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La Salute del Respiro: una attualità nazionale Ernesto Pozzi

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.

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La Salute del Respiro: una attualità nazionale Ernesto Pozzi

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  1. 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 Fondazione IRCCS Policlinico San Matteo Università di Pavia

  2. 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

  3. COPD EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

  4. CHANGING GLOBAL DEMOGRAPHICS • People > 60yr EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

  5. MORTALITY IN FEMALES EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

  6. COPD Mortality by GenderU.S. 1980-2000 Number Deaths x 1000 Source: US Centers for Disease Control and Prevention, 2002

  7. Differences in survival, men vs women, after initiating long-term oxygen terapy Machado et al AJRCCM 2006

  8. 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

  9. 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

  10. 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

  11. Global Epidemiology of Smoking

  12. OTHER RISK FACTORS • Occupation Pollution • Indoor • outdoor EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

  13. 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

  14. Geographical distribution of ECRHS centres

  15. PM2.5 levels across ECRHS centres PM2.5 levels across ECRHS centres

  16. 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

  17. 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

  18. INCIDENCE OF COPD ACCORDING TO THE HISTORY OF CHRONIC COUGH AND PHLEGM De Marco, Cerveri et al AJRCCM 2006

  19. GLOBAL BURDEN • Hospitalizations • Number and duration • Comorbidity EPIDEMIOLOGICAL PERSPECTIVES “Mortality rates will increase by 50% over the next 15 years” Lopez, ERJ 2006

  20. N° RICOVERI Aumento del numero dei ricoveri per BPCOdal 1999 al 2003 in Italia

  21. EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Zoia et al, Resp Med 2005

  22. EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Patients with and without previous diagnosis Without diagnosis With diagnosis

  23. EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT Percentage of patients with and without spirometry

  24. EXACERBATIONS AS A STARTING POINT OF PROACTIVE COPD MANAGEMENT

  25. Epidemiologia della BPCO Ricoveri in regime ordinario SDO - Ministero della Salute, 2005

  26. COPD Exacerbations : Mortality 1016 pts with severe COPD exacerbation (PaCO2> 50 mm Hg) 60 49% 50 43% 40 33% 30 Mortality (%) 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

  27. Total costs (€ billion) of respiratory diseases in Europe in 2000

  28. Piano sanitario nazionale 2006-2008

  29. ASTHMA PREVALENCE IN ADULTS:GOOD NEWS?Weiland and PearceEditorialThorax 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

  30. INCREASE IN DIAGNOSED ASTHMA BUT NOT IN SYMPTOMS IN THE EUROPEAN COMMUNITY RESPIRATORY HEALTH SURVEY Chinn,Jarvis, Burney,Cerveri et al Thorax 2004

  31. ** “Diagnosed asthma” ** Current medication * Attack of asthma Woken with shortness of breath Woken with chest tightness Wheeze without a cold Net change (%) NET CHANGE IN IN PREVALENCE ( per 10 years of follow-up) OF SYMPTOMS, DIAGNOSED ASTHMA, AND CURRENT MEDICATION IN THE ECRHS Chinn, Cerveri and ECRHS group Thorax 2004 * p = 0.011 ** p<0.001

  32. 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

  33. 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

  34. 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

  35. 1992-1993 1998-2000 Anti-asthmatic treatment Asthma attacks ASTHMA ATTACKS AND ANTI-ASTHMATIC TREATMENT IN ITALY (1993 AND 2000) 3.6% 3.2% 2.5% 1.9% Verlato,Cerveri et al, J Allergy Clin Immunol 2003

  36. 1992-1993 1998-2000 NASAL ALLERGIES IN ITALY (1993 AND 2000) 18.3% 15.4% P < 0.001 Nasal allergies

  37. 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

  38. 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)

  39. 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

  40. Tumor necrosis factor polymorphisms and asthma in two international population-based cohorts ( ECRHS and SAPALDIA studies) Castro Giner, ECRHS and Sapaldia groups AJRCCM, submitted

  41. ASTHMA SEVERITY IN THE GENERAL POPULATIONAccording to GINA 2006 Classification(ECRHS II; 1999-2002) de Marco ECRHS group JACI 2006

  42. 13.2% Light burden 72.8% No burden 14% Heavy burden THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES (ECRHS II; 1999-2002) No burden no productivity losses no use of hospital services 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

  43. THE BURDEN OF ASTHMA REMAINS SUBSTANTIAL IN EUROPE A DECADE AFTER THE GINA GUIDELINES(ECRHS II; 1999-2002) • 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 FEV1 % predicted Accordini, Cerveri and ECRHS group Allergy 2007

  44. 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 Peters et al JACI 2007

  45. PREVALENCE OF ASTHMA TREATMENT ADHERENCE AT ECRHS I AND II ECRHS I 1992-3 ECRHS II 1998-2002 Corsico,Cerveri and ECRHS group Resp Med 2007

  46. Utilizzo farmaci R03 (antiasmatici) Bisogno terapeutico teorico CAMPANIA EMILIA LOMBARDIA ITALIA Dati Fondazione SKF DDD = dose media mantenimento giornaliera

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