WABIP Newsletter 2021, Issue 1

Volume 09

Issue 01

January 2021

Inside This Issue

Editorial, 2

Technology Corner, 3-6

Tips from the Experts, 7-9

Humanitarian News, 10-15

Best Image Contest, 16

WABIP News, 17

Research, 18

Links, 19

Editorial: 21st WCBIP 2020 at a Glance

WABIP Newsletter

J A N U A R Y 2 0 2 1 V O L U M E 9 , I S S U E 1

EXECUTIVE BOARD

Hideo Saka, MD

Japan, Chair

Stefano Gasparini,

Italy, Vice-Chair

Silvia Quadrelli, MD

Argenna, Immediate

Past-Chair

David Fielding MD

Australia, Treasurer

Naofumi Shinagawa,

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

Guangfa Wang MD

Beijing, China

President WCBIP 2020

We are pleased to report that the 21st congress

and the rst virtual congress of the WABIP was an

astounding success. This 2 ½ day event was com-

prised of world class presentaons by IP experts

from North America, South America, Europe, Africa,

Oceania and Asia.

In the evening of Nov 19, 2020 (Beijing me), the

opening ceremony began with a brief introducon

video on history of intervenonal pulmonology, to

its phenomenal growth, and to the current state of

the WABIP with nearly 10,000 members worldwide.

The ceremony also highlighted the rapid develop-

ment of IP in China. Myself, the president of WCBIP

2020, underscored the complexies organizing this

event, especially during the age of COVID-19. Also

in the ceremony were leaders from Chinese Thorac-

ic Society, Chinese Endoscopist Associaon, Chi-

nese Medical Associaon and China Naonal

Health Commission. They expressed their sincerest

gratude and warm congratulaon on the con-

gress, and especially to our colleagues ghng

against COVID-19. Last but not least, WABIP Chair

Prof. Silvia Quadrelli gave a wonderful presentaon

on the WABIP, and announced the WABIP Awards

recognizing those with signicant contribuons to

bronchology and intervenonal pulmonology.

The total number of registrants is 13,240 from 72

countries and regions, and the total visits to the

congress is 162,177. The most viewed session was

“Intervenonal pulmonology in the pandemic of

COVID-19”, which had 32,613 total viewers. And

ed for 2nd most popular sessions were “the Chal-

lenges of COVID-19 pandemic to Intervenonal

Pulmonologists” by myself and “Clinical Ulity of

Ultrathin Bronchoscopes” by Dr. Masahide Oki

from Japan.

While COVID-19 was indeed a hot topic of the con-

gress, lung cancer remained one of the main focus-

es of the event. Many topics and discussions were

related to early diagnosis, precision staging, genec

or pathologic technologies and intervenonal therapies.

Early lung cancer therapies with PDT, microwave, radiofre-

quency or cryotherapy aroused great interest from the audi-

ences. These novel technologies might be the standard ther-

apies to lung cancer tomorrow. Addionally, the interven-

onal therapies aracted great aenon to the aendees

either on dierent modalies, complicaons, long term out-

comes and peri-procedure care. Stem cell and gene therapy

on COPD were also discussed on the congress. The congress

also covered other technologies or elds in bronchology and

intervenonal pulmonology such as benign or malignant air-

way stenosis, cryobiopsy, thoracoscopy, trans-vascular or

trans thoracic modalies and IP educaon. Suce to say,

WCBIP 2020 oered a full spectrum of topics on bronchology

and intervenonal pulmonology.

Lastly, we are pleased to have had a closing ceremony

aracng thousands of audiences globally. The ceremony

began with “Forbearance with Bronchoscopy A Review of

Gratuitous Indicaons”, a presentaon by Dr. Atul Mehta,

which highlighted the boundary of bronchoscopy procedures

and reminded us these technologies should be not be used

for gratuitous indicaons. Addionally, organizing commiee

member Dr. Jie Zhang announced 5 best oral winners and 10

best poster winners for their excellent presentaons based

on the scoring of session chairs. I gave a summary of the con-

gress, emphasizing parcipaon of 256 conrmed speakers

who conducted 398 speeches in 125 academic sessions. Only

3 speakers were absent from the congress. Among 50 oral

presentaons, only four were absent.

Also in the closing ceremony, the new chair of WABIP, Dr.

Hideo Saka, had armed the success of the congress and

expressed his gratude to all involved. He also noted some

improvement in the future WCBIPs. Last but not least, as per

tradion in all WCBIP closing ceremonies, the WABIP ag was

transferred (but virtually this me) to Dr. Philippe Astoul who

will be organizing the next WCBIP in 2022 in Marseille,

France.

In conclusion, the congress created a milestone for WABIP

with the above menoned number of parcipants, sessions,

and over 25 company sponsors, and 17 industry symposia

and workshops. But there is no mistaking that we owe the

success of this congress to you and WABIP members who

submied over 600 abstracts and parcipated in our many

oerings. It has been my honor and pleasure to be the 21st

President of the WCBIP. Let us take sasfacon in the suc-

cess of WCBIP 2020, while we look forward to WCBIP Mar-

seille and having another wonderful scienc event .

Technology Corner

Currently Available EBUS-TBNA Needles

INTRODUCTION

The oncological approach to lung cancer was revoluonized forever aer the introducon of linear EBUS in the early 21st century

[1,2] as a tool for invasive mediasnal staging. The development and improvement of the materials and equipment used are ongo-

ing and are unlikely to end soon - something that should always be in the mind of those who deal with cases as complex and chal-

lenging as lung cancer can be. Therefore, since Olympus launched their rst EBUS-TBNA needle, the dedicated 22-gauge TBNA nee-

dle (NA-201SX-4022, Olympus, Tokyo, Japan)[3]; several other needles have emerged on the market. The purpose is to achieve the

most reliable sample, less trauma to the biopsied ssue, increased safety for the paent and the life of the bronchoscope and im-

proved ergonomics for the bronchoscopist. In addion, other diagnoses are also possible using EBUS, such as sarcoidosis, lympho-

ma and granulomatous infecous diseases - situaons in which the maintenance of adequate ssue architecture is even more im-

portant.

