June 2009 Issue 4

Newsletter

www.crfindia.com

ROAM trains rural doctors to detect and manage OADs

response from Dr Nitin Kareer, the distribution was illuminating. Most of In an ambitious move to equip at then Divisional Commissioner of them had had no update on OADs after least one doctor in every village to Pune. Participants included Dr Nitin their graduation. Much like many of c o r r e c t l y d e t e c t a n d m a n a g e Bhalerao, Assistant District Health their urban colleagues, they prescribed obstructive airways diseases (OADs), Officer, and Dr Ashok Randive, oral medication either because they did CRF has launched a new training Medical Officer, District Training not know about inhaler devices or programme called Rural Obstructive Teamboth post-graduate doctors. Of because they believed in the myths Airways Diseases about inhalation Mission or ROAM, therapy. Even those In terms of numbers, the burden of OADs in rural areas is for short. ROAM can among them familiar help reduce the three times that in urban areas. Here, OADs remain underwith inhalation huge burden of therapy preferred to diagnosed, wrongly diagnosed, under-treated or wrongly OADs in India and use it as a last resort. managed. This is largely due to lack of awareness among make available a Dr Sundeep large portion of the doctors and ROAM hopes to help remedy the situation. Salvi, Director, CRF resources currently observed after the being sucked up by the rest, 23 doctors were MBBS and 8 programme: It was at once humbling the diseases to fight other problems in were BAMS doctors. Most of the and overwhelming to think of the health and nutrition. sessions were conducted in Marathi enormity of the task. But, my fellow ROAM will first train doctors at the and Hindi. faculty members, all of whom 96 primary health centres (PHCs) in The feedback from participating interacted freely with the participants Pune. Later, depending on the doctors during the certificate felt that ROAM had made an response from the government, the training will be scaled up to cover the entire state. CRF is hopeful of a ASTHMA COPD Estimated number of patients with positive response from the government 180 300 chronic asthma and COPD authorities at various levels and enthusiastic participation from doctors (in lakhs) 250 150 in the rural areas to make ROAM a successful component of the national 200 120 health mission.

CRF's training initiative to improve respiratory health in Indian villages

16 14 12 10 8 6 4 2 0 2005 2015 2030 Year Malaria Tuberculosis COPD

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auspicious beginning. It was very evident that the participants had a genuine hunger for knowledge.

The OAD burden

According to the National Commission on Macroeconomics and Health (NCMH), in 2005, the prevalence of OADs was about 45 million. It is expected to exceed 57 million by the year 2016. It is true that a larger percentage of urban dwellers are victims of OADs compared to the percentage of patients in the rural areas. However, the fact remains that more than 70 percent of Indians live in villages. Thus, in terms of sheer numbers, the burden of OADs in rural areas is already three times that in urban areas. The gap threatens to widen alarmingly by 2016. NCMH statistics reveal that almost Rs. 25209 crore was spent on the management of COPD in the year 2005 while the figure would have been just
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Enthusiastic response to first ROAM

Thirty-three doctors drawn from 31 primary health centres in Pune attended the inaugural ROAM session at CRF on December 7, 2008. Each primary health centre (PHC) caters to 100 villages and 1 lakh people. The first ROAM was made possible by the prompt and positive

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ROAM trains PHC doctors

Contd. from Page 1 Rs. 2941 crore had the cases been managed according to guidelines. For asthma, these figures are Rs.7641 crore and Rs. 2200 crore respectively. In the annual budget, Rs 30,000 crore is the amount allotted to health. It is clear that asthma and COPD together take up almost the entire budget earmarked for health. Traditional biomass fuels like wood, crop residues and animal dung account for nearly 75 percent of the household energy consumption in India. These emit a substantial amount of fuel carbon as products of incomplete combustion. This is one of the risk factors for development of COPD, especially among women in the rural areas. able to distinguish between asthma and COPD in order to manage these diseases differently. They must realise the importance of inhalation therapy and how its cost-effective nature makes it more important in villages. They need to make optimum use of simple diagnostic devices like peak flow meters to detect and manage OADs better. Once the doctors are equipped and empowered, they can ensure adequate management of OAD patients at the grass root level, improve respiratory health status and at the same time bring down the national expenditure on these diseases.

Exposure to kitchen smoke is a major risk factor for COPD, especially in the rural areas where biomass fuels are commonly used

national programme for OADs, particularly asthma and COPD. According to WHO figures, TB and malaria are more or less under control but we remain blind to the biggest threat looming before us in the form of COPD. Observed Dr Monica Barne, programme coordinator, CRF, after the first ROAM: Those doctors from faroff villages found it tough to find transport to make it to CRF.

Understandably, they came fretting about having lost another Sunday. But, they left as enthusiastic ambassadors of the programme. We will definitely remain in touch with all of them. Our greatest reward as members of the CRF team would be to help them make a difference, out there, where it really matters. We are looking forward to conducting one ROAM every month.

