Early chronic obstructive pulmonary disease: Beyond spirometry

The significant healthcare burden associated with chronic obstructive pulmonary disease(COPD) is driving us to improve our understanding of the natural history of this disease. Historically, the focus has been largely centred on diagnosing and treating individuals with moderate and severe disease. However, it is now recognised that the speed of decline in lung function as measured by forced expiratory volume in 1 s occurs faster in the earlier stages of the disease process. As a result, a clearer understanding of the potential benefits of treatment in early COPD is needed. It is recognised that many patients with COPD remain undiagnosed in the community which has prompted global case-finding initiatives. In this review we discuss the difficulties in diagnosing COPD in its early stages, examine the roleof case-finding and look at the evidence for early intervention with therapeutic agents. There is a growing interest in the phenotypic variation amongst patients with COPD and we explore the role of phenotyping in early COPD and its potential benefits in providing a more individualised approach to COPD management. The majority of patients with COPD are known to die from non-respiratory causes such as cardiovascular disease. The mechanistic link is thought to relate to systemic inflammation, causing us to question whether earlier interventions could have a beneficial impact on the burden of co-morbidities for patients with COPD.

Active Case Finding of Pulmonary Tuberculosis among Prison Inmates in Aba Federal Prison, Abia State, Nigeria

Background: Conditions in prisons favour rapid transmission of Mycobacterium tuberculosis and progression to tuberculosis (TB) disease, resulting in higher prevalence rates of TB in prisons than in the corresponding general population. However, in many developing countries with high TB burden, passive case-finding remains the usual approach to case detection of TB in prisons. On this premise, the Abia State TB Control Programme conducted a pilot study to assess the contribution of active case finding to tuberculosis control in Aba Federal Prison. Methods: The inmates were clinically screened and those with symptoms suggestive of TB cases were tested by sputum smear microscopy. Results: Out of the total number of 477 prison inmates present in the prison at the time of study, 449 (94.1%) were clinically screened for history of cough of 2 weeks’ duration;52 (10.42%) met the inclusion criteria for sputum smear microscopy. Eleven of the 52 (21.15%) tested for acid fast bacilli (AFB) by direct smear light microscopy were positive for AFB. One inmate was on anti-tuberculosis therapy;this with the 11 cases detected in the course of this study gave a total of 12 inmates of Aba prison with active pulmonary tuberculosis at the time of this study. This gives a minimum point prevalence rate of 2405 cases per 100,000 prison inmates. Four of the 11 prison cells had at least one smear positive case with 7 of the 11 cases concentrated in two cells. The age group of 25 - 34 years had the highest number of sputum positive cases. Conclusion: Active case-finding resulted in detection of 11 new cases of sputum positive tuberculosis (an increase in detection rate of 1100%) and the prevalence of sputum positive TB is very high (2405 cases per 100,000 prison inmates) in Aba prison. There is an urgent need to institute more effective TB case-finding and control in the prison.

Operational adaptations of the trachoma pre-validation surveillance strategy employed in Ghana:a qualitative assessment of successes and challenges

Background:In 2009 Ghana began to design a trachoma pre-validation surveillance plan,based on then-current WHO recommendations.The plan aimed to identify active trachoma resurgence and identify and manage trichiasis cases,through both active and passive surveillance approaches.This paper outlines and reviews the adaptations made by Ghana between 2011 and 2016.The assessment will provide a learning opportunity for a number of countries as they progress towards elimination status.Methods:A mixed methods approach was taken,comprising in-depth interviews and documents review.Between January and April 2016,20 in-depth interviews were conducted with persons involved in the operationalisation of the trachoma surveillance system from across all levels of the health system.A three-tier thematic coding framework was developed using a primarily inductive approach but also allowed for a more iterative approach,which drew on aspects of grounded theory.Results:During the operationalisation of the Ghana surveillance plan there were a number of adaptations(as compared to the WHO recommendations),these included:(i)Inclusion of surveillance of active trachoma in the passive surveillance approach,as compared to trichiasis alone.Issues with case identification,challenges in implementation coverage and a non-specific reporting structure hampered effectiveness;(ii)Random selection and increase in number of sites selected for the active surveillance component.This likely lacked the spatiotemporal power to be able to identify recrudescence in a timely manner;(iii)Targeted trichiasis door-to-door case searches,led by ophthalmic nurses.An effective methodology to identify trichiasis cases but resource intensive;(iv)A buddy system between ophthalmic nurses to support technical skills in an elimination setting where it is difficult to attain diagnostic and surgical skills,due to a lack of cases.The strategy did not take into account the loss of proficiency within experienced personnel.Conclusions:Ghana developed a comprehensive surveillance system that exceeded the WHO recommendations but issues with sensitivity and specificity likely led to an inefficient use of resources.Improved targeted surveillance strategies for identification of recrudescence and trichiasis case searches,need to be evaluated.Strategies must address the contextual changes that arise because of transmission decline,such as loss of surgical skills.