Volume 09
Issue 03
October 2021
Inside This Issue
Editorial, 2-3
Tips from the Experts, 4-6
Humanitarian News, 7-12
Best Image Contest, 13
WABIP News, 14
Research, 15
Links, 16
Lexical Considerations Regarding
Interventional Pulmonology: An Opinion
WABIP Newsletter
O C T O B E R 2 0 2 1 V O L U M E 9 , I S S U E 3
EXECUTIVE BOARD
Hideo Saka, MD
Japan, Chair
Stefano Gasparini,
MD
Italy, Vice-Chair
Silvia Quadrelli, MD
Argenna, Immediate
Past-Chair
David Fielding MD
Australia, Treasurer
Naofumi Shinagawa,
MD
Japan,
Secretary General
Philippe Astoul, MD
France, President
WCBIP 2022
Menaldi Rasmin, MD
Indonesia, President
WCBIP 2024
STAFF
Michael Mendoza
General Manager
Judy McConnell
Administrator
Kazuhiro Yasufuku
Newsleer Editor-in-
chief
P A G E 2
Stefano Gasparini
Polytechnic University of Marche Region
Department of Biomedic Sciences and Public
Health
Pulmonary Diseases Unit, Azienda Ospedaliero-
Universitaria “Ospedali Riuni”
Ancona, Italy
The denion “Intervenonal Pulmonology” was
ocially introduced in 2001 in a paper published by
Luis Seijo and Dan Sterman
1
. While in the paper the
term “Intervenonal Pulmonology” was limited to
dene “advanced bronchoscopic and pleuroscopic
techniques for the treatment of a spectrum of tho-
racic disorders”, such as rigid bronchoscopic
debulking and stenng, balloon dilataon, endo-
bronchial laser/cryo/electrocautery/brachitherapy,
in the immediately following years the meaning of
this denion has expanded. Today, we include in
the denion of Intervenonal Pulmonology all the
invasive or semi-invasive procedures performed by
pulmonologists not only for therapy but also for
diagnosis of respiratory diseases (bronchoscopy
and related techniques, thoracoscopy, thoracic
drainage inseron, percutaneous biopsies, pleural
biopsies, percutaneous tracheostomy). In a joint
ERS/ATS document
2
, Intervenonal Pulmonology
was dened as “the art and science of medicine as
related to the performance of diagnosc and inva-
sive therapeuc procedures that require addional
training and experse beyond that required in a
standard pulmonary medicine training pro-
gramme".
This term was immediately successful and has been widely
accepted by the Scienc Community. The most important
Scienc Sociees involved in the eld of thoracic endoscopy
changed their name and added “intervenonal pulmonolo-
gy”, like Word Associaon for Bronchology (WAB) which be-
came WABIP, European Associaon for Bronchology (now
EABIP), American Associaon for Bronchology (now AABIP).
Even the previous Journal of Bronchology, in 2009 became
Journal of Bronchology & Intervenonal Pulmonology
(JOBIP). In the last years several books tled “Intervenonal
Pulmonology”
3
were published, and in the chapters of these
books all the diagnosc and therapeuc techniques related
to bronchoscopy and thoracoscopy are included.
The main reasons for the success of this denion are three:
1) the previously used term of “thoracic endoscopy” is an
understatement since “endoscopy” means “to look in-
to” (from greek “endoscópesis”, a compound word consisng
of “éndon”, which means inside and “scopeín”, which means
to watch carefully). Today, most bronchoscopic/
thoracoscopic procedures involves some kind of maneuver or
sampling and are not limited to exploraon; 2) some pulmo-
nary intervenonal procedures are not based on endoscopy
(like drainage inseron, percutaneous biopsies); 3) the deni-
on “Intervenonal Pulmonology” underlines and emphasiz-
es the role of the pulmonologist as the professional gure
with the competences and the knowledges to perform such
procedures and reiterates that this eld of medicine belongs
to the pneumological specialty or to the Colleagues that are
involved in the diagnosis and treatment of respiratory diseas-
es.
Other speciales arrived before Pulmonology to understand
the importance of qualifying an area of their competence
with the term “intervenonal”. The dicon of “Intervenonal
Radiology” was coined in 1967 by Alexander Margulis
4
, Direc-
tor of Radiology Department at the University of San Francis-
co. A lile later is the birth of “Intervenonal Cardiology” by
Andreas Gruenzig from Zurich
5
, which in 1974 extended the
use of percutaneous angioplasty to coronary arteries, revolu-
onizing the therapy of ischemic heart disease.
If it is true that the term “Intervenonal” has been widely
accepted, it is equally true that there is some terminological
confusion, and frequently denions such as “intervenonal
bronchoscopy”, “intervenonal bronchology”, “operave
bronchoscopy”, “advanced bronchoscopy” are encountered.
W A B I P N E W S L E T T E R
P A G E 3
terminology used in Intervenonal Pulmonology will be
reached.
References
1) Seijo LM et al. N Engl J Med 2001; 344: 740-749
2) Bolliger CT et al. Eur Respir J 2002; 356-373
3) Principles and pracce of Intervenonal Pulmonology. A Ernst,
FJF Herth Eds. Springer Science, New York 2013
4) Margulis A. AJR 1967; 101: 265-286
5) Gruentzig A. Am Heart J 1982; 103: 779-783
6) Intervenonal bronchoscopy. Bolliger C et al. 2000
7) Hardavella G et al. Breathe 2015; 11: 202-212
8) Intervenonal Bronchoscopy. Mehta A, Jain P Eds. Springer Sci-
ence New York 2013
9) hps://www.cuimc.columbia.edu/pulmonary/clinical-centers/
intervenonal-bronchoscopy
What does it mean “Intervenonal bronchoscopy”?
