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Marsha A Ivey,1,2 Sheree M Smith,3,4 Geza Benke,1 Brett G Toelle,5,6 Michael L Hunter,7 Alan L James,8 Graeme P Maguire,9 Richard Wood-Baker,10 David P Johns,11 Guy B Marks,5,12 Michael J Abramson1 1School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia; 2School of Medicine, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago; 3School of Nursing and Midwifery, Campbelltown Campus, Western Sydney University, Penrith, NSW, 2751, Australia; 4Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; 5Respiratory and Environmental Epidemiology Group, Woolcock Institute of Medical Research, Sydney, NSW, 2037, Australia; 6Sydney Local Health District, Sydney, NSW, 2050, Australia; 7School of Population and Global Health, University of Western Australia, Perth, WA, 6009, Australia; 8Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital and Medical School, University of Western Australia, Perth, WA, 6009, Australia; 9Curtin Medical School, Curtin University, Perth, WA, 6102, Australia; 10School of Medicine, University of Tasmania, Hobart, TAS, 7000, Australia; 11Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; 12School of Clinical Medicine, University of New South Wales, Sydney, NSW, 2052, AustraliaCorrespondence: Michael J Abramson, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia, Tel +61 3 9903 0573, Fax +61 3 9903 0556, Email michael.abramson@monash.eduPurpose: Tobacco smoking is the major risk factor for COPD, and it is common for other risk factors in never-smokers to be overlooked. We examined the prevalence of COPD among never-smokers in Australia and identified associated risk factors.Methods: We used data from the Australia Burden of Obstructive Lung Disease (BOLD) study, a cross-section of people aged ≥ 40 years from six sites. Participants completed interviews and post-bronchodilator spirometry. COPD was primarily defined as an FEV1/FVC ratio < 0.70 and secondarily as the ratio less than the lower limit of normal (LLN).Results: The prevalence of COPD in the 1656 never-smokers who completed the study was 10.5% (95% CI: 9.1– 12.1%) [ratio

Yijun Zhou,1 Maria R Ampon,2 Michael J Abramson,3 Alan L James,4 Graeme P Maguire,5 Richard Wood-Baker,6 David P Johns,6 Guy B Marks,1,7 Helen K Reddel,2,8,9 Brett G Toelle1,8,9 1The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; 2Australian Centre for Airways Disease Monitoring, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; 3School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia; 4Sir Charles Gairdner Hospital, Perth, WA, Australia; 5Curtin Medical School, Curtin University, Perth, WA, Australia; 6Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; 7South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; 8Faculty of Medicine, Health and Human Science, Macquarie University, Sydney, NSW, Australia; 9Sydney Local Health District, Sydney, NSW, AustraliaCorrespondence: Brett G Toelle, Woolcock Institute of Medical Research, 431 Glebe Point Road, Glebe, NSW, 2037, Australia, Email brett.toelle@woolcock.org.auPurpose: Population data on the burden of chronic obstructive pulmonary disease (COPD) are often based on patient-reported diagnoses of COPD, emphysema or chronic bronchitis, without spirometry. We aimed to investigate the relationship between health burden, quality of life and severity of airway obstruction in Australian adults aged ≥ 40 years.Methods: We used data from the BOLD Australia study, which included randomly selected adults aged ≥ 40 years from six study sites to reflect the sociodemographic and geographic diversity of the Australian population (n = 3522). Participants with post-bronchodilator airflow limitation (ratio of forced expiratory volume in 1 second FEV1 to forced vital capacity < 0.7) were grouped by GOLD spirometry grades 1– 4. Quality of life was assessed with Short Form 12 (SF-12) Health Survey Questionnaire. Health burden was assessed as lost time off work or social activities, and healthcare utilization.Results: Of the study sample, 2969 participants did not have airflow limitation, 294 (8.4%) were classified as GOLD Grade 1, 212 (6.0%) as GOLD 2 and 43 (1.2%) as GOLD 3– 4. Participants with higher GOLD grades had more respiratory symptoms, more comorbidities and greater burden than those with lower GOLD grades. The scores of mental and physical subscales of SF-12 were lower, indicating worse quality of life, from the no airflow limitation group to the GOLD 3– 4 group (P = 0.03 and P < 0.001, respectively).Conclusion: Greater airflow limitation is associated with greater burden and poor quality of life. Interventions to prevent, or reduce the level of, airflow limitation will reduce the symptom burden and improve quality of life for patients.Keywords: chronic obstructive pulmonary disease, airflow limitation, comorbidities, The Burden of Obstructive Lung Disease, quality of life

Kate Petrie,1 Brett G Toelle,2,3 Richard Wood-Baker,4 Graeme P Maguire,5 Alan L James,6,7 Michael Hunter,8,9 David P Johns,4 Guy B Marks,2,10 Johnson George,1,11 Michael J Abramson11 1Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; 2Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; 3Sydney Local Health District, Sydney, NSW, Australia; 4College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia; 5Western Clinical School, University of Melbourne, Melbourne, Australia and General Internal Medicine, Western Health, Melbourne, VIC, Australia; 6Sir Charles Gairdner Hospital, West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Perth, WA, Australia; 7University of Western Australia, Medical School, Perth, WA, Australia; 8School of Population and Global Health, University of Western Australia, Perth, WA, Australia; 9Busselton Population Medical Research Institute, Busselton, WA, Australia; 10South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; 11School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, AustraliaCorrespondence: Michael J AbramsonSchool of Public Health and Preventive Medicine, Monash University, Level 2, 553 St Kilda Road, Melbourne, VIC, 3004, AustraliaTel +61 3 9903 0573Fax +61 3 9903 0556Email michael.abramson@monash.eduPurpose: Spirometry is necessary to confirm COPD, but many patients are diagnosed based on clinical presentation and/or chest x-ray. There are also those who do not present to primary care for case finding and remain undiagnosed. We aimed to identify: (a) factors that are associated with undiagnosed COPD; and (b) factors that are associated with a potential misdiagnosis of COPD.Patients and Methods: This analysis used data from the Burden of Obstructive Lung Disease (BOLD), a cross-sectional study of community dwelling adults randomly selected from six study sites, chosen to provide a representative sample of the Australian population (n= 3357). Participants were grouped by COPD diagnostic criteria based on spirometry and self-reported diagnosis. Odds ratios for predictors of undiagnosed and misdiagnosed were estimated using logistic regression.Results: Of the BOLD Australia sample, 1.8% had confirmed COPD, of whom only half self-reported a diagnosis of COPD. A further 6.9% probably had COPD, but were undiagnosed. The priority target population for case finding of undiagnosed COPD was aged ≥ 60 years (particularly those ≥ 75 years), with wheezing, shortness of breath and a body mass index (BMI) < 25kg/m2. The priority target population for identifying and reviewing misdiagnosed COPD was aged < 60 years, female, with no wheezing and a BMI ≥ 25kg/m2.Conclusion: Challenges continue in accurately diagnosing COPD and greater efforts are needed to identify undiagnosed and misdiagnosed individuals to ensure an accurate diagnosis and the initiation of appropriate management in order to reduce the burden of COPD.Keywords: case finding, diagnosis, spirometry, epidemiology

