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Prevalence of COPD in India

Discuss About The Annals Of The New York Academy Of Sciences.

Chronic obstructive pulmonary disease (COPD) is said to be a communal health problem in India and is a vital cause of death and morbidity within the country (1). The identification of COPD is centered on spirometry, symptoms and availability of the COPD risk factors. Smoking is the significant cause for COPD development, while biomass fuel exposure is the significant risk factor for COPD development in the female population and the non-smokers in India (2). COPD is thought to be prevalent in India, in 2005, COPD accounted for about 7 % deaths and about 3% DALYs (disability-adjusted life-years) in India (3). There are about 12 million Indian adults with COPD and the predominance of COPD varies with the method applied and the population (4). The occurrence of COPD ranges between 2.12% - 9.4% in northern India and between 1.4% - 4.08% in southern India, the predominance in women is constantly lower in comparison to men (5). Rough estimations suggest that there is about 30 million patient of COPD in India; India has also contributed greatly to the growing COPD mortality percentage, which is above 20% (556,000 cases) out of the world’s 2,748,000 cases annually (5).

Worldwide, COPD is the significant cause of mortality and morbidity, the World Health Organization estimates that 65 million individuals suffer from COPD (5). 3 million individuals and above died in 2005 of COPD corresponding to about 5% of all the global deaths in that year, and it is feared to be the 3rd leading death caused by the year 2030 (24). Middle- and low- income countries have shouldered a great burden of COPD with about 90% of the COPD deaths occurring in these states (6).

COPD in India is a progressive, chronic, difficult and expensive infection to treat which currently has no cure in India. There is a great need for secondary and primary prevention strategies set to ensure reduction of the developing COPD burden in the country (7). The country has set very few strategies for making its citizens knowledgeable of the various risk aspects connected to COPD. For effective policy decision making for efficient management of COPD, there is need to conduct intensive studies within various states in India to produce enough evidence and knowledge about the disease in the country. A great number of patients with COPD remain wrongly diagnosed or undiagnosed in the clinical practices because of various reasons mostly associated with misinterpretation of the facts associated with COPD in India, this has resulted in the increased occurrence of COPD in the country (8). For this reason, there is the need for creation of policies that facilitate the programs for raising awareness in the country to enable the medical practitioners, as well as other individuals, understand the infection, factors facilitating it and how to manage COPD (9).

Risk Factors for COPD in India

There is a very limited number of the centers for pulmonary rehabilitation within India, this has resulted in higher prevalence rates of COPD in the country, as the needs for the COPD patients are catered for ineffectively (10). However, strategies are underway to ensure effective care and management of COPD patients, the scientists and physicians in India are called upon to carry out research that will lead to creation of better, newer and easier methods of diagnosis of the disease as well as development of newer inhalation devices and drugs that will help improve life’s quality and improve symptom detection, and also halt and revert the progress of COPD in India (11). There is the limited nationwide effort towards cubing COPD in India as some areas especially the rural areas are neglected, the rural areas have very little knowledge on COPD diseases and the anti-COPD campaigns fail to reach the individuals in rural areas, therefore, increased COPD rates in rural Indian regions. For this reason, there is the need for the Indian National COPD control and prevention program that will focus on every part of India for the purpose of curbing COPD (12).

The presence of very few pulmonary rehabilitation structures especially in the rural Indian areas results in the increased chances of COPD occurrence, this calls on for governmental intervention to ensure the provision of adequate pulmonary rehabilitation centers nationwide (13). Pulmonary rehabilitation is effective in managing COPD; however, it has been difficult setting up these programs especially in rural India due to the resource-poor settings (14). Limited randomized medical trials offered from India, studied that home-based rehabilitation and exercise teaching options were effective in the resource-poor settings (15). Exercising is essential for the patient’s health welfare (16).  There are very few programs for assessing the nutritional status by BMI, bio-impendence analysis and skin-fold anthropometry in COPD patients; and this has increased the occurrence of malnutrition in COPD patients this has raised various debates in the country regarding nutritional therapy programs for the COPD patients (17). The national debate concerning nutritional therapy shoots from the point that there are varying benefits with dietary supplementation within COPD patients (18).