In the book “Intervenonal Bronchoscopy” edited
by Chris Bolliger and Praveen Mathur
6
, interven-
onal bronchoscopy is dened as “all aspects of
diagnosc and therapeuc bronchoscopy, which go
beyond the techniques of inspecon, simple lavage
and biopsies of the tracheobronchial tree”. But, if
we look at some books, some papers and some
internet web sites, we nd that this denion is
somemes used to describe complex therapeucal
procedures (laser resecon, electrocautery, cryo-
therapy, stenng, photodynamic therapy)
7
, but at
other mes it includes also diagnosc procedures
(TBNA, EBUS-TBNA, electromagnec navigaon,
bronchoscopy in hemoptysis)
8
, and even BAL and
endobronchial biopsy
9
.
The term “intervenonal” in medicine, according to
the Cambridge Diconary, is “the act of interven-
ing, interfering or interceding with the aim of mod-
ifying the outcome”. According to this denion,
even a simple bronchoscopy aimed to verify the
condion of the airways may modify the diagnosis.
To introduce an instrument into the airways is al-
ways an intervenon. In other words, bronchosco-
py is a procedure that in any case belong to Inter-
venonal Pulmonology. The same concept can be
applied for the term “operave bronchoscopy”.
Concerning the term “advanced bronchoscopy”, it
could be confusing, since the burden between
basic and advanced bronchoscopy is blurred. What
today is an advanced technique, could become
basic in the future (TBNA was an advanced tech-
nique in the ‘80s, today it is considered basic; to-
day roboc bronchoscopy is an advanced tech-
nique, but maybe it could become roune and
basic in the future); furthermore, what is advanced
for somebody could be basic for others.
In conclusion, my opinion is that bronchoscopy is
always an operave and intervenonal procedure,
even when performed for simple diagnosc pur-
poses. I suggest to employ the denions of diag-
nosc and therapeuc bronchoscopy, both includ-
ed in the eld of “Intervenonal Pulmonology”.
Let’s leave the precious adjecve “intervenonal”
to our pulmonology specialty.
I hope that a discussion on this issue will take place
in our Associaon and that a standardizaon of the
Tips from the Experts
P A G E 4 V O L U M E 9 , I S S U E 3
Introducon
Recurrent respiratory papillomatosis (RRP) is a disease caused by infecon of the respiratory tract with human papilloma virus (HPV) sub-
types 6 and 11 [10]. RRP has an esmated incidence of 1.8 cases per 100,000 adults in the United States [2, 13]. Occasionally, papillomas
undergo malignant transformaon [1]. While vaccinaon could prevent development of RRP, once the papillomas develop, current standard
of care is removal via debridement or ablave therapy, most oen bronchoscopically when present in the trachea [1, 5, 11]. These means
include laser, argon plasma coagulaon, microdebrider, and photodynamic therapy [1]. Herein we outline the most common approaches to
bronchoscopic intervenon for RRP.
Indicaons, descripons, techniques, and complicaons for specic RRP intervenons
Indicaons for surgical management of tracheobronchial papillomatosis, in this case bronchoscopic intervenon, largely relate to maintain-
ing airway patency and/or palliaon of symptoms thought to be related to the presence of papillomas (e.g. stridor, wheezing, recurrent
pneumonia, and dyspnea) [1]. All modalies listed below are eecve at achieving this endpoint, albiet with diering technical aspects and
complicaons. Remission is unpredictable and re-intervenon is common [11].
Laser
There are several laser systems that have been used in the treatment of RRP, all allowing for applicaon of thermal energy which desiccate
and coagulate the ssues and minimize bleeding. Currently, carbon dioxide (CO2) laser is the preferred method of papilloma removal in the
otolaryngology pracces, however other lasers including neodymium:yrium aluminum garnet (Nd:YAG), potassium tanyl phosphate
(KTP), have also been used [5, 7, 15, 16] and oer similar characteriscs and rates of remission [1].
Technique for applicaon of laser includes use of a exible quartz ber advanced through a exible or rigid bronchoscope. Given the risk of
airway re, FiO
2
during laser operaon should be decreased to <0.4. Specialized ET tubes for laser have also been developed to minimize
complicaon of airway re should a exible bronchoscope be used. Care should be taken to maintain laser orientaon coaxial to the trache-
al lumen as laser penetraon into ssue can vary with dierent systems [7]. Other complicaons include airway perforaon and airway
stricture, incidence of which are thought to be lower with CO2 laser compared to other modalies [1].
Argon Plasma Coagulaon
Argon plasma coagulaon (APC) is an ablave therapy that uses a tungsten wire to deliver a spark to insuated argon gas which causes ioni-
zaon. The ionized gas creates an electrical arc to the nearest ground, in this case the ssue nearest the probe p. The plasma causes an
ablave, vaporizing, and coagulaon eect from the applied thermal energy. It has been used for the treatment of airway papillomas suc-
cessfully since 1997 [3].