Need for ROAM

OADs remain under-diagnosed or wrongly diagnosed in the villages. It is also under-treated or wrongly managed. This is largely due to lack of awareness among the doctors about the management of these diseases according to latest guidelines and using the latest drugs and devices available. There is a critical need to train the doctors who are caring for the maximum number of people in India, meaning those catering to the rural population. These doctors need to be

To w a r d s a national mission
Diseases like TB and malaria are still being tackled on a war footing and have been in focus for several years, leading to their decline. OADs have been claiming more lives and threaten to be greater threat in the future. Yet, there is no

Dr H H Chavan District Health Officer, Pune District

We really appreciate this initiative taken by Chest Research Foundation in training the doctors at all the PHCs of Pune district in the correct management of asthma and COPD. The scientific content of the programme is something that our medical officers will really benefit from and it will help them manage their cases of asthma and COPD very well. Many of our MOs have procured the peak flow meters as well as the emergency management kits and we are in the process of making the other devices and drugs available at the PHCs. We hope that with the help of CRF we will be able to revolutionise the management of obstructive airways diseases in all villages of Pune district and provide better respiratory health care.

Participants in the first ROAM on December 7, 2008

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Strengthens case for control-based therapy

CRF study shows asthma not under control in 62% of patients

A recent CRF study has revealed that as much as 62 percent of patients under treatment for asthma for at least a year, do not have their asthma under control. While lack of compliance is a major reason, the study indicates that when it comes to asthma, control may depend on factors beyond medicines. The results show that in those patients who live in houses with damp walls, the risk of uncontrolled asthma is 3.15 times higher. Also, the use of biomass fuels like wood, cow dung cakes and kerosene increased the risk 2.57 times. The 4-month study involved 241 known patients of asthma in Pune, who have been under treatment for at least one year. They included those under treatment of general practitioners, general physicians or chest physicians in the city as well as those from three major hospitals in Pune.
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Guidelines for management

Step 1: Assess Control
The best way to assess asthma control is to use scientifically designed questionnaires to record patient-reported outcomes. Several such questionnaires have been developed. The Asthma Control Test (ACT), the Asthma Control Questionnaire (ACQ) and the Asthma Therapy Assessment Questionnaire (ATAQ) have all been studied, validated and published.

Step 2: Troubleshoot
The level of asthma control depends on the behaviour of both physicians and patients.

Step 3: Educate Patient

Education should be an integral part of asthma management. Children as young as 3 years can be taught simple asthma management skills. Parents and caregivers must be involved in the case of smaller children. Adolescents may have some unique difficulties regarding adherence that may be helped through peer support group education. Specific information should be provided about diagnosis, differences between controllers and relievers, potential side effects of medications, use of inhaler devices, prevention of symptoms and attacks, signs that suggest that asthma is worsening, how to respond to attacks and action plan for monitoring control of asthma. Patients should be instructed how to monitor symptoms with ACT, how to monitor lung function with a peak flow meter and how to use a written asthma action plan.

Step 4: Schedule Follow-up

Asthma management driven by level of asthma control demands close partnership between physicians and patients. The physician should set a realistic target for asthma control while balancing the risks and benefits of therapy. It is important to individualise treatment goals and treatment programmes. Therapy should be directed towards attaining the patient's personal best. Patients should be seen 2 to 6 weeks after treatment intensification to assess for response. If results at baseline or at the time of therapy intensification are abnormal, spirometry should be repeated. To maintain asthma control, the patient should be seen for a scheduled follow-up evaluation 12 weeks (or earlier, if symptoms occur) after each reduction in asthma medication. In real life, only a few patients will have frequent and severe exacerbations. These patients require closer follow up (every 3 to 6 months) to maximise opportunities to intervene and monitor and to minimise impairment and risk.

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They were administered the Asthma Control Test (ACT), a set of internationally-accepted standardised questions. Apart from demographic data, other information gathered included the type of cooking fuel used and the presence of dampness in the walls. An earlier CRF study had revealed a strong link between the presence of

fungi (which thrive on damp walls) and the prevalence of asthma in children. The study had found 2.2 times more fungi in air samples obtained from homes of children with asthma, compared to other homes in the same locality. The prevalence of wall dampness on non-bathroom walls was more in homes with asthma-affected children.

Why this gap?

Going by what we know about the disease today and the medicines that are easily available, asthma should be in control in at least 90 percent of patients. Yet, as the CRF study revealed, only 38 percent of patients have their asthma under control. Why is there such a huge gap between what ought to be and what is?

In 1995, the Global Initiative for Asthma (GINA) recommended the classification of asthma into four categories, based on severity: intermittent, persistent mild, persistent moderate and persistent severe. Severity assessment was to be largely based on presence of symptoms and spiromteric indices. This classification was to be used as a guide Contd on page 5

