1. Manila, Philippines

2. BOLD Manila, Philippines  COPD a growing cause of morbidity & mortality worldwide  5 th leading cause of death (2001)  3rd in 2020 (WHO)

3. BOLD Manila, Philippines Local COPD Burden  Paucity of data and only estimates  Rural Banca- Banca (1987)  3.7%  Urban San Andres Bukid (1990)  2.3%  Estimate using a mathematical model (1999)  6.3%

4. Accurate estimates of the COPD prevalence using standardized methods in population-based studies:  to anticipate future burden of disease  target key risk factors  plan for providing COPD-related health services BOLD Manila, Philippines

5. Primary Objectives: Measure the prevalence of COPD and its various risk factors in the city of Manila Secondary Objectives: Determine extent to which variations in risk factors contribute to variations in the prevalence of COPD  Describe the distribution of COPD according to age, sex and smoking history BOLD Manila, Philippines

6. Eligibility Criteria  Residents of the City of Manila  Aged 40 years and above  Signed informed consent BOLD Manila, Philippines

7. Stratified, three stage cluster sampling City of Manila (population = 1,568,092) 6 Districts of Manila sampled zones (by random sampling) (n=27) sampled barangays (random sampling) ( n=54) sampled households (systematic sampling) (n= 965) all eligible members of sampled household (n=1639) BOLD Manila, Philippines Study Design

8. Questionnaires Validated questionnaires used in multinational studies (1978 ATS/DLD Respiratory Symptom Questionnaire and questionnaires used in the European Community Respiratory Health Study and US Lung Health Study)  Linguistic validation through translation and back translation BOLD Manila, Philippines

9. Spirometry Data sent to the Pulmonary Function Quality Center in Salt Lake City To be deemed usable for analysis, spirometry had to meet ATS acceptability and reproducibility criteria Data Management and Analysis Done at the Operating Center, Portland, Oregon BOLD Manila, Philippines

10. Initial training—05/2005 Fieldwork—10/2005-05/2006 Participants were selected using a stratified, three-stage cluster sampling design 918 (58%) completed the full protocol –i.e., questionnaire & post bronchodilator spirometry Response rates: –Men 55% –Women 60% BOLD Manila, Philippines

11. Manila, Philippines Prevalence of ever smoking in population 1 ages >40 by sex 83% 31% Ever smoked 1 Unweighted data for the sample of responders Overall = 55% Males Females

12. National Nutrition Health Study Prevalence of ever smoking in population 1 ages >20 years (1999) 71% 17% Ever smoked Overall = 45% Males Females

13. Manila, Philippines Population Prevalence of GOLD Stage I+, GOLD Stage II+ & Doctor Diagnosed COPD *Post BD FEV1/FVC<70% ** Post BD FEV 1 /FVC <70% and post BD FEV 1 <80% ***Includes chronic bronchitis, emphysema or COPD

14. COPD Prevalence in City of Manila 12% or 1 out of 8 individuals 40 years and above Out of 361,864 individuals (2002 census) 40 years and above, there are 45,233 COPD patients 2-3% doctor-diagnosed COPD highlights importance of spirometry to diagnose COPD

15. Manila, Philippines Estimated Population Prevalence of GOLD Stage II+ COPD* by age and sex (NHANES) * Post BD FEV 1 /FVC <70% and post BD FEV 1 <80%

16. The prevalence of COPD that is GOLD stage II or higher increases steadily with age for men and women BOLD Manila, Philippines

17. Manila, Philippines Estimated Population Prevalence of Gold Stage II+ COPD* by pack years and sex * Post BD FEV 1 /FVC <70% and post BD FEV 1 <80%

18. The relation between prevalence of GOLD stage II + COPD and pack years was evident among males but less clear with women The fairly high prevalence of GOLD stage II + COPD in the never smokers raise important questions about role of other risk factors BOLD Manila, Philippines

19. The BOLD Study, Lancet September 2007

20. CONCLUSIONS COPD prevalence of 12% is much higher than previous estimates Smoking prevalence of 55% in the city of Manila may be higher than the national figure Prevalence of COPD among never smokers is 7% indicating other risk factors

21. CONCLUSIONS Relation between prevalence of COPD and pack years was evident in men but less clear in women Doctor-diagnosed COPD underestimates the true prevalence of the disease

22. USEFULNESS OF STUDY  It is possible to get more accurate estimates of burden of COPD & its risk factors generated from population-based studies using standardized methods  Studies like this can help assess the effectiveness of health intervention programs – preventive (anti-smoking), diagnostic (spirometry), or therapeutic (anti-inflammatory drugs) across time and even across different areas in the country

23. USEFULNESS OF STUDY  Assist public health officials in developing best possible primary and secondary prevention policies on COPD for their areas

24. PHILIPPINE BOLD STUDY WHAT IS NEXT?  Rural study in Nueva Ecija  Other areas in the Philippines ?

25. BOLD Manila, Philippines Investigators: Renato B. Dantes, MD Fernando Ayuyao, MD Norberto A. Francisco, MD Lakan U. Berratio Teresita S de Guia, MD Gerard Garcia, MD Camilo C. Roa, Jr., MD Leander P. Simpao, MD Lenora C. Fernandez, MD Lourdes Amarillo, MSc Luisito F. Idolor, MD Ma. Flordeliza Sanchez Sullian S. Naval, MD Thessa Reyes Daniel Tan, MD Cecil Tady, MD

26. BOLD Manila, Philippines Acknowledgements: BOLD COLLABORATIVE RESEARCH GROUP A. Sonia Buist, MD William M. Vollmer, PhD Robert L. Jensen, PhD Suzanne Gillespie, MS Mary Ann McBurnie, PhD

27. SPONSORS OF THE STUDY Philippine College of Chest Physicians Philippine College of Physicians Boehringer Ingelheim (Phil) GlaxoSmithKline United Laboratories (Phil) Altana Pfizer BOLD Manila, Philippines

28. Thank you!