Bronchoscopy Intervenons for Recurrent Respiratory Papillomatosis
Sepmiu Murgu, MD
The University of Chicago
Grady Hedstrom, MD
The University of Chicago
Tips from the Experts
P A G E 5 V O L U M E 9 , I S S U E 3
Technique includes introducon of a exible APC probe via a exible or rigid bronchoscope. Similar to laser, airway re is a concern at high
oxygen content, thus care should be taken to only apply APC at FiO2 <0.4. Separaon of the probe from the target ssue by a small distance,
<1cm, is necessary to achieve a plasma arc. Thus, APC should be considered a non-contact ablave therapy. Rare complicaons include air-
way burns and perforaon, and very rarely, gas embolism. Overall complicaons are thought to be rare (3.7%) [12].
Microdebrider
Microdebriders are considered an alternave to thermal energy techniques such as laser or APC. The device uses a rotatory cung cup at the
p of a rigid sucon catheter to facilitate rapid ssue removal [4]. Microdebriders have been compared with CO2 laser in prospecve manner
and found to be equally safe and eecve, with potenally lower procedural cost [8].
Technique includes introducon of the rigid microdebrider device via rigid bronchoscope as currently there is no exible opon. Sucon is
applied and contact with target papilloma facilitates cung and removal of ssue. Because ssue removal occurs without thermal energy,
there are no venlatory or FiO2 requirements for use and airway re is not a concern [4,8]. However, because ssue is cut and removed di-
rectly without thermal coagulave eects, bleeding is of concern, and it oen requires thermal energy for its control.
Photodynamic Therapy
Photodynamic therapy (PDT) is a technique that uses an infusion of a photosensizer, pormer sodium or Photofrin, prior to applicaon of
630 nm red light [6]. The photosensizer preferenally is retained in the papilloma cells and when acvated by red light, produces oxygen
free radicals leading to cytotoxic damage and death [10]. While most data published to date relate to its use in the larynx, a recent mulcen-
ter retrospecve case series outlined its use as safe and eecve for bronchoscopic use in tracheal lesions [6].
Technique includes infusion of pormer sodium, 2mg/kg, 48-72 hours prior to bronchoscopic intervenon [6]. A exible 630 nm red light
catheter is introduced via exible bronchoscopy near the target papilloma. The papilloma is then exposed to red light for several minutes.
Cellular death results in sloughing of aected ssue over the following days to weeks (Figure). Repeat exible and/or rigid bronchoscopy for
debulking and cleaning of the aected area is necessary to prevent airway obstrucon from denuded ssue. Complicaons arising from PDT
are thought to be relavely rare, however include photosensivity reacons, airway obstrucon, airway perforaon, and potenally airway
stricture [6].
Other consideraons
HPV genomic DNA has been detected in the plume created by laser ablaon of papillomas [1]. Thus, it is recommended that for ablave ther-
apies, such as laser or APC, appropriate precauons and PPE be used by healthcare providers to reduce the risk of coinfecon. Apneic anes-
thesia and minimal use of jet venlaon may reduce airborne transmission.
Conclusions
There are several modalies for bronchoscopic intervenon which have been demonstrated to be safe and eecve for treatment of tracheal
or airway RRP. Selecon of technique should be individualized based on operator experience, local resources, and paent factors for minimiz-
ing potenal side eects. Repeat intervenon is very oen necessary and mulple approaches may be applied in a single paent.
Tips from the Experts
P A G E 6 V O L U M E 9 , I S S U E 3
Figure
Figure Legend
A cluster of lower tracheal papilloma lesions (le panel). Biopsies showed papilloma and transformaon to squamous cell carcinoma in situ.
PDT was performed with a 1 cm rigid ber, 200 J/cm, adjacent placement (middle panel). At 48 hours post light applicaon, there was airway
edema with minimal sloughing of necroc material, removed using forceps (right panel).
References :
1. Alkotob M et al. J. Bronchol. Interv. Pulmonol. vol. 11, no. 2, Apr. 2004, pp. 132–139.
2. Armstrong L et al. AOHNS, vol. 125, no. 7, 1999, p. 743., hps://doi.org/10.1001/archotol.125.7.743.
3. Bergler W et al. J Laryngol Otol. vol. 111, no. 4, 1997, pp. 381–384., hps://doi.org/10.1017/s0022215100137387.
4. Casal R et al. Respirology, vol. 18, no. 6, 2013, pp. 1011–1015., hps://doi.org/10.1111/resp.12087.
5. Derkay C et al. The Laryngoscope, vol. 118, no. 7, 2008, pp. 1236–1247., hps://doi.org/10.1097/mlg.0b013e31816a7135.
6. Glisinski K et al. Photodiagnosis Photodyn Ther. vol. 30, 2020, p. 101711., hps://doi.org/10.1016/j.pdpdt.2020.101711.
7. Khemasuwan DJ. Thorac. Dis, vol. 7, no. Supplement 4, Dec. 2015, pp. S380–8., hps://doi.org/10.3978/j.issn.2072-1439.2015.12.55.
8. Pasquale K et al. The Laryngoscope, vol. 113, no. 1, 2003, pp. 139–143., hps://doi.org/10.1097/00005537-200301000-00026.
9. Patel N et al. Rhinology & Laryngology, vol. 112, no. 1, 2003, pp. 7–10., hps://doi.org/10.1177/000348940311200102.
10. Proo AE et al. Photodynamic Therapy: Mechanisms, 1989, hps://doi.org/10.1117/12.978012.
11. “Recurrent Respiratory Papillomatosis or Laryngeal Papillomatosis.” Naonal Instute of Deafness and Other Communicaon Disorders, U.S. Depart-
ment of Health and Human Services, hps://www.nidcd.nih.gov/health/recurrent-respiratory-papillomatosis.
