Hurst, JR

Quaderi, SA

UCL Discovery

OTHERPERSPECTIVEThe unmet global burden of COPDS.A. Quaderi and J.R. Hurst*UCL Respiratory, University College London, London, UKGlobal Health, Epidemiology and Genomics (2018), 3, e4, page 1 of 3. doi:10.1017/gheg.2018.1Received 6 November 2017; Revised 16 January 2018; Accepted 26 January 2018Key words: Chronic obstructive pulmonary disease, smoking, air pollution, Low and middle income countries.Chronic respiratory diseases receive little attention andfunding in comparison with other major causes of globalmorbidity and mortality [1]. Chronic obstructive pulmonarydisease (COPD) is a major public health problem. COPD isthe end result of a susceptible lung being exposed to sufﬁ-cient environmental stimulus. Caused principally by tobaccosmoking and household air pollution (HAP), COPD is asilent 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 lead-ing cause of death [3].The relentless decline in lung function that characterisesCOPD is associated with progressive symptoms and functionalimpairment, with susceptibility to respiratory infections called‘exacerbations’. Exacerbations are responsible for much of themorbidity and mortality. COPD has a signiﬁcant impact onquality of life for those living with the condition, and on localeconomies for those affected, those caring for the affectedand health services. A population literally struggling for breathis, in consequence, unproductive. The majority of cases ofchronic lung disease are preventable. Exposure reductioninitiatives must focus on tobacco control, and cook-stoveinterventions: either cleaner fuel (ideally), or better ventilation(at the least). Awareness campaigns and health programmeshave the potential to revolutionise the diagnosis and manage-ment of COPD and COPD exacerbations, improving qualityof life and health service cost and burden. LMICs face uniquechallenges in managing COPD, including sub-optimal anddiverse primary care systems which present challenges withdiagnosis and management, especially during exacerbations.A better understanding of how to prevent, diagnose and man-age COPD in both rural and urban settings would make a realdifference in countries of need.Two important aspects to consider when addressing theglobal economic burden of COPD are that of underdiagno-sis and comorbidities [4]. Firstly, COPD remains underdiag-nosed in many jurisdictions [5]. Studies included in reviewsfocusing on the global economic burden of COPD are allbased on diagnosed COPD, and a simple multiplication ofthese values by the number of COPD patients to calculatethe overall economic burden of COPD will underestimatethe contribution of undiagnosed COPD [5]. Secondly,COPD is known to be associated with a signiﬁcant numberof comorbid conditions, and estimating costs that are dir-ectly attributable to COPD fails to consider the burden ofsuch comorbidities [4]. Adjusting for comorbidities by calcu-lating excess costs with an appropriate comparison groupcan provide a better opportunity, but even this results inan 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 theGlobal Burden ofDisease (GBD), COPD isalready the third leading cause of death worldwide, some-thing that WHO had not predicted to occur until 2030 [9].* Address for correspondence: JRHurst JR, UCL Respiratory, UniversityCollege London, London, UK.(Email: j.hurst@ucl.ac.uk)© 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.global health, epidemiology and genomics• The economic impact of COPD among LMICs is expectedto increase to £1.7 trillion by 2030 [10].• In 15 years, COPD is expected to become the leadingcause of death worldwide [3].Air pollution and HAPAir pollution is the biggest environmental cause of deathworldwide, with HAP accounting for about 3.5–4 milliondeaths every year [11]. Extensive literature supports a causalassociation between HAP and chronic lung diseases [12],respiratory infections and respiratory tract cancers.One-third of the world’s population, some three billion peo-ple use fuel derived from organic material (biomass) or solidfuel including coal, wood and charcoal as an energy sourceto heat and light their homes, and to cook. Respiratory mor-bidity relates to products of incomplete combustion such ascarbon monoxide, and to particulate matter (PM).PM include both organic and inorganic particles, and repre-sents the sum of all solid and liquid particles suspended in theair, many of which are hazardous. PM10 is the most widelyused indicator of the health hazard of indoor air pollution.The EU and the US Environmental Protection Agency haveset standards for annual mean PM10 levels in outdoor air at40 and 50 µg/m3, respectively [13]. When burning solid fuels,peak levels of PM10 in biomass-using homes can be as high as10 000 µg/m3, 200 times more than the standard in high-income countries. PM2.5 are ﬁner particles which penetratedeep into the lung and have the greatest health-damagingpotential. Pollutants are particularly damaging and of concernto children growing up in homes with HAP, the effect on thedeveloping lung results in lung function that does not reachmaximum potential.Household air pollution statistics• Air pollution is the biggest environmental cause of deathworldwide [14].• Three billion people worldwide are exposed to toxicamounts of HAP every day [11].• HAP accounts for up to four million deaths annually [11].SmokingTobacco is a legal drug which is currently responsible for thedeaths of an estimated six million people across the worldeach year, with many of these deaths occurring prematurely[15]. Tobacco smoking is associated with morbidity and mor-tality from non-communicable respiratory diseases (NCDs),including about 600 000 people who are estimated to dieevery year from the effects of second-hand smoke [15].The poor tend to smoke themost. Globally, 84% of smokerslive in developing and transitional economy countries [16].Tobacco smoke potentiates the detrimental effects of biomasssmoke exposure. The WHO stated that in 2015, over 1.1billion people smoked tobacco, males smoked tobacco morethan females, and although it is declining worldwide and inmany countries, the prevalence of tobacco smoking appearsto be increasing in the Eastern Mediterranean and Africa [17].Tobacco and smoking statistics• Due to the incomplete combustion of formaldehyde andDEET, one mosquito coil burning for 8 h releases thesame amount of PM2.5 as 100 cigarettes [18].