RACHEL PRYOR EPID 691 FEBRUARY 25, 2013 Asthma and COPD

What is asthma? Disorder of the airways causing swelling and narrowing; which leads to wheezing, shortness of breath, chest tightness, and coughing Most common asthma triggers: dust, animal dander, weather changes, pollution, mold, pollen, respiratory infections, stress, tobacco smoke There is no cure for asthma.  alth/PMH /

Four categories of asthma According to the National Heart, Lung, and Blood Institute the four categories are: 1. Intermittent - daytime symptoms that occur less than two times/week and nighttime symptoms occur less than two times/month. Normal pulmonary function tests (PFT). 2. Mild persistent - daytime symptoms occurring two or more times/week and nighttime symptoms occurring two or more times/month. Normal PFT.  ts/AsthmaPlan pdf 3. Moderate persistent - daily daytime symptoms and at least one weekly nighttime symptom, and/or PFT reduced to 60 – 80% of normal. 4. Severe persistent - continuous daytime symptoms and frequent night symptoms and PFT that may be less than 60% of normal.  National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.

Asthma: Incidence and Prevalence 18.9 million adults, or 8.2% of the adult population, in the U.S. have asthma 7.1 million children, or 9.5% of children, in the U.S. have asthma  Incidence of asthma in adults is 3.8/1000 at-risk adults Incidence of asthma in children is 12.5/1000 at-risk children  Among children 0-4 years old, incidence is 23.4/1000 children!  Winer, Rachel A., Xiaoting Qin, B.A., Harrington, Theresa, Moorman, Jeanne, Zahran, Hatice. Asthma Incidence among Children and Adults: Findings from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey—United States, 2006–2008. Asthma, February 2012, Vol. 49, No. 1, Pages (doi: / ).

What is “at-risk”?

Asthma Prevalence by Race/Ethnicity

Asthma Prevalence by Sex and Race

Asthma Prevalence by SES and Race

More statistics Number of deaths caused by asthma (in 2010): 3,404  1.1/100,000 of the population Number of outpatient visits per year with asthma as primary diagnosis (in 2009): 1.2 million Number of ED visits with asthma as primary diagnosis (in 2009): 2.1 million Number of hospital discharges with asthma as first-listed diagnosis (in 2009): 479,000  Average length of stay: 4.3 days 

The incidence of asthma is increasing From 2001 – 2009, the incidence of asthma increased by 4.3 million  Rates grew the most (almost a 50% increase!) among black children  Why?  Hygiene hypothesis: we’re “too clean”  Sedentary lifestyle: decreases lung strength  Obesity: increases overall inflammatory response of the human body  Changes in immune system as we “modernize” 

The cost of asthma Medical expenses per person per year is $3300 on average. 40% of uninsured people could not afford their asthma-related medications, and 11% of insured people could not afford their asthma- related medications between Asthma costs in the US in 2002 were approximately $53 billion – in 2007 they were approximately $56 billion. 59% of children and 33% of adults with asthma missed school or work due to asthma in  On average, children missed 4 days of school and adults missed 5 days of work because of asthma  ndex.html

Asthma and Public Health There are many public health initiatives in place to reduce asthma exacerbations Community Preventative Services Task Force’s initiative “Asthma Control: Home Based Multi Trigger, Multicomponent Environmental Interventions”  Home visits are conducted by a trained person to assess home environments and educate families about what can be done to decrease asthma triggers and also how to better self-manage one’s asthma 

Public Health Initiatives cont. Healthy People 2020 goal: “Promote respiratory health through better prevention, detection, treatment, and education efforts”  Specific objectives: bjectiveslist.aspx?topicId=36  “Increase the number of States, Territories, and the District of Columbia with a comprehensive asthma surveillance system for tracking asthma cases, illness, and disability at the State level”  No Virginia data on the CDC website! 

In 2008, less than half of the people diagnosed with asthma reported being taught how to avoid triggers. 48% of adults who were taught about trigger avoidance did not follow most of their doctor’s teaching. 