David P Johns,1 Aruneema Das,1 Brett G Toelle,2,3 Michael J Abramson,4 Guy B Marks,2,5 Richard Wood-Baker,1 E Haydn Walters1,6 1Faculty of Health, NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Tasmania, 2Woolcock Emphysema Centre, Woolcock Institute of Medical Research, University of Sydney, 3Sydney Local Health District, Sydney, New South Wales, 4Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, 5South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, 6Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Background and objective: We have explored whether assessing the degree of concavity in the descending limb of the maximum expiratory flow–volume curve enhanced spirometric detection of early small airway disease. Methods: We used spirometry records from 890 individuals aged ≥40 years (mean 59 years), recruited for the Burden of Obstructive Lung Disease Australia study. Central and peripheral concavity indices were developed from forced expired flows at 50% and 75% of the forced vital capacity, respectively, using an ideal line joining peak flow to zero flow. Results: From the 268 subjects classified as normal never smokers, mean values for post-bronchodilator central concavity were 18.6% in males and 9.1% in females and those for peripheral concavity were 50.5% in males and 52.4% in females. There were moderately strong correlations between concavity and forced expired ratio (forced expiratory volume in 1 second/forced vital capacity) and mid-flow rate (forced expiratory flow between 25% and 75% of the FVC [FEF25%–75%]; r=-0.70 to -0.79). The additional number of individuals detected as abnormal using the concavity indices was substantial, especially compared with FEF25%–75%, where it was approximately doubled. Concavity was more specific for symptoms. Conclusion: The inclusion of these concavity measures in the routine reports of spirometry would add information on small airway obstruction at no extra cost, time, or effort. Keywords: early airway disease, airflow obstruction, COPD

The Physician Asthma Care Education (PACE) program significantly improved asthma prescribing and communication behaviours of primary care paediatricians in the USA. We tested the feasibility and acceptability of a modified PACE program with Australian general practitioners (GP) and measured its impact on self-reported consulting behaviours in a pilot study. Recruitment took place through a local GP division. Twenty-five GP completed two PACE Australia workshops, which incorporated paediatric asthma management consistent with Australian asthma guidelines and focussed on effective communication strategies. Program feasibility, usefulness and perceived benefit were measured by questionnaires before the workshop and 1 month later, and an evaluation questionnaire after each workshop. GP were universally enthusiastic and supportive of the workshops. The most useful elements they reported were communication skills, case studies, device demonstrations and the toolkit provided. GP self reports of the perceived helpfulness of the key communication strategies and their confidence in their application and reported frequency of use increased significantly after the workshops. The PACE program shows promise in improving the way in which Australian GP manage asthma consultations, particularly with regard to doctorDSpatient communication. The impact of the modified PACE Australia program on the processes and outcomes of GP care of children with asthma is now being measured in a randomised controlled trial. [ABSTRACT FROM AUTHOR]

Background: Individuals with Preserved Ratio Impaired Spirometry (PRISm), defined as FEV 1 /FVC ≥0.7 and FEV1 <80% predicted, are at higher risk of developing COPD. However, data for Australian adults are limited. We aimed to describe prevalence of PRISm and its relationship with clinical characteristics in Australia. Method: Data from the Burden of Lung Disease (BOLD) Australia study of randomly selected adults aged ≥40 years from six sites was classified into airflow limitation, PRISm, or normal spirometry groups. Demographic, clinical characteristics, and lung function were compared between groups. Results: Of the study sample ( n = 3518), 387 (11%) had PRISm, 549 (15.6%) had airflow limitation, and 2582 (73.4%) had normal spirometry. PRISm was more common in Indigenous Australian adults. Adults with PRISm had more frequent respiratory symptoms, more comorbidities, greater health burden and poorer quality of life than those with normal spirometry. Pre- and post-bronchodilator FEV 1 and FVC were lower in adults with PRISm than those with airflow limitation. Adults with PRISm were less likely to use respiratory medicine than those with airflow limitation (OR = 0.56, 95% CI 0.38-0.81). Conclusions: PRISm was present in 11% of adults in this study and they had similar respiratory symptoms and health burden as adults with airflow limitation., Competing Interests: Declaration of conflicting of interestsMJA holds investigator initiated grants from Pfizer, Boehringer-Ingelheim, Sanofi and GSK. He has conducted an unrelated consultancy for Sanofi. He has also received a speaker’s fee from GSK. RWB reports cohort grants from the National Health & Medical Research Council. GBM has received funding for advisory boards with AstraZeneca. HKR holds investigator initiated grants from AstraZeneca, GlaxoSmithKline, Chiesi, Sanofi and Perpetual Philanthropy. She has received consulting fees from AstraZeneca, Chiesi and Novartis and honoraria from Alkem, AstraZeneca, Boehringer Ingelheim, Chiesi, Getz, GlaxoSmithKline, Novartis, Sanofi and Teva. HKR holds a leadership role in the Global Initiative for Asthma (GINA) and is a member of the National Asthma Council Guidelines Committee. All other authors declare no competing interests.