12. Reichle G et al. Pneumologie, vol. 54, no. 11, 2000, pp. 508–516., hps://doi.org/10.1055/s-2000-8254.
13. RRPF.org, hp://www.rrpf.org/about.html.
14. Venkatesan N et al. Otolaryngol. Clin. North Am, vol. 45, no. 3, 2012, pp. 671–694., hps://doi.org/10.1016/j.otc.2012.03.006.
15. Zeitels S et al. Curr Opin Otolaryngol Head Neck Surg, vol. 15, no. 6, 2007, pp. 394–400., hps://doi.org/10.1097/moo.0b013e3282f1b2.
16. Zeitels S et al. Ann. Otol. Rhinol. Laryngol. vol. 115, no. 9, 2006, pp. 679–685., hps://doi.org/10.1177/000348940611500905
Humanitarian News
W A B I P N E W S L E T T E R P A G E 7
The COVID-19 Vaccine Patent Waiver: An Acon to Advance
Equitable Access to Medicines?
“Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entled to
the enjoyment of the highest aainable standard of health conducive to living a life in dignity.”
Commiee on Economic, Social and Cultural Rights - General comment No. 14 on the highest aainable standard of health
As specied in the General comment no. 14, the right to health is an inclusive right. It extends not only to mely and appro-
priate health care but also to the underlying determinants of health, such as: access to safe and potable water and adequate
sanitaon; an adequate supply of safe food, nutrion and housing; healthy occupaonal and environmental condions; and
access to health-related educaon and informaon.
Health equity relates to the fairness in distribuon of health resources and outcomes. This applies both to equity between
cizens in specic countries as well as between countries. There is general consensus amongst scholars, polical bodies,
opinion leaders and general populaon that solving these inequies—the huge and remediable dierences in health be-
tween and within countries—is a maer of social jusce, essenal for the linked concepts of fairness, jusce, and freedom.
However, much before the beginning of the COVID-19 epidemic, it was obvious that at a naonal and global level, that ob-
jecve of increasing equality could not be further from reality. Historically, ethical principles in health policy have oen been
disregarded for vulnerable groups, with the distribuon of life-saving drugs considered too expensive and unsustainable and
the recipients deemed unt and unworthy. The Alma Ata Declaraon could not expose it more clearly “The exisng gross
inequality in the health status of the people, parcularly between developed and developing countries as well as within coun-
tries, is polically, socially, and economically unacceptable and is, therefore, of common concern to all countries”. But more
than 40 years later lile real acon has been taken.
The problem is not new, but in Anthony Fauci’s words, the pandemic “shone a bright light on our own society's failings”. Dur-
ing this pandemic, unacceptable disparies intra and inter-countries have achieved their highest levels in the modern era
and have highlighted the serious adverse eects of using an unfeered market-orientated approach to health development.
The ethical distribuon of life-saving medical and public health intervenons amongst vulnerable groups has rarely been
respected. Factors as esmang how much lives are worth linked to an individual's country of origin, the pharmaceucal
industry's priorisaon of prot, the manipulaon of vulnerable groups in clinical trials made the human right to health un-
aainable for many people. The COVID-19 pandemic was an opportunity to remediate that long-standing history of unethical
pracces in global health by making a safe, eecve vaccine accessible to all iniang a new era of global health more ori-
ented to ethical decision making.
At the beginning of the pandemic, vaccine companies such as Pzer stated that they would make sure low-income countries
“have the same access [to the vaccine] as the rest of the world.” Yet what we are seeing today is a massive global disparity in
the allocaon of available vaccines.
High-income countries, represenng just 20% of the global adult populaon, have purchased more than half of all vaccine
doses, resulng in huge disparies of available doses. Of the remaining doses, 33% have been purchased by low-middle in-
come countries (LMIC), who account for 81% of the global adult populaon; and 13% have been by COVAX. Wealthy coun-
tries such as the U.S., Canada, UK and others formalized bilateral agreements with the companies producing the vaccines in
order to their assure their posion at the front of the line well before the vaccines were available. Those strategies to secure
preferenal access, may be understandable within the naonal context, but clearly jeopardise supplies for other countries.
As an example, the COVAX iniave was established to assure and equitable distribuon of vaccines but its goal was never
achieved as vaccine naonalism shown by countries' decisions to accumulate vaccines and inoculate groups that are not at
Humanitarian News
W A B I P N E W S L E T T E R P A G E 8
high risk (as teenagers) has substanally reduced the availability of vaccines. It is esmated that most of low-incomes coun-
tries will not be vaccinated unl the last month of 2023.
It may be argued that If the pharmaceucal companies pung in years of research and development are based in and sup-
ported by high-income countries, those countries have a right to receive their products rst, but having vaccines to cover
low risk populaon when most countries don’t even have enough vaccines to protect their health care workers or their el-
derly populaons seems dicult to jusfy from an ethical point of view. Beyond the global interest of reducing variants, the
moral imperave to provide a fair distribuon of vaccines cannot be ignored.
These deals do not only talk about naons or regions priorising their cizens. Most of all, these negoaons remark the
power of patent-holders. That power allow large pharmaceucal companies to make decisions of high public impact about
access to vital lifesaving healthcare, and at what price.
Patents are generally seen as necessary incenves for the development of medicines. However, the COVID epidemic has
brought to light many quesons that need be asked around the extent of that control in the hands of private patent-holders.
For example, it is known that the research and development by pharmaceucal companies is largely supported by govern-
ment subsidies, which makes the price cited for most medical products mulple mes the real producon cost. Considering
that subsidies given by governments to pharmaceucal companies are nanced with the taxes paid for by cizens (including
vulnerable groups), this unreasonable pricing of drugs and vaccines is of dubious morality and denies vulnerable groups their
right to health. In fact price pracce turn most pharmaceucal rms into the most protable companies compared to other
industries.