Reasons for poor asthma control

1: Patient-related factors
Poor adherence Compliance with the prescribed therapy is the cornerstone of effective asthma management. Adherence is affected by such factors as the number of medications prescribed, duration of treatment, interval between visits to the doctor, the patient's daily schedule, family situation and so on. The complex set of factors, which influences a patient's ability or desire to adhere constantly changes with the patient's circumstances and the level of asthma severity. Steroid phobia One of the most common fears of asthma treatment is side effects associated with regular use of inhaled steroids. Many patients (and, surprisingly, even many physicians) withhold the use of inhaled steroids for fear of significant side effects. Inhalation therapy is often viewed by patients and their relatives as something that should be used only when the disease is severely advanced. They believe that inhalers deliver strong medication. Incorrect use of inhalers More than 70 percent of asthma patients do not use their inhalers correctly and the resultant poor control is blamed on the medicine. Patients have been known to forget correct technique even after using the inhaler for several years. Ignorance about inflammation Very few asthmatics believe asthma to be an inflammatory disease of the airways. In India, inhaled corticosteroids are regularly used by less than 2 percent of asthma patients. Over-estimating control Patients often over-estimate the level of their asthma control and discontinue medication off and on. Many do not carry their relief medication with them. Some use only reliever medications, while some expect inhaled corticosteroids to provide rapid relief. Stigma Some patients feel handicapped and embarrassed by their asthma, and do not want to take their medication in front of other people. Submission Many people who live with severe asthma symptoms for a long time forget what good health feels like and simply accept a health status that is far less than optimal.

2: Doctor-related factors
Wrongly estimating degree of control Physicians often fail to estimate the degree of asthma control and severity correctly, because they fail to document the basic set of longitudinal clinical information. Using a questionnaire like ACT will help remedy this. Missing the triggers Poor control is frequently due to persistent exposure to triggers such as indoor air pollutants or allergens (mosquito coil, agarbattis, biomass fuel smoke, passive or active smoking, perfumes, scents, fungus growth on damp walls, cockroaches, house dust, house dust mites and pets like cats and dogs), or outdoor triggers (vehicular air pollutants especially diesel exhaust, chemical fumes, smoke from fire crackers during celebrations and residing close to locations with high levels of outdoor allergens). Wrong diagnosis Conditions that might be confused with asthma include vocal cord dysfunction, cardiovascular disorders, COPD, pulmonary tuberculosis and hyperventilation syndrome. Failing to treat co-morbidities Several co-morbidities can have a significant impact on asthma control. These include rhinosinusitis and gastroesophageal reflux. Ignoring stress Psychological stress can lead to poor asthma control. Stress may be due to disturbed relationships at home, deaths or serious illnesses in the family, divorces and work pressures. It is important to draw the patient out and provide counselling, if necessary. Offending drugs Some drugs can also contribute to poor asthma control. These include non-cardioselective beta blockers, angiotensin converting enzyme (ACE) inhibitors and aspirin or other non-steroidal anti-inflammatory drugs.

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...Asthma not under control

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to decide appropriate pharmacotherapy. These evidencebased guidelines formed the backbone of over 100 national asthma management guidelines in use across the world. In spite of the guidelines, the disparity between theory and practice seems to have led to a wide gap between good intentions and real asthma control. This was the conclusion of three large multinational, community-based studies, which preceded the CRF study. These were Asthma in America study (AIA), Asthma Insights and Realities in Europe (AIRE) study (conducted in seven European countries) and the Asthma Insights and Reality in Asia-Pacific (AIRAP) study (eight countries).

The control route to therapy

In 2004, the GINA executive committee recommended that the strategy be revised to emphasise asthma management based on clinical control, rather than by severity. They suggested that the old approach be used only for research and not in the clinic. Of course, asthma severity evaluation is still required at only during initial assessment. Assessment of control is now considered central to effective management of asthma. Clinical manifestations of asthma vary from time to time. Therefore, control needs to be assessed at every visit and treatment adjusted accordingly. The step care of asthma management should be based on asthma control. Asthma is now classified by the level of control: controlled, partly controlled or uncontrolled.

ACT, a powerful tool

The Asthma Control Test (ACT) has been developed by Quality Metric Health Outcome Solutions and has recently been recognised as a validated instrument for the

a s s e s s m e n t a n d monitoring of asthma by the National Heart, Lung, and Blood Institute (NHLBI) in its Guidelines for the Diagnosis and Management of Asthma. ACT is a simple 5-item questionnaire that has been shown to be useful not only to see whether the patients' asthma is controlled but also to assess how well it is controlled. Out of original 22 questions, 5 questions which have the greatest importance for a specialist while assessing a patient were finalised for the questionnaire. Later, this questionnaire was validated by comparing with the specialist's rating of asthma control, the patient's lung function, and the influence of the specialist's decision to change therapy. ACT has been shown to be reliable, valid and responsive to changes in asthma control over time. This questionnaire has been designed for self administration and can be completed while the patient is waiting to be seen by the clinician. The five items of the ACT cover the 4 weeks before the visit, and include an assessment of the number of work days lost or school days missed, dyspnoea frequency, rescue medication requirement, nocturnal awakenings, and selfassessment of asthma control. All these parameters are known sources of patient dissatisfaction with asthma care. The ACT questionnaire can also be used to evaluate the degree of asthma control. Each answer corresponds to a numeric score, which

are totalled to arrive at the ACT score. A score of more than 20 indicates that asthma is well controlled; 16 to 19 indicates that it is not well controlled; and 15 or less indicates that asthma is poorly controlled. On the basis of these categorisations, recommendations to step up or step down asthma treatment can be made. Not only does the ACT help in assessing the presence of asthma control, but also helps physicians foster a partnership with patients and engage them in their own asthma management.

