Time to acknowledge, address, and take action against bronchiectasis
Authors: Sanjay H Chotirmall, Pamela J McShane
Journal: The Lancet Global Health (2019)

The global population has exceeded 8 billion, of which more than three-quarters of people live in Africa (17%) and Asia (60%).1UNPopulation Division World Population Prospects: the 2017 revision, key findings and advance tables. United Nations, New York2017Google Scholar China and India remain the two most populous countries, and by 2024 each country is expected to be home to more than 1·4 billion people.1UNPopulation Division World Population Prospects: the 2017 revision, key findings and advance tables. United Nations, New York2017Google Scholar The population aged 60 years or more is growing rapidly, fertility rates are decreasing, and life expectancy is increasing:1UNPopulation Division World Population Prospects: the 2017 revision, key findings and advance tables. United Nations, New York2017Google Scholar chronic disease is therefore ascendant with cardiorespiratory, metabolic, and cancer-related consequences. Within these individual diseases, some are better recognised than others, and regretfully bronchiectasis is not one of these diseases. Bronchiectasis—a chronic progressive and under-recognised airway disease—is fast becoming a global issue with substantial consequences for patients, communities, and health-care systems.2Chotirmall SH Chalmers JD Bronchiectasis: an emerging global epidemic.BMC Pulm Med. 2018; 18: 76Crossref PubMed Scopus (13) Google Scholar, 3Chalmers JD Chang AB Chotirmall SH Dhar R McShane PJ Bronchiectasis.Nat Rev Dis Primers. 2018; 4: 45Crossref PubMed Scopus (50) Google Scholar In some countries, the recognition of bronchiectasis as a chronic disease has been challenging despite the progressive, terminal, and irreversible symptoms with no licensed available treatment.4Chalmers JD Chotirmall SH Bronchiectasis: new therapies and new perspectives.Lancet Respir Med. 2018; 6: 715-726Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar In light of the magnitude of bronchiectasis as an urgent global health concern, international collaboration has begun, national registries formed, and pharmaceutical companies have taken an interest in developing therapies.3Chalmers JD Chang AB Chotirmall SH Dhar R McShane PJ Bronchiectasis.Nat Rev Dis Primers. 2018; 4: 45Crossref PubMed Scopus (50) Google Scholar Regrettably, despite initial investment of effort and funding, international multi-centre trials of prospective therapeutics have largely been unsuccessful, threatening to obstruct progress.4Chalmers JD Chotirmall SH Bronchiectasis: new therapies and new perspectives.Lancet Respir Med. 2018; 6: 715-726Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 5Chotirmall SH Chalmers JD RESPIRE: breathing new life into bronchiectasis.Eur Respir J. 2018; 511702444Crossref PubMed Scopus (37) Google Scholar Arguably, the most plausible explanation for these failures lies in the heterogeneity of the patient population with bronchiectasis, but the vast scope of this problem is only beginning to be realised.4Chalmers JD Chotirmall SH Bronchiectasis: new therapies and new perspectives.Lancet Respir Med. 2018; 6: 715-726Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 5Chotirmall SH Chalmers JD RESPIRE: breathing new life into bronchiectasis.Eur Respir J. 2018; 511702444Crossref PubMed Scopus (37) Google Scholar Published in The Lancet Global Health, Raja Dhar and colleagues' study6Dhar R Singh S Talwar D et al.Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India Registry.Lancet Glob Health. 2019; 7: e1269-e1279Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar of the European Multicentre Bronchiectasis Audit and Research Collaboration and Respiratory Research Network of India Registry provides some new and crucial information about the heterogeneity of bronchiectasis at an even deeper level than first thought. This first look at a large Asian bronchiectasis dataset illustrates the extent of geographic variation inherent in this disease, which surpasses inter-patient variability. The Indian registry is made up of a relatively young population of which 56·9% were men with a median age of 56 years, a substantive difference compared with mean ages of 65 years across continental Europe and Australia and a female gender predominance in the USA, UK, and Spain.3Chalmers JD Chang AB Chotirmall SH Dhar R McShane PJ Bronchiectasis.Nat Rev Dis Primers. 