In this arcle, we will review the current needles available on the market and their parcularies.

BACKGROUND

Important qualies for EBUS-TBNA needle:

• Ergonomics: ergonomic handle for comfortable use by bronchoscopy.

• Safety: easy and safe locking mechanism, avoiding accidental protrusion of the needle during puncture and needle passage.

• Elegance and soness: needle penetraon as smoothly as possible, so the force necessary to cross the airway and the lymph

node capsule is minimized, avoiding damage to the carlage and contaminaon of the sample with airway material and blood.

• Flexibility: adequate exibility to reduce the distance from the p of the bronchoscope with the airway wall that occurs when

it is inserted into the distal poron of the working channel.

• Visibility: Echogenic p for adequate real-me visibility of the needle under ultrasound during the procedure.

In order to encompass all these characteriscs in the best possible way, several needles have emerged on the market over the

years as new technologies have been developed and new needs have been perceived.

W A B I P N E W S L E T T E R

P A G E 3

Kazuhiro Yasufuku MD, PhD, FRCSC

Division of Thoracic Surgery,

Toronto General Hospital,

University Health Network

Camila Greggianin MD

Division of Thoracic Surgery,

Toronto General Hospital,

University Health Network

CLINICAL APPLICATION - CURRENT NEEDLES AVAILABLE ON THE MARKET [4–9]

There is no published clinical trial comparing the accuracy of all available needles, so the current ones will be listed, highlighng their par-

cularies and potenal advantages. In this arcle, we will not cover mini-forceps.

Olympus

• ViziShot:

The classic needle developed since its prototype together with the EBUS linear bronchoscope. The available sizes are 21g and 22g.

• ViziShot 2:

The design and the material of the outer sheath have been revised which now provides beer exibility of the needle with 10 degrees

more angulaon when set on the bronchoscope. The p of the sheath is also green in color, which allows for easier endoscopic viewing.

There is also less movement of the outer sheath when advancing the needle out. The p of the needle is redesigned to be sharper, for a

less traumac ssue inseron. The available sizes are 25g, 22g, 21g.

Within the Vizishot 2 family, there is also the 19g FLEX needle, which, due to its internal diameter of 1 mm, is able to sample ssue for his-

topathological analysis, not only cytological. Despite the larger diameter, due to the spiral laser cuts along the sides of the needle surface,

the exibility is improved compared to the classical ViziShot lineup. The result is a greater angle which facilitates the visualizaon of the

most challenging lymph node staons.

Recently, the newest 25g size Vizishot 2 needle was launched. This needle can cover all the quality expected for the product, with extreme

smoothness during penetraon. In general, smaller needles generate less trauma in the sample, and therefore less blood contaminaon -

which is a crucial factor during rapid on-site cytological evaluaon.

Cook Medical

• EchoTip

Ultra

In its design, this needle features a highly exible spiral sheath, with the aim to facilitate access to regions where greater bronchoscope

angulaons are required. In addion, the p is a ball p type conguraon. Available in sizes 22g and 25g.

• EchoTip ProCore

This Cook needle is designed for the acquision of histological material, regardless of caliber, due to the design of its p. The 22g needle is

designed with a built-in ball p, while the 25g needle has a beveled p. Both, although dierent, aim to incise lymph node ssue during the

passage of the needle and collect the material inside the needle.

Boston Scienc

• Expect

Pulmonary

Available in sizes 22g and 25g, the material of this needle is cobalt-chromium which is 24% harder than stainless steel (data provided by the

company), thus being more resistant to deformaon aer several passages and excellent tracon properes. However, due to the rigidity

of the needle the inseron angle of the needle is not as steep as the Olympus needle. It also has great clarity in the echographic image. A

non-inferiority was shown in a study comparing 22g with 25g needles[10].

• Acquire

Pulmonary

The main feature of this needle is its Franseen style p. This design was already used for other radiological approaches to ne-needle punc-

ture and aims to collect histological material even for smaller diameter needles. Like the Expect, it is also made of chromium-cobalt, main-

taining its same qualies: good needle penetraon, beer ability to push, resistance to torsion and deformaon aer several passes. How-

ever, similar to the Expect needle, the inseron angle of the needle is not as steep as the Olympus needle.

W A B I P N E W S L E T T E R P A G E 4

Medi-Globe

• SonoTip® EBUS Pro Flex:

Derived from the EUS needles already made by the company. It is the rst needle completely made from Ninol. Made of ninol or stain-

less steel, compable with Olympus, Pentax and Fujilm EBUS-scopes. Sharpe p as most of the other needles. Available only in size 22g.

• SonoTip TopGain® EBUS-TBNB:

It has a p like Boston Acquire, which is called a "crown cut" by the manufacturer, with the aim of reducing the fragmentaon of the mate-

rial when the needle is introduced. Available only in size 22g, but in stainless steel and ninol.

Table 1: Comparison between needles.

W A B I P N E W S L E T T E R P A G E 5

Brand and type of

the needle

Picture

EBUS scope com-

patibility

Needle size (g)

25 22 21 20 19

Olympus

ViziShot

Olympus

x x

Olympus

ViziShot 2

Olympus x x x

Cook Medical

EchoTip® Ultra

Olympus, Pentax x x

Cook Medical

EchoTip Pro-

Core®

Olympus, Pentax x x

Boston

Scientific

Expect

Pulmonary

Olympus x x

CONCLUSION

Minimally invasive strategies with the greatest possible accuracy should be the focus of today's bronchoscopist. Performing a trans-

bronchial puncture is not limited to the bronchoscopic technique alone. The acquision of an adequate sample for diagnosis starts with the

indicaon of the procedure, adequate training, knowledge and choice of the needle according to the diagnosc hypothesis and purpose of

EBUS, in addion to a muldisciplinary relaonship between the bronchoscopist and the cytologist.

