Chronic respiratory diseases: issues for national program managers

1. Chronic respiratory diseases: issues for national program managers (Dr. Eugene Zheleznyakov, Technical Officer, Chronic Disease Prevention and Management, WHO, Geneva)

2. BURDEN

3. Did you know?? 4 000 000PEOPLE DIED FROMCHRONIC RESPIRATORY DISEASES IN 2005

4. Chronic respiratory diseases worldwide Main NCDs include: • Cardiovascular diseases mainly heart disease and stroke • Cancer • Chronic respiratory diseases • Diabetes

5. Projected disease deaths and burden, 2005 Preventing Chronic Diseases, a vital investment, WHO, 2005 Main causes of global burden of disease (DALYs) Main causes of death Communicable diseases Maternal/perinatal Nutrional deficiencies 7% Cardiovascular Cancer 4% CRD Diabetes Other chronic diseases Injuries

6. Chronic respiratory diseases worldwide Hundreds of millions of people have chronic respiratory diseases • includingalmost 300 million people with • asthma • 65 million people with chronic obstructive pulmonary disease (COPD) • Millions of people with allergic rhinitis, sleep apnoea syndrome and other chronic respiratory conditions

7. Chronic Respiratory Diseases

8. Burden of Major Respiratory Conditions Condition Deaths DALYs* % % Lower Respiratory Infections 6.6 5.8 COPD 4.8 1.9 Tuberculosis 2.8 2.4 Lung/ 2.2 0.8 Bronchus /Trachea Cancer Asthma 0.4 1.0 Total 16.8 11.9 *DALYs = Disability-Adjusted Life-Years Source: World Health Report 2003

9. 4 million people die each year from CRD In 2030: COPD: 4th cause of death (Plos Med 2006) Tobacco > 8 million deaths (Plos Med 2006) Biomass fuel combustion > 10 million deaths(Ezzatti, Science 2005) > 50% of the world population will be allergic Chronic respiratory diseases

10. Disability Adjusted Life Years One DALY: one lost year of “healthy” life DALY = YLD + YLL COPD onset expected death death 55 65 75 YLD YLL 50 Years of Life with Disability Years of Life Lost What are DALYs? age (years)

11. Increasing Burden of Diseases and Injuries: Change in Rank Order of DALYs* *DALYs = Disability-Adjusted Life-Years Source: WHO Evidence, Information and Policy, 2005 *DALYs: Disability Adjusted Life Years

12. Age-standardized disability-adjusted life year (DALY) rates from respiratory diseases by country (per 100,000) Canuckguy et al. 2009

14. Tobacco Indoor air pollution RISK FACTORS

15. The relative importance of Tobacco Smoke and other risk factors relevant for COPD Opposite patterns in different geographic areas EUROPE versus AFRICA Source: World Health Report 2002

16. EUROPE Disease burden (DALYs) in 2000 attributable to selected risk factors Blood pressure Tobacco Tobacco Alcohol Cholesterol High Body Mass Index Fruit and vegetable intake Physical inactivity Illicit drugs Lead exposure Unsafe sex Iron deficiency Occupational risk factors for injury Urban air pollution Urban air pollution Childhood sexual abuse Underweight Unsafe water, sanitation, and hygiene Indoor smoke from solid fuels Number of Disability-Adjusted Life Years (000s) 0 5000 10000 15000 20000

17. Unsafe sex Underweight Unsafe water, sanitation, and hygiene Vitamin A deficiency Zinc deficiency Indoor pollution Indoor smoke from solid fuels Iron deficiency Alcohol Blood pressure Lack of contraception Tobacco Tobacco Cholesterol Unsafe health care injections Global climate change Occupational risk factors for injury Fruit and vegetable intake 0 10000 20000 30000 40000 50000 60000 70000 Number of Disability-Adjusted Life Years (000s) AFRICA Disease burden (DALYs) in 2000 attributable to selected risk factors Lead exposure

18. Source: World Health Report, 2002

19. Source: World Health Report, 2002

20. Particles (complex mixtures of chemicals in solid form and droplets) Carbon monoxide Nitrous oxides Sulphur oxides (mainly from coal) Formaldehyde Carcinogens (e.g. benzopyrene and benzene) *Small particles with a diameter of 10 microns (PM10) or less are able to penetrate deep into the lungs and appear to have the greatest health-damaging potential Indoor smoke

21. Acute lower respiratory infections (ALRI) Chronic obstructive pulmonary disease (COPD) Lung cancer Other: (low birth weight and perinatal mortality (still births and deaths in the first week of life) asthma otitis media (middle ear infection) and other acute upper respiratory infections tuberculosis nasopharyngeal cancer laryngeal cancer cataract (blindness) cardiovascular diseases Health effects

