FRESH AIR Uganda. survey about the burden of COPD and its risk factors in a rural area of Uganda

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1 FRESH AIR Uganda survey about the burden of COPD and its risk factors in a rural area of Uganda FREDERIK VA N GEMERT, GENERAL PRACTITIONER AND R ESEA RCHER

2 FRESH AIR Survey Uganda Research team: The Netherlands: Uganda: United Kingdom: Frederik van Gemert, Thys van der Molen, Niels Chavannes, Ioanna Tsiligianni, Corina de Jong Moses Kamya, Bruce Kirenga, Simon Luzige, Patrick Musinguzi Rupert Jones, Sian Williams Collaboration: International Primary Care Respiratory Group (IPCRG) University Medical Centre Groningen (UMCG), the Netherlands Groningen Research Institute of Asthma and COPD (GRIAC) Leiden University Medical Centre (LUMC), the Netherlands Makerere University, Mulago Hospital, Uganda

3 Non-communicable diseases In 2011 UN meeting recognized non-communicable diseases (NCDs) as a global threat Main NCDs are cardiovasculair diseases, stroke, diabetes, cancer and chronic respiratory diseases Globally, total number of NCDs deaths is rising 2 out of 3 deaths are attributable to NCDs 4 out of 5 in low- and middle-income countries (LMICs) The greatest burden is found in the poorest and most vulnerable population Beaglehole et al, Priority actions for NCD crisis, Lancet 2008 Beaglehole et al, UN High-Level Meeting on NCDs, Lancet 2011 WHO: NCDs action plan , 2012

4 What is COPD? Chronic obstructive pulmonary disease = COPD A set of lung diseases that limit air flow and is not fully reversible. Usually progressive and is associated with inflammation of the lungs as they respond to noxious particles or gases Potentially preventable with proper precautions and avoidance of risk factors Symptomatic treatment is available GOLD strategy for diagnosis,management and prevention of COPD, 2015

5 Common symptoms of COPD Breathlessness Increased effort to breathe Heaviness or a need for air Excessive mucus or phlegm Chronic cough Wheezing These symptoms get worse when exercising, or during an exacerbation (= worsening of patient s symptoms beyond normal day-today variation, and acute in onset) GOLD strategy for diagnosis,management and prevention of COPD, 2015

6 Burden of COPD Slowly progressive disease, which means it gets worse over time Daily activities may become more difficult as disease worsens 4 million die every year of COPD; more than 90% in LMICs Globally, primary cause is tobacco smoke, but in LMICs biomass fuel exposure is the biggest risk factor WHO: chronic obstructive pulmonary disease: facts sheet 2015 Van Gemert et al, Impact asthma and COPD in sub-saharan Africa, Prim Care Respir J 2011

7 Chronic respiratory diseases in Africa Non-communicable diseases receive insufficient attention COPD is globally 4ᵗʰ leading cause of death Knowledge of COPD is poor Data on COPD and related risk factors are scarce Biomass fuel use, tobacco smoke, occupational exposure, kerosene lamps, chest infections, untreated asthma, TB and social economic factors Image was taken with permission of person involved WHO Global Surveillance, Prevention and Control of CRD 2007 Van Gemert et al, Impact asthma and COPD in sub-saharan Africa, Prim Care Respir J 2011 Forum of International Respiratory Societies, Respiratory diseases in the World, 2014

8 WHO, Indoor Air Pollution 2007 Perez-Padilla et al, Respiratory health effects of indoor air pollution, Int J Tuber Lung Dis 2010 Van Gemert et al, Impact of asthma and COPD in sub-saharan Africa, Prim Care Respir J 2011 Kurmi et al, Indoor air pollution and the lung in low and middle income countries, Eur Resp J 2013 Biomass fuel use Wood, dung, crop residues, grass, twigs, and charcoal 3 billion people and 90% of rural households in LMICs rely on biomass fuel In Africa, most rural households use wood as main solid fuel for cooking open fire with 3 rocks supporting the pot causing extremely high levels of pollution due to insufficient combustion combined with poor ventilation affecting women, especially responsible for cooking, and their young children Image was taken with permission of person involved