References:

1. Yasufuku K et al. Chest 2004;126:122–8. hps://doi.org/10.1378/chest.126.1.122.

2. Krasnik M et al. Thorax 2003;58:1083–6. hps://doi.org/10.1136/thorax.58.12.1083.

3. Yasufuku K et al. Lung Cancer 2005;50:347–54. hps://doi.org/10.1016/j.lungcan.2005.07.013.

4. Dincer HE et al. Med Devices Evid Res 2016;9:467–73. hps://doi.org/10.2147/MDER.S62724.

5. Olympus America | Medical | n.d. hps://medical.olympusamerica.com/ (accessed December 20, 2020).

6. Medical Devices for Minimally Invasive Procedures | Cook Medical n.d. hps://www.cookmedical.com/ (accessed December 20, 2020).

7. Boston Scienc- US - Boston Scienc n.d. hps://www.bostonscienc.com/en-US/Home.html (accessed December 20, 2020).

8. SonoTip Pro Control - Medi-Globe GmbH EN n.d. hps://www.medi-globe.de/en/sonop-pro-control.html (accessed December 20, 2020).

9. Medical Technology, Services & Soluons Global Leader | Medtronic n.d. hps://www.medtronic.com/ca-en/index.html (accessed December 20,

2020).

10. Di Felice C et al. J Thorac Dis 2019;11:3643–9. hps://doi.org/10.21037/jtd.2019.04.20

W A B I P N E W S L E T T E R P A G E 6

Boston Scientific

Acquire

Pulmonary

Olympus x x

Medi-Globe

SonoTip® EBUS Pro

Flex

Olympus, Fujifilm,

Pentax

Medi-Globe

SonoTip TopGain®

EBUS-TBNB

Olympus, Fujifilm,

Pentax

Tips from the Experts

P A G E 7 V O L U M E 9 , I S S U E 1

Introducon

Percutaneous tracheostomy placement for paents with respiratory failure requiring long-term weaning from mechanical venlaon is a

standard pracce in the intensive care unit. The COVID-19 pandemic has brought new concerns regarding the safety, ming, and technique

for tracheostomy placement due to the potenal for transmission to healthcare workers (HCWs). As a result, expert consensus statements

have been formulated and updated as we connue to gain experience with thoughul adaptaons for tracheostomy placement in paents

aected by COVID-19.

Indicaons:

At our instuons, paents who require long-term venlator management and weaning including paents with COVID-19, are considered

for tracheostomy placement. In order to safely perform tracheostomy placement, the paent must be hemodynamically stable and be able

to withstand periods of apnea during the procedure. Ideally, tracheostomy placement will assist hospitals to decompress the intensive care

units and allow for the safe transfer of paents to long term acute care facilies for weaning from mechanical venlaon.

Procedural Consideraons

Planning

When considering tracheostomy placement at our instuons for COVID-19 paents, the following quesons are being addressed.

1.What is the overall prognosis of the paent? Have goals of care been discussed with the paent or family members?

2. How stable is the paent? Is medical opmizaon required prior to tracheostomy for coagulopathy, shock or hypotension requiring high

doses of pressors, or high venlator requirements (>40-60% FiO2 or PEEP 10-14cmH20).

3. Will the team be able to successfully perform the tracheostomy at the bedside? Or should a surgical approach be considered in the oper-

ang room?

4. Is enhanced personal protecve equipment (PPE) available?

5. Which team members are necessary in the room? In our experience with the percutaneous approach, an operator and bronchoscopist

are required along with a respiratory therapist and nurse. Alternavely, an anesthesia team member may replace both the respiratory ther-

apist and nurse during the procedure in order to minimize exposures and conserve PPE.

Technical Guidelines

Recommendaons from consensus statement have been described and summarized below (1,2).

1. Tracheostomy should be considered when prolonged mechanical venlaon is ancipated.

2. Both open surgical and percutaneous approaches for tracheostomy are acceptable.

3. Use of enhanced PPE to migate risk to HCWs is encouraged.

Technique and Timing of Tracheostomy for Paents with COVID-19

Chrisne Argento, MD

Northwestern Memorial Hospital

Ajay Wagh, MD

The University of Chicago

Tips from the Experts

P A G E 8 V O L U M E 9 , I S S U E 1

4. Tracheostomy should be performed in a negave-pressure room.

5. Ulize the least number of providers with the highest level of experience.

6. Maintain closed circuit venlaon while paent is on mechanical venlaon with in-line sucon.

7. Use techniques and equipment with which operators are familiar, condent, and experienced.

8. Encourage the maintenance of a bloodless eld, minimal use of diathermy, and use of smoke evacuator when using an open surgical ap-

proach.

9. Consider a trial of apnea aer preoxygenaon with FiO2 of 100% and PEEP of 5cmH2O to evaluate physiological readiness.

Suggested Timing

The ming of percutaneous tracheostomy placement for paents with COVID-19 has been unclear with insucient evidence for any rm rec-

ommendaons (1). Our instuons follow the suggesons from the published expert panel reports (1, 2).

1. Delay the procedure unl at least day 10 of mechanical venlaon.

2. Consider only when paents are showing signs of clinical improvement.

Due to prior studies demonstrang absence of viral shedding aer 21 days from symptom onset, some groups have suggested waing this

period of me prior to performing tracheostomy. In a single system, mul-center study, Chao and colleagues reported that it is reasonable to

consider tracheostomy before 14 days since they found a (weak) posive correlaon (R

0.1382, p=0.04) where paents who underwent ear-

lier tracheostomies tended to achieve earlier venlator liberaon (3). Another study from Avilés-Jurado and colleagues found that the suc-

cessful weaning rate was higher in the early bedside surgical tracheostomy group (<10 days intubaon) compared with the late tracheostomy

group (>10 days intubaon) with no infecons among surgeons idened at the end of the study (4). An analysis of 148 paents who under-

went tracheostomies in the rst 2 months of the pandemic in New York City, showed that early tracheostomy was noninferior to late trache-

ostomy and it did not contribute to increased infecons of clinicians (5).