Building that bridge

It takes two to make asthma control happen. Both doctors and patients (including parents, if the patient is a child), need to work together to build a bridge across the asthma control chasm, dividing the 95 percent potential and the 38 percent reality. For long, the wellmeaning doctor has been holding the

reins and the patient, despite being the victim, has been passively complying with instructions or at least trying to do so. This must change. Asthma control assessment involves many factors, all of them pertaining to the quality of life of the person who has asthma. The person may be dependent on the doctor for treatment and other guidelines but is solely responsible for implementing the treatment plan and for judging its effectiveness. He or she needs to be armed with enough knowledge and be constantly motivated to stick to the treatment plan. We are on the right road to better asthma control when the patient takes charge of his asthma. The role of the doctor moves up from merely prescribing medicines to empowering and facilitating guided self-management. The physician's most powerful tool in this may be the humble questionnaire.

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This study won Dr Sneha Limaye Best Poster Award at NAPCON 2008 Lucknow

CRF study finds significant drop in lung function in just 6 months

Objective tests conducted by spirometry indicated major deterioration in lung function, corroborating the reported worsening of symptoms. T h e n o n - s m o k e r s demonstrated a worsening i n r u n n y n o s e , Drop in lung function in smokers accompanied by a significant decrease in after 6 months peak expiratory flow (PEF) 0 parameters, indicating Foreign students who smoke show a large airway obstruction. marked deterioration in lung function and As much as 85 percent of the students found air -10 a worsening of respiratory symptoms pollution in Pune to be (FVC) within 6 months of stay in India. worse than in their motherland. Most of the in the number of vehicles on the Within the study duration of six (FEV1) students were from Iran, -20 road have resulted in rapidly rising months, there was a jump of more but there were also pollution levels. than 30 percent in cough (with and students from Korea, without sputum) among smokers, What effect does this pollution Thailand, Yemen, Djibouti, have on the respiratory health of while the average increase was (FEF25% - 75%) -30 Ethiopia, Nepal, foreign students? According to a about 10 percent among nonAfghanistan, Indonesia, CRF study, pollution is bad Mauritius, Bhutan, for their lungs, but the Canada, China, Eritrea, adverse impact is more Prevalence of respiratory symptoms among foreign students 50 Iraq, Japan, Kenya, significant in the case of M y a n m a r, R w a n d a , students who smoke. 43 Tajikistan, Tanzania and Ladan Zarrabi and the USA. Narsis Kroupi from Iran, 40 The significant two students of Pune 34 deterioration in lung University, decided to take 31 31 function among the Baseline up this study because they 30 had fallen victims to After 6 months smokers could be due to several factors: increase in respiratory problems when 23 smoking, inferior quality of 22 22 they came to Pune to study. cigarettes, unfiltered 19 They conducted the study 20 cigarettes and poor under the guidance of Dr 16 15 ambient air quality. While Sundeep Salvi and Dr 13 12 the study has served a Sneha Limaye of CRF. warning, there is a definite 10 8 The researchers 6 need for more long-term recruited 100 foreign 4 3 studies to arrive at more students from different conclusive findings. colleges in Pune, who had 0 come to India not more Runny Blocked Irritation Cough Sputum Breath- Wheeze Chest than three months before production lessness nose nose in eyes pain the study commenced on According to Maharashtra state's directorate of higher education, there are about 1.75 lakh foreign students studying in 80-odd colleges in Pune. Unfortunately, the Oxford of the East also has the dubious distinction of being the 13th most polluted city in India. Rapid urbanisation and a quantum jump August 1, 2007. In the first phase, they used a detailed questionnaire and spirometry tests to gather respiratory health data of the subjects. In the second phase, after six months, the same tools were used to measure the changes. The study revealed a marked deterioration in the lung health of foreign students in Pune who were smokers. smokers. The other symptoms recorded included runny or blocked nose, irritation in eyes, breathlessness, wheezing and chest pain.

Smoking worsens pollution effect in foreign students

- 7.85% - 10.68%

- 21.05%

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This study Won Dr Bill Brashier Silver Travel Sponsorship at ERS 2008 Berlin

CRF compares 1-dose tiotropium-formoterol with 4-dose ipratopium-salbutamol

A recent CRF study has established that a single dose of the combination of long-acting anti-cholinergic tiotropium with long-acting beta-2 agonist formoterol results in the same bronchodilation but yields superior trough values as four doses of the combination of the shortacting bronchodilators, ipratropium bromide and salbutamol. The randomised, double-blind, placebocontrolled, cross-over study involved 18 moderate-to-severe COPD subjects.The participants were given a single dose of 18mcg tiotropium with 12mcg formoterol, or four doses (over 24 hours) of 40mcg ipratopium bromide with 200mcg salbutamol,

Tiotropium combination offers superior trough values, similar bronchodilation

A spirometry session during the trial

administered via a Rotahaler. FEV1 and FVC were measured at baseline and 5, 15 and 30 minutes, 1, 2, 3, 4, 6, 8, 10, 12 and 24 hours drug administration, using a spirometer. Both values indicated better and longer-lasting response with the tiotropiumformoterol combination. This finding is significant as a more convenient dosage improves patient compliance and adherence. A once-a-day regimen can definitely help improve the management of COPD, compared to four-times-a-day dose of the short-acting bronchodilators that has been the norm for long.