Background and Objective: Most evidence about difficult-to-treat and severe asthma (DTTA) comes from clinical trials and registries. We aimed to identify people with DTTA from a large nationally representative asthma population and describe their characteristics and healthcare utilization compared with people whose asthma was not 'difficult-to-treat'., Methods: We conducted a cross-sectional survey of Australians aged ≥18 years with current asthma from large web-based survey panels. Enrolment was stratified by gender, age-group and state/territory based on national population data for people with asthma. Difficult-to-treat or severe asthma was defined by poor symptom control, exacerbations and/or oral corticosteroid/biologic use despite medium/high-dose inhaled therapy. Outcomes included exacerbations, healthcare utilization, multimorbidity, quality of life and coronavirus disease of 2019 (COVID-19)-related behaviour. Weighted data were analysed using SAS version 9.4., Results: The survey was conducted in February-March 2021. The weighted sample comprised 6048 adults with current asthma (average age 47.3 ± SD 18.1 years, 59.9% female), with 1313 (21.7%) satisfying ≥1 DTTA criteria. Of these, 50.4% had very poorly controlled symptoms (Asthma Control Test ≤15), 36.2% were current smokers, and 85.4% had ≥1 additional chronic condition, most commonly anxiety/depression. More than twice as many participants with DTTA versus non-DTTA had ≥1 urgent general practitioner (GP) visit (61.4% vs. 27.5%, OR 4.8 [4.2-5.5, p < 0.0001]), or ≥1 emergency room visit (41.9% vs. 17.9%, OR 3.8 [3.3-4.4, p < 0.0001]) in the previous 12 months., Conclusion: Our findings emphasize the burden of uncontrolled symptoms, current smoking, multimorbidity and healthcare utilization in people with DTTA in the community, who may be under-represented in registries or clinical trials., (© 2024 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Background: Diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the community is variable, often without spirometry. Some studies report that adults with both diagnostic labels (asthma+COPD) have worse health outcomes than those with asthma or COPD only, but data for Australian adults are limited. We investigated the relationship between clinical characteristics and self-reported diagnoses of asthma, COPD and both., Method: We used data from the BOLD Australia study, which included randomly selected adults aged ≥40 years from six study sites. The BOLD questionnaires and spirometry test were used in all sites. Participants were grouped by self-reported diagnosis. Demographic and clinical characteristics and lung function were compared between groups., Results: Of the study sample (n=3522), 336 reported asthma only, 172 reported COPD only, 77 reported asthma+COPD and 2937 reported neither. Fewer than half of participants with a COPD diagnosis (with or without asthma) had airflow limitation. Participants with asthma+COPD had more respiratory symptoms and greater airflow limitation than those with either diagnosis alone. Having asthma+COPD was independently associated with a higher probability of having clinically important breathlessness (modified Medical Research Council score ≥2) than asthma only (adjusted OR 3.44, 95% CI 1.86-6.33) or COPD only (adjusted OR 3.28, 95% CI 1.69-6.39). Airflow limitation (Global Initiative for Chronic Obstructive Lung Disease 2 or higher, using post-bronchodilator forced expiratory volume in 1 s/forced vital capacity ratio <0.7) was similar between asthma only and COPD only, but twice as prevalent in asthma+COPD (adjusted OR 2.18 and 2.58, respectively)., Conclusions: Adults with diagnoses of asthma+COPD have a higher symptom and disease burden than those with diagnoses of asthma only or COPD only. These patients should receive regular comprehensive reviews because of the substantially increased burden of having both diagnoses., Competing Interests: Conflict of interest: M.J. Abramson holds investigator-initiated grants from Pfizer, Boehringer Ingelheim, Sanofi and GSK. He has conducted an unrelated consultancy for Sanofi. He has also received a speaker's fee from GSK. R. Wood-Baker reports cohort grants from the National Health and Medical Research Council. G.B. Marks has received funding for advisory boards with AstraZeneca. H.K. Reddel holds investigator-initiated grants from AstraZeneca, GlaxoSmithKline, Novartis and Perpetual Philanthropy. She has received consulting fees from AstraZeneca and GlaxoSmithKline, and honoraria for advisory boards and independent medical education from AstraZeneca, GlaxoSmithKline, TEVA, Boehringer Ingelheim, Sanofi, Getz and Chiesi. She holds non-funded leadership roles in the Global Initiative for Asthma (GINA) and National Asthma Council (NAC). All other authors declare no competing interests., (Copyright ©The authors 2023.)

