In a follow–up to the 2011 United Nations (UN) high level political declaration on non-communicable diseases (NCDs) [1], the World Health Assembly, in 2012, endorsed a new health goal (the “25 by 25 goal”), which focuses on reduction of premature deaths from COPD and other NCDs by 25% by the year 2025 [2]. Despite this initiative, experts have reported that COPD remains a growing [3], but neglected global epidemic [4]. The World Health Organization (WHO) estimated that there were about 62 million people with moderate to severe COPD in 2002, with the total number of COPD cases predicted to increase to about 200 million in 2010 [5,6]. According to the 2010 Global Burden of Disease (GBD) study, COPD was responsible for about 5% of global disability–adjusted life years – DALYs (76.7 million) – and 5% of total deaths (2.9 million) [7,8]. COPD is currently rated the fourth most common specific cause of death globally and predicted to be the third by 2030, in the absence of interventions that address the risks – especially tobacco smoking, exposures to combustion products of biomass fuels and environmental pollution [9,10].

The burden of COPD has been reported to be high in some high–income countries (HIC), particularly due to high prevalence of smoking in these settings [11]. For example, between years 2000 and 2010, about 4%–10% of adults were diagnosed with non–reversible and progressive airway obstruction (a basic feature of COPD) in population–based surveys across many European countries, with smoking indicated as a major risk [12]. The WHO has estimated that in many HIC up to 73% of COPD deaths are related to tobacco smoking [6]. The European Union (EU) reported that the direct cost from COPD was over 38.6 billion Euros in 2005, representing about 3% of total health care expenditure [13,14]. In the United States (US), over 2.7 million adults were estimated to have COPD in 2011, with about 135 000 deaths reported [15]. In 2010, the US government spent nearly US$ 49.9 billion on COPD, including 29.5 billion spent on direct health care, 8.0 billion on indirect morbidity and 12.4 billion on indirect mortality costs, respectively [15].

Meanwhile, it has been estimated that despite a high prevalence of COPD in some HIC, 90% of COPD deaths still occur in low– and middle–income countries (LMIC)in the future

[4] and 40% of these deaths are attributable to smoking [6]. The burden in LMIC has been comparatively high owing to relatively low COPD awareness, challenges with COPD diagnosis and increased exposures to additional risk factors, especially combustion products of biomass fuels [16]. Salvi and colleagues reported that about 3 billion people globally are exposed to smoke from biomass fuel, compared to 1 billion people who smoke tobacco globally [17]. In many developing countries COPD is neglected by governments, physicians, experts and the pharmaceutical industry, although it's been identified as an important public health problem [4].

In the last two decades, the Burden of Obstructive Lung Disease (BOLD) initiative has been collecting country–specific data on the prevalence, risk factors and socioeconomic burden of COPD, using standardized and tested methods for conducting COPD surveys in the general population [18]. This is expected to provide governments of many nations with country–specific evidence on which to develop policy on COPD prevention and management [18]. As noted above, this initiative is yet to take a full effect in many LMIC [19]. In addition, spirometry (the gold standard for COPD diagnosis) is not widely available in many LMIC [16]. Even when it is there, professionals in LMIC are often not being trained properly on how to use spirometers or interpret spirometry results. There is concern that COPD burden has been underestimated, owing to over–reliance on doctor’s diagnosis, with many diagnoses not being based on spirometry and international diagnostic guidelines [20]. The lack of routine COPD data collation and effective health information management system in many LMIC also implies that these settings could have been grossly under–represented in global burden of COPD estimates [11].

Some global and regional estimates of COPD burden have been published [1,21–23]. However, despite the fact that COPD is now prevalent in both HIC and LMIC, experts have raised concerns that reliable estimates of COPD prevalence are still few in many parts of the world. Moreover, many of the estimates are based on varying definitions and diagnostic criteria of COPD [9]. Also, some of the current estimates were reported before the BOLD surveys in several countries, thereby failing to account for the additional spirometry–based epidemiological data from the BOLD surveys. There is a need for a revised and updated estimate of COPD prevalence across world regions. We conducted a systematic review of COPD prevalence based on spirometry data across world regions. Our aim was to provide global and regional prevalence rates of COPD that could facilitate adequate policy response in these regions.

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Global and regional estimates of COPD prevalence: Systematic review and meta-analysis.

