Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings

Abstract

IMPORTANCEMost of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low-and middle-income countries (LMICs), with significant economic effects.OBJECTIVE To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. DESIGN, SETTING, AND PARTICIPANTSA cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age-and sex-stratified sample of the population 40 years or older.EXPOSURES Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. MAIN OUTCOMES AND MEASURESThe primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. CONCLUSIONS AND RELEVANCEThis study demonstrated that screening instruments for COPD were feasible to administer in 3 low-and middle-income settings. Further research is needed to assess instrument performance in other low-and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.

The association between household biomass fuel use and leukocyte telomere length among toddlers in Bhaktapur, Nepal

“…the same in a survey in 2018-2020 [40]. At the beginning of the study, our site was severely affected by a large earthquake.…”

“…We also have comprehensive data on other exposures such as growth, household, and socioeconomic characteristics. The longitudinal design, the ability to measure several potential confounding variables, and the relatively large sample size, provide strengths to our findings of an association between the exposure of biomass fuel and LTL in young children [3,39,40].…”

Recognising the importance of chronic lung disease: a consensus statement from the Global Alliance for Chronic Diseases (Lung Diseases group)

“…The challenge is much more than the availability of equipment, and relates to the training and ability of the front line, community based primary care workforce. In a recent population-based screening study of 10,709 people in 3 LMIC sites, the overall prevalence of COPD was 9.4% and > 95% were previously undiagnosed [42]. There is now the need to test implementation of tools to screen for COPD in LMIC settings, and to understand if screening is of benefit to individuals and society.…”

Availability, affordability and access to essential medications for asthma and chronic obstructive pulmonary disease in three low- and middle-income country settings

“…Global Excellence in COPD Outcomes (GECo) is a population-based study in three distinct geographic and economic regions in Asia, South America, and sub-Saharan Africa [10,12]. We carried out a cross-sectional survey of public and private pharmacies (including health centers and informal pharmacies) in defined catchment areas in Bhaktapur, Nepal (2019), Lima, Peru (2017), and Nakaseke, Uganda (2019) (see Fig 1 and S1 Data) as part of the parent GECo Study to assess pricing and availability of medications for the management of asthma and COPD [10].…”