The World Trade Organizaon’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) has clearly stat-
ed that while eorts to protect the intellectual property rights of innovang companies has encouraged investment in drug
discovery, the creaon of the 20-year patent for new drugs has meant that many poor people all over the world have not
been able to aord them. This unfairness was patently evident during the 1990s when life-saving anretroviral drugs were
inially denied to those in developing countries because of the unreasonably high costs of the drugs. Patent-holders can
even refuse licenses to third pares to produce a patented medicine transforming the patent-holder in the only provider of
that medicine resulng in dangerous limitaons for its supply. It also impact the price of a medicine as patent-holders can
charge high prices for licenses or access.
In order to decrease the unfairness of distribuon between rich and poor countries, many organizaons, academic leaders
and even policy makers have urged to take concrete acons. Amongst the possible soluons is a vaccine patent waiver,
which was proposed by India and South Africa back in October of 2020. This would allow other companies, including those in
developing countries, to make generic brands of exisng vaccines. The intellectual property temporary waiver proposal
would allow countries to choose not to apply or implement patents and other exclusivies that could obstruct the produc-
on and supply of COVID-19 medical tools, unl global herd immunity is reached. Aer the inial proposal of India and South
Africa in October 2020, now the proposal is ocially endorsed by 58 sponsoring governments, and 100 countries supporng
the proposal overall.
However a small number of wealthy countries, as the U.S. , the European Union, UK, Japan, and Australia amongst others,
opposed the proposal. In a remarkable decision, on May 5th, United States President Biden decided to change U.S. policy,
backing the proposal.
Maintaining patents is ethically unacceptable as it means deliberately refusing to help countries in desperate need and vio-
lates the principle of benecence (doing good for others), jusce and non-malecence (not creang harm for others) and it
results in concrete consequences as the occurrence of evitable deaths. This is because vaccine patents, which are a form of
intellectual property (IP) rights, lead to create monopolies that contribute to increased prices and decreased access. This
injusce has been described as ‘vaccine apartheid’ because it creates obscene disparies in vaccine access.
Under internaonal trade law, mechanisms exist for States to issue compulsory patent licenses – following certain criteria
and in specic circumstances. Compulsory licenses allow the State to grant permission to a third party to produce the pa-
tented invenon, e.g. medicine, without the patent-holders consent.
Waiving patents is not a radical or new proposal and it would not be the rst me that patent waivers were allowed. In
2001, the “Doha Declaraon on TRIPS and Public Health” eliminated patents on drugs for HIV, allowing for cheaper produc-
Humanitarian News
W A B I P N E W S L E T T E R P A G E 9
on and more aordable products. It was also the case during the 1980’s with the hepas B vaccines. However tradional-
ly, countries have been reluctant to use compulsory licenses because of the strong industry opposion. But in the devas-
tang context of Covid-19 many social actors are urging for change. Some countries have adopted legal measures to facili-
tate compulsory licensing where needed for Covid-19 and other States should follow soon. However, in general, compulsory
licensing is not complete and mely enough for COVID-19 vaccines: it is a slow mechanism as it requires separate negoa-
ons between countries and companies, and mainly because would not provide access to key elements in producon such
as trade secrets, it maintains barriers for collaboraon and import and export of products and materials and does not cover
future vaccines. The waiver would remove any obstacles for global vaccine producon, present and future. However, in the
light of the opposion, it seems that without a strong internaonal movement and direct pressure, that sort of acon is un-
likely.
Under the 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), pharmaceucal companies have
at least 20 years from ling a patent to prot from their investments in developing pharmaceucal products throughout the
world. Global IP rights, whether adopted in accordance with TRIPS, or subsequent bilateral and mullateral agreements, are
part of a wider legal system which facilitates that powerful actors such as the European Union (EU) and the USA have includ-
ed TRIPS-plus clauses that oen force countries of the Global South to concede to more stringent patent protecons in order
to gain trade advantages and also to escape trade sancons. In so doing, IP law commodies medicines that are essenal to
human survival and well-being, and sacrices the lives and health of the poor and vulnerable in order to priorize corporate
protability. That comes from the common interpretaon by the internaonal IP system that healthcare products and ser-
vices derive their value from their tradability and not from their nature of public goods.
The World Trade Organizaon (WTO) Doha Declaraon on TRIPS and Public Health recognizes human rights and allows
states to use all of the ‘exibilies’ within the TRIPS regime to protect public health, agreeing on the need for access to med-
icines in a public health emergency. However, this internaonal consensus on employing TRIPS exibilies of IP has always
been strongly contested by pharmaceucal companies and their host governments and even during this pandemic the
aempts of LMIC to try to obtain a TRIPS waiver to increase their supply of vaccines have been unsuccessful.
Crics of a waiver argue that this process would not create rapid increase in supply, because the complex manufacturing
processes and the length of me it takes to build new factories are amongst the major obstacles to increasing the global sup-
ply of vaccines and so, patents are not the liming factor. It is also said that compeon for access to the raw materials
could slow the already working producon and even results in decrease of supply. And of course they claim that if compa-
nies have no prot incenve to create these new health care products, then we may see a drop in the investments of the
pharmaceucal rms. This later seems a more than quesonable argument taking into account the magnitude of billionaire
prots of the pharmaceucal companies. Moderna's share price has gained more than 700% since February 2020, while
BioNTech has surged 600% and CanSino Biologics' stock is up about 440% over the same period. For example it is expected
Moderna to make $13.2 billion in Covid-19 vaccine revenue in 2021. It must be kept in mind that vaccine producon was
possible because the company has received billions of dollars in funding from the US government for development of its
vaccine. It means that in most of the cases, the nancial risk of developing the vaccines was eecvely carried by the taxpay-
ers, funded by public money which makes at least somewhat dubious that they are only property of these companies and
could be freely used to deliver these enormous prots.