Background and Objective: Breathlessness is prevalent and associated with medical consequences. Obesity is related to breathlessness. However, the magnitude of its contribution has not been clearly documented. This investigation aimed to determine the contribution of obesity to breathlessness by estimating the population attributable fraction (PAF) in a representative sample of Australian adults., Methods: A cross-sectional, nationally representative survey of Australian residents aged ≥18 years was conducted in October 2019. Breathlessness was defined as modified Medical Research Council (mMRC) dyspnoea scale grade ≥2. BMI was calculated from self-reported height and weight. Adjusted relative risks (aRRs) were estimated using a generalized linear model with Poisson distribution, adjusted for age group and/or participant-reported diagnosed illnesses. Adjusted PAFs were estimated using aRR and obesity prevalence in Australian adults., Results: Among those who completed the National Breathlessness Survey, 9769 participants (51.4% female) were included in the analysis; 28.1% of participants were obese. The prevalence of breathlessness was 9.54%. The aRR of obesity for breathlessness was 2.04, adjusted for age. Adjusting for various co-morbid conditions, the aRR was slightly attenuated to around 1.85-1.98. The PAF, adjusted only for age, was 24.6% (95% CI 20.1-29.1) and after further adjustment for co-morbid conditions, the PAF ranged from 21.1% to 23.6%. Obesity accounted for a higher proportion of breathlessness in women than in men., Conclusion: Our results demonstrate that obesity accounts for around a quarter of breathlessness symptoms in Australian adults. This has important implications for health policy in light of the global trend in increasing obesity., (© 2022 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Background: Large electricity-generating wind turbines emit both audible sound and inaudible infrasound at very low frequencies that are outside of the normal human range of hearing. Sufferers of wind turbine syndrome (WTS) have attributed their ill-health and particularly their sleep disturbance to the signature pattern of infrasound. Critics have argued that these symptoms are psychological in origin and are attributable to nocebo effects., Objectives: We aimed to test the effects of 72 h of infrasound (1.6-20 Hz at a sound level of ∼ 90 dB pk re 20 μ Pa , simulating a wind turbine infrasound signature) exposure on human physiology, particularly sleep., Methods: We conducted a randomized double-blind triple-arm crossover laboratory-based study of 72 h exposure with a > 10 -d washout conducted in a noise-insulated sleep laboratory in the style of a studio apartment. The exposures were infrasound ( ∼ 90   dB pk), sham infrasound (same speakers not generating infrasound), and traffic noise exposure [active control; at a sound pressure level of 40-50 dB LA eq,night and 70 dB LAF max transient maxima, night (2200 to 0700 hours)]. The following physiological and psychological measures and systems were tested for their sensitivity to infrasound: wake after sleep onset (WASO; primary outcome) and other measures of sleep physiology, wake electroencephalography, WTS symptoms, cardiovascular physiology, and neurobehavioral performance., Results: We randomized 37 noise-sensitive but otherwise healthy adults (18-72 years of age; 51% female) into the study before a COVID19-related public health order forced the study to close. WASO was not affected by infrasound compared with sham infrasound ( - 1.36 min; 95% CI: - 6.60 , 3.88, p = 0.60 ) but was worsened by the active control traffic exposure compared with sham by 6.07 min (95% CI: 0.75, 11.39, p = 0.02 ). Infrasound did not worsen any subjective or objective measures used., Discussion: Our findings did not support the idea that infrasound causes WTS. High level, but inaudible, infrasound did not appear to perturb any physiological or psychological measure tested in these study participants. https://doi.org/10.1289/EHP10757.

Background: Breathlessness is a common symptom related to a significant health burden. However, the association of breathlessness with clinical characteristics, especially objective pulmonary test results is scarce. We aimed to identify the characteristics independently associated with breathlessness in Australian adults., Method: The analysis used data from BOLD Australia, a cross-sectional study that included randomly selected adults aged ≥40 years from six sites in Australia. Clinical characteristics and spirometry results were compared for breathlessness (modified Medical Research Council [mMRC] grade ≥2)., Results: Among all respondents ( n = 3321), 252 participants (7.6%) reported breathlessness. The main univariate associations were obesity, chronic respiratory diseases, heart diseases and being Indigenous Australians (odds ratios [ORs] = 2.78, 5.20, 3.77 and 4.38, respectively). Participants with breathlessness had lower pre-and post-bronchodilator lung function than those without. Impaired spirometry results including FVC or FEV 1 below 80% predicted, or FEV 1 /FVC < LLN were independently associated with breathlessness (adjusted ORs = 2.66, 2.94 and 2.34, respectively)., Conclusions: Breathlessness is common among Australian adults and is independently associated with obesity, chronic respiratory diseases, heart diseases, being Indigenous Australians, and impaired spirometry. Multi-disciplinary assessment and comprehensive investigation is needed in clinical practice to address the many factors associated with breathlessness in the population., Competing Interests: Declaration of conflicting interestsMJA holds investigator initiated grants from Pfizer, Boehringer-Ingelheim, Sanofi and GSK. He has conducted an unrelated consultancy for Sanofi. He has also received a speaker’s fee from GSK. RWB reports cohort grants from the National Health & Medical Research Council. GBM has received funding for advisory boards with AstraZeneca. HKR holds investigator initiated grants from AstraZeneca, GlaxoSmithKline, Novartis, Perpetual Philanthropy. She has received consulting fees from AstraZeneca and GlaxoSmithKline and honoraria for advisory boards and independent medical education from AstraZeneca, GlaxoSmithKline, TEVA, Boehringer-Ingelheim, Sanofi, Getz and Chiesi. HKR holds non-funded leadership roles in the Global Initiative for Asthma (GINA) and National Asthma Council (NAC). All other authors declare no competing interests.

The small size and large surface area of ultrafine particles (UFP) enhance their ability to deposit in the lung periphery and their reactivity. The Ultrafine Particles from Traffic Emissions and Children's Health (UPTECH) cross-sectional study was conducted in 8-11-year-old schoolchildren attending 25 primary (elementary) schools, randomly selected from the Brisbane Metropolitan Area, Queensland, Australia. Main study findings outlined indirect evidence of distal airway deposition (raised C reactive protein) but as yet, there is no direct evidence in the literature of effects of UFP exposure on peripheral airway function. We present further UPTECH study data from two sensitive peripheral airway function tests, Oscillometry and Multiple Breath Nitrogen Washout (MBNW), performed in 577 and 627 children (88% and 96% of UPTECH study cohort) respectively: mean(SD) age 10.1(0.9) years, 46% male, with 50% atopy and 14% current asthma. Bayesian generalised linear mixed effects regression models were used to estimate the effect of UFP particle number count (PNC) exposure on key oscillometry (airway resistance, (Rrs), and reactance, (Xrs)) and MBNW (lung clearance index, (LCI) and functional residual capacity, (FRC)) indices. We adjusted for age, sex, and height, and potential confounders including socio-economic disadvantage, PM 2.5 and NO 2 exposure. All models contained an interaction term between UFP PNC exposure and atopy, allowing estimation of the effect of exposure on non-atopic and atopic students. Increasing UFP PNC was associated with greater lung stiffness as evidenced by a decrease in Xrs [mean (95% credible interval) -1.63 (-3.36 to -0.05)%] per 1000#.cm -3 ]. It was also associated with greater lung stiffness (decrease in Xrs) in atopic subjects across all models [mean change ranging from -2.06 to -2.40% per 1000#.cm -3 ]. A paradoxical positive effect was observed for Rrs across all models [mean change ranging from -1.55 to -1.70% per 1000#.cm -3 ] (decreases in Rrs indicating an increase in airway calibre), which was present for both atopic and non-atopic subjects. No effects on MBNW indices were observed. In conclusion, a modest detrimental effect of UFP on peripheral airway function among atopic subjects, as assessed by respiratory system reactance, was observed extending the main UPTECH study findings which reported a positive association with a biomarker for systemic inflammation, C-reactive protein (CRP). Further studies are warranted to explore the pathophysiological mechanisms underlying increased respiratory stiffness, and whether it persists through to adolescence and adulthood., (Copyright © 2022. Published by Elsevier Inc.)