That being said, there is now data showing that the peak of infecvity of COVID-19 is between day 1- 5 of symptom onset with a signicant

decline aer days 10- 15. Machine learning models suggest that tracheostomy in COVID-19 paents should be considered between days 13

and 17. This is a paent-centered approach as in the rst 12-14 days of mechanical venlaon paents may either be successfully weaned o

the venlator or do not survive their crical illness (6).

Other Suggesons

Best pracces are discussed in detail in the aforemenoned CHEST guidelines (1). Angel and colleagues suggested the use of bronchoscopic

visualizaon alongside the endotracheal tube as a novel method to reduce exposure to aerosol while visualizing proper tracheostomy tube

placement (7). Addional modicaons to the standard percutaneous tracheostomy procedure ulized at our instuons to minimize aero-

sol exposure include:

1. Clamping of the endotracheal tube prior to inseron of the bronchoscope (with the bronchoscope adapter) into the endotracheal tube

as well as minimizing re-entry of the bronchoscope.

2. Draping or covering the face and endotracheal tube and packing the nose and mouth during bronchoscopy.

3. Ulizing manual venlaon with periods of apnea during high aerosol generang moments of the procedure (i.e., when dilang the sto-

ma and during placement of the tracheostomy tube).

4. Occasional assistance from anesthesia colleagues to ensure adequate sedaon and oer hemodynamic support during the procedure to

help minimize addional personnel in the room while maintaining experse with airway, sedaon and mechanical venlaon.

5. We have successfully ulized disposable bronchoscopes for use during tracheostomy (Figure 1), although the subopmal suconing, visi-

bility, and sness of these scopes may be liming factors for an opmal procedure. Studies are needed to conrm the long-term outcomes

of paents who undergo any intervenonal procedure using these disposable devices.

Quality Control

Aer tracheostomy, paents may be transferred to the medical oor once they demonstrate a stable venlator/oxygen requirement or a

long-term acute care facility where ongoing weaning can take place as appropriate. Once the paent is liberated from the venlator, trache-

ostomy decannulaon protocols are followed with modicaons such as maintaining a closed circuit using a heat and moisture exchanger

Tips from the Experts

P A G E 9 V O L U M E 9 , I S S U E 1

(HME) along with a viral lter, minimizing inner cannula or tracheostomy tube changes, and maintaining cu inaon even while o mechani-

cal venlaon unl the paent has either tested negave for COVID-19 or is ready for decannulaon. Any paent noted to have diculty

phonang or breathing following tracheostomy requires a bronchoscopy to evaluate for laryngotracheal stenosis, or obstrucng granulaon

ssue.

Conclusions

The COVID-19 pandemic has complicated roune tracheostomy placement for paents with COVID-19 related respiratory failure due to con-

cerns for increased risk of aerosolized exposure of virus to HCWs. Several adjustments to percutaneous tracheostomy procedural technique

have been proposed to improve safety and have demonstrated success. Professional sociees connue to collaborate to ensure safety for

healthcare workers involved in placement and care of paents requiring tracheostomy.

References:

1. Lamb C et al. Chest. 2020 Oct; 158(4): 1499-1514. PMID: 32512006

2. McGrath B et al. Lancet Respir Med 2020; 8: 717-25. PMID: 32422180

3. Chao T et al. Annals of Surgery. Sept 2020. 272(3): e181-186. PMID: 32541213

4. Avilés-Jurado et al. JAMA Otolaryngol Head Neck Surg. Oct 2020. PMID: 33034625

5. Kwak PE et al. JAMA Otolaryngol Head Neck Surg. Published online December 17, 2020. doi:10.1001/jamaoto.2020.4837

6. Takhar A, et al. Crit Care Explor. 2020; 2 (11) e0279

7. Angel L et al. Ann Thorac Surg. 2020 Sep;110(3):1006-1011. PMID: 32339508

Figure 1: Percutaneous tracheostomy procedure performed at

Northwestern Memorial Hospital ulizing enhanced PPE and

use of a disposable bronchoscope (Ambu ®).

Humanitarian News

W A B I P N E W S L E T T E R P A G E 10

Ethical Issues of Vaccinaon

Sciensts have esmated that 60 to 90 percent of a country's populaon needs to be vaccinated against COVID-19 for coun-

tries to achieve herd immunity and prevent mass future breakouts.

Although tradionally the vast majority of individuals get vaccinaons as recommended, more recently vaccine hesitancy has

increased, mainly fueled by misinformaon through social media but also polical opposions around the world.

Raonal academic analysis clearly show that with any new an-COVID vaccine, serious side eects are extremely rare and

can be detected only aer millions of people are vaccinated. Like in any other vaccine, if those extremely rare events are

detected, society should balance that very low probability of serious reacons with the very real possibility of millions of

deaths related to COVID-19 and/or to the collapse of the health care systems if a large amount of the populaon does not

acquire immunity soon.

But in spite of those obvious benets, many naons could struggle to achieve the required percentage of immunizaon.

In Italy, a study has found that nearly 40 percent of Italians will opt not to take the vaccine. In the UK, a study carried out by

King's College and Ipsos Mori in August 2020 found that just 50 percent of the UK populaon would be willing to be vaccinat-

ed and a similar reluctance has been found in France with 54 percent of people surveyed by Ipos showing that would decline

a vaccinaon. Results of surveys in the US are variable but even the more opmisc do not show more than 60% of the pop-

ulaon would denitely or probably get inoculated.

The potenal harm of these beliefs is that reluctance to get a COVID-19 vaccine could hamper its eecveness.

In 2015, the World Health Organizaon (WHO) declared that the United Kingdom had eradicated rubella and in 2016 it was

designated as measles-free country. Immunizaon rates in UK children were high at that me. By 2016, more than 95% of

the country’s 5-year-olds had received one dose of MMR, and roughly 85% had received the pre-school booster that maxim-

izes immunity. But during the rst half of 2019, Europe had 90,000 cases of measles — more than 17 mes the number re-

ported in the whole of 2016 and several European countries (including the United Kingdom) lost its measles-free status. Sim-

ilarly, the United States, is experiencing a remarkable increase of cases of measles cases since 1992.