9 Biomass fuel More than 250 organic compounds Including carbon monoxide, nitrogen oxide, sulphur oxide, variety of pollutants, carcinogens, co-carcinogens, and free radicals, most of them having health damaging effects Particulate matter (PM₂.₅) Smallest particle mean arodynamic diameter of 2.5µg and penetrate deep into the lungs WHO recomendation: 24 hours mean maximum 25µg/m³ Average PM₂.₅ µg/m³ Maximum PM₂.₅ µg/m³ Fullerton et al, Indoor air pollution from biomass smoke is a major health concern in the developing world, Royal Soc Trop Med Hygiene 2008 Gordon et al, Respiratory risks from household air pollution in low and middle income countries, Lancet Respir Med 2014 WHO: Indoor air quality guidelines: household fuel combustion 2014

10 Health effects of biomass smoke Respiratory illnesses Children: acute lower tract infections, reduced lung growth, asthma trigger Adults: COPD, tuberculosis, lung cancer, asthma trigger, respiratory tract infections Non-respiratory illnesses Fetus: intra-uterine growth restriction Children: low birthweight, nutritional deficiency Adults: cardiovascular diseases, stroke, cataracts, and problems during pregnancy (pre-term birth, still birth, maternal deaths) Fullerton et al, Indoor air pollution from biomass smoke is a major health concern in the developing world, Royal Soc Trop Med Hygiene 2008 Gordon et al, Respiratory risks from household air pollution in low and middle income countries, Lancet Respir Med 2014

11 FRESH AIR pilot survey (in 2011) Assessing beliefs and attitudes concerning respiratory symptoms, biomass fuel use, tobacco smoking and use of health services Evaluating feasibility spirometry in the field Adapting screening questionnaire to local conditions Image was taken with permission of person and party involved Van Gemert et al, Impact of respiratory symptoms in a rural area of a sub-saharan country, Prim Care Respir J 2013

12 Top-10 morbidity cases Masindi district (out-patients) cases total percentage 1. Malaria 160, Cough or cold 98, Intestinal worms 17, Oral disease and conditions 13, Diarrhea, acute 10, Skin disease 10, Eye conditions 7, Injuries 7, Pneumonia 7, Gasto-intestinal disorders 6, Source: OPD Medical Department, District of Masindi

13 Healthcare workers in Masindi district Knowledge of CRD and their risk factors is limited Know word asthma, but do not understand implication Word COPD totally unknown Spirometry and inhaled medication not available TB-negative is an often mentioned diagnosis Treatment of exacerbations At health centres: antibiotics In hospital: antibiotics, salbutamol tablets and and aminophylline drip Image was taken with permission of person involved Van Gemert et al, Impact of respiratory symptoms in a rural area of a sub-saharan country, Prim Care Respir J 2013

14 Person with COPD in Masindi district doesn t have a diagnosis accepts symptoms and limitations as part of life has no idea about risk factors has no medication Treatment with local herbs Traditional healers (will never be mentioned) No money to buy medicine at private dispensaries is often stigmatised has a low trust in health centres (respiratory symptoms) Van Gemert et al, Impact of respiratory symptoms in a rural area of a sub-saharan country, Prim Care Respir J 2013

15 Lessons from FRESH AIR pilot-survey Lack of knowledge has created different beliefs and attitudes towards respiratory symptoms Exposure of risk factors is determined by their cultural tradition and gender, tribal origin and poverty Women cannot change age-old cooking tradition by themselves Men smoke tobacco (and simonko) anywhere they want The importance of national and local cultures and social systems, values and beliefs needs to be recognised Van Gemert et al, Impact of respiratory symptoms in a rural area of a sub-saharan country, Prim Care Respir J 2013