22. Disease burden (DALYs) due to indoor air pollution by level of development - 2004

23. Attributable mortality for indoor smoke from solid fuel use

24. Broad impacts of biomass fuel use

25. WHO global approach to control Chronic Respiratory Diseases

28. The aim of the WHO chronic respiratory diseases programme as a part of NCD programme is to support member states in their efforts to reduce the toll of morbidity, disability and premature mortality related to chronic respiratory diseases, and specifically, asthma and COPD. Objectives: 1. Surveillance to map the magnitude of chronic respiratory diseases and analyze their determinants with particular reference to poor and disadvantaged populations, and to monitor future trends. 2. Primary prevention to reduce the level of exposure of individuals and populations to common risk factors, particularly tobacco, poor nutrition, frequent lower respiratory infections during childhood, and environmental air pollution (indoor, outdoor, and occupational). 3. Secondary and tertiary prevention to strengthen health care for people with chronic respiratory diseases by identifying cost-effective interventions, upgrading standards and accessibility of care at different levels of the health care system.

29. May 2010

33. In most regions of the world the four major NCDs (cardiovascular disease, cancer, diabetes and chronic respiratory diseases) contribute to at least 50% of the NCD burden. Protocols address these NCDs only Only evidence based and cost effective interventions, feasible for application in primary care in low resource settings have been selected Protocols take cognizance of the fact that most major NCDs are not symptomatic until late in the development of the disease The integrated multifactorial risk approach is more appropriate for low resource settings because it is more cost effective and it improves health outcomes Clinical protocols

34. Protocol: 6P  Breathlessness/cough Make a probable diagnosis based on the following Ask about severity of breathlessness (walk, climbing stairs, talking or at rest), blood stained sputum, chest pain, past history of TB, asthma, COPD, heart failure. Tobacco use (yes/No). Examine cyanosis, bilateral pitting oedema, abnormal breath sounds, heart murmur. temperature, respiratory and heart rate, blood pressure and peak flow. • IF Severe breathlessness ( Breathless at rest or while talking) with • Respiratory rate >30 per minute • Confused or agitated • Use of accessory muscles of respiration • Peak flow <50% • Oximetry <90% • Suspect TB or lung cancer if • >2 weeks of daily or frequent, persistent cough or sputum or • Past history of TB or • Unintentional weight loss or • Known diagnosis of HIV or • Chest pain on breathing or • Blood stained sputum If Non-severe breathlessness with • wheezing,or tightness in chest or recent increased sputum • Respiratory rate 20-30/ minute Peak flow >50 to <80% Moderate exacerbation asthma/COPD Peak flow >80% mild exacerbation asthma/COPD Referto confirm or exclude TB or lung cancer Wheezing, silent chest or Rhonchi Temperature >38º C With or without Pleural pain Purulent sputum Bilateral Pitting oedema Lower respiratory tract infection (Protocol 18P) Possible cardiac failure (Protocol 14P) Protocol 17P Severe exacerbation Asthma /COPD

35. Protocol: 15 P Follow up of stable cases of asthma / COPD ASK: Asthma and COPD both present with cough, difficult breathing, tight chest and/ or wheezing Differentiate between Asthma and COPD If the diagnosis of asthma or COPD is known go to protocol 16P Measure PEF Give salbutamol 2 puffs and remeasure in 15 minutes If PEF improves by 20% diagnose asthma ( protocol16P ) If no change diagnose COPD (protocol 16P) Test:

36. Management of Stable Asthma or COPD Protocol: 16P ASK: Assess level of ASTHMA CONTROL

37. Protocol: 16P continued Acceptable control Uncontrolled Treat Correct inhaler technique and assure that patient is complying with his treatment • On current treatment: • Continue inhaled beclomethasone at current dose • Continue salbutamol as-needed only • Review after 3 months • On treatment: • Double dose of inhaled beclomethasone • Salbutamol as-needed (not more than 4 times daily) • If on maximum dose (1000/500µg/twice daily) of inhaled corticosteroid, add 10mg oral prednisone and refer • No treatment • Beclomethasone 1 (250/100µg) puff twice daily • Salbutamol as-needed (not more than 2 puffs 4 times daily) Refer • If diagnosis in doubt • If uncontrolled on beclomethasone 2 puffs twice daily • if uncontrolled on high dose of beclomethasone plus oral corticosteroids • If diagnosis in doubt • If discontinuation of beclomethasone is being considered based on good control

38. Protocol: 16P continued • Advice to patients and family • •Avoid trigger factors for asthma attacks. • •Eliminate cockroaches from the house (not when the patient is present). • •Use synthetic mattresses and pillows or cover them with a synthetic cloth. • •Remove carpets from the house, especially from sleeping areas • •Shake and expose mattresses, pillows, bedspreads and blankets to the sun. • •Advice on cleaning without raising dust: • -Sprinkle the floor with water before sweeping • -Clean furniture with a moist cloth. • -Clean the blades of fans to get rid of dust • -Avoid storing books, toys, cloth, shoes and other items that accumulate dust, in sleeping areas Teach how to use the metered-dose inhaler for asthma (figure) •Teach and check the correct use of metered-dose inhalers. •Use a spacer with a mouthpiece, unless the patient cannot tolerate it or cannot use it because of breathlessness. In these cases, use a spacer with a mask. •Check whether the patient co-ordinates inhalation with activating the inhaler.