Voluntary licensing is oered as an alternave. However, arrangements where patent-holders voluntarily license their pa-
tents freely on reasonable terms are needed. Precedents cauons not to let our hopes run too high about those voluntary
contribuons. As Yuanqiong Hu, Senior Legal and Policy Advisor at MSF’s (Médecins sans Froners) Access Campaign said.
“Governments that oppose the monopoly waiver proposal know that simply asking pharmaceucal corporaons to voluntari-
ly do the right thing will not get us anywhere, when these aempts have so far failed to secure global access to COVID-19
medical tools for people who urgently need them. It’s me for change, not charity”.
Potenal opons to patent waiver could be to increase direct patent licensing, allowing the rms producing vaccines to part-
ner with specic companies to increase producon while sll protecng their intellectual property. Addionally, exporng
exisng vaccines could alleviate the shortage of vaccines in some countries. At May 2021, the U.S. had donated only around
1% of the vaccines it has produced although President Biden has recently pledged to donate 20 million U.S.-made vaccines.
On the other hand, many middle-income countries like China and Russia or low-income countries like India have already ex-
ported a signicant proporon of their vaccines to other countries.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
Vaccine donaons are not the soluon to the scarcity of COVID-19 vaccines in many countries. Yet, the potenal number of
surplus vaccine doses purchased by wealthy naons are suciently large to help with near-term vaccine demands while in-
vestments are made in technology transfer to LMICs and in scaling up global manufacturing capacity for vaccines. Maximiz-
ing the potenal of vaccine donaons in this pandemic depends on vaccine doses going where they can do the most good,
but there is no full agreement where they should go. COVAX has been cricized for its populaon-based allocaon scheme
that does not direct most of its early vaccine supplies to the sengs at the greatest risk of otherwise having high COVID-19
death rates. But even if Covax in the most opmisc scenario, succeeds in reaching its targets, only 20% of people in low and
middle income countries (LMICs) will be fully vaccinated by the end of 2021, because those planned targets were very mod-
est based on a “scarcity mindset”—expecng that total global doses would be limited and rich naons would likely hoard the
supply. But the rapid development of several vaccines allowed the rich naons to buy more doses than they could ever use
and are not sharing with anyone. Canada has procured enough doses to vaccinate all its cizens 10 mes over. UK could vac-
cinate everyone in the UK eight mes over.
On the other hand, naons donang COVID-19 vaccines bilaterally have used their donaons (as any internaonal bilateral
cooperaon) more as a means of polical inuence than advancing global vaccine equity and saving lives. It is imperave
that donor countries keep the commitment of grounding future COVID-19 vaccine donaons in epidemiology and not geo-
polics.
But even when donaons are the quickest way to increase availability of vaccines they are not enough. Donaons are a char-
ity model and aer the ‘‘gi’’ is over the vaccine supply dilemma remains. It is imperave to create a sustainable model for
LMICs to be able to make their own vaccines to ensure populaon-wide vaccinaon soon enough to prevent thousands of
deaths. The model of donaons rather than allowing for equitable vaccine access as a basic human right for all people every-
where, turned to a charitable donaon and market purchase scheme through the COVAX iniave. This type of model,
which focuses on charity and not rights, keeps the colonial ideology’, in parcular by addressing the untold idea that to be
colonized was to be inferior. Vaccine access should not be a queson of charity but of states fullling their human rights
commitments under internaonal law.
A waiver of intellectual property protecons on covid-19 vaccines, including on their components and raw materials is an
urgent rst step that must be taken soon. It will need to be reinforced by transfer of technical knowledge from vaccine mak-
ers in the global north to regional hubs or directly to manufacturers in the global south and by the nancial help needed for
wide subsidizaon of manufacturing in LMICs.
The People’s Vaccine Alliance, a grouping of several non-prot, non-governmental organizaons including Global Jusce
Now, Oxfam and Amnesty Internaonal, is calling for the pharmaceucal rms to share their technology so that global pro-
ducon of vaccines can be quickly increased, claiming that the scarcity of vaccines is arcially created by these monopolies,
and that there is enough space for these companies to make a more than decent return instead of obscene prots that cre-
ate a few new billionaires. Addionally Dr Christos Christou, MSF Internaonal President has claimed that “Countries must
stop obstrucng and show the leadership required to deliver on the ‘global solidarity’ they have so oen declared during this
pandemic”. “It’s me to champion access to medical tools for everyone, wherever they live.”
Internaonal human rights law provides a universal framework for advancing global health with jusce, transforming moral
imperaves into legal entlements. The right to the highest aainable standard of health, rst arculated in 1946 in the
WHO Constuon, has evolved through the progression of treaes such as the Internaonal Covenant on Economic, Social
and Cultural Rights (ICESCR). Nearly every country in the world has now raed at least one internaonal agreement that
imposes specic obligaons that lead to the realisaon of the right to health, including explicit obligaons to prevent, treat
and control epidemics.