16 Principles of FRESH AIR Uganda Work in close cooperation with: Village leader (LC1) to Chairman of district (LC5) Village health teams to District Health Officer National University Research and development of local expertise in the provision of public health was an integral component of the survey Image was taken with permission of person involved

17 Methodology in rural Masindi district Making use of local health system and local health care workers Randomly sampling of 300 men and 300 women above the age of 30 years 30 villages (probability proportionate to size) Random sampling of 20 households (enumeration) Performing survey in selected villages Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

18 Study procedures of FRESH AIR Local healthcare workers were trained to perform high quality survey Questionnaires (screening and air pollution) Spirometry (testing how much air and how fast a patient can exhale) Clinical COPD Questionnaire (healthrelated quality of life) Image was taken with permission of person and party involved Out of 620 participants, 609 signed informed consent and eventually 588 provided acceptable spirometry (success rate of almost 95%) Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

19 Demographic data of participants Men Women Population 291 (49.5%) 297 (50.5%) Age in years 45.0 (12.8) 45.5 (14.5) BMI (kg/m²) 22.2 (3.2) 23.7 (4.9) Smoking status Current smoker 100 (34 %) 22 (7 %) Former smoker 63 (22 %) 24 (8 %) Never smoker 128 (44 %) 251 (85 %) Biomass fuel use Indoor exposure 265 (91 %) 281 (95 %) Time per day 3.1 hours 5.2 hours Years exposed Outdoor exposure 262 (90 %) 282 (95 %) Time per day 1.3 hours 1.9 hours Years exposed Kerosene-based lighting 275 (95 %) 277 (94%) Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

20 Participants with COPD (Lower Limit of Normal) Prevalence COPD: 16.2% (n=95) Participants with COPD (FEV₁/FVC < LLN) Men Women 20 40% Gender male female Persons 47% (n=45) 53% (n=50) 37% Age (SD) 45 (11) 48 (16) 15 33% 39% in age group years 7% above 70 years Severity in GOLD classification Men Women Total 1 (mild) 37 (82%) 37 (74%) 74 (78%) 2 (moderate) 7 (16%) 12 (24%) 19 (20%) Number of participants % 17% 14% 10% 11% 2% 8% 4% 3 (severe) 1 (2%) 1 (2%) 2 (2%) 4 (very severe) % Age in categories (years) > 80 Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

21 Participants with COPD Symptoms, health-related quality of life score¹ and shortness of breath score² was mild Exacerbation rate was high 29% more than one last year, increasing with age 20% had more than two last year Image was taken with permission of person involved ¹Measured with the Clinical COPD Questionnaire (CCQ) ²Measured with the Medical Research Council dyspnoea score (MRC) Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

22 Smoking status and COPD Many young men with COPD smoked In age group 30-39: 65% (n =11) current smoker 18% (n = 3) former smoker Young women hardly smoked Mean age (in years) and smoking status: Men Women Current 40 (8) 53 (18) Former 48 (11) 63 (16) Never 50 (14) 43 (13) Data are mean age in years ± standard deviation (SD) 40 Mean age and smoking status: Count Data are number of patients ± standard deviation (SD) % 8% current smoker 24% 18% former smoker 32% 74% never a smoker Gender male female In villages situated in tobaccogrowing fields, leaves are often dried indoors using open fire and guarded by elderly and young children Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

23 Comparison non-copd and COPD Non-COPD COPD P value Age 45 (SD ±13) 47 (SD ±14) (NS) Gender 50% men 47% men (NS) Education None Primary Secundary Tertiary 20% 61% 15% 4% 22% 59% 18% 1% (NS) Ethnicity Bantu non-bantu 56% 44% 43% 57% Living in tobacco-growing areas Yes 40% 46% Cooking area In same building In separate building 16% 84% 19% 81% (NS) (NS) Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

