37
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      The unmet global burden of COPD

      article-commentary

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Chronic respiratory diseases receive little attention and funding in comparison with other major causes of global morbidity and mortality [1]. Chronic obstructive pulmonary disease (COPD) is a major public health problem. COPD is the end result of a susceptible lung being exposed to sufficient environmental stimulus. Caused principally by tobacco smoking and household air pollution (HAP), COPD is a silent killer in low- and middle-income countries (LMICs): an estimated 328 million people have COPD worldwide [2], and in 15 years, COPD is expected to become the leading cause of death [3]. The relentless decline in lung function that characterises COPD is associated with progressive symptoms and functional impairment, with susceptibility to respiratory infections called ‘exacerbations’. Exacerbations are responsible for much of the morbidity and mortality. COPD has a significant impact on quality of life for those living with the condition, and on local economies for those affected, those caring for the affected and health services. A population literally struggling for breath is, in consequence, unproductive. The majority of cases of chronic lung disease are preventable. Exposure reduction initiatives must focus on tobacco control, and cook-stove interventions: either cleaner fuel (ideally), or better ventilation (at the least). Awareness campaigns and health programmes have the potential to revolutionise the diagnosis and management of COPD and COPD exacerbations, improving quality of life and health service cost and burden. LMICs face unique challenges in managing COPD, including sub-optimal and diverse primary care systems which present challenges with diagnosis and management, especially during exacerbations. A better understanding of how to prevent, diagnose and manage COPD in both rural and urban settings would make a real difference in countries of need. Two important aspects to consider when addressing the global economic burden of COPD are that of underdiagnosis and comorbidities [4]. Firstly, COPD remains underdiagnosed in many jurisdictions [5]. Studies included in reviews focusing on the global economic burden of COPD are all based on diagnosed COPD, and a simple multiplication of these values by the number of COPD patients to calculate the overall economic burden of COPD will underestimate the contribution of undiagnosed COPD [5]. Secondly, COPD is known to be associated with a significant number of comorbid conditions, and estimating costs that are directly attributable to COPD fails to consider the burden of such comorbidities [4]. Adjusting for comorbidities by calculating excess costs with an appropriate comparison group can provide a better opportunity, but even this results in an underestimation of the costs of the comorbidities [6–8]. Global COPD statistics More than 90% of COPD-related deaths occur in LMICs [3]. According to the Global Burden of Disease (GBD), COPD is already the third leading cause of death worldwide, something that WHO had not predicted to occur until 2030 [9]. The economic impact of COPD among LMICs is expected to increase to £1.7 trillion by 2030 [10]. In 15 years, COPD is expected to become the leading cause of death worldwide [3]. Air pollution and HAP Air pollution is the biggest environmental cause of death worldwide, with HAP accounting for about 3.5–4 million deaths every year [11]. Extensive literature supports a causal association between HAP and chronic lung diseases [12], respiratory infections and respiratory tract cancers. One-third of the world's population, some three billion people use fuel derived from organic material (biomass) or solid fuel including coal, wood and charcoal as an energy source to heat and light their homes, and to cook. Respiratory morbidity relates to products of incomplete combustion such as carbon monoxide, and to particulate matter (PM). PM include both organic and inorganic particles, and represents the sum of all solid and liquid particles suspended in the air, many of which are hazardous. PM10 is the most widely used indicator of the health hazard of indoor air pollution. The EU and the US Environmental Protection Agency have set standards for annual mean PM10 levels in outdoor air at 40  and 50 µg/m3, respectively [13]. When burning solid fuels, peak levels of PM10 in biomass-using homes can be as high as 10 000 µg/m3, 200 times more than the standard in high-income countries. PM2.5 are finer particles which penetrate deep into the lung and have the greatest health-damaging potential. Pollutants are particularly damaging and of concern to children growing up in homes with HAP, the effect on the developing lung results in lung function that does not reach maximum potential. Household air pollution statistics Air pollution is the biggest environmental cause of death worldwide [14]. Three billion people worldwide are exposed to toxic amounts of HAP every day [11]. HAP accounts for up to four million deaths annually [11]. Smoking Tobacco is a legal drug which is currently responsible for the deaths of an estimated six million people across the world each year, with many of these deaths occurring prematurely [15]. Tobacco smoking is associated with morbidity and mortality from non-communicable respiratory diseases (NCDs), including about 600 000 people who are estimated to die every year from the effects of second-hand smoke [15]. The poor tend to smoke the most. Globally, 84% of smokers live in developing and transitional economy countries [16]. Tobacco smoke potentiates the detrimental effects of biomass smoke exposure. The WHO stated that in 2015, over 1.1 billion people smoked tobacco, males smoked tobacco more than females, and although it is declining worldwide and in many countries, the prevalence of tobacco smoking appears to be increasing in the Eastern Mediterranean and Africa [17]. Tobacco and smoking statistics Due to the incomplete combustion of formaldehyde and DEET, one mosquito coil burning for 8 h releases the same amount of PM2.5 as 100 cigarettes [18]. A 1 h hookah session with shisha tobacco is equivalent to smoking over 100 cigarettes [19]. Those who have never smoked tobacco can still get COPD – think ‘biomass COPD’. COPD: under-recognition and inequity There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD. TB, HIV/AIDS and malaria all compete for headlines and funds; COPD is rarely the headline. There is global under-recognition of COPD. This needs to change and we welcome recent initiatives highlighting unmet needs in NCDs. The United Nations (UN) declaration of NCDs, and the World Health Assembly in 2012, endorsed a new health goal (the ‘25 by 25 goal’), which focuses on the reduction of premature deaths from COPD and other NCDs by 25% by the year 2025 [20]. Many NCDs occur together in the context of multi-morbidity, yet despite this initiative, COPD remains a growing but neglected global epidemic. It is under-recognised, under-diagnosed and under-treated resulting in millions of people continuing to suffer from this preventable and treatable condition. The lower an individual's socio-economic position, the higher their risk of poor health: women and children living in severe poverty have the greatest exposures to HAP [21]. In the poorest countries, cooking with solid fuels can be the equivalent of smoking two packs of cigarettes a day [22]. A 1-year old would have accumulated a two pack year smoking history having never seen tobacco. Inaction to mitigate COPD therefore exacerbates health inequalities. Climbing the ‘energy ladder’ occurs gradually as most LMIC households use a combination of fuels. The poorest, at the bottom of the ladder, use crop waste or dung which is the most harmful when undergoing incomplete combustion. Those at the top of the ladder use electricity or natural gas. Increasing prosperity and development has a direct positive correlation with increasing use of cleaner and more efficient fuels for cooking [23]. The unmet global burden of COPD is a silent killer in LMICs. In conclusion, we suggest that given the high and rising global burden of COPD, a revolution in the diagnosis and management of COPD and exacerbations of COPD in LMICs must be an urgent priority. Summary An estimated 328 million people have COPD worldwide [3]. In 15 years, COPD is expected to become the leading cause of death worldwide [3]. Three billion people worldwide are exposed to toxic amounts of HAP every day and HAP accounts for 3.5–4 million deaths annually [11]. Those who have never smoked tobacco can still get COPD – think ‘biomass COPD’.