Those gures made WHO consider hesitancy to vaccinate as one the ten gravest threats to global health and governments

around the world started to discuss the possibility of adopng policies that would make vaccinaons mandatory. That is be-

cause evidence of vaccinaon’s eecveness is unequivocal and, for instance, Government agency Public Health England

esmates that the measles vaccine combined with mumps and rubella vaccines have prevented 20 million cases of measles

and saved 4,500 lives. In terms of improving public health, vaccinaon is second only to providing clean drinking water.

One of the main factors that explains that relaxed atude towards vaccines is that many people thought that many infec-

ous diseases were relavely harmless. The introducon of some vaccines, has dramacally reduced the number of infec-

ons in the developed world; such reducon, in turn, made invisible to many people the possible severe consequences of

certain infecous diseases and, accordingly, the benets of vaccines. For example, as reported by the Oxford Vaccine Group,

the year before the measles vaccine was introduced in the UK (1967), there had been 460,407 suspected cases of measles in

the country, with 99 measles-related deaths. Aer the introducon of the vaccine, the number of measles cases per year

dropped to around 10,000, with one or two deaths, by the end of the 1980s. Vaccines made and are sll making a dierence.

But in a sense, this success backred: people started to forget, because they could no longer see, that certain infecous dis-

eases can have very severe consequences and even be lethal for certain vulnerable people.

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W A B I P N E W S L E T T E R P A G E 11

Legal compulsion is a strategy that governments have used previously to overcome such reluctance. In England, the vaccina-

on of all infants was made mandatory in 1853, and parents who failed to vaccinate their children faced nes or prison. Ob-

viously it was a controversial decision as many Brish people consider that it was a raonal way to guard against the danger

of resurgent smallpox, but many others saw a violaon of their bodies and rights. Legal compulsion resulted in a strong an-

vaccinaon movement that resisted the law through protests and demonstraons and that got in 1898 the addion of a

“conscience clause” that excused parents who believed that vaccinaon would harm their children’s health. Unfortunately it

meant that by 1911 only about 56 percent of newborns were being vaccinated. Vaccinaon was also made mandatory in

other European naons as Germany in 1873 aer its experience in the Franco-Prussian War.

In the United States, the rst school vaccinaon requirements were enacted in the 1850s to prevent smallpox. There were

many court challenges from people who considered those policies a violaon of constuonal liberes. Conicng decisions

in these cases culminated in the landmark Supreme Court case Jacobson v. Massachuses in 1905, which held that compul-

sory vaccinaon was a legimate exercise of state governments’ “police powers” to guard the health, welfare, safety, and

morals of cizens. Several federal and state eorts to eradicate measles in the 1960s resulted in many mandates policies. By

the 1990s, all 50 states required students to receive certain immunizaons, and most states required coverage for those in

daycare centers .

Ethical debates and objecons about mandates arise because some individuals and communies disagree with the man-

dates, and/or have religious or philosophical beliefs that conict with vaccinaon. Tension results when individuals want to

exercise their right to protect themselves and/or their children by refusing vaccinaon, if they do not accept exisng medical

or safety evidence, or if their ideological beliefs do not support vaccinaon.

In that context: is there any ethical juscaon for the governments to priorize the common good over individual autono-

my and create policies for mandatory vaccinaon?

There is a large body of literature on the juscaon for the use of coercion in public health, mainly in infecous diseases.

Mandatory vaccinaon is usually jused on Millian principles: harm to others. According to John Stuart Mill, the most

prominent arguments from bioethicists appeal to prevenng harm to others.

In fact, at least two plausible principled juscaons may be oered for mandatory vaccinaon: the harm principle and the

prevenon of free riders.

The harm principle, described by John Stuart Mill in On Liberty, considers that the only juscaon for coercive acon

against an individual is the presence of imminent harm to other members of society. A person’s own good is insucient rea-

son. Those who sustain the legimacy of mandates, point that people who refuse to be vaccinated or to have their children

vaccinated harm others. On the other hand, the counter-argument is that while being vaccinated clearly benets others, it is

less obvious that the failure to be vaccinated harms others as some other factors inuence the likelihood of disease trans-

mission.

The argument that each individual has within his or her power the ability of self-protecon and so can choose to receive a

vaccine, and has no moral claim to force another person to receive it, is extremely weak. Some people cannot undergo vac-

cinaon because of medical contraindicaons or have a diminished biological capacity to develop immunity in response to a

vaccine, not taking into account that no vaccine is 100 percent eecve and some people can receive the vaccine and fail to

develop the intended immunity. All these people may be placed in danger by infecous diseases that unvaccinated members

of the community may spread.

Other potent argument for the use of compulsion is to prevent the problem of free riders, those people who use a public

good without assuming their fair share of the cost. The herd immunity created by high levels of immunizaon can be consid-

ered a public good, by being nonexcludable (if it is available to some people, it must be available to everyone), and nonrival-

rous (the protecon that one individual gets does not diminish the protecon of others). An individual’s self-interested strat-

egy would be to allow everyone else to assume the small risk of vaccinaon but avoid vaccinaon himself and in that way

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W A B I P N E W S L E T T E R P A G E 12

taking selsh prot of the risks other people have faced.

Regarding to herd immunity Hardin has described the phenomena of the “tragedy of the commons”. In this situaon, the

availability of a shared resource is undermined by self-interested acons. If only one individual refuses vaccinaon, he will

not aect the protecon of the whole community, but if many people make that choice, herd immunity will eventually not

be achieved and the community will stay vulnerable to disease outbreaks.

We many see free riding and the tragedy of the commons as problems of distribuve jusce, in which the benets and bur-

dens of immunizaon are not fairly distributed among all members of society.

Addionally “the clean hand principle” has been described as the situaon in which moral imperave prohibits people from

becoming accomplices in the collecve harm that would result from the failure to achieve herd immunity.

In most of these views, compulsory vaccinaon is jused by the fact that the state has an obligaon to preserve the com-

mon good of herd immunity in order to protect vulnerable people .