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Change (%) from baseline

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ISAAC reports similar findings in 31 countries

CRF study of 15,000 children links paracetamol in first year with asthma later
association. The link has been consistently observed across the world and across communities. The study showed a dose-response effect: the more the amount of paracetamol consumed, the greater was the odds of its association with asthma. There is also plausible biological explanation for paracetamol causing asthma, as Dr Salvi said: Inflammation in asthma causes oxidative stress. One of the defence mechanisms of the body is the presence of the antioxidant, glutathione, in the airway lining fluid. Paracetamol causes depletion of glutathione. This adds to the oxidative stress which aggravates the inflammation, thus setting off a vicious cycle. Interestingly, as reported in the European Respiratory Journal (Eur Respir J 2008; 32: 1231-1236), in another study conducted by the Global Allergy and Asthma European Network (GA2LEN), weekly use of paracetamol, compared with less frequent use, was strongly and positively associated with asthma after controlling for confounders. In the light of the latest findings, the need is to take the investigation further and arrive at some definite conclusions. Until then researchers have advised discretion, by not giving paracetamol to children for every little

Some of the children who participated in the study

R e s e a r c h e r s f r o m C R F, participating in the International Study of Asthma and Allergies in Childhood (ISAAC) study, have found that the use of paracetamol for fever in the first year of life was associated with at least 46 percent increased risk of asthma by the age of 7 years. The CRF team studied over 15,000 children from Pimpri, Chinchwad and Nagpur. According to a report published in The Lancet [Beasley R et. al. Lancet 2008; 372(9643): 10391048], more than 2 lakh children aged 6 to 7 years from 73 centres in 31 countries were included in the analysis. Use of paracetamol for fever in the first year of life was associated with an increased risk of asthma symptoms when aged 6 to 7 years. Current use of paracetamol was associated with a dose-dependent increased risk of asthma symptoms. Use of paracetamol was similarly associated with the risk of severe asthma symptoms, with population-

attributable risks between 22 percent and 38 percent. Paracetamol use, both in the first year of life and in children aged 6 to 7 years, was also associated with an increased risk of symptoms of rhinoconjunctivitis and eczema. However, the findings do not constitute a reason to stop the use of paracetamol in childhood. The current WHO guidelines recommend that paracetamol be not used routinely but be reserved for children with high fever. It became the preferred drug for treatment of fever because of Reye's syndrome, a rare but serious complication of aspirin therapy in children.

Evolving link between paracetamol and asthma

l A population-based

case control study from the UK in 664 adult asthmatics indicated a dose-dependent association between paracetamol use and asthma, with odds of asthma as high as 2.38 in subjects who used paracetamol daily as compared to non-paracetamol users. (Shaheen SO et al. Thorax 2000; 55: 266-70). conducted in 9400 children showed that frequent paracetamol use in late pregnancy (20-32 weeks), was associated with an increased risk of wheezing in the offspring at 30-42 months. (Shaheen SO et al. Thorax 2002; 57: 958-63). This is the study that began it all. study of paracetamol use and newly diagnosed asthma among 121,700 women it was found that paracetamol use was associated with an increased rate of newly diagnosed, adult-onset asthma. (Barr RG et al. Am J Respir Crit Care Med 2004; 169: 836-41). association of paracetamol usage and asthma was reported in 13,492 subjects in a cross-sectional analysis of the United States Third National Health and Nutrition Examination Survey (NHANES III) (McKeever TM et al. Am J Respir Crit Care Med 2005: 171; 966-71). study organised by the Global Allergy and Asthma European Network (GA2LEN), across 12 European centres, compared 521 cases of asthma and reporting of asthma symptoms within the preceding 12 months with 507 controls with no diagnosis of asthma and no asthmatic symptoms within the preceding 12 months. It showed that weekly use of paracetamol, compared with less frequent use, was strongly positively associated with asthma. (Shaheen S. Eur Respir J. 2008 Nov; 32(5):1231-6).

l A study

l In a prospective

l A dose-dependent

Causal connection?
Dr Sundeep Salvi who led the research for the CRF team observes that though there is a need for more research to establish a causal relationship between paracetamol and asthma, three factors suggest the possibility of a cause-effect

l A multi-centric

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World's worst killer disease no longer limited to smokers

CRF joins hands with Imperial College to investigate non-smoking COPD in unique Indo-British study
When a recent CRF study in Pune threw up the finding that more than 50 percent of COPD patients studied did NOT smoke, it was only yet another confirmation of an increasing trend in the developing world. More and more people are falling victim to COPD, not because of smoking but presumably on account of indoor air pollution. Given that, as against 1 billion smokers, about 3 billion people (mainly women and children) are exposed to high levels of indoor air pollution in these countries, there is an urgent need to take a closer look at non-smoking phenotype COPD and reassess our medical armoury. That need is being answered by The Study of Prevalence of COPD and Phenotypic Characterisation of Smoking and Non-Smoking COPD in A Rural Setting in India, better known as the IMVAC study. This unique Indo-British collaborative study by researchers from London and Pune is the first of such scale in the world to focus on the non-smoking causes of COPD. In addition to CRF, Vadu Rural Health Program (VRHP) and National Heart and Lung Institute (NHLI), a division of Imperial College, London are the two organisations participating in the study. The co-ordinating investigators are Professor Peter Barnes, Head of Respiratory Medicine, NHLI, Imperial College; Dr Sundeep Salvi, Director, CRF; and, Dr Sanjay Juvekar, Public Health Scientist, VRHP. IMVAC was inaugurated by Mrs Vandana Chavan, Ex-Mayor of Pune and leading environmentalist at Chest Research Foundation (CRF) on January 30, 2008.