          Related collections

          Most cited references18

          • Record: found
          • Abstract: found
          • Article: not found

          Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.

          Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. Bill & Melinda Gates Foundation. Copyright © 2012 Elsevier Ltd. All rights reserved.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Respiratory risks from household air pollution in low and middle income countries.

            A third of the world's population uses solid fuel derived from plant material (biomass) or coal for cooking, heating, or lighting. These fuels are smoky, often used in an open fire or simple stove with incomplete combustion, and result in a large amount of household air pollution when smoke is poorly vented. Air pollution is the biggest environmental cause of death worldwide, with household air pollution accounting for about 3·5-4 million deaths every year. Women and children living in severe poverty have the greatest exposures to household air pollution. In this Commission, we review evidence for the association between household air pollution and respiratory infections, respiratory tract cancers, and chronic lung diseases. Respiratory infections (comprising both upper and lower respiratory tract infections with viruses, bacteria, and mycobacteria) have all been associated with exposure to household air pollution. Respiratory tract cancers, including both nasopharyngeal cancer and lung cancer, are strongly associated with pollution from coal burning and further data are needed about other solid fuels. Chronic lung diseases, including chronic obstructive pulmonary disease and bronchiectasis in women, are associated with solid fuel use for cooking, and the damaging effects of exposure to household air pollution in early life on lung development are yet to be fully described. We also review appropriate ways to measure exposure to household air pollution, as well as study design issues and potential effective interventions to prevent these disease burdens. Measurement of household air pollution needs individual, rather than fixed in place, monitoring because exposure varies by age, gender, location, and household role. Women and children are particularly susceptible to the toxic effects of pollution and are exposed to the highest concentrations. Interventions should target these high-risk groups and be of sufficient quality to make the air clean. To make clean energy available to all people is the long-term goal, with an intermediate solution being to make available energy that is clean enough to have a health impact.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease.

              Although cigarette smoking is the most important cause of chronic obstructive pulmonary disease (COPD), a substantial proportion of COPD cases cannot be explained by smoking alone. To evaluate the risk factors for COPD besides personal cigarette smoking. We constituted an ad hoc subcommittee of the American Thoracic Society Environmental and Occupational Health Assembly. An international group of members was invited, based on their scientific expertise in a specific risk factor for COPD. For each risk factor area, the committee reviewed the literature, summarized the evidence, and developed conclusions about the likelihood of it causing COPD. All conclusions were based on unanimous consensus. The population-attributable fraction for smoking as a cause of COPD ranged from 9.7 to 97.9%, but was less than 80% in most studies, indicating a substantial burden of disease attributable to nonsmoking risk factors. On the basis of our review, we concluded that specific genetic syndromes and occupational exposures were causally related to the development of COPD. Traffic and other outdoor pollution, secondhand smoke, biomass smoke, and dietary factors are associated with COPD, but sufficient criteria for causation were not met. Chronic asthma and tuberculosis are associated with irreversible loss of lung function, but there remains uncertainty about whether there are important phenotypic differences compared with COPD as it is typically encountered in clinical settings. In public health terms, a substantive burden of COPD is attributable to risk factors other than smoking. To prevent COPD-related disability and mortality, efforts must focus on prevention and cessation of exposure to smoking and these other, less well-recognized risk factors.
                Bookmark

                Author and article information

                Journal
                Glob Health Epidemiol Genom
                Glob Health Epidemiol Genom
                GHG
                Global Health, Epidemiology and Genomics
                Cambridge University Press (Cambridge, UK )
                2054-4200
                2018
                6 April 2018
                : 3
                : e4
                Affiliations
                [1]UCL Respiratory, University College London , London, UK
                Author notes
                [* ]Address for correspondence: JRHurst JR, UCL Respiratory, University College London , London, UK. (Email: j.hurst@ 123456ucl.ac.uk )
                Article
                S2054420018000015 00001
                10.1017/gheg.2018.1
                5921960
                29868229
                85231f5b-93c1-4126-96c5-08123db838a6
                © The Author(s) 2018

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 06 November 2017
                : 16 January 2018
                : 26 January 2018
                Page count
                References: 23, Pages: 3
                Categories
                Other
                Perspective

                chronic obstructive pulmonary disease,smoking,air pollution,low and middle income countries

                Comments

                Comment on this article