La Salute del Respiro, epidemiologia, costi sanitari ed implicazioni
sociali delle malattie respiratorie croniche ostruttive e delle
allergopatie respiratorie
Milano, 26 gennaio 2007
La Salute del Respiro: una attualità nazionale
Ernesto Pozzi
Clinica Malattie Apparato Respiratorio
Università
di
Pavia
Fondazione
IRCCS
Policlinico
San Matteo
Of the six
leading causes
of death in the
United States,
only COPD has
been increasing
steadily since
1970
Jemal A. et al. JAMA 2005
2
COPD
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50% over
the next 15 years” Lopez, ERJ 2006
CHANGING GLOBAL DEMOGRAPHICS
People > 60yr
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50% over
the next 15 years” Lopez, ERJ 2006
 MORTALITY IN FEMALES
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50% over
the next 15 years” Lopez, ERJ 2006
Number Deaths x 1000
COPD Mortality by Gender
U.S. 1980-2000
70
60
Men
50
40
Women
30
20
10
0
1980
1985
1990
1995
2000
Source: US Centers for Disease Control and Prevention,
Differences in survival, men vs women,
after initiating long-term oxygen terapy
Machado et al
AJRCCM 2006
CONTINUED USE OF TOBACCO
Low rates of smoking cessation (~30%)
 Young smokers (particularly females)
 Smoking in non-developed countries
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50% over
the next 15 years” Lopez, ERJ 2006
NET CHANGE IN ACTIVE SMOKING % PER 10 YRS
ECRHS I 1990-94; ECRHS II 1998-2002
(9053 subjects, age range 20-44 years at ECRHS I)
Janson, Cerveri and ECRHS group
ERJ 2006
NET CHANGE IN PASSIVE SMOKING % PER 10 YRS
ECRHS I 1990-94; ECRHS II 1998-2002
(9053 subjects, age range 20-44 years at ECRHS I)
Janson, Cerveri and ECRHS group
ERJ 2006
Global Epidemiology of
Smoking
OTHER RISK FACTORS
Occupation
Pollution
•Indoor
•outdoor
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50%
over the next 15 years” Lopez, ERJ 2006
AIR POLLUTION AND LUNG FUNCTION
IN THE ECRHS
• Rationale:
Long term effects of air pollution on lung
function have not been studied across
European adult populations before, and in
particular evidence for effects on change in
lung function among adults is weak.
Gotschi, Sunyier and ECRHS group
Lancet, submitted
Geographical distribution of ECRHS centres
0
10 20 30 40 50
PM2.5 levels across ECRHS centres
PM2.5 levels across ECRHS centres
REUMUPGOAL TAOVNOGAER IP HUBSPSGNAS BAACPAVETU
AIR POLLUTION AND LUNG FUNCTION
IN THE ECRHS
Measurements and Main Results:
No significant associations were found between PM2.5
and any of the lung function measures neither for lung
function level nor for change in lung function.
Conclusions:
The heterogeneity of the studied populations in
combination with limitations of the cross-community
comparison approach are plausible explanations of the
observed null-findings.Future studies on long term
effects of air pollution on lung function should be based
on within-community comparisons.
Gotschi, Sunyier and ECRHS group
Lancet, submitted
COPD PREVALENCE
 Prevalenza di COPD in aumento costante
>10% tra la popolazione > 40 anni
Chapman et al. ERJ 2006
 Prevalenza di COPD 3.6% tra la popolazione di
eta’ 20-45 years
de Marco et al. Thorax 2004
INCIDENCE OF COPD ACCORDING
TO THE HISTORY OF CHRONIC COUGH AND PHLEGM
ECRHS I
(1991-1993)
ECRHS II
(1998-2002)
no chronic cough
and sputum
production
4,083 (92.6%)
(n = 4,407)
324 (7.4%)
new occurrence
chronic cough
and sputum
production
277 (62.0%)
remission
(n = 447)
170 (38.0%)
persistence
incidence rate (cases/1,000/year)
absence
4.04 [2.29 - 7.11]
0
4
8
12
16
De Marco, Cerveri et al
AJRCCM 2006
GLOBAL BURDEN
Hospitalizations
 Number and duration
 Comorbidity
EPIDEMIOLOGICAL PERSPECTIVES