COPD, the kitchen variety?

As much as 75 percent of Indian homes use biomass fuels (like wood, coal and gobar) for cooking. The same is true of half the population of the world. The fumes from these fuels are toxic to the lungs. In fact, the level of pollutants can be 3 to 10 times higher than the outdoor air in India's worst polluted cities. IMVAC will seek answers to some fundamental questions in the minds of doctors and researchers all over the world. Is kitchen COPD different from the more conventional smoking COPD? Does the prognosis differ? Are there different mediators at play? Do they require radically different therapies? The main tools being used in the first phase of the study are questionnaires designed and validated by Burden of Obstructive Lung Disease (BOLD), spirometry, Global Positioning System (GPS) and indoor and outdoor air pollution monitoring. IMVAC is slated to be one of the biggest BOLD studies in the world, with a sample size of 3500.

Mrs Vandana Chavan hands over a copy of the Memorandum of Understanding pertaining to IMVAC to Dr Sundeep Salvi to mark the inauguration of the study at CRF on January 30, 2008. From left to right: Dr Sanjay Juvekar, Prof Anthony Newman Taylor, Sir Malcolm Green, Mrs Vandana Chavan, Prof Peter Barnes, Dr Sundeep Salvi.

In the ongoing first phase, IMVAC will study prevalence of COPD using the BOLD questionnaire and pre- and post-bronchodilator spirometry. It will also measure ambient air pollutants in the region and indoor air pollutants in homes using different cooking fuels. IMVAC will undertake detailed characterisation of particulate matter for organic and inorganic ions and metals from these homes. GPS will be used to determine spatial distribution of the prevalence of COPD and its association with air pollutants. During the second phase IMVAC will isolate a stratified sample of

different COPD phenotype subjects (cigarette smoke exposure, bidi smoke exposure and chullah smoke exposure) diagnosed on the basis of BOLD methodology and age-matched controls. There will be spirometry, body plethysmography, impulse oscillometry and lung diffusion studies, in addition to high resolution CT scan and chest X-ray. Cellular and mediator profile will be studied using induced sputum and peripheral venous blood. DNA samples will be extracted and preserved for future COPD genetic studies. The second phase of IMVAC will also study the effects of steroids on key inflammatory parameters.

Vadu the venue

IMVAC covers 22 villages around Vadu, about 30 km from Pune, spread over 225 sq.km. with a total population of more than 80,000. Till January 31, 2009 questionnaires have been administered to 1739 subjects while 1475 people have participated in spirometry tests. A team of 10 field workers have been specially trained to conduct the study.

An IMVAC field training session in progress in a village near Vadu

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First in India to use EU-scale values

CRF-Symbiosis study derives peak flow meter predicted values for children
Medical technology students learn pulmonary function tests at CRF
Pulmonary function tests (PFTs) hardly find any place in medical curriculum. Not surprisingly, even many seasoned physicians find it difficult to understand and interpret spirometry, methacholine challenge, IOS and DLCO. In association with Symbiosis Institute of Health Sciences (SIHS), CRF has now started training B.Sc. students of medical technology as technicians in various PFTs. The first batch of SIHS students was trained from December 8 to 13, 2008. The students were assessed through a written examination and a practical test. The faculty observed how the students communicated with the patients and demonstrated the tests. At the end of the programme, the students joined the regular Spirometry Simplified workshop held for physicians on December 13 and took keen interest in the case studies. With rising incidence and prevalence of obstructive airways diseases, there is an increasing demand for technicians to man PFT laboratories. CRF and Symbiosis hope that this module will not only provide more employment opportunities but will also contribute to better use of modern diagnostic techniques.

Taking a peak flow meter reading

For long, scientists and doctors in India have bemoaned the lack of data on the prevalence of respiratory diseases among Indian school children. Very few studies have examined the impact of socio-economic, environmental and lifestyle factors on respiratory diseases among school children. The available predicted values were either from studies outside India or used the old peak flow meter, which has now been replaced by the new EU-scale device. Now, as part of an ongoing study in association with the Symbiosis Institute of Health Sciences (SIHS), CRF has developed normal predicted equations for boys and girls between the age of 4 and 15 years, using the revised EU-scale peak flow meter. The study has developed one equation for girls and another for boys. It enables easy calculation of the normal value once the height of the child is known.

The study covers students of two schools run by Symbiosis, comprising children from various economic strata. The researchers filtered out children who had no history of respiratory problems and studied them to arrive at the values. The study uses demography and a respiratory health questionnaire, to be filled in by parents, as the tools. Apart from parameters like height, weight and body mass index, the CRF team measures peak inspiratory and peak expiratory flow rates. The study is conducted as part of the school's annual medical checkup. The study commenced in June 2008. Over the next 5 years, the study will closely monitor the progress of more than 3,000 students, assessing the growth of their lungs and airways, evaluating the prevalence of respiratory symptoms including asthma and studying the pattern of food allergies, if any.