In the specic case of COVID-19 the impact of the failure of vaccinaon is not only in terms of deaths from the disease but

also in the enormous economic, health and social consequences of alternave control measures, as lockdown or travel re-

stricons and the unavailability of health care resources for other acute or chronic disease management, consequences

which may be long-term even aer a relave control of the epidemic.

As Julian Savulescu recently described in the Journal of Medical Ethics there is a strong case for making any vaccinaon man-

datory (or compulsory) if four condions are met: a) there is a grave threat to public health, b) the vaccine is safe and eec-

ve, c) mandatory vaccinaon has a superior cost/benet prole compared with other alternaves and d) the level of coer-

cion is proporonate.

As in any ethical analysis, all those variables have to be pondered as it happens with the conict amongst dierent ethical

principal and, consequently, there is always some subjecvity in the given value to each one of them.

Taking that into account, even facing the variaon in tesng rates, and ways of assigning deaths from country to country,

aer months of persistence of the epidemic, there is no doubt that COVID-19 health implicaons may present a grave public

health problem not only as an acute disease but also amongst survivors because of the potenal long-term consequences.

Of course, some will argue that this disease is not “grave” enough to warrant mandatory vaccinaon, compared for instance

with the Spanish inuenza that killed around 50–100 million people and aicted younger rather than older people. The

judgement if COVID-19 is suciently grave requires more data than the available ones, but most of people in the academic

and polical environments would agree that COVID-19 is a grave public health emergency.

The item about the safety of the vaccine is especially sensive as there are concerns that tesng has been rushed and the

vaccine may not be safe or eecve. However, the stascal probability ancipates that no vaccine could be said to be 100%

safe. There will be risks as in any other vaccines and it is not impossible that they will be greater than with well-established

vaccines. But again, the judgement of how much eecve and how much safe it must be to warrant mandatory vaccinaon

will be a maer of discussion. Of course, safety would need to be very high, but a 0% risk opon is realiscally unlikely.

Mandatory vaccinaon must be considered jusable when there are benets to the individual and to the whole community

by prevenng transmission. But an important addional juscaon would be to prevent exhauson of healthcare resources

and to protect other adults who cannot be vaccinated for medical reasons.

Thirdly: has mandatory vaccinaon a superior cost/benet prole compared with other alternaves? In an ideal world, eve-

ryone would want to be vaccinated against Covid and there would be enough vaccine to do that job. We don't live in that

world. Unfortunately the surveys menoned above open doubts about the willingness of the populaon about receiving

COVID-19 vaccine. But addionally, not only reaching herd immunity is important but how fast we reach it in equally im-

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W A B I P N E W S L E T T E R P A G E 13

portant. A delay in reaching herd immunity may mean tens of thousands of lost lives all over the world. People parcularly

vulnerable (those that cannot be vaccinated for medical reasons or the elderly or chronically sick people) crically depend on

stopping the spread of the disease as soon as possible.

There are other policies that are alternaves to the vaccinaon. They include mainly prolonged or intermient lockdown and

vigorous track and trace programs or enforced quarannes with tracking devices. But on one hand most of those policies

are acvely resisted by the populaon (because of the economic, social and emoonal consequences) and addionally the

long-term costs and benets of such policies are not completely known. It means it cannot be accurately pondered if a man-

datory policy of COVID-19 vaccinaon is ethically jused unl the exact costs of the vaccine, the impact of the problem and

the eecveness of the alternave measures is more sciencally grounded. However, in spite of the lack of denive g-

ures, it is certainly feasible that it could be jused.

If it is considered that coercive vaccinaon can be jused, those who defend freedoms at all costs must admit that, in any

country, there are many other situaons in which mandatory acons exist. In the gravest emergencies, where there is dan-

ger for the whole populaon, people are mandated to take arms to serve their country, in spite of the high risk of death or

permanent injury. Taxes are not oponal to be paid, the use of seat belt or abstenon of alcohol when driving is mandatory.

Even in those countries whose policies favour intervenons of the government as limited as possible, there are public poli-

cies that are mandatory in order to protect and promote the common good.

Mandatory public health policies include any policy that contains a non-voluntary element to vaccine consent. It may be

through the imposion of a penalty or cost for refusal. There are a range of possible penales or costs which can coerce peo-

ple. Australia has the “No Jab, No Pay” scheme which withholds child benets if the child is not vaccinated, and a “No Jab,

No Play” scheme which withholds kindergarten childcare benets. Italy introduced nes for unvaccinated children who

aend school. In the USA, state regulaons mandate that children cannot aend school if they are not vaccinated, and

healthcare workers are required to vaccinate.

Finally, proporonality between the level of coercion and the gravity of the problem should exist. Coercion is jused when

the restricon of liberty is both minimized and proporonate to the expected advantages oered by the more coercive poli-

cy.

The Nueld Council of Bioethics produced an inuenal report on public health which considers when coercion and manda-

tory vaccinaon might be jused: “When assessing whether more direcve policies are acceptable, the following factors

should be taken into account: the risks associated with the vaccinaon and with the disease itself, and the seriousness of the

threat of the disease to the populaon. In the case of incenvized policies, the size of the incenve involved should be ap-

propriate so that it would not unduly compromise the voluntariness of consent.”

The result of this approach is an “Intervenon ladder”, which includes measures as educaon and incenves, as well as co-

ercive measures. In some way it reects the principle of the “duty of easy rescue” : if the cost to an individual is small of

some act, but the benet or harm to another is large, there is a strong moral obligaon to perform that act (the classical

example is “if you noce a child has fallen in and appears to be drowning and to wade in and pull the child out would be easy

but it will mean that you get your clothes wet and muddy, you have the moral obligaon to rescue the

child? As the importance of saving a child so far outweighs the cost of geng one’s clothes muddy and missing a class”).

That principle appropriately balances respect for autonomy with jusce.

Most of experts agree on considering two circumstances in which quasi-mandatory vaccinaon measures are more likely to

be jused. First, for highly contagious and serious diseases and second for disease eradicaon if the disease is serious and if

eradicaon is potenally possible.

