hospital (the hospital is usually an acute care provider), there exists a significant lack of community/private chamber-based training for the doctors in most of the LMICs. We should recognize ‘Primary Care’ service as a speciality and develop skilled professionals accordingly. Reimbursement is an essential component of healthcare and out-of-pocket payment is two-thirds of the whole healthcare expenditure in many LMICs, we need to analyse the ‘willing-to-pay’ and ‘willing-to-accept’ aspects of health economics to set up healthcare configuration accordingly. Bangladesh Primary Care Respiratory Society (BPCRS) conducted a 6-month e-learning blended course on asthma care for primary care respiratory physicians (PCPs) which improved asthma care across the country. To date (before the COVID pandemic) we trained ~1200 PCPs in asthma care and currently, we have launched the ‘Asthma Right Care’ movement with the International Primary Care Respiratory Group (IPCRG). We do not have funders for the educational programme, participants paid for the course (Tk 30,000/− or $300 per student) and after the completion of this course, their practice got added value resulting in increased reimbursement of their knowledge and skill by the patient. Every intervention needs to justify by a feasibility study. We could not conduct the feasibility study on it due to lack of funds, however, it is included in our ‘To-do list’ in future. We are conducting implementation research on pulmonary rehabilitation (PR) in Bangladesh under the guidance and supervision of an experienced research team at the University of Edinburgh. Our feasibility study (using the mixed method) is already complete and manuscript writing is going on for the publication of the study. It indicates that PR is effective and deliverable in Bangladesh. There was enthusiasm for the acceptability feasibility and scalability of the approach, But recognition of the limitations due to resource and manpower requirements. It was also uncertain whether there was sufficient financial incentive for clinicians to engage, and there remains a barrier of the cost of medications. In discussion, innovative ways to provide and administer inhaled medications were discussed. Jennifer Ann Mendoza-Wi (Philippines) TB has always been in the top 10 leading causes of death in the Philippines. In 21 August 2017, the ‘Ubo Patrol’ project, a year-long program, was launched in all barangays of Dagupan City, province of Pangasinan in the Philippines, targeting Presumptive TB patients with a cough or ‘ubo’. The main objective was to intensify case detection among identified vulnerable groups—children, urban poor, inmates and with HIV/diabetes mellitus (DM). Each barangay had ‘Ubo Patrollers’. These are nurses, midwives and Barangay Health Workers (BHWs) oriented on the National TB Program, who conduct monthly house-to-house visits checking on the household members. A ‘text hotline’ would have been operationalized for people with productive cough of at least 2 weeks. They identify TB Presumptives and these are then referred for check-up which includes a free chest x-ray and sputum examination. In addition, active case-finding is performed among vulnerable groups. Treatment is initiated once a diagnosis is made. The ‘Ubo Patrol’ fulfilled its objective of delivering free and accessible TB diagnostic services. There was an increase in case detection rate by 2% from 2016 to 2017. * Stigma against TB continues to affect the health-seeking behaviours. The Ubo Patrol has helped those affected by other problems such as lack of time and lack of resources. The project fulfilled its objective—it has delivered free and accessible TB diagnostic services, and a TB hotline was established. Highly congested areas were given priority. Generally, the response to the UBO Patrol is positive. The project is in cooperation with the Philippine Tuberculosis Society (PTSI) which allowed the Dagupan City Health Office (CHO) to use their mobile x-ray unit which was brought to the barangays. The Dagupan CHO staff was composed of the CHO nurses, midwives, medical technologists and volunteer Pulmonologists. The budget was from the City Mayor's Office, including Salaries and transportation. Drug treatment was supervised by the staff.; anti-TB drugs are free. Inasmuch as this was launched by the City Mayor/s office, it is anticipated that this project will be continued. The mobile x-ray unit, the ‘free’ medical check-up and on-the-spot laboratory