39. Protocol: 16P continued Stable COPD Categorize and treat according to severity as below

40. Protocol: 16P continued Advise to patients and family Smoking and indoor air pollution are the major risk factors for COPD. •It is essential that COPD patients stop smoking and avoid dusts, tobacco smoke, and other types of smoke •Keep the area where meals are cooked well ventilated by opening windows and doors. •If possible, cook with wood or carbon outside the house •If possible or build an oven in the kitchen with bricks and a chimney that vents the smoke outside. •Use masks for respiratory protection or stop working in areas with occupational dust or pollution.

41. Protocol: 17 PExacerbation of asthma and COPD • Severe exacerbation • salbutamol up to 8 puffs every 20 minutes for 1 hour (preferably with spacer) and reassess. • Supplemental oxygen over 4 liters/min (30%) by nasal canula to maintain saturation >90% • oral prednisone 40 mg and continue 40 mg once daily for 7 days • Consider continuous salbutamol nebulisation (1-2 ml of 0.5% salbutamol solution in 3 ml NaCl) for 1 hour if severe breathlessness and low pulse oximetry (<88%) • Consider addition of ipratropium bromide (2 puffs inhaled or 2 mL ipratropium solution added to salbutamol and NaCl for nebulisation) • If temperature is >38o C and/or sputum is purulent give: • Erythromycin (250 -500 mg every 6 hours), or • Amoxicyllin (250 -500 mg every 8 hours) • Assess response to treatment in one hour Treatment • Moderate exacerbation • salbutamol up to 8 puffs every 20 minutes for 1 hour and reassess. • Give oral prednisone 1mg/kg • If temperature is >38o C and/or sputum is purulent give: • Erythromycin • or • Amoxicyllin • Assess response to treatment in 2 hours • Mild exacerbation • salbutamol up to 4 puffs every 20 minutes for 1 hour and reassess • If temperature is >38o C and/or sputum is purulent give: • Erythromycin • or • Amoxicyllin

42. Protocol: 17 P(continued) Assess response to treatment • Good response • Peak flow improved, respiratory rate decreased (normal < 20 per minute) • Discharge home: follow-up in 1 week. • Ensure that patient will have salbutamol inhaler for home use: advise 2 puffs every 4 hours for breathlessness or wheezing • Prescribe oral prednisone 40 mg once daily for 7 days • Poor response: If decreased peak flow; or confused or drowsy ,or worsened breathlessness: REFER urgently. • Ifno response after 2 hours of treatment with salbutamol REFER • While awaiting transport, • administer oxygen (30% mask or 2-4 liters/min by nasal prongs) to keep saturation >90% if possible • Continue salbutamol, nebulised if possible (1-2 ml of 0.5% salbutamol solution in 3 ml NaCl every 20 minutes or continuous if severe respiratory distress) • Follow up after 1 week: • Assess symptoms (breathlessness, wheeze) and signs (respiratory rate, lung exam, pulse oximetry) • .If NO improvement treat as moderate/severe exacerbation (as above) If poor response to therapy refer • If good response continue long term treatment and follow up (use protocol 15 P)

43. TOBACCO USE

44. Framework Convention on Tobacco Control (FCTC) Today the FCTC has 140 parties (16 November 2006)

45.  Reducing NCD risk factors

46.  Reducing NCD risk factors

47.  Reducing NCD risk factors

48. Interventions on the source of pollution Switching from solid fuels (biomass, coal) to cleaner and more efficient fuels and energy technologies such as liquid petroleum gas, biogas, electricity, solar power Improved stoves 2. Interventions to the living environment Better ventilation of the living environment – enlarged windows, chimneys, etc. 3. Interventions to user behavior Context-specific interventions Interventions to reduce indoor air pollution

49. Multisectoral collaboration Multilateral Bilateral Agencies Educational Sector Professional Associations Communities, churches, religious leaders Patient Groups Private sector, media CRD and public health experts Related Ministries NGOs

50. Global Alliance against Chronic Respiratory Diseases Web site: www.who.int/gard E-mail: gard@who.int