HOW TO CALCULATE PREDICTED VALUE

Using new EU-scale peak flow meter for children between the age of 4 and 15 years

BOYS
PEFR (lit/min) = (Height in cm X 3.491) 233.42
(Measure height in centimetres. Multiply this value by 3.491. Then subtract 233.420 from the result.)
Example: If height of the boy is 125 cm, (125 X 3.491) 233.420 = 202.955. Rounding this off, the predicted value is 203.

GIRLS
PEFR (lit/min) = (Height in cm X 3.272) 214.491
(Measure height in centimetres. Multiply this value by 3.272. Then subtract 214.491 from the result.)
Example: If height of the girl is 93 cm, (93 X 3.272) 214.491 = 89.805. Rounding this off, the predicted value is 90.

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ROAD goes to Lanka; spirometry via Web

Demand takes CRF training programmes outside Pune

Spirometry demonstration during ROAD, Mumbai

From its inception in 2002, CRF has trained more than 800 doctors in spirometry and management of obstructive airways diseases (OADs). The Refresher Course in Obstructive Airways Diseases (ROAD) and the Spirometry Simplified workshop have been highly appreciated by general practitioners, post-graduate students, physicians and chest physicians. Many have credited ROAD with bringing about a positive change in their understanding and practice of respiratory medicine. Faced with practical difficulties in coming to Pune to attend the programmes, doctors across India and outside the country have been demanding that the sessions be held at other locations, too. And CRF has responded.
Participants in the first ROAD in Sri Lanka

ROAD in Lanka
The first ROAD outside India was conducted in Sri Lanka at Jetwing Beach, Negombo, on September 27 and 28, 2008. The programme witnessed active participation from eminent chest physicians of Sri Lanka. Dr A T Munasinghe, Dr Vijitha Senaratne and Dr Amitha Fernando were present throughout the programme. Dr Fernando gave an overview of the epidemiological aspects of OADs in Sri Lanka and the challenges in managing the diseases. Dr Munasinghe and Dr Senaratne shared their experiences and challenges in day-to-day practice. In all, 51 doctors from Sri Lanka attended the programme, with the spirometry session witnessing maximum participation.

Doctors said that earlier they were not aware of the need for pulmonary rehabilitation of COPD patients. They also appreciated the need to communicate effectively with the patients to ensure good compliance.

ROAD in Mumbai
Before Lanka, the first ever ROAD outside Pune was held in Mumbai at the S P Jain Auditorium of Bombay Hospital on September 13 and 14, 2008. The faculty comprised some of Mumbai's most eminent chest physicians including Dr Zarir Udwadia, Dr Sujeet Rajan, Dr Sandeep Tandon, Dr Prahlad Prabhudesai, Dr P S Tampi and Dr Alpa Dalal and renowned paediatrician Dr Y K Amdekar. The 49 doctors who attended the programme included chest physicians, p h y s i c i a n s , paediatricians, general practitioners, and post-graduate students of general medicine as well as chest medicine. Dr Uttam Kumar Paul had come all the way from Raiganj, West

Bengal. Three were so impressed by the programme that they were attending for the second time. They lauded the calibre of the programme and the excellent way in which it simplified a lot of complicated issues like pathogenesis and spirometry. The sessions were quite interactive and many doctors shared their experiences in clinical practice. This offered valuable insights. CRF is now planning to conduct ROAD in more cities.

Spirometry by Web
Many doctors outside Pune and Maharashtra find it difficult to take almost three days off their schedule to attend the half-day Spirometry Simplified workshop. In order to make this popular workshop accessible to doctors at distant locations, CRF is now offering it through Web-conferencing. Already, 45 doctors in Lucknow, Gorakhpur, Kanpur, Bangalore and Mysore have benefited from the workshop via the Web. Connecting to three centres at a time, CRF can train up to 30 doctors in one afternoon without their having to travel.

What They Said

Want a CRF programme in your city?

This (ROAD) workshop has helped me improve my clinical practice as I can now manage my patients according to latest guidelines on diagnosis and management of asthma and COPD. Dr Anand Kale, Shirole, Kolhapur, Maharashtra This is a remarkable CME. It is well organised and to the point. The follow-up has been prompt. The resource personnel, the material provided and the conference facilities have all been good. I think we should take up more case studies. There should be a Web conference at least once every six months. We also need more sessions on interpretation. Dr B Mohan, Holdsworth Memorial Hospital, Mysore

I have been practising for more than 20 years but I must appreciate that the programme had something new and interesting to offer, even for me. Dr A T Munasinghe, President, Respiratory Disease Study Group, Sri Lanka

This Web conference has made me realize the importance and significance of spirometry in diagnosing, grading severity and management of obstructive airway diseases (including assessing response to treatment). Dr Mahesh T, Bangalore

I am now more confident in approaching, diagnosing and managing OAD patients. Patients are doing better now than before I attended the ROAD programme. Finally, I have now understood that OADs cannot be ruled out completely without performing spirometry. Dr N R Singh, Lafarge India Limited, Meghalaya

I could learn a lot in a short period of time and have gained a deeper insight into spirometry procedure than what would have been possible by reading any books. I appreciate that a lot of time was devoted for interaction with the audience. Dr Mahesh M, J. S. S Hospital, Mysore, participant in Spirometry Web conference

CRF has the team, the tools and the expertise to conduct specialised training programmes related to obstructive airways diseases and their management. Do you want CRF to conduct a programme in your city? Please write to Dr Monica Barne at drmonica@crfindia.com.