• A 1 h hookah session with shisha tobacco is equivalent tosmoking over 100 cigarettes [19].• Those who have never smoked tobacco can still getCOPD – think ‘biomass COPD’.COPD: under-recognition and inequityThere is a need for governments, policy makers and inter-national organizations to consider strengthening collabora-tions to address COPD. TB, HIV/AIDS and malaria allcompete for headlines and funds; COPD is rarely the headline.There is global under-recognition of COPD. This needs tochange and we welcome recent initiatives highlighting unmetneeds in NCDs. The United Nations (UN) declaration ofNCDs, and the World Health Assembly in 2012, endorseda new health goal (the ‘25 by 25 goal’), which focuses on thereduction of premature deaths from COPD and otherNCDs by 25% by the year 2025 [20]. Many NCDs occurtogether in the context ofmulti-morbidity, yet despite this ini-tiative, COPD remains a growing but neglected global epi-demic. It is under-recognised, under-diagnosed andunder-treated resulting inmillions of people continuing to suf-fer from this preventable and treatable condition.The lower an individual’s socio-economic position, thehigher their risk of poor health: women and children livingin severe poverty have the greatest exposures to HAP[21]. In the poorest countries, cooking with solid fuels canbe the equivalent of smoking two packs of cigarettes a day[22]. A 1-year old would have accumulated a two packyear smoking history having never seen tobacco. Inactionto mitigate COPD therefore exacerbates health inequalities.Climbing the ‘energy ladder’ occurs gradually as mostLMIC households use a combination of fuels. The poorest,at the bottom of the ladder, use crop waste or dungwhich is the most harmful when undergoing incompletecombustion. Those at the top of the ladder use electricityor natural gas. Increasing prosperity and development hasa direct positive correlation with increasing use of cleanerand more efﬁcient fuels for cooking [23].The unmet global burden of COPD is a silent killer inLMICs. In conclusion, we suggest that given the high andrising global burden of COPD, a revolution in the diagnosisand management of COPD and exacerbations of COPD inLMICs must be an urgent priority.Summary• An estimated 328 million people have COPD worldwide [3].cambridge.org/gheg• In 15 years, COPD is expected to become the leadingcause of death worldwide [3].• Three billion people worldwide are exposed to toxicamounts of HAP every day and HAP accounts for 3.5–4million deaths annually [11].• Those who have never smoked tobacco can still getCOPD – think ‘biomass COPD’.References1. Lopez-Campos JL, et al. Global burden of COPD.Respirology 2016; 21: 14–23.2. Eisner MD, et al. An ofﬁcial American Thoracic Societypublic policy statement: novel risk factors and the globalburden of chronic obstructive pulmonary disease. AmericanJournal of Respiratory and Critical Care Medicine 2011; 182:693–718.3. Alwan A. Global Status Report on Non-CommunicableDiseases. WHO, 2010.4. Ehteshami-Afshar S, et al. The global economic burden ofasthma and chronic obstructive pulmonary disease. TheInternational Journal of Tuberculosis and Lung Disease 2016; 20:11–23.5. Soriano JB, Zielinski J, Price D. Screening for and earlydetection of chronic obstructive pulmonary disease. TheLancet 2009; 374: 721–732.6. Akazawa M, et al. Economic burden prior to COPDdiagnosis: a matched case-control study in the United States.Respiratory Medicine 2008; 102: 1744–1752.7. Nair K, et al. Burden of illness for an employed populationwith chronic obstructive pulmonary disease. Population HealthManagement 2012; 15: 267–275.8. Ford ES, et al. Total and state-speciﬁc medical andabsenteeism costs of COPD among adults aged ⩾18 years inthe United States for 2010 and projections through 2020.Chest 2015; 147: 31–45.9. Lozano R, et al. Global and regional mortality from 235causes of death for 20 age groups in 1990 and 2010: asystematic analysis for the Global Burden of Disease Study2010. The Lancet 2012; 380: 2095–2128.10. Bloom DE, Mitgang E, Osher B. Program on the GlobalDemography of Aging. Oxford University Press: OxfordTextbook of Geriatric Medicine, 2012.11. Gordon SB, et al. Respiratory risks from household airpollution in low and middle income countries. The LancetRespiratory Medicine 2014; 2: 823–860.12. Jiang X-Q, et al. Air pollution and chronic airway diseases:what should people know and do? Journal of Thoracic Disease2016; 8: E31–E40.13. Rehfuess E. Fuel for Life: Household Energy and Health.WHO, 2006.14. Health Effects Institute. 2017. State of Global Air 2017.Special Report. Boston, MA: Health Effects Institute.15. Britton J. Death, disease and tobacco. The Lancet 2017; 389:1861–1862.16. Guindon GE, Boisclair D. Past. Current and Future Trendsin Tobacco Use. HNP Discussion paper, Economics ofTobacco Control Paper No.6. February 2003.17. WHO global report on trends in prevalence of tobaccosmoking, 2015.18. LiuW, et al. Mosquito coil emissions and health implications.Environmental Health Perspectives 2003; 111: 1454–1460.19. American Lung Association. Hookah Smoking: A GrowingThreat to Public Health Issue Brief, 2011.20. NCD Global Monitoring Framework. WHO, 2011.21. WHO. Health Inequities and Their Causes Factsheet. WorldHealth Organization, Geneva, 2017.22. Rehfuess E. WHO. Fuel for life: Household energy andhealth. World Health Organization, 2006.23. Van der Kroon B, et al. The energy ladder: theoreticalmyth or empirical truth? Results from a meta-analysis.Renewable and Sustainable Energy Reviews 2013; 20: 504–513.cambridge.org/gheg

The unmet global burden of COPD

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The unmet global burden of COPD

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