Objective: The aim of this study was to determine the seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) antibodies in high-risk communities and quarantine workers in Vietnam., Methods: The prevalence of SARS-CoV-2 antibodies was measured in household contacts, close contacts, community members, and migrant workers from two sub-communes in which COVID-19 outbreaks occurred in early 2021: Bac Ma 1 and Tien. The prevalence of SARS-CoV-2 antibodies was also evaluated among quarantine workers at two facilities responsible for quarantining of contacts of COVID-19 cases., Results: Among 2069 participants from the two sub-communes, six individuals (0.3%) had detectable SARS-CoV-2 antibodies despite no history of COVID-19. This included one Vietnamese migrant worker, two community members, two household contacts, and one close contact of known COVID-19 cases. Among 50 workers at two COVID-19 quarantine facilities, including 15 health care workers (HCWs), one of the HCWs tested positive for SARS-CoV-2 antibodies (1/50, 2.0%) despite no known disease., Conclusion: The prevalence of SARS-CoV-2 antibodies was low in Vietnamese 'hotspots', suggesting limited community transmission., Competing Interests: None declared, (© 2021 The Authors.)

The association between the indoor environment and lifetime prevalence of otitis media (OM) in Australian children was assessed. We analysed data from a cross-sectional study of children, aged 7-11 years, performed in twelve Australian cities during 2007-2008. The main outcome was a parental report of their child's diagnosis with OM by a doctor. Information on the indoor environment (energy sources used for heating, cooling, and cooking, pets, and second-hand smoke exposure), in the first year of life and at present, was collected from parents by a questionnaire. Multi-level logistic regression models were used to adjust for individual- and area-level confounders. Our analysis comprised 2872 children (51% female, mean age: 10.0 (SD 1.2)). Of those, 1097 (39%) were reported to have OM. Exposure to gas heating in the first year of life was significantly associated with higher odds of OM in adjusted models (OR:1.22; 95% CI: 1.00,1.47), as was current exposure to reverse-cycle air conditioning (OR: 1.52, 95% CI: 1.27,1.82). Ownership of a cat or dog at any time was also associated with high odds of OM (OR: 1.50; 95% CI: 1.17,1.92). No other significant associations were observed. In this national study of Australian children, indoor environmental exposures associated with the lifetime prevalence of OM were gas heating, reverse-cycle air conditioning and pet ownership. Exposures in both early life and later childhood may both play a role in OM.

Introduction: We aimed to determine normal thresholds for positive bronchodilator responses for oscillometry in an Australian general population sample aged ≥40 years, to guide clinical interpretation. We also examined relationships between bronchodilator responses and respiratory symptoms, asthma diagnosis, smoking and baseline lung function., Methods: Subjects recruited from Sydney, Melbourne and Busselton, Australia, underwent measurements of spirometry, resistance ( R rs 6 ) and reactance ( X rs 6 ) at 6 Hz, before and after inhalation of salbutamol 200 μg. Respiratory symptoms and/or medication use, asthma diagnosis, and smoking were recorded. Threshold bronchodilator responses were defined as the fifth percentile of decrease in R rs 6 and 95th percentile increase in X rs 6 in a healthy subgroup., Results: Of 1318 participants, 1145 (570 female) were analysed. The lower threshold for Δ R rs 6 was -1.38 cmH 2 O·s·L -1 (-30.0% or -1.42 Z-scores) and upper threshold for Δ X rs 6 was 0.57 cmH 2 O·s·L -1 (1.36 Z-scores). Respiratory symptoms and/or medication use, asthma diagnosis, and smoking all predicted bronchodilator response, as did baseline oscillometry and spirometry. When categorised into clinically relevant groups according to those predictors, Δ X rs 6 was more sensitive than spirometry in smokers without current asthma or chronic obstructive pulmonary disease (COPD), ∼20% having a positive response. Using absolute or Z-score change provided similar prevalences of responsiveness, except in COPD, in which responsiveness measured by absolute change was twice that for Z-score., Discussion: This study describes normative thresholds for bronchodilator responses in oscillometry parameters, including intra-breath parameters, as determined by absolute, relative and Z-score changes. Positive bronchodilator response by oscillometry correlated with clinical factors and baseline function, which may inform the clinical interpretation of oscillometry., Competing Interests: Conflict of interest: K. Jetmalani is a part-time employee of GlaxoSmithKline. Conflict of interest: N.J. Brown has nothing to disclose. Conflict of interest: C. Boustany has nothing to disclose. Conflict of interest: B.G. Toelle has nothing to disclose. Conflict of interest: G.B. Marks has nothing to disclose. Conflict of interest: M.J. Abramson reports an investigator-initiated grant to conduct the BOLD study in Australia from the National Health and Medical Research Council during the conduct of the study; and investigator-initiated grants for unrelated research from Pfizer and Boehringer Ingelheim, personal fees for unrelated consultancies and assistance with congress attendance from Sanofi, and a speaker's fee from GlaxoSmithKline, outside the submitted work. Conflict of interest: D.P. Johns has nothing to disclose. Conflict of interest: A.L. James has nothing to disclose. Conflict of interest: M. Hunter has nothing to disclose. Conflict of interest: A.W. Musk has nothing to disclose. Conflict of interest: N. Berend is a part-time employee of GlaxoSmithKline. Conflict of interest: C.S. Farah has nothing to disclose. Conflict of interest: D.G. Chapman has nothing to disclose. Conflict of interest: C. Thamrin has a patent WO 2006130922 A1 issued, which is broadly relevant to the work. In addition, she has intellectual property arrangements with Thorasys, Thoracic Medical Systems and Restech srl relating to research collaborations, but does not have any financial relationships with either company. Conflict of interest: G.G. King reports intellectual property arrangements covering research collaborations and provision of FOT devices for research from Restech during the conduct of the study; fees for consultancy services (which include lectures and advisory board services), conference attendance support and unrestricted research grants from AstraZeneca, Boehringer Ingelheim, CycloPharm, GlaxoSmithKline, Novartis, Menarini and MundiPharma, and research grants and fellowships from the National Health and Medical Research Council, the Asthma Foundation and philanthropic donations via Sydney University, outside the submitted work., (Copyright ©The authors 2021.)

