Unmet Diagnostic and Therapeutic Opportunities for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Countries

Abstract

Rationale Chronic obstructive pulmonary disease (COPD) is a prevalent and burdensome condition in low- and middle-income countries (LMICs). Challenges to better care include more effective diagnosis and access to affordable interventions. There are no previous reports describing therapeutic needs of populations with COPD in LMICs who were identified through screening. Objectives To describe unmet therapeutic need in screening-detected COPD in LMIC settings. Methods We compared interventions recommended by the international Global Initiative for Chronic Obstructive Lung Disease COPD strategy document, with that received in 1,000 people with COPD identified by population screening at three LMIC sites in Nepal, Peru, and Uganda. We calculated costs using data on the availability and affordability of medicines. Measurement and Main Results The greatest unmet need for nonpharmacological interventions was for education and vaccinations (applicable to all), pulmonary rehabilitation (49%), smoking cessation (30%), and advice on biomass smoke exposure (26%). Ninety-five percent of the cases were previously undiagnosed, and few were receiving therapy (4.5% had short-acting β-agonists). Only three of 47 people (6%) with a previous COPD diagnosis had access to drugs consistent with recommendations. None of those with more severe COPD were accessing appropriate maintenance inhalers. Even when available, maintenance treatments were unaffordable, with 30 days of treatment costing more than a low-skilled worker’s daily average wage. Conclusions We found a significant missed opportunity to reduce the burden of COPD in LMIC settings, with most cases undiagnosed. Although there is unmet need in developing novel therapies, in LMICs where the burden is greatest, better diagnosis combined with access to affordable interventions could translate to immediate benefit.

Chronic Obstructive Pulmonary Disease Self-Management in Three Low- and Middle-Income Countries: A Pilot Randomized Trial

“…Self-management interventions for COPD that include action plans have shown variable results for improving respiratory disease–related quality of life and respiratory-related hospital admissions. However, pooled analyses have shown that such interventions can lead to improvements in these outcomes ( 3 , 27 ). Aboumatar and colleagues examined the effect of a transitional care and long-term self-management support intervention after discharge for individuals hospitalized for COPD in Baltimore, Maryland ( 28 ).…”

“…These and other factors, such as existing workload and specific role within the overall health system, would influence intervention fit or required adaptations in a particular setting. Furthermore, in the absence of COPD medication availability ( 3 , 17 ), CHWs would be unable to carry out their duties in the distribution of evidence-based treatments. As such, task-shifting strategies should complement larger-scale structural reforms to improve the quality and accessibility of chronic disease treatment and care.…”

“…Because of a lack of resources and capacity, health systems in these countries are ill prepared to diagnose, treat, and manage the growing burden of COPD. Indeed, a significant proportion of COPD cases in LMICs remain undiagnosed and untreated ( 2 , 3 ).…”

Recognizing and Managing the Burdens of Chronic Breathlessness Alongside the Burdens of Chronic Obstructive Pulmonary Disease

“…Florman and colleagues are to be commended for drawing attention to the overwhelming burden generated by chronic obstructive pulmonary disease (COPD) in low- and middle-income countries ( 1 ). Access to the resources for its diagnosis and treatment are extremely limited, reflecting the reality in Nepal, Peru, and Uganda.…”

Role of Community Health Workers in Chronic Obstructive Pulmonary Disease Care in Low- and Middle-Income Countries

“…In high-income countries, tobacco smoking contributes to 70% of the COPD cases, but in LMICs nonsmoking risk factors, such as exposure to biomass smoke, ambient air pollution, occupational exposures, recurrent respiratory tract infections during childhood, past history of pulmonary tuberculosis, poverty, poor nutrition, and poorly treated asthma account for 60–70% of the COPD burden ( 3 ). More than 90% of the patients with COPD in LMICs remain undiagnosed, untreated, or wrongly treated ( 4 ). Limited resources, lack of availability of proper diagnostic tools, poor access to affordable drugs, and overstretched healthcare systems contribute to poor quality of care in the LMICs.…”