Public health and health expenditure as well as income

COPD and related comorbidities treatment require frequent hospitalization and established resources and this can be very costly to the health center and the patients. The hospitalization rate is about four times more in the elderly (above 65 years) than in the patients who are younger. The mean hospital stay lengths range between 4 - 16 days in a standard intensive care unit (19). In India, the financial and economic burden of COPD treatment is overwhelming for the common individuals and the amount of the healthcare expenditure that is out-of-pocket is about 62.41% (20). The Indian social structure does not offer enough protection to the older individuals and this results in less observance of the treatment process this has affected the prevalence of COPD in India. 

Challenges in COPD Diagnosis and Management

The medical expenditure required in COPD treatment include direct medical, direct non-medical costs these costs are usually too expensive for most Indian health systems and the COPD patients (21). The direct medical costs involve the expenditure incurred in hospital, laboratory finding and medical charges. The burden of costs causes deviation from the current COPD Indian guidelines (for instance, 70% of the patients were offered a combination of inhaled corticosteroids and bronchodilator, with only 16.7 of them getting the beta-2 agonist) for the purpose of cutting on the costs of expenditure this results in more care and management of COPD in the healthcare systems (22). On the other hand, the direct non-medical costs involve the total diet and additional (for instance, the traveling expenses) care charges required, these charges may be too high for some patients a condition that has led to the failure of medical access by some patients, therefore, the increased prevalence in India (23). The average of total straight non-medical charges in private medical centers in India is about 528.10 ± 212.72 and this is higher than in the rural, charitable hospitals which offer free food services (23). To curb COPD progress in regard to the total direct medical charges, there is the need to support the COPD patients, particularly the poor for quality healthcare provision (24).

Education

There is need to educate the clinicians on the various factors and diagnostic features of COPD (25). It has been found that; a great number of patients with COPD remain wrongly diagnosed or undiagnosed in the clinical practices because of various reasons mostly associated with misinterpretation of the facts associated with COPD in India, this has resulted in increased occurrence of COPD in the country (26). These misinterpretations include; Spirometry which is a tool of COPD diagnosis is under-utilized by the clinicians due to absence of knowledge and limited spirometer availability; COPD is believed to be caused only by smoking tobacco, this results in under-diagnosis of the condition of COPD in individuals who do not smoke and this has contributed to about half of the COPD cases in India; there is also the strain in making the difference between COPD and asthma (27). The cases of poor or under-diagnosis of COPD results in increased suffering of the patients and therefore, increased worsening of the disease condition. For this reason, nurses, doctors, and other medical professionals need to be educated clearly for effective diagnosis, care, and management of COPD within India (28).

Economic Implications of COPD in India

Awareness

COPD prevalence, as seen before, has a high prevalence rate in India and this has been attributed to factors such as poor diagnosis of the infection (28). For this reason, there is the need for raising awareness among the clinicians to enable effective use of the COPD diagnostic tools such as spectrometry (29). The program of both postgraduate and undergraduate medical education needs to be strengthened within India to empower the doctors with effective knowledge for better management of COPD (30).  There is the need for the inhalation therapy which is made available to every patient suffering from COPD (31).

Social class

The level of occupation and education are closely connected, and some respiratory disorders are a result of occupational exposure. Women usually have occupations that are less exposed to fumes and dust that cause respiratory disorders this aspect explains the lower occurrence of COPD in women than in men in India (32). Therefore the more the exposure to fumes and dust as a result of a particular occupation the greater the risk of COPD diseases (33). Education, on the other hand, is an important risk element for the symptoms of COPD after the modification for occupational disclosure. After amendment for smoking and occupational exposure, the ratios of COPD in primary against university educated topics is 2.9 (1.3–6.5) and the matching ratios for spirometry flow of air restriction are 5.2 (2.0–13.4) (34).

The damaging of the small airways and the alveolar tissue is mediated by oxidants, smoking intensely affects the antioxidant/oxidant balance it also escalates the oxidative stress and this explains the increased vulnerability towards COPD in relation to the social class, heavy alcohol intake is also related to airflow restriction (35). Studies indicate that the socioeconomic incline is slightly affected by the selective access or drift to healthcare. The incline also originates in education which, contrasting with social class and income, precedes the disease (36).