Even this summary analysis show that mandatory vaccinaon can be ethically jused but, although it has existed in various

forms for more than 200 years, there is a paucity of good epidemiological studies of the eects of dierent mandates. The

introducon of laws for mandatory vaccinaon is usually accompanied by other measures of educaon and publicity, which

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W A B I P N E W S L E T T E R P A G E 14

makes it harder to idenfy the specic eects of legislaon. It makes answering the relevant queson whether mandatory

vaccinaon is eecve, a complicated task.

But even taking those confounding variables into account, there is some evidence that mandatory vaccinaon may help. In

the United States, naonwide surveys in the 1970s showed that the incidence of measles was higher in states without man-

dates, and lowest in states where mandates were strictly enforced. Also in Italy and France immunizaon coverage has risen

with the introducon of mandates. And the No Jab, No Pay legislaon withholding state benets in Australia coincided with

full immunizaon rates rising by around 3% allowing to achieve a naonwide coverage nearly 95%.

However the World Health Organizaon considers that persuading people on the merits of a COVID-19 vaccine would be far

more eecve than trying to make the jabs mandatory. Most of data show that the problem is not vaccine refusal, but vac-

cine hesitancy. In most countries, the proporon of the populaon that staunchly opposes vaccines is less than 2% and the

bigger problem is the large group of people with some concerns about vaccinaon that might make them hesitant. It is rea-

sonable to think that the minority of people who refuse vaccines will rarely change their minds but the hesitant populaon,

may respond to informaon campaigns. It would favour a greater investment in educaon and more eorts to facilitate

meaningful conversaons between concerned people and health-care professionals. But every context is dierent and it

must be taken in consideraon that in the last decade the power of mass media and mainly of tools as social media and non-

expert inuencers is increasingly strong and that power is not easily balanced by the tradional communicaon tools of the

governments.

Another problem of the restricve policies is that even being inially very successful, its eecveness vanishes over me. A

study on the eecveness of state-level varicella vaccinaon mandates indicates that “the impact of the mandate is a short-

run phenomenon. The importance of the mandate eect relave to the aggregate me trend (…) is cut by more than a half

by the fourth year aer the mandate and disappears completely approximately six to seven years aer the mandate” .

Coercion may be applied through penales or costs but also through incenves. The dierent types of vaccinaon policies

could be successful in achieving herd immunity, depending on factors such as parcular socio-economic circumstances or

cultural contexts. But deciding which policy to implement should always consider the principles of least infringement and of

least restricve alternave.

The principle of least infringement states that public health authories, when choosing between available policies for achiev-

ing a certain public health goal, should select the health policy that infringes the least upon certain individual rights. Such

rights include the right not to be harmed, the right to receive benecial medical treatments, the right to free movement and

associaon, and the right to bodily integrity and to personal autonomy.

Not only penales may be restricve, the restricveness of any type of intervenon depends on variables of the context of

individuals targeted. Giving nancial incenves might exert a dierent inuence on the decision-making of those who are in

great need of money (for whom is almost impossible to reasonably refuse those incenves) while others might remain in-

dierent to that same incenve.

The principle of least restricve alternave (PLRA) advises to implement the least restricve policy that is eecve, and it

means that governments should test the ecacy of possible policies, starng from the least to the most restricve: persua-

sion, nudging, provision of incenves, withholding of nancial benets, imposion of nancial penales, withholding of so-

cial services and goods and, as a last resort, compulsory vaccinaon. Compulsory vaccinaon should be seen as a measure of

last resort and some of the less restricve opons discussed should be sucient for the realizaon of herd immunity.

Convincing people to vaccinate without coercing them is always preferable, and where some coercion is necessary to

achieve herd immunity, a lower degree of coercion is always preferable. Besides, coercive policies would be necessary only

where outright vaccine refusal is a signicant factor in low vaccinaon rates; where this is not the case, alternave and less

restricve policies such as nudging, improving accessibility and minimizing logisc barriers to vaccinaon are not only ethi-

cally preferable on the basis of the PLRA but probably also very eecve .

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W A B I P N E W S L E T T E R P A G E 15

As one of the main goals is to limit as much as possible the amount of people who are burdened with restricons on liberty

or autonomy, the governments should grant non-medical exempons to a certain number of people who have deeply held

beliefs against vaccinaon, provided they are not too large a group.

In summary, it can denitely be said that there is a collecve responsibility, or collecve moral obligaon, to achieve herd

immunity and that there is an individual moral obligaon to contribute to the realizaon of herd immunity by being vaccinat-

ed. At the same me, the state has an instuonal responsibility to implement vaccinaon policies that can guarantee at

least the realizaon of herd immunity and the policies should follow the principle of least restricve alternave that would

be eecve in achieving this goal.

On the other hand, a principle of fairness requires that everybody—not just the smallest number of people that can realize

herd immunity—makes their fair contribuon to herd immunity by geng vaccinated. The state is morally jused in requir-

ing each individual to be vaccinated in the absence of legimate medical reasons for exempons; and compulsory vaccina-

on without non-medical exempons is ethically jused.

Even when mandatory vaccinaon can be ethically jused it is quite possible that some mixture of altruism and nancial

and non-nancial benets will obviate the need to introduce mandatory vaccinaon. It is much beer that people voluntarily

choose on the basis of reasons to act well, rather than being forced to do so, and in any case, coercion by incenves is beer

than imposing penales. Educaon, communicaon and structuring the rewards and punishments in a just and fair way is

one way of giving people reasons for acon.

References:

1. Savulescu J. J. Med. Ethics Published Online First: 05 November 2020. doi: 10.1136/medethics-2020-106821

2. Flanigan J. HEC Forum 2014;26(1):5–25. doi:10.1007/s10730-013-9221-5

3. Nueld Council on Bioethics. Public health: ethical issues. London: Nueld Council on Bioethics, 2007: 60.

4. Giubilini A. J Appl Philos 2020;37(3):446–66. doi:10.1111/japp.12400

5. Giubilini A. The ethics of vaccinaon. Palgrave Macmillan, 2019.

6. Nueld Council on Bioethics. Public Health: Ethical Issues. London, 2007

7. Drew L. Nature 575, S58-S60 (2019) doi: hps://doi.org/10.1038/d41586-019-03642-w8. Salmon, D.A et al... Emerging Themes in

Epidemiology. 2006;3:13.