The United Naons (UN) Commiee responsible for interpreng the ICESCR, has emphasized that states ‘have a duty to pre-
vent intellectual property and patent legal regimes from undermining the enjoyment of economic, social and cultural rights’,
and that the IP regime should be interpreted and implemented in a manner supporve of the duty of states ‘to protect public
health’.
Arguments to defend IPRs simply do not hold. The protecons of IPRs to the vaccine companies are causing health and soci-
oeconomic suering globally, rather than alleviang them. Delaying vaccine access for billions of people threatens the con-
nuaon of the pandemic and development of new dangerous variants.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 11
The inequalies and injusce concerning access to vaccines and medical supplies needed during COVID pandemic do not
occur out of the blue. The commodicaon of essenal medicines is the consequence of the prevalent system of global capi-
talism that allows manufacturers and states to value nancial prot over human life. The worsening of inequality crisis trig-
gered by COVID-19 is framed by the economic model and has meant an increase in poverty, unemployment and a colossal
suering for millions of people while, at the same me, allowed some of the world’s largest corporaons to get billions of
dollars in prots to shareholders then increasing the gap between rich and poor in an unprecedented magnitude. COVID-19
should be the opportunity for radically restructuring business models (at least in health care) with the purpose of granng a
decent status of wellbeing for everyone by creang an economy for all. It is necessary to keep in mind that we are able to
live together because all the members of the society (having raonalized it or not) have signed the basic covenant, the social
pact, to come together and form a people, a collecvity. That is the foundaon of democracy, the collecve renunciaon of
the individual rights and freedom that each one would have in the State of Nature, in order to design authories directed to
the get the good of all considered together. That social contract includes the idea of reciprocated dues: the authority is
commied to the good of the individuals who constute it, and each individual is likewise commied to the good of the
whole. That social pact requires the collecve percepon that each individual is really geng from the authority the preser-
vaon of their wealth, the protecon of their lives, liberty, and well-being in general, Locke easily imagine the condions
under which the contract with the government or the economic and polical elites is destroyed, driving men feel jused in
resisng the authority. It has been well said “Let no man pull you so low as to hate him” but the imperave of our me is
“Let no man pull him so low as to hate you”.
The me for declaraons and pompous words is over. It is urgent to act and prevent suering and death for thousands and
thousands of people. And it will not be done without understanding that the pandemic is not over unl it's over everywhere.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
References
1. Goncalves G. BMJ 2021;373:n1249
2. Kohler JC et al. BMC Med 18, 193 (2020). hps://doi.org/10.1186/s12916-020-01661-3
3. McMahon A. Journal of Medical Ethics 2021;47:142-148.
4. Médecins Sans Fronères. Countries obstrucng COVID-19 patent waiver must allow negoaon hps://www.msf.org/countries
obstrucng-covid-19-patent-waiver-must-allow-negoaons Date accessed: August 1, 2021
5. Rouw A et al. Global COVID-19 vaccine access: a snapshot of inequality. hps://www.k.org/policy-watch/global-covid-19-vaccine-
access-snapshot-of-inequality/ Date accessed: July 14, 2021
6. Sekalala S et al. BMJ Global Health 2021;6:e006169.
7. United Naons Human Rights Oce of the High Commissioner (OHCHR). Internaonal covenant on economic, social and cultural
rights, 1966. Available: hps://www.ohchr.org/documents/professionalinterest/cescr.pdf
8. Wilkinson RG et al. (2003). Social Determinants of Health: The Solid Facts. Geneva: World Health Organizaon.
*The views expressed in this arcle are those of the author (Silvia Quadrelli) and do not necessarily reect the ocial posi-
ons of the Execuve Board or Internaonal Board of Regents of the WABIP.
Best Image Contest 2021 (3 of 3)
Descripon:
Malignant Peripheral Nerve Sheath Tumor involving the pleura (A) in paent with Neurobromatosis (B)
Submiers:
Dr. Syeda Samia rasheed, Dr. Varun, Dr. Tiyagesh, Dr. Hari Kishan Gonuguntla
[Division of Intervenonal Pulmonology, Yashoda Hospitals, Hyderabad, India]
Best Image Contest
P A G E 13
This image is the 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2020. Please
stay tuned to the next Image Contest opening later this year! Find the above image and more at the WABIP
Academy Image Library at hps://www.WABIPacademy.com/imagelibrary
P A G E 14
WABIP News
New EBUS-TBNA Secon
Thank you to all those who applied for this new WABIP secon. We are happy to
announce 110 people joined from over 30 countries. Furthermore, we are
pleased to welcome Dr. Atul Mehta, Dr. Rocco Trisolini & Dr. Takahiro Nakajima
as secon coordinators. Under the auspices of these three, the secon will em-
bark on many new projects and acvies that improve WABIP members’
knowledge and technical skills of EBUS-TBNA. Please visit the secon page at
hps://www.wabip.com/ebus for all the latest news & updates from the sec-
on.
Invitaon to WCBIP 2022 Marseille, France
We would like to cordially invite you to join us in MARSEILLE, France, for
the 22nd WCBIP/WCBE from October 6th to 9th, 2022.
Organized by the WABIP and IBES, our biennial internaonal meeng is
dedicated to Bronchology and Intervenonal Pulmonology and will oer
high-caliber scienc programs with emphasis on new bronchoscopy
techniques, technologies and hands-on procedure workshops in which
you can meet and collaborate with colleagues from all around the world.
The pandemic has changed the format of conferences in general. And as
we have seen in our most recent WCBIP, purely virtual events can be just
as successful as tradional ones. The 22nd WCBIP shall be a “hybrid” event that will adopt this new format of meengs while
accommodang those who can be on-site in beauful Marseille, France.