Housing

Home dampness and poor housing with increased dust mites of the house and using the gas stove are all related to decreased lung functioning, lower socioeconomic level, and respiratory symptoms (37). Household crowding which is very common in India has been assumed to cause greater respiratory infection instances, therefore, increasing the number of respiratory conditions (38). Children in homes that use the gas stove for cooking are said to be at a higher risk of respiratory disorders than those who use electricity for cooking, also adults using the gas stove for cooking were at an increased threat of reduced ventilator functioning and the respiratory symptoms among the men but not in women (39). Communal air pollution exposure is a great aspect that determines COPD prevalence among Indians (40).

Smoking

The most conspicuous cause of lung infections is smoking; children raised in homes with individuals who smoke are at a greater threat of respiratory diseases than children from homes that are tobacco-free (41). Tobacco smoking in adolescence and in childhood affects the development of lung functioning (42). This social aspect is greatly associated with the occurrence of COPD among the Indian citizens especially the men who are thought to be exposed to smoking more than the women. And the success rate of quitting is greatly inclined towards the higher level of the social class (43). 

Ethnicity

Ethnicity is the main aspect determining the major socio-economic factors that affect the occurrence of COPD; it is related to the combination of living in regions growing tobacco, smoking, and education (44). However, other factors such as genetic or cultural factors and lifestyle that differ in various ethnic communities indicate the association of ethnicity and COPD (45). 

Lifestyle

There is a significant association between age groups and the quality of living; older patients with COPD indicate a more compromised lifestyle. And the harshness of the disease increases due to age-related deterioration of the patient’s physical functioning of the lungs, this results in the impaired quality living of the patients with COPD (46).  There is an association between the level of education and the quality of life of the patients, the COPD patients who are more educated tend to live a better lifestyle than the ones with lower educational level (47). The reason for the quality lifestyle in educated patients has increased COPD awareness, prompt health-seeking characteristics, and self-care management (48).

Poor delivery procedures due to failure to access professional midwives (where most Indian women prefer to deliver in their homes due to some misleading cultural beliefs) can result in respiratory diseases during infancy (49). These early respiratory disorders can be as a result of decreased lung capacities independent of the low delivery weight effects, a situation that can be reverted by approaching professional midwives during pregnancy and birth (50).

In India, there has been an increase in the burden of the non-communicable diseases, which have been on an increase from the 1990s. As per 2016, 3 out of 5 leading mortality causes constituted the non-communicable diseases, and COPD was ranked as the second greatest cause of mortality in India (51). These results can be ascribed to the increased poverty in India therefore poor housing conditions, reduced quality of living, increased exposure to fuels and dust that facilitate increased rates of respiratory disorders, low levels of education and awareness and inability to access effective medical care as well as insufficient policies regarding management and control of COPD (52). Different studies indicate the changing COPD prevalence rates in various states, the predominance ranges from 1.2 to 19% in women and 2 to 22% in men (53). COPD has become the 4th leading factor of life lose yearly in the EAG (Empowered Action Group) States comprising Uttarakhand, Madhya Pradesh, Bihar, Chhattisgarh, Jharkhand, Odisha, Uttar Pradesh and Rajasthan (53). COPD is also ranked 7th cause of death in the State of the Northern-East including Arunachal Pradesh, Nagaland, Mizoram, Sikkim, Tripura, Manipur, and Assam (53). In the remaining Indian states, COPD was ranked 4th among all the causes of life lost years (54). These results indicate the need for increased improvement of strategies meant to curb COPD prevalence in India (55).

COPD has affected about 5-15% of the grownups in countries that are industrialized, in 1990, COPD was ranked as the 12th global causative factor of a combination of disability and deaths, and this data is scientifically predicted to rise to the 5th position as one of the factors that cause mortality globally (56). This inclining gradient of COPD is attributed to the increased exposure to fuels and dust due to the type of occupation and increased smoking rates especially in young adults and adolescents in the industrialized countries. For countries that are still developing, COPD is mainly influenced by the lower socio-economic factors (57).

Conclusion

COPD (Chronic obstructive pulmonary disease) is a condition that is characterized by reduced respiratory airflow; these features do not usually change significantly over some months. COPD can be grouped into emphysema and chronic bronchitis. COPD is the core respiratory infection that affects the quality and length of lives worldwide (58). World Health Organization describes COPD as a disease of the lungs that is characterized by prolonged lung airflow obstruction that inhibits the usual breathing and it is not fully adjustable (59).

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