9. Colgrove J. Immunizaon and Ethics: Benecence, Coercion, Public Health, and the State.The Oxford Handbook of Public Health Eth-

ics. DOI: 10.1093/oxfordhb/9780190245191.013.38

*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 (1 of 3)

Descripon:

A 74-year-old woman was found to have a foreign body in her trachea during follow-up for a parod tumor. Neck X-ray

and computed tomography revealed a metallic material penetrang the vertebral body and trachea (arrow). Bronchos-

copy showed that the organized material was penetrang the trachea. She had received acupuncture for neck sness

more than 20 years ago, so the foreign body was suspected of being a broken acupuncture needle. The paent had no

complaints related to the foreign body; therefore, we decided to follow the paent.

Best Image Contest

P A G E 16

This image is 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 Acade-

my Image Library at hps://www.WABIPacademy.com/imagelibrary

Submier:

Takahiro Nakajima, MD

(Department of General Thoracic Surgery, Chiba University Graduate School of Medicine)

P A G E 17

WABIP News

Annual Board of Regents Meeng 2021

With the new business year, the WABIP Regents (member society representaves) shall meet and vote on

WABIP acvity and nancial reports for our annual lings as a non-prot organizaon in Japan. The meeng

will be held via teleconferencing on MARCH 20, 2021. Regents may also submit their votes to approve our

annual reports and government documents via proxy.

WCBIP 2020 & Beyond

We are very pleased to have successfully concluded WCBIP 2020, amid especially challenging circumstances

before and during the event. This WCBIP proves that running huge virtual events with 35,000+ total parci-

pants is completely possible for the WABIP. We will be using some components of this virtual model as a

basis for our WCBIP events going forward, especially as we strive to include parcipaon from our 10,000

WABIP members from around the world, whether on-site or virtually. See you at WCBIP 2022 in Marseille

France, and WCBIP 2024 in Bali Indonesia!

New Open Commiee Posions

As we begin a new term, a number of new commiee posions are now open. We cordially invite you to ap-

ply for open posions in our: Awards Commiee, Bylaws Revision Commiee, Conict of Interest Oversight

Commiee, or Connued Medical Educaon Commiee. Send your applicaon via hps://

www.wabip.com/forms/commiees

Announcing the 2021 APCB & 2021 ECBIP

Our dear friends and partners at the Asia Pacic Associaon and the European Associaon will be hosng

their biennial events this year, which will both be in October of this year.

Even Perfecon Has Room for Improvement

Appropriate staging of lung cancer is the most crucial aspect of the workup of lung cancer. The proper management and the prognosis hinges upon

the correct stage of lung cancer. Under-staging lung cancer has been a chronic problem leading to sub-opmal therapy, a high “relapse” rate, and

poor outcomes.

We have come a long way in surgical and minimally invasive lung cancer staging with modalies such as Endobronchial Ultrasound (EBUS) guided

Transbronchial Needle Aspiraon (TBNA) of the mediasnal and hilar lymph node. EBUS-TBNA has made lung cancer staging more accessible and

cheaper.

Despite surgical and medical procedural advancements and meculous staging guidelines, the discrepancy between the clinical and pathological

staging of lung cancer persists at an alarming rate.

A recent study (1) evaluated the accuracy of the complete clinical lymph node staging by assessing the agreement between imaging, clinical, and

pathological nodal stage in paents with Non-Small Cell Lung Cancer (NSCLC) eligible for surgery and evaluate the incidence and localizaon of oc-

cult lymph node metastasis (OLM). Three hundred and ninety paents with NSCLC from a single center were studied. The clinical staging based on

CT/PET and lymph node biopsies with EBUS-TBNA or mediasnoscopy were conrmed by nal pathological staging aer anatomical resecon. Any

paent who did not go thru surgical resecon was excluded from the study since their pathological stage could not be veried. Similarly, paents

with enlarged lymph nodes in staon 5 and 6 were excluded since EBUS-TBNA could not evaluate them.

Overall, nal clinical staging corresponded to surgical staging outcomes in 65.5 % of paents.

In the subgroup of paents staged as clinical stage, cN0 (clinically no nodal involvement), 23.1 % had OLM. Paents who underwent staging by

EBUS/EUS were inaccurately staged in as much as 50 % of cases, involving both over staging (39.6 %) and under staging (11.3 %). Remarkably, of all

paents with OLM, 50.0 % had primary tumors ≤30 mm.

The study shows that in the absence of an anatomical parenchymal resecon with systemac mediasnal lymph node dissecon, 23% of paents

with clinical stage N0 would have been undertreated due to the presence of OLM. These paents would have risked being under staged and under-

treated with sub-lobar resecon (segmentectomy or wedge resecon) or non-surgical treatment modalies such as Stereotacc Ablave Radiother-

apy (SABR). Unidened OLM would not only result in missed removal of these involved nodes but could also result in missed opportunies to oer

paents adjuvant chemotherapy resulng in poor outcomes and survival.

Based on this study and many others in the past, OLM is frequently idened in clinically N0 and N1 NSCLC, tumors <3 cm, and oen in regions be-

yond the reach of current staging techniques. These ndings raise a valid concern in paents managed non-surgically (SABR) or with sub-lobar re-

secons since they are never subjected to the nal scruny of pathological staging. It is conceivable that novel therapeuc approaches such as

bronchoscopic ablaon of parenchymal tumors will face similar challenges once they are FDA approved and adapted as mainstream modalies for a

select group of paents.

Our struggles to improve must go on!

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 18

Associate editor:

Dr. Ali Musani

Associate editor:

Dr. Sepmiu Murgu

Reference:

1. Beyaz F et al. Lung Cancer. 2020 Dec;150:186-194. doi: 10.1016/

j.lungcan.2020.10.022. Epub 2020 Nov 7. PMID: 33189983.

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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

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