Asthma in Virginia In 2010, the Virginia Asthma Coalition released a plan for Virginia And VDH does track Virginia data (though the last comprehensive report was written in 2007, using data through 2004) 7.3% of adults (412,370 people) in Virginia have asthma 9% of children (152,277 people) in Virginia have asthma In 2004, total cost of asthma hospitalizations in Virginia was $96 million! (which was a 58% increase from 1999) 

Asthma in Virginia Current asthma rates in Virginia have slightly increased since 2000 (average in 2000 was 7.1%, in 2008 it was 9.3%)

Virginia compared to the US

Virginia Stats

Virginia Stats

ResearchNeeds According to the EPA, some of the most important areas of research related to asthma include:  More information about the induction and exacerbation of asthma  Why the incidence of asthma is increasing  What factors make one more susceptible to asthma  Risk assessment of environmental pollutants and asthma 

What is COPD? COPD is Chronic Obstructive Pulmonary Disease and is characterized by diseases that cause airflow blockage and problems related to breathing. It includes emphysema, chronic bronchitis, and asthma (in some cases). COPD is caused by:  Tobacco exposure  Asthma  Air pollutants  Genetic factors  Respiratory infections 

Chronic bronchitis vs. emphysema Chronic bronchitis is characterized by a long-term cough with mucous production Emphysema is characterized by destruction of the lungs overtime

COPD: Prevalence There is a vast under-diagnosis of COPD. 6.3% of American adults (approximately 15 million people) have been diagnosed with COPD. In adults aged 18-44, 3.2% of the population has been diagnosed with COPD. In adults ages 65 and older, 11.6% have been diagnosed with COPD. White adults have the highest rate of COPD (6.3%). 6.1% of black adults and 4.3% of Hispanic adults have COPD. 9.5% of those with COPD did not have a high school diploma 

In 2008, 9.8 million adults were diagnosed with chronic bronchitis. In 2008, 3.8 million adults reported having ever been diagnosed with emphysema. Surprisingly (to me), more women than men suffer from these diseases.

Age-adjusted prevalence of COPD among adults

COPD in Virginia Chronic bronchitis is the second leading hospital discharge diagnosis in Virginia. Emphysema is the seventh leading hospital diagnosis in Virginia. 

Respiratory Disease Deaths in Virginia

Morbidity and mortality The estimated cost of COPD in 2010 was $49.9 billion.  $29.5 billion related to direct hospital costs, $8 billion on indirect morbidity costs, and $12.4 billion on indirect mortality costs COPD is the third leading cause of death in the USA, claiming 124,477 lives in ,000 hospitalizations in 2006 were due to COPD. 

Disparities and COPD More Caucasians than African Americans have chronic bronchitis (50.8 per 1000 vs per 1000).  Rate among Hispanics only 20.6 per The same is true of emphysema (21.1 per 1000 Caucasians vs. 8.1 per 1000 African Americans vs. 6.3 per 1000 Hispanics) Among the uninsured, African Americans were significantly less likely than Caucasians to receive a lung transplant (61 vs 68%) 50.5 per 100,000 White men died from COPD in 2006 Death rate for White women was 39.1 per 100,000 Death rate for Black men was 37.7 per 100,000 Death rate for Black women was 18.9 per 100,000  publications/solddc-chapters/copd.pdf

Public Health Research and COPD Access to healthcare is a huge obstacle for Hispanics who suffer from COPD  Studies who that they are twice as likely as Caucasians to utilize the ER for management of their COPD  Words such as wheeze and dyspnea do not translate well into Spanish  Hispanics are often grouped all together, rather than being treated as people from various countries  More research needs to be done to define subgroups of Hispanics and their relationship to the healthcare system in the United States 

Public Health Research and COPD Very limited information has been collected about Asian Americans, Native Americans, and Native Pacific Islanders and the prevalence of COPD among these groups 

Healthy People 2020 and COPD Reduce activity limitations among adults with chronic obstructive pulmonary disease (COPD) Reduce deaths from chronic obstructive pulmonary disease (COPD) among adults Reduce hospitalizations for chronic obstructive pulmonary disease (COPD) Reduce emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) Increase the proportion of adults with abnormal lung function whose underlying obstructive disease has been diagnosed 

COPD Asthma Rarely occurs before age 45 Rarely occurs in a non- smoker Little can be done to improve sx. of COPD once patients experience them COPD patients rarely go a day without experiencing sx. Lung function never returns to normal Can occur with asthma Can occur at any age Can occur in a smoker or non-smoker Removing environmental triggers can greatly improve asthmatic sx. Asthmatics can go great lengths of time in between experiencing sx. Lung function returns to normal between attacks Asthma vs. COPD COPD is often misdiagnosed as asthma, which leads to ineffective treatment and management. (

SMOKING CESSATION IS KEY! 85 to 90% of COPD deaths are caused by smoking. Smokers are 12% (in men) and 13% (in women) more likely to die from COPD than non-smokers.  Smokers likelihood of developing COPD is 50%. Risk of COPD decreased by 50% after quitting smoking.  Laniado-Laborín, Rafael. Smoking and Chronic Obstructive Pulmonary Disease (COPD): Parallel Epidemics of the 21st Century. International Journal of Environmental Research and Public Health, 2009, 6, ; doi: /ijerph

Questions?