“Mortality rates will increase by 50%
over the next 15 years” Lopez, ERJ 2006
Aumento del numero dei ricoveri per BPCO
dal 1999 al 2003 in Italia
250,000
DRG 88 = malattia polmonare cronica ostruttiva
N° RICOVERI
DRG 87 = edema polmonare e insufficienza respiratoria
200,000
DRG 475 = diagnosi relative all'apparato respiratorio
con respirazione assistita
1999
2000
150,000
2001
100,000
2002
2003
50,000
0
DRG 88
DRG 87
DRG 475
TOTALE
EXACERBATIONS
AS A STARTING POINT
OF PROACTIVE COPD MANAGEMENT
Zoia et al,
Resp Med 2005
EXACERBATIONS
AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT
Patients with and without previous diagnosis
Without
diagnosis
28%
72%
With
diagnosis
EXACERBATIONS
AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT
Percentage of patients with and without spirometry
No
44%
Yes
56%
EXACERBATIONS
AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT
100%
n 33
n 85
n 118
90%
80%
70%
60%
50%
40%
53%
30%
20%
46%
28%
10%
0%
Without previous
diagnosis
With previous
diagnosis
Co-morbidity
Total sample
Whole group
Epidemiologia della BPCO
Ricoveri in regime ordinario
Diagnosi principale
n. dimissioni
Malattia polmonare cronica ostruttiva
degenza media
120188
10.01
Bronchite cronica ostruttiva, riacutizzata
88083
9.77
Insufficienza respiratoria
70054
13.15
Bronchite cronica ostruttiva, non riacutizzata
22978
12.00
Bronchite, non specificata se acuta o cronica
4216
4.69
Bronchite cronica semplice
2328
10.04
Bronchite cronica non specificata
2039
9.36
Bronchite cronica mucopurulenta
1256
10.33
SDO - Ministero della Salute, 2005
COPD Exacerbations : Mortality
1016 pts with severe COPD exacerbation
60
(PaCO2 > 50 mm Hg)
49%
50
Mortality (%)
43%
40
33%
30
20%
20
11%
10
0
Hospital
stay
60 days
180 days
1 year
2 years
Connors AF Jr et al. Am J Respir Crit Care Med. 1996;154:959-67
Total costs (€ billion) of respiratory diseases in
Europe in 2000
Piano sanitario nazionale
2006-2008
 ASTHMA PREVALENCE IN ADULTS:GOOD NEWS?
Weiland and Pearce
Editorial
Thorax 2004
 THE EPIDEMIC HAS ENDED,OR HAS IT ?
Shafazand and Colice
Editorial
Chest 2004
 THE PREVALENCE OF ASTHMA IS NO LONGER
INCREASING IN SOME COUNTRIES
Anderson
Editorial
BMJ 2005
Trend dell’asma negli adulti
non
in ulteriore aumento in parecchie nazioni
INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS
IN THE EUROPEAN COMMUNITY RESPIRATORY HEALTH
SURVEY
Chinn,Jarvis, Burney,Cerveri et al
Thorax 2004
NET CHANGE IN IN PREVALENCE ( per 10 years of follow-up) OF
SYMPTOMS, DIAGNOSED ASTHMA, AND CURRENT MEDICATION
IN THE ECRHS
*
*
“Diagnosed asthma”
Current medication
*
*
*
Attack of asthma
Woken with shortness of
breath
Woken with chest
tightness
Wheeze without a
cold
Net change
(%)
-2,0
* p = 0.011
-1,5
-1,0
** p<0.001
-0,5
0,0
0,5
1,0
1,5
2,0
2,5
3,0
Chinn, Cerveri and ECRHS group
Thorax 2004
INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS
IN THE ECRHS
“…. Either increased use of effective treatments has
led to decreased morbidity among asthmatic
subjects or those with mild disease have become
more likely to label themselves as asthmatic”
Chinn, Cerveri and ECRHS group
Thorax 2004
NET CHANGE IN PREVALENCE ( per 10 years of follow-up)
OF DIAGNOSED ASTHMA AND NASAL RHINITIS
IN THE ECRHS
(11169 subjects )
PREVALENCE IN ECRHS I:
24%
PREVALENCE IN ECRHS I:
26%
PREVALENCE IN ECRHS I:
26%
PREVALENCE IN ECRHS I:
5%
Chinn, Cerveri and ECRHS group
Thorax 2004
INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS
IN THE ECRHS
“….An increase in reported nasal allergies was
observed that was greater in the youngest age
group. It is not possible to be certain whether it is
explained by biological changes occurring at