Background and Objective: Chronic respiratory symptoms (in particular, breathlessness and cough) can cause physical, social and emotional distress, and may indicate the presence of an underlying disease that presages future poor health outcomes. Our aim was to investigate the burden of breathlessness in Australian adults, including breathlessness that may be undiagnosed, unlabelled or untreated., Methods: The National Breathlessness Survey was a cross-sectional, web-based survey conducted in October 2019. Australian adults were randomly selected from a large web-based survey panel with recruitment stratified by age-group, gender and state of residence according to national population data. The main outcome measures were modified Medical Research Council (mMRC) dyspnoea scale, EuroQol visual analog scale, Dyspnoea-12 score and 4-item Patient Health Questionnaire (PHQ-4)., Results: Among all respondents (n = 10,072; 51.1% female; median age group 40-49 years), 9.5% reported clinically important breathlessness (mMRC dyspnoea grade ≥ 2, 2 = 'I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level'). Among those with clinically important breathlessness, 49.1% rated their general health as fair or poor and 44.2% had at least moderate depression or anxiety symptoms (PHQ ≥ 6) but over half (50.8%) did not report a current respiratory or heart condition diagnosis., Conclusion: Breathlessness is common among Australian adults, and is associated with a substantial burden of ill health, including among people without a diagnosed respiratory or heart condition. The extent of underdiagnosis of these conditions or alternative causes of breathlessness requires further investigation., (© 2021 Asian Pacific Society of Respirology.)

As a response to the coronavirus disease 2019 (COVID-19) pandemic, Vietnam enforced strict quarantine, contact tracing and physical distancing policies resulting in one of the lowest numbers of individuals infected with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) globally. This study aimed to determine the prevalence of SARS-CoV-2 antibody positivity among high-risk populations in Vietnam. A prevalence survey was undertaken within four communities in Vietnam, where at least two COVID-19 cases had been confirmed. Participants were classified according to the location of exposure: household contacts, close contacts, community members, and healthcare workers (HCWs) responsible for treating COVID-19 cases. Participants completed a baseline questionnaire and SARS-CoV-2 IgG antibodies were quantified using a commercial assay. A total of 3049 community members and 149 health care workers consented to the study. Among 13 individuals who were seropositive (0.4%), five household contacts (5/27, 18.5%), one close contact (1/53, 1.9%), and seven community members (7/2954, 0.2%) had detectable SARS-CoV-2 antibodies. All HCWs were negative for SARS-CoV-2 antibodies. Participants were tested a median of 15.1 (interquartile range from 14.9 to 15.2) weeks after exposure. Our study found a low prevalence of SARS-CoV-2 antibodies in high-risk communities and healthcare workers in communities in Vietnam with known COVID-19 cases.

Access to up-to-date Australian disease prevalence estimates assists health services and consumer organisations to plan and allocate resources. The Burden of Obstructive Lung Disease study was conducted between 2006 and 2012 and provided chronic obstructive pulmonary disease (COPD) (post-bronchodilator airflow limitation) prevalence estimates weighted to the 2006 Australian census. Using the 2016 Australian census, an updated prevalence estimate of all COPD is 8.30% (95% confidence interval = 6.59%-10.01%) for adults aged 40 or more years in Australia and includes 2.52% with mild breathlessness, 0.99% with moderate breathlessness and 0.91% with severe breathlessness., (© 2021 Royal Australasian College of Physicians.)

The prevalence of allergic diseases in Australian children is high, but few studies have assessed the potential role of outdoor air pollution in allergic sensitization. We investigated the association between outdoor air pollution and the prevalence of aeroallergen sensitization in a national cross-sectional study of Australian children aged 7-11 years. Children were recruited from 55 participating schools in 12 Australian cities during 2007-2008. Parents completed a detailed (70-item) questionnaire. Outdoor nitrogen dioxide (NO 2 ), as a proxy for exposure to traffic-related emissions, was estimated using measurements from regulatory monitors near each school and a national land-use regression (LUR) model. Three averaging periods were assessed, using information on duration of residence at the address, including lifetime, previous (lifetime, excluding the last year), and recent (the last year only). The LUR model was used as an additional source of recent exposure estimates at school and home addresses. Skin prick tests (SPTs) were performed to measure sensitization to eight common aeroallergens. Multilevel logistic regression estimated the association between NO 2 and sensitization (by individual allergens, indoor and outdoor allergens, and all allergens combined), after adjustment for individual- and area-level covariates. In total, 2226 children had a completed questionnaire and SPT. The prevalence of sensitization to any allergen was 44.4%. Sensitization to house dust mites (HDMs) was the most common (36.1%), while sensitization to Aspergillus was the least common (3.4%). Measured mean (±s.d.) NO 2 exposure was between 9 (±2.9) ppb and 9.5 (±3.2) ppb, depending on the averaging period. An IQR (4 ppb) increase in measured previous NO 2 exposure was associated with greater odds of sensitization to HDMs (OR: 1.21, 95% CI: 1.01-1.43, P = 0.035). We found evidence of an association between relatively low outdoor NO 2 concentrations and sensitization to HDMs, but not other aeroallergens, in Australian children aged 7-11 years., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