In this congress, we will reinforce the importance of intervenonal pulmonology in this ever-changing world. Indeed globalizaon
marks a break in physical space and a break in communicaon mes that permeate our daily lives and medical pracces. We will
maximize communicaon technologies to oer equal educaon regardless of aendees’ places of parcipaon. This presents a
great opportunity for our 10,000 worldwide WABIP members to get all the latest informaon regarding advances in technologies,
educaon, and research in the eld of lung airway and pleural disorders through our numerous didacc lectures, interacve ses-
sions, and expert panel discussions.
We warmly welcome you in Marseille in October 2022 for this excing event to share scienc experse, but also to meet friends
and enjoy the gentle and sincere hospitality of the people by the Mediterranean Sea. Visit the congress site at hps://
www.WCBIP.org
Navigaon Bronchoscopy Webinar 2021
We are pleased to announce our Navigaon Bronchoscopy course is now being
oered as a Zoom webinar and for FREE to all WABIP members. Under the direcon
of Dr. Erik van der Heijden and team, this 2-day webinar will cover:
• The idencaon of paents suitable for navigaon bronchoscopy
• The design of clinical work-up that should enable a navigaon bronchoscopy program
• Disnguishing the dierent navigaon guidance techniques, pro’s and con’s
• Performance of dierent navigaon bronchoscopy techniques
• Interpretaon of navigaon technique results and drawing conclusions
Registraon starts in early November 2021. Please visit hps://www.wabip.com/navigaon for more informaon.
New secon coordinators:
Dr. Atul Mehta, Dr. Rocco Trisolini, Dr. Takahiro Nakajima
Hideo Saka, MD (Chair WABIP), Philippe Astoul, MD, PhD (President WCBIP),
Hervé Dutau, MD (President WCBE)
Don’t Listen To The Person Who Has The Answers, Listen To The Person Who Has The Quesons! (Albert Einstein)
Lung cancer staging is paramount in determining the therapeuc approach, especially surgery vs. no surgery. Nodal staging is one of the crical
components of staging and perhaps the most controversial one due to the sampling of the precise locaons or lack thereof.
The current guidelines from the American College of Chest Physicians for mediasnal staging for peripheral clinical stage IA tumor (negave nodal
involvement by CT and PET) suggest that invasive pre-operave evaluaon of the mediasnal nodes is not required (Grade 2B).
Nonetheless, studies have shown that CT and PET negave nodes can be posive with invasive sampling such as Endobronchial Ultrasound-guided
Transbronchial Needle Aspiraon (EBUS-TBNA) in upwards of 10% of the paents with peripheral T1 disease. Other studies have concluded that N2
and N3 disease is seen in up to 11-13% of the paents with T1 lesions.
One must wonder why such high nodal posivity in the ipsilateral and contralateral nodes with small peripheral lesions. One of the possible con-
founding factors might be the “denion” of peripheral vs. central lesions. Dierent authors have used dierent denions of peripheral, including
distance from the pleura, distance from the mediasnum, medial and lateral thirds, etc. The queson one must ask is, considering similar growing
data, is it safe to not perform invasive staging of the mediasnum in paents with T1 peripheral lesions or to revisit the current staging strategy?
A recent study by DuComb et al. published in May 2020 CHEST (1) looked at the prevalence of N2/N3 diseases in the radiologically occult medias-
num with T1 tumors (cT1N0M0) in non-small cell cancer (NSCLC). The authors used the Naonal Lung Screening Trial data. They used X, Y, and Z
coordinates (Fig 1) from the main carina to evaluate the centrality of the nodule. This is a relavely novel and objecve technique. They found no
associaon between nodule locaon (central or peripheral) and the risk of nodal involvement. They also did not nd any dierence in nodal in-
volvement based on tumor size (within T1) or locaon. The authors found approximately 8% radiologically occult mediasnal involvement on EBUS
TBNA or another invasive sampling of the mediasnum and hilum. Hence, they recommend expanding the invasive staging to all peripheral T1 lung
tumors regardless of their centrality, size, or locaon. Some potenal limitaons of
the study include 1, lack of systemac use of PET scans in staging in this study pop-
ulaon, which has shown increased sensivity over CT for mediasnal nodal in-
volvement 2, lack of standard denion of central and peripheral in the previous
studies liming fare comparison to the this study’s data 3, lack of proven dierence
in the management and outcomes with single staon radiologically occult N2 dis-
ease.
I believe there is enough growing evidence to quesons the current algorithm of
staging strategies and perform more studies like Dr. DuComb’s to move the needle
on the precise therapy for lung cancer.
Reference: DuComb et al; CHEST 2020; 158(5):2192-2199
Ali I. Musani MD
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 15
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
Figure 1: Reprinted from “Chest, 2020 Nov;158(5):2192-2199., DuComb EA,
Tonelli BA, Tuo Y, Cole BF, Mori V, Bates JHT, Washko GR, San José Estépar R,
Kinsey CM., Evidence for Expanding Invasive Mediasnal Staging for Peripheral
T1 Lung Tumors”, with permission from Elsevier.
P A G E
16
WABIP ACADEMY- WEBCASTS
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
W A B I P N E W S L E T T E R
Links
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
surgeons.
www.jrs.or.jp The Japanese Respirology Society
sites.google.com/site/asendoscopiarespiratoria/
Asociación Sudamericana de Endoscopía Respiratoria
P A G E 16