tests encourage patients to get diagnosed and treated. The project is feasible because it ‘brings’ to the patient the tools to diagnose and treat cough or the ‘UBO’. NOTE *The project was stopped due to the breakdown of the PTSI (Philippine Tuberculosis Society Inc.) mobile x-ray unit. With the acquisition of its own mobile x-ray unit this August, 2022, this will be re-launched. This program rated highly on potential impact and feasibility, although it was noted that the government support and proactive approach required political stability. The proactive approach, if handled sensitively, could overcome the problem of stigma inhibiting people seeking care. Sustainable access to equipment may be an issue. Hung-Ling Huang, Wei-Chang Huang, Kun-Der Lin, Shin-Shin Liu, Meng-HsuanCheng, Chun-Shih Chin, Chau-Chyun Sheu, Jann-Yuan Wang, I-TeLee and Inn-Wen Chong (Taiwan) DM has been regarded as an important co-morbidity of latent tuberculosis infection (LTBI) and active tuberculosis (TB) at the population level, and is associated with poor TB outcomes. Whether new approaches to treatment for patients with DM concomitant with latent tuberculosis will improve outcomes remains unknown. A primary care model was established for patients with poorly controlled diabetes, defined as at least one result of HbA1c level ≥9% within the recent 1 year. The approach involves screening and treatment of LTBI, as well as management of treatment-related adverse reactions, through the multidisciplinary collaboration of pulmonologists, endocrinologists and public health professionals. Before execution, a coordinator held meetings to assemble a collaborative task force and standard protocols were established. Continuous medical education was given to joining members. During execution, case managers identify target participants, conduct an interview and obtain informed consent. LTBI testing was then done and participants with positive results were enrolled. The benefits and indications were emphasized and the suitability of treatment was evaluated. Treatment regimens were selected through shared decision-making. Participants undertook directly observed preventive therapy and were constantly under clinical follow-up. Adverse events were followed on a monthly basis. After execution, regular meetings were arranged to review the progress of the project. The model was implemented from 2018 in several hospitals in Taiwan. The screening rate of latent tuberculosis was 92.7% (980 of 1057 eligible cases) and the QuantiFERON-TB Gold (QFT) positivity rate was 26.7%. Totally 77.4% of participants accepted LTBI treatment. Of the 200 patients, 62 (31.0%) and 138 (69.0%) received either the 9H or 3HP regimens, respectively. The completion rate of the 3HP and 9H groups was 84.1% and 79.0% (p = 0.494), respectively. No participants were diagnosed with active pulmonary tuberculosis in following 1 year. This collaborative primary care model provides a template to implement LTBI intervention successfully in a DM population and was carried out in many other hospitals in Taiwan. The QFT is not cheap and would cost about 70 US dollars a person. It was reimbursed by national health insurance in Taiwan. However, concerning the cost and quality of life of patients suffering from active tuberculosis, such intervention is worthy. The approach is only suggested in areas of low tuberculosis burden. It would not be appropriate in high tuberculosis burden areas because any benefits would only be short-term as the patients would be likely to be repeatedly exposed to TB in the future, with the risk of recurrent latent infection. Further, in high-burden areas, the development of medication resistance through such a short course of treatment is a great concern. It was felt that the potential impact of the approach would be low in all countries with a high TB burden, for the reasons outlined by the presenter, and thus the feasibility and broad implementation were thought to be low. Even in low-burden TB countries, the benefits may be questionable when many of the DM patients are elderly and thus the adverse effects of TB drugs may outweigh the benefits. Le Thi Tuyet Lan, Nguyen Nhu Vinh, Truong Thi Thanh Thuy, Pham Anh Tuan, Tran Trung De, Pham Quoc Dung, Vo Thi Ri, Vu Tran Thien Quan, Nguyen Hong Thien Tam (Vietnam) The management of Respiratory conditions including COPD, Asthma, TB, non-TB infections and Lung Cancer may be suboptimal due to delays and inefficiencies in referral from primary hea