A critical element of the risk assessment of exposure to airborne ambient ultrafine particles (UFP) is the quantification of respiratory tract deposition (RTD) of the particles, which is intrinsically challenging, particularly at the population scale. In this study, we used a recently proposed method to experimentally determine the RTD of urban UFP in a large group of children exposed to these particles in a school setting in Brisbane, Australia. Children are one of the most susceptible population groups; However, little is known about the deposition of UFP from urban traffic in their airways. In order to advance the knowledge in this field, the objectives of this study were: to determine the deposition of ambient urbane UFP in large number children, to catergorize the source of inhaled UFPs and hence to assess the contribution of air pollution sources to the deposition. RTD was measured in children aged 8-11 at primary schools using a flow-through chamber bag system. First, the inhaled and exhaled air was separated; then the particle number size distribution and particle number concentration were measured. The sources of inhaled UFP were categorized according to their particle number size distribution by a K means cluster technique. A total of 128 children from five schools performed the RTD measurement. The mean total deposition fraction of urban UFP in all children was 0.59 ± 0.10. Inhaled UFP were categorized into two groups: traffic and urban background, with the GMD of corresponding particle number size distribution of 20 nm and 40 nm, respectively. The total deposition fraction (mean ± SD) of UFP from these two groups was 0.68 ± 0.09 for traffic and 0.55 ± 0.08 for urban background respectively. This is the first study in which RTD was measured in a large group of children inhaling real urban UFP. First, we proved that this novel method can indeed be applied easily and quickly to a large group of people. Second, we quantified the RTD of children, thus providing an important input to the risk assessment for exposure to UFP., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Allergic disease is a recognized global epidemic and a significant cause of ill health and poor quality of life. The prevalence of pollen allergy is high throughout the world, and pollen exposure itself plays a role in emergency department presentations and hospitalizations for asthma. Lung function and airway inflammation are important measures of asthma activity and control., Objective: To examine associations between exposure to multiple pollen types and lung function and markers of airway inflammation at 8 and 14 years of age, and to explore potential modification by residential greenness., Methods: A cohort of high-risk children living in Sydney, Australia had spirometry and fractional exhaled nitric oxide (FeNO) measured at 8 and 14 years of age. Ambient pollen concentration on the day of lung function measurement and up to three days prior was used as the exposure measure. Residential greenness was derived from satellite imagery. We modelled the association between six pollen types and lung function and FeNO. We also assessed modifying effects of residential greenness., Results: Casuarina, cypress and Pinus pollen in the air the day before measurement and 3 days prior respectively, were associated with reduced lung function in 8-year-olds. The pollen exposures were associated with decreases in FEV 1 and FVC; however, the FEV 1 /FVC ratio was not affected. Effect modification by greenness was not observed due to loss of power., Conclusions & Clinical Relevance: Airborne tree pollen of cypress, Casuarina and Pinus and not grass in some regions may be detrimental to childhood lung function., (© 2020 John Wiley & Sons Ltd.)

Medication non-adherence is associated with sub-optimal asthma control. Identification of medical and psychological characteristics associated with non-adherence is important to enable a targeted and personalized approach when working with patients and for the development of interventions to improve patient outcomes by improving medication adherence. We enrolled adults who had diagnosed asthma and who were prescribed daily inhaled corticosteroid medication. We used published and validated instruments to measure medical characteristics including asthma features, practical asthma knowledge and perceived involvement in care and psychological characteristics including anxiety, depression, optimism, and personality traits, to assess the relationship with medication non-adherence. A total of 126 participants provided data, with 64 (50.8%) of the participants identified as non-adherent. Multivariate analyses showed that younger age, high neuroticism scores and a previous asthma hospital admission were associated with non-adherence. Interestingly, depression was associated with a lower risk of non-adherence. This study showed that a personalized medicine approach would include interventions targeting those who are younger, who have been in hospital for asthma and who rate high on the neuroticism personality trait. Given the availability of effective medications for asthma, better understanding of the characteristics associated with non-adherence is important to enhance optimal self-management.

Background: Although electronic monitoring is the "gold standard" for adherence monitoring, the range of inhaler devices on the market exceeds the availability of appropriate monitoring devices. Simple tools, applicable across a range of inhalers, are needed to assess patients' adherence to prescribed inhaled medication. This study reports on the validation of an Inhaler Adherence Questionnaire (IAQ)., Methods: Seventy-four adults who self-reported doctor diagnosed asthma and who were prescribed daily inhaled corticosteroids (ICS) for asthma contributed data for these analyses. These participants were part of a larger study, investigating factors associated with non-adherence to prescribed daily inhaled corticosteroid medication. Participants were informed the research was investigating asthma management without explicit mention that medication adherence was being monitored. Inhaled corticosteroid medication adherence was measured in two ways. Firstly, participants completed the 6-item IAQ at enrolment. Secondly, ICS via pressurised Metered Dose Inhaler (pMDI) use was monitored electronically using the DoserCT which recorded daily use over 6 weeks. During the 6 weeks of prospective medication monitoring via the DoserCT we did not have contact with participants so that the adherence measure would reflect usual self-management behaviour., Results: Two of the six questions in the IAQ had poor face validity and their exclusion from the questionnaire resulted in improved internal consistency. Mean days adherent were 37.1, 29.2 and 33.2% for subjects with IAQ scores of 0, 1 and 2 respectively. Higher IAQ scores of 3 and 4 were associated with greater mean days adherent of 73.7 and 67.4% respectively. A cut-point of 2 or less had a sensitivity of 73% and a specificity of 80% for detecting non-adherence. The area under the ROC curve was 0.764 (p < 0.001)., Conclusions: The modified 4-item IAQ is simple, quick to complete and useful for measuring adherence with prescribed daily inhaled medication. This validation of the IAQ provides evidence for its utility in research and it will be important to validate this simple, inexpensive tool for use in clinical practice.