particular ages or by factors occurring earlier in
life that make this younger cohort more
suceptible.. ”
Chinn, Cerveri and ECRHS group
Thorax 2004
ASTHMA ATTACKS AND ANTI-ASTHMATIC
TREATMENT IN ITALY (1993 AND 2000)
Crude prevalence (95% CI)
5
4
3.6%
1992-1993
3.2%
3
2.5%
1998-2000
1.9%
2
1
0
Asthma
attacks
Antiasthmatic
treatment
Verlato,Cerveri et al, J Allergy Clin Immunol 2003
Crude prevalence (95% CI)
NASAL ALLERGIES
IN ITALY
(1993 AND 2000)
25
20
15.4
%
P<
0.001
15
10
5
0
Nasal
allergies
18.3
%
1992-1993
1998-2000
CONCLUSIONI
 Non aumento in Italia di attacchi di asma negli
anni 90
 Nuovi farmaci, miglior strategia globale di
trattamento, di accesso alle strutture sanitarie
e di controllo degli allergeni “indoor”
determinanti di una minore espressione della
malattia
 Ancora attenzione particolarmente focalizzata
alla rinite allergica
EPIDEMIOLOGIA DELL’ASMA

Stabilizzazione dovuta al miglioramento
dei trattamenti antiasmatici

Plateau per raggiunto sviluppo della
patologia in tutti i soggetti “suscettibili”
(“Saturation”: massimo effetto del
cambiamento dell’esposizione ambientale
negli individui suscettibili)
ALLERGIC RHINITIS AND ASTHMA COMORBIDITY
IN A SURVEY OF YOUNG ADULTS IN ITALY
About 60 % of asthmatics reported AR
Subjects with AR had eightfold risk of
having asthma compared to subjects
without AR
Bugiani and ECRHS group, Allergy 2005
Tumor necrosis factor polymorphisms and asthma
in two international population-based cohorts
( ECRHS and SAPALDIA studies)
ECRHS
SAPALDIA
Age 18-44
Age 18-44
All ages
Subjects
(number)
3659
3572
6071
Gender
(% males)
48
50
50
Mean age
(years ± SD)
34±7
33±8
41±11
Asthma Symptoms
(%)
3.7
2.92
2.89
Physician diagnosed
asthma
(%)
6.55
6.19
6.2
Atopy
(%)
22.52
18.11
16.2
Castro Giner, ECRHS and Sapaldia groups
AJRCCM, submitted
ASTHMA SEVERITY IN THE GENERAL POPULATION
According to GINA 2006 Classification
(ECRHS II; 1999-2002)
severe
18%
remission
12%
moderate
17%
mild
8%
intermittent
45%
de Marco ECRHS group
JACI 2006
THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN
EUROPE A DECADE AFTER THE GINA GUIDELINES
(ECRHS II; 1999-2002)
13.2%
Light
burden
72.8%
No burden
No burden
no productivity losses
no use of hospital services
14%
Heavy
burden
Light burden
up to 12 lost working days or
up to 3 days per months
limited
no use of hospital services
Heavy burden
> 12 lost working days or
> 3 days per months
limited or
use of hospital services
Accordini, Cerveri and ECRHS group
Allergy 2007
THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN
EUROPE A DECADE AFTER THE GINA GUIDELINES
(ECRHS II; 1999-2002)
light burden
heavy burden
35
30
•Light burden
up to 12 lost working days or
up to 3 days per months limited
no use of hospital services
25
%
20
15
•Heavy burden
> 12 lost working days or
> 3 days per months limited or
use of hospital services
10
5
0
60
70
80
90
100
110
120
130
140
FEV1 % predicted
Accordini, Cerveri and ECRHS group
Allergy 2007
REAL-WORLD EVALUATION OF
ASTHMA CONTROL AND TREATMENT(REACT):
Findings from a national Web-based survey
(1812 patients with moderate to severe asthma
using standard asthma medications)
55%
Uncontrolled
asthma
45%
Controlled
asthma
1
2
Peters et al
JACI 2007
PREVALENCE OF ASTHMA TREATMENT ADHERENCE
AT ECRHS I AND II
ECRHS I 1992-3
ECRHS II 1998-2002
Prevalence (%)
90
80
70
60
50
40
30
20
10
ECRHS I
ECRHS II
0
Mediterranean
Continental
Nordic
Extra-Europe
Geographic Macroarea
Corsico,Cerveri and ECRHS group
Resp Med 2007
Utilizzo farmaci R03 (antiasmatici)
100
DDD/1000 ab/die
90
Bisogno terapeutico teorico
80
70
60
50
40
46
39
39
34
30
20
10
0
ITALIA
DDD = dose media mantenimento giornaliera
CAMPANIA
EMILIA
LOMBARDIA
Dati Fondazione SKF