Respiratory Health in the World

Український пульмонологічний журнал. 2005, No 3 (додаток) Respiratory diseases constitute a major health problem of the world today. In developed countries high incidence of asthma, chronic obstructive pulmonary disease (COPD) and lung cancer is observed [1]. This is the effect of cigarette smoking, developing industries and pollution of the environment. In underdeveloped countries major problems include tuberculosis (TB) and other res piratory system infections [2]. Every fifth death case is believed to be caused by a lung disease — the global annual mortality rate amounts to 10 million [3]. The most frequent causes of deaths related to lung diseases are, as follows: pneumonia (more than 4 million), TB (more than 2 million), COPD (more than 2 million) and lung cancer (about 1 million) (fig. 1). Average death rate, due to lung diseases, is estimated at 70/100,000 [1]. This indicator, how ever, is higher in Ukraine (80/100,000), and lower in Poland, at only 40/100,000 [1]. Polish data seem to be underestimated. Respiratory diseases have become a significant socio eco nomic problem. In Europe, they are responsible for additional costs of more than 100 billion EUR p.a., of which 50 % are indirect costs of lost work days [1]. Drug expenditures account only for 7 % of total outlays, ambulatory care accounts for 9 % while inpatient care — 18 % [1] (fig. 2). Cost distribution varies, significantly, between individual countries (fig. 3). In Western Europe the high est costs are incurred due to asthma and COPD (primarily indirect costs). On the other hand, in Central and Eastern Europe countries both tuberculosis and occupational respiratory diseases play major role. Cost distribution also varies within incidents of indi vidual diseases. With respect to COPD 2/3 of the costs are relat ed to disability, while drugs, outpatient and inpatient care account for ca. 10 % of the costs [1]. Asthma generates high outpatient care costs (mainly drugs at more than 25 %), while the share of costs related to lost work days accounts for 50 %. With respect to pneumonia most of the costs are related to hospitalization, with smaller share of drugs and ambulatory care in total costs. Tuberculosis Tuberculosis continues to be one of the major health problem but incidence rate and change dynamics vary between different regions. WHO estimates point out to more than 8 millions new cases of tuberculosis annually and more than 2 millions deaths [4]. Majority of these cases occur in countries of Asia, Africa, and South America. Nearly half of the total number of new cases are recorded in India (1,8 millions), China (1,5) and Indonesia (0,6) (fig. 4) [2]. The highest inci dence rate has been observed in Zimbabwe (700/100,000), Cambodia (550), Kenya (540), Mozambique (436), Congo (383), Uganda (363), Thailand (377), Ethiopia (370), Afghanistan (333), Philippines (320), Nigeria (304) and Bangladesh (221) (2). For eco nomic reasons most of the affected population is not receiving any antituberculous treatment. International subsidies are insufficient to effectively overcome epidemics in these countries. According to WHO effective combating of tuberculosis in poor countries will require increasing the subsidies by additional 1 billion € p.a. European epidemiological situation is much better although significant regional differences occur (fig. 5). In isolated popula tions such as Island, Malta, San Marino incidence of tuberculosis amounts to as low as 4 cases per 100,000 [5]. In Western Europe incidence rate is higher (ca. 10/100,000) while in Central European countries the incidence level is nearly four times higher. The worst situation is observed in the countries of the former Soviet Union with average incidence exceeding 80/100,000 (5). In Poland, annu al incidence rate amounts to 26/100,000 while in Ukraine — 82/100,000 [2]. Furthermore, the change dynamics also vary significantly. In many countries such as: Belgium, the Netherlands, Ireland, Den mark, Germany, France, Switzerland, Poland, Slovenia, and Croa tia the tuberculosis incidence rate is consistently decreasing [1]. In other countries (e.g. Romania, Bulgaria, Albania, Moldova) consis tent increase in the number of new cases is observed, while in yet other countries (e.g. Russia, Belarus, Ukraine, Lithuania, Latvia, Estonia) the number of cases of tuberculosis doubled within a short time [1]. During the last decade, the number of TB new cases increased by more than 100,000 (from 232,000 to 335,000) and the average incidence rate increased from 28 to 40/100,000 [2]. TB spread is facilitated by poverty, malnutrition, alcoholism, limited access to medical care, increased migration, and HIV infec tions [4]. TB has remained a significant cause of deaths with majo rity registered in poor countries of Africa and Asia. In many Euro pean countries TB related mortality has declined significantly. In the Netherlands the TB related mortality rate amounts to 0.1/100,000 and in Scandinavia, the UK, Germany, Austria, and Switzerland the mortality rate remains below 1/100,000 [5]. In other countries, such as France, Italy, Spain, Portugal, and Poland TB mortality remains higher (at 1–5/100,000) but in Eastern Europe (Russia, Ukraine, Lithuania, Moldova, Romania etc.) mortality rate exceeds 10/100,000 [1]. TB constitutes a significant cause of death in Asian and African countries. In the countries of high incidence rates (Cambodia, Ke nya, Mozambique) mortality exceeds the level of 100/100,000, while Zimbabwe recorded as much as 150/100,000 [2]. Pneumonia Respiratory system infections are widely spread around the world, accounting for 25 % of the total number of physician con sultations. Within this number, pneumonia accounts for 2–3 %. In majority, these are cases of community acquired pneumonia, normal ly subject to outpatient treatment. Epidemiological data is diver sified and include, primarily, hospitalized patients: 1625/100,000 in the U.S., 900 in Finland, 470 in the UK, 266 in Spain and 242 in Italy [6, 7]. Incidence rate has been increasing in the young and eld erly populations. In the U.S. the number of pneumonia cases requir ing hospitalization has increased from 93/100,000 for the age group of below 45 to 1010/100,000 for the age group of above 65 [7]. In majority of cases, etiology of pneumonia remains unknown and there are significant regional differences in pathogens causing pneumonia. The most frequent causes of pneumonia are, as fol lows Streptococcus pneumoniae, Hemophilus influenzae and atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneu moniae and Legionella pneumophila). In the U.S. more than 100,000 patients are hospitalised because of S. pneumoniae and Mycoplasma pneumoniae, about 50,000 suffering from Chlamy dia pneumoniae and nearly 18,000 suffering from Legionella pneumophila [7]. In the pediatric population pneumonia is mainly caused by Mycoplasma pneumoniae and S. pneumoniae [8]. In mechanically ventilated patients majority of pneumonia cases (83 %) are caused by Gram (–) bacteria and as much as 57 % results from drug resistant bacteria (MRSA, P. aeruginosa, A. baumannii, or S. maltophilia) [9]. The most frequent cause of bronchial and upper respiratory tract infections are viruses (respiratory syncytial virus, rhinovirus, influenza, parainfluenza viruses etc.) [10]. Each year the 5–15 % of the total population suffers from flue [10]. Pneumonia constitutes one of the most important causes of deaths. About 10 % of the hospitalized patients die from pneu monia. The morbidity rate is the highest in the UK (120/100,000 males and 80/100,000 females), in the Netherlands (80/100,000 and 60/100,000 respectively) and in Ireland (70/100,000) [1]. The lowest morbidity rate, below 15/100,000, has been recorded in Greece, Hungary, Macedonia, and Armenia [1]. Poland registered 20 deaths per 100,000 both in male and female population (fig. 6). The fact that also Ukraine registers only few deaths caused by pneumonia should be interpreted conservatively since the data is very likely to by underestimated [1]. Morbidity resulting from pneu © Zielonka T. M., 2005 T. M. Zielonka RESPIRATORY HEALTH IN THE WORLD