24 Comparison risk factors and COPD Biomass fuel exposure (indoors) Years exposed Hours exposed per day Biomass fuel exposure (outdoors) Smoking status Chest infections Years exposed Hours exposed per day Current smoker Former smoker Never smoker None 1 or 2 per year More than 2 per year Non-COPD COPD P value 93% Men Women % Men Women Men Women 33% 7% 21% 6% 46% 87% Men Women 12% 8% 55% 56% 33% 36% 91% Men Women % Men Women Men Women 44% 8% 24% 18% 32% 74% Men Women 9% 10% 33% 62% 58% 28% (NS) (NS) (NS) (NS) P=0.002 Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

25 Ethnicity and risk factors COPD 43% Men 37% women 63% Active smoker Age group Bantu 11% men 21% and women 0% Living in tobacco growing area 15% 72% Charcoal use 40% 22% Education None Primary Secondary Tertiary Bantu Non-Bantu P value men 7.7% women 17.1% men 57.3% women 65.1% men 28.7% women 14.3% men 6.3% women 3.4% Admitted hospital 17% 6.3% 57% Men 56% women 44% Non-Bantu 33% men 58% and women 11% men 9.5% women 51.6% men 72.3% women 45.1% men 14.9% women 2.5% men 3.4% women 0.8% Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

26 Conclusion FRESH AIR Uganda Using LLN, prevalence COPD was 16.2% 39%, both men and women, between year of age Almost everybody was exposed to biomass smoke Tobacco smoking particularly done by young men With a life expectancy of 52 years, COPD represents a major threat for people of all ages in rural areas of Uganda Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015 Uganda National Household Survey, Uganda Bureau of Statistics 2010

27 For sub-saharan Africa? Prevalence COPD is probably high Adults between 30 and 40 years of age, living in a rural area, are a forgotten group of people Socio-economic factors are linked with higher prevalence of COPD Different types of COPD (phenotypes) Caused by tobacco smoke Caused by biomass smoke It is not clear what stage in life, exposure to biomass smoke causes most pulmonary damage Salvi, The silent epidemic of COPD in Africa. Lancet Global Health 2015 Respiratory diseases in the world: realities of today-opportunities for tomorrow, Forum of International Societies 2013 Van Gemert et al, Prevalence COPD and associated risk factors in sub-saharan Africa, Lancet Global Health, 2015

28 Early origin of COPD Growing evidence that the harmful effects of biomass smoke starts early in childhood, and even before birth when a pregnant woman is cooking This is associated with low birth weight and reduced lung function Exposure to biomass smoke causes poor lung growth during childhood and respiratory infections among young children This has a lasting effect in adulthood, and substantially increased COPD risk Kurmi et al, Indoor air pollution and the lung in LMICs, Eur Respir J 2012 Gordon et al, Respiratory risks from household air pollution in LMICs, Lancet Respir Med 2014 Rennard et al, Early COPD: definition, assessment and prevention, Lancet 2015

29 Situation in rural Africa COPD is a unknown disease, both in terms of public awareness and in public health planning People are unaware of damage to respiratory and nonrespiratory health caused by tobacco and biomass smoke This leads to failure to make simple steps to avoid exposure to biomass smoke Public awareness and control of (household) environment are important steps in preventing respiratory and nonrespiratory diseases Forum of International Respiratory Societies, Respiratory diseases in the World, 2014

30 Challenge for healthy lungs Prevention and intervention programmes Early detection, diagnosis and treatment Research Burden of chronic respiratory diseases for all stages of life Risk factors during all stages of life Quantitative and qualitative surveys on the effects of biomass smoke during all stages of life Exposure-response relationship of biomass fuel use mean exposures and peak exposures Awareness of detrimental effects of tobacco and biomass smoke (Global Bridges awareness survey and Horizon 2020)

31 FRESH AIR Uganda was sponsored by University Medical Centre Groningen (Netherlands), and funded by International Primary Care Respiratory Group (IPCRG) A new world unfolds.. FRESH AIR Uganda WHO-GARD demonstration project We thank the staff of the district health office and the healthcare workers of Masindi district for making FRESH AIR Uganda possible