Background: Four months of rifampin treatment for latent tuberculosis infection is safer, has superior treatment completion rates, and is as effective as 9 months of isoniazid. However, daily medication costs are higher for a 4-month rifampin regimen than a 9-month isoniazid regimen., Objective: To compare health care use and associated costs of 4 months of rifampin and 9 months of isoniazid., Design: Health system cost comparison using all health care activities recorded during 2 randomized clinical trials. (ClinicalTrials.gov: NCT00931736 and NCT00170209)., Setting: High-income countries (Australia, Canada, Saudi Arabia, and South Korea), middle-income countries (Brazil and Indonesia), and African countries (Benin, Ghana, and Guinea)., Participants: Adults and children with clinical or epidemiologic factors associated with increased risk for developing tuberculosis that warranted treatment for latent tuberculosis infection., Measurements: Health system costs per participant., Results: A total of 6012 adults and 829 children were included. In both adults and children, greater health system use and higher costs were observed with 9 months of isoniazid than with 4 months of rifampin. In adults, the ratios of costs of 4 months of rifampin versus 9 months of isoniazid were 0.76 (95% CI, 0.70 to 0.82) in high-income countries, 0.90 (CI, 0.85 to 0.96) in middle-income countries, and 0.80 (CI, 0.78 to 0.81) in African countries. Similar findings were observed in the pediatric population., Limitation: Costs may have been overestimated because the trial protocol required a minimum number of follow-up visits, although fewer than recommended by many authoritative guidelines., Conclusion: A 4-month rifampin regimen was safer and less expensive than 9 months of isoniazid in all settings. This regimen could be adopted by tuberculosis programs in many countries as first-line therapy for latent tuberculosis infection., Primary Funding Source: Canadian Institutes of Health Research.

Smoking cessation remains a health promotion target. Applying the Transtheoretical Model to Australian Burden of Obstructive Lung Diseases (BOLD) data, we examined differences in stages of change (SoC) and readiness to quit decisional behaviours. Factors were identified likely to influence readiness of smokers, ≥40 years old, to quit. Analysis was restricted to current smokers classified to one of three stages: pre-contemplation (PC), contemplation (C) or preparation (P) to quit. Their ability to balance positive and negative consequences was measured using decisional balance. Among 314 smokers, 43.0% females and 60.8% overweight/obese, the distribution of SoC was: 38.1% PC, 38.3% C and 23.5% P. Overweight/obesity was associated with readiness to quit in stages C and P and there were more negative than positive attitudes towards smoking in those stages. Males were significantly heavier smokers in PC and C stages. Females used smoking cessation medication more frequently in PC stage, were more embarrassed about smoking and had greater negative reinforcements from smoking. Age started smoking and factors related to smoking history were associated with readiness to quit and increased the odds of being in stage C or P. An overweight/obese smoker was likely to be contemplating or preparing to quit. In these stages, smokers have more negative attitudes toward smoking. Starting smoking later, taking advice on cessation from health providers and using quit medications indicate increased readiness to quit. Evaluating these factors in smokers and developing cessation gain-framed messages may prove useful to healthcare providers.

Objective: To assess the influence of the trajectory of weight gain from birth to adolescence on cardiovascular and metabolic risk. We studied childhood body mass index (BMI) trajectories from birth to age 14 years and cardiometabolic risk factors at age 14 years., Study Design: In total, 410 children with weight and height measurements were assessed from birth throughout childhood, from the Childhood Asthma Prevention Study, a prospective community-based cohort. BMI trajectory groups were determined by latent basis growth mixture models. Of these subjects, 190 had detailed cardiometabolic risk factors assessed at age 14 years., Results: Three BMI trajectory groups were identified; normal BMI, "early rising" excess BMI from 2 years, and "late rising" excess BMI from 5 years. Differences were found between normal and excess BMI in children at 14 years of age. In addition, children with an early rising BMI trajectory had statistically significantly higher central adiposity and a more atherogenic lipoprotein profile at age 14 years than children with a late rising BMI trajectory (P < .05). No differences between BMI trajectory groups in vascular structure or function was identified at age 14 years., Conclusions: Earlier onset of an elevated BMI trajectory persisting from birth to age 14 years results in an unfavorable cardiometabolic risk profile at age 14 years, including central adiposity and more atherogenic lipoproteins, independent of achieved BMI., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Carotid Intima Media Thickness (CIMT) is a marker of subclinical atherosclerosis, associated with cardiovascular risk in adults. Telomere length (TL) is a marker of cellular ageing. We sought to determine whether telomere length in early childhood and/or at 14-years is associated with CIMT in adolescence, in a community-based cohort study., Methods: 118 children had TL measured at mean age 3.6-years and 165 children had TL and CIMT, measured at 14-years, from the community-based Childhood Asthma Prevention Study., Results: TL in early childhood was significantly inversely associated with CIMT at 14 years, p = 0.04. TL in teenage life was also significantly inversely associated with CIMT at 14 years, p = 0.03. This latter association was no longer significant, however, after adjusting for early life TL., Conclusion: TL measured in early childhood and adolescence is significantly associated with CIMT at 14-years, suggesting that telomere length is a biological marker or even early determinant of late cardiovascular risk., (Copyright © 2018 Elsevier B.V. All rights reserved.)