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Maria Cheraghi

Meet CRF's first Ph.D. student

Maria Cheraghi, who has been the first student of the University of Pune to do research at CRF, is grateful to three sets of people for what she has achieved so far: My parents for giving me good education, my husband for giving me excellent support and Dr Salvi of CRF for being a wonderful guide. Hailing from Ahwaz, Iran, Maria worked as a special nurse in ICU and CCU for more than 10 years after her B.Sc. in nursing. She had reached the level of a matron, when she decided to further her education. In May 2003, she enrolled for her M.Sc. with University of Pune. After attaining her M.Sc. degree from University of Pune, she decided to do Ph.D. in epidemiology in public health. Dr. Anita Kar, who has been giving her unlimited support in her career, then directed her to Dr. Sundeep Salvi and his research institute, CRF. Says Dr Salvi, Ideally, the topic one chooses for research should be novel, feasible and have practical application. Her selection fitted the bill perfectly. Her findings would be relevant to India, Iran and the whole world because a part of her project is related to International Study of Asthma and Allergic in children (ISAAC). Moreover, she could go on to play an important role in setting up a research institute and thus making a significant contribution to respiratory research. So far, during her research, she has had opportunity to attended couple of important courses in statistics, advanced epidemiology and genetic epidemiology in India as well as in Germany. Her research paper on the Influence of risk factors on childhood asthma is expected to be ready by May 2009. Meanwhile she has done pilot study on 730 subjects and has obtained interesting results. Two abstracts have been accepted in national and international conferences. She considers herself fortunate to have gained the opportunity to do her research at CRF. I have access to wonderful journals. I get to participate in some of the workshops conducted here. Above all, CRF has a wonderful team and everyone is always willing to help. Dr Bill Brashier and Dr Salvi have been very patient in solving the problems which I encounter in my research. I have also got opportunity to participate in the Journal Club of CRF, which has helped me develop my knowledge in different areas of research. I got to know how to work as part of a team, while conducting studies at CRF. I have also got the opportunity to write a review article, which has been sent to an international journal and is now published. Thanks to CRF I have been able to meet leading Indian and international scientists, and discuss my work with them. Dr Salvi notes, Maria is very tenacious. She is very clear about her goal and will not take no for an answer till she achieves it. Her zeal is admirable. It is definitely not easy for someone who is a foreigner to interact with 4000 subjects in different parts of Pune city with diverse culture and socio-economic backgrounds. She is definitely a model for other students for focus and sheer hard work. Maria's husband, Ali Reza, is doing his doctorate in financial management. Her son, Amir, studying in grade 3, knows Persian, Hindi, Marathi, English and French. What is Maria's plan for the future? I would like to build on what I have gained here by pursuing a postdoctorate programme in Europe or Australia. This will help to acquire a multidimensional understanding of public health in the developing as well as the developed world. I would like to be an effective researcher in the field of public health and contribute to the worldwide mission of ensuring health for all.

Childhood asthma risk factors

This is one of the three abstracts that Maria will be presenting at ERS 2009. Title: Risk factors for childhood asthma in Pune city, India. Ms. Maria Cheraghi, Dr. Bill Brashier, Ms. Sapna Madas and Dr. Sundeep Salvi, Chest Research Foundation, Pune, and School of Health Sciences, University of Pune, Pune. Body: We aimed to study the risk factors associated with childhood asthma in Pune city, India, since these have not been well studied. 6198 boys and girls between the ages of 6-7, and 13-14, from 17 randomly selected schools were invited to participate in this study. Parents of 3909 children consented. They then filled the ISAAC questionnaire (to determine asthma prevalence) and an additional set of questions that captured the presence of potential risk factors. Associations between asthma prevalence and risk factors were analyzed using the Chi square test, and expressed as adjusted OR. Results: Risk factors associated with childhood asthma included: family history of asthma [OR:7.24 (5.17-10.12)], caesarean delivery [OR:4.01 (2.84-5.67)], use of biomass fuel for cooking [OR:3.19 (1.24-8.21)], no separate kitchen [OR: 2.37 (1.44-3.90)], mixed feeds versus breast milk alone during first 6 months [OR:2.03 (1.43-2.88)], snoring [OR:1.88 (1.26-2.81)], preterm birth [OR:1.73 (1.12-2.64)], damp walls at home [OR:1.69 (1.16-2.45)], male sex [OR:1.49 (1.04-2.13)], and parental smoking [OR:1.45 (1.0-2.11)]. Conclusion: Apart from known risk factors noted in western countries, preterm birth, snoring, damp walls at home, no separate kitchen at home and use of biomass fuel for cooking were new risk factors associated with childhood asthma in Pune city, India.

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