It is conventional wisdom that it is possible to reduce exposure to indoor air pollution, improve health outcomes, and decrease greenhouse gas emissions in the rural areas of developing countries through the adoption of improved cooking stoves This belief is largely supported by observational field studies and engineering or laboratory experiments However, a new evidence is provided, from a randomized control trial conducted in rural Orissa, India (one of the poorest places in India), on the benefits of a commonly used improved stove that laboratory tests showed to reduce indoor air pollution and require less fuel Households are tracked for up to four years after they received the stove [BREAD Working Paper No 338] URL:[http://iplecondukeedu/bread/papers/working/338pdf]

Up in Smoke: The Influence of Household Behavior on the Long-Run Impact of Improved Cooking Stoves

SETTING Field sites in 12 districts in different parts of India. OBJECTIVE To determine the nationwide population prevalence of and risk factors for asthma and chronic bronchitis (CB) in adults. DESIGN A standardised validated questionnaire based on the International Union Against Tuberculosis and Lung Disease's 1984 questionnaire was used to assess asthma and CB prevalence. Multivariate logistic regression analyses were performed to determine the risk factor associations. Estimates standardised to the 2011 population projection estimates for India were used to calculate the national disease burden. RESULTS A total of 85,105 men and 84,470 women from 12 urban and 11 rural sites were interviewed. One or more respiratory symptoms were present in 8.5% of individuals. The overall prevalence of asthma and CB was respectively 2.05% (adults aged ≥15 years) and 3.49% (adults aged ≥35 years). Advancing age, smoking, household environmental tobacco smoke exposure, asthma in a first-degree relative, and use of unclean cooking fuels were associated with increased odds of asthma and CB. The national burden of asthma and CB was estimated at respectively 17.23 and 14.84 million. CONCLUSION Asthma and CB in adults pose an enormous health care burden in India. Most of the associated risk factors are preventable.

Indian study on epidemiology of asthma, respiratory symptoms and chronic bronchitis in adults (INSEARCH).

Laboratory studies suggest that improved cooking stoves can reduce indoor air pollution, improve health, and decrease greenhouse gas emissions in developing countries. We provide evidence, from a large-scale randomized trial in India, on the benefits of a common, laboratory-validated stove with a four-year follow-up. While smoke inhalation initially falls, this effect disappears by year two. We find no changes across health outcomes or greenhouse gas emissions. Households used the stoves irregularly and inappropriately, failed to maintain them, and usage declined over time. This study underscores the need to test environmental technologies in real-world settings where behavior may undermine potential impacts.

/pdf/up-in-smoke-the-influence-of-household-behavior-on-the-long-2tbdhv255m.pdf

Indoor air pollution is the degradation of indoor air quality by harmful chemicals and other materials; it can be up to 10 times worse than outdoor air pollution. This is because contained areas enable potential pollutants to build up more than open spaces. Statistics suggest that in developing countries, health impacts of indoor air pollution far outweigh those of outdoor air pollution. Indoor air pollution from solid fuels accounted for 3.5 million deaths and 4.5% global daily-adjusted life year (DALY) in 2010; it also accounted for 16% particulate matter pollution. Though there is a decrease in household air pollution from solid fuels in southeast Asia, still it ranked third among risk factors in the report of the Global Burden of Disease.(1) This paper provides an evidence-based insight into indoor air pollution, its effect on health, and suggested control measures.

Indoor air pollution in India: implications on health and its control.

Background: Chronic obstructive pulmonary disease (COPD) is the 13th leading cause of burden of disease worldwide and is expected to become 5th by 2020. Biomass fuel combustion significantly contributes to COPD, although smoking is recognized as the most important risk factor. Rural women in developing countries bear the largest share of this burden resulting from chronic exposures to biomass fuel smoke. Although there is considerable strength of evidence for the association between COPD and biomass smoke exposure, limited information is available on the background prevalence of COPD in these populations. Objective: This study was conducted to estimate the prevalence of COPD and its associated factors among non-smoking rural women in Tiruvallur district of Tamilnadu in Southern India. Design: This cross-sectional study was conducted among 900 non-smoking women aged above 30 years, from 45 rural villages of Tiruvallur district of Tamilnadu in Southern India in the period between January and May 2007. COPD assessments were done using a combination of clinical examination and spirometry. Logistic regression analysis was performed to examine the association between COPD and use of biomass for cooking. R software was used for statistical analysis. Results: The overall prevalence of COPD in this study was found to be 2.44% (95% CI: 1.43-3.45). COPD prevalence was higher in biomass fuel users than the clean fuel users 2.5 vs. 2%, (OR: 1.24; 95% CI: 0.36-6.64) and it was two times higher (3%) in women who spend >2 hours/day in the kitchen involved in cooking. Use of solid fuel was associated with higher risk for COPD, although no statistically significant results were obtained in this study. Conclusion: The estimates generated in this study will contribute significantly to the growing database of available information on COPD prevalence in rural women. Moreover, with concomitant indoor air pollution measurements, it may be possible to increase the resolution of the association between biomass use and COPD prevalence and refine available attributable burden of disease estimates. Keywords: chronic obstructive pulmonary disease; prevalence; biomass fuel users; rural women; disease burden (Published: 3 November 2011) Citation: Global Health Action 2011, 4 : 7226 - DOI: 10.3402/gha.v4i0.7226

Prevalence of chronic obstructive pulmonary disease in rural women of Tamilnadu: implications for refining disease burden assessments attributable to household biomass combustion

Omprakash Abirami

Papers

Prevalence of chronic obstructive pulmonary disease in rural women of Tamilnadu: implications for refining disease burden assessments attributable to household biomass combustion