2018; 4: 45Crossref PubMed Scopus (50) Google Scholar More than one-third of bronchiectasis in India occurred after tuberculosis, a preventable cause. By contrast, and as evidence that calls to action to reduce disease are successful, only 4% of bronchiectasis patients in the US Bronchiectasis Registry have a history of tuberculosis.7Aksamit TR O'Donnell AE Barker A et al.Adult patients with bronchiectasis: a first look at the US bronchiectasis research registry.Chest. 2017; 151: 982-992Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar In Indian centres where immunoglobulins were tested, 26% of patients had a treatable cause, but this proportion decreased to 10·5% across the entire database. This gap might be due to poorly resourced health-care systems but also access issues including that of geographic limitation, service availability, or health systems capability. Poor adherence to guideline-based bronchiectasis management was evident, with only about 3% of the Indian population with bronchiectasis tested according to guidelines and less than half receiving airway clearance therapy, the mainstay of bronchiectasis management. Conversely, 63·2% of patients were treated with an inhaled corticosteroid, a therapy not recommended. As the full effect of the heterogeneity presented by the Indian registry is recognised, health-care professionals and stakeholders must remain conscious of the fact that data from Africa, South America, and much of Asia is not currently available hence the global prevalence of bronchiectasis is underestimated. The magnitude of this problem and its attendant heterogeneity is matched in equal measure by the opportunities it presents for improvement. An urgent call to action is justified. For India, this call to action begins first with the recognition that young, mainly non-smoking men of employment age have severe disease of increasing prevalence characterised by frequent exacerbations that require admission to a hospital as presented by Dhar and colleagues.6Dhar R Singh S Talwar D et al.Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India Registry.Lancet Glob Health. 2019; 7: e1269-e1279Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar Undoubtedly, this outcome affects the Indian economy by reducing the workforce in addition to other downstream mechanisms. Second, the poor adherence to guideline-based therapy suggests that physicians in India and elsewhere need support to adequately care for their patients. Finally, the call to action prompted by this work has a global effect; more attention and support toward bronchiectasis research is necessary to better understand the pathophysiology of the disease and develop effective therapy. The time has come to acknowledge, address, and take action against bronchiectasis internationally: acknowledge that epidemiological data, its economic burden, and disease mechanisms and endo-phenotypes are poorly understood;4Chalmers JD Chotirmall SH Bronchiectasis: new therapies and new perspectives.Lancet Respir Med. 2018; 6: 715-726Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 8Mac Aogain M Tiew PY Lim AYH et al.Distinct "immunoallertypes" of disease and high frequencies of sensitization in non-cystic fibrosis bronchiectasis.Am J Respir Crit Care Med. 2019; 199: 842-853Crossref PubMed Scopus (29) Google Scholar address these gaps with investment focused on improved diagnosis, and access to clinical care, specialists, and resources; and take action on the lessons learnt in the geographic variation and disease heterogeneity. These three domains require focused research portfolios that account for emerging concepts and technologies such as multi-omics, precision medicine, artificial intelligence, and digital health care.9Chotirmall SH Future directions: the next 10 years in research. European Respiratory Society, Sheffield2018Google Scholar, 10Chandrasekaran R Mac Aogain M Chalmers JD Elborn SJ Chotirmall SH Geographic variation in the aetiology, epidemiology and microbiology of bronchiectasis.BMC Pulm Med. 2018; 18: 83Crossref PubMed Scopus (55) Google Scholar The time is now for the health-care community to do what is right for patients with bronchiectasis. We declare no competing interests. Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India RegistryPatients with bronchiectasis in India have more severe disease and have distinct characteristics from those reported in other countries. This study provides a benchmark to improve quality of care for patients with bronchiectasis in India. Full-Text PDF Open Access