In the 23rd in a series of assessments
of Healthy People 2010, Senior Executive Advisor
to the Assistant Secretary for Health Larry Fields chaired
a focus area Progress Review on Respiratory Diseases.
Dr. Fields noted how widespread chronic respiratory illnesses
continue to be among the total population and how severe
their consequences can be, especially in the early and
late years of life. In conducting the review, Dr. Fields
was assisted by staff of the co-lead agencies for this
Healthy People 2010 focus area, the National
Institutes of Health (NIH) and the Centers for Disease
Control and Prevention (CDC). Also participating were
representatives of other U.S. Department of Health and
Human Services (HHS) offices and agencies.
The complete text for the Respiratory Diseases focus
area of Healthy People 2010 is available at
www.healthypeople.gov/document/html/volume2/24respiratory.htm.
The meeting agenda, tabulated data for all focus area
objectives, charts, and other materials used in the Progress
Review can be found at www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa24-rd.htm.
Data Trends
Richard Klein of the CDC National Center for Health
Statistics provided an overview of progress achieved
in meeting the targets of selected objectives in the
Respiratory Diseases focus area. In the United States,
chronic respiratory diseases afflict approximately 3.6
million children and 22 million adults, Mr. Klein noted.
Consequently, these diseases impose an annual societal
burden of approximately 20 million physician and outpatient
visits, 3.5 hospital emergency visits, 1.2 million hospitalizations,
and 124,000 deaths. In general, the objectives in the
Respiratory Diseases focus area for which data are available
have shown either an improvement or no significant change
so far in this decade. Major exceptions are noted below.
Asthma—From 1980 to 1996, a
74 percent increase was recorded for self-reported asthma
and, from 1980 to 1999, an 85 percent increase was recorded
in physician visits prompted by this condition. In recent
years, available data show decreases in asthma mortality
rates for most age groups. The notable exception to this
trend is children younger than age 5, for whom the asthma
death rate increased from 1.7 per million in 1999 to
2.1 per million in 2001. The 2010 target is 1.0 deaths
per million for this age group (Obj. 24-1a). There is
a strong ascending gradient with advancing age in asthma
mortality rates. For adults age 65 years and older, the
death rate from asthma was 60.7 per million in 2001,
compared with 69.5 per million in 1999. The target is
60.0 per million (Obj. 24-1e). In addition, there are
marked differences in asthma mortality rates by racial
or ethnic group and by gender. Among the age group 35
to 64 years, for example, the asthma death rate for non-Hispanic
blacks in 2001 (45.1 per million) was by far the highest
of any racial or ethnic group for whom data were available.
(The death rate for non-Hispanic whites in this age group
was 10.5 per million.) In 2001, 35- to 64-year-old females
died from asthma at a rate of 74.4 per million, compared
with a rate of 41.2 per million for males in the age
group. The target is 9.0 per million (Obj. 24-1d).
In 2001, the rate of hospitalization for asthma was
highest—at 56.2 per 10,000 population—among
children younger than age 5 years, compared with 11.8
per 10,000 among the age group 5 to 64 years and 21.4
per 10,000 among the age group 65 years and older. Between
1998 and 2001, the changes in the rate of hospitalization
for asthma that occurred for these three age groups were
not statistically significant. Among children younger
than age 5 years, males had a higher asthma hospitalization
rate (71.4 per 10,000) in 2001 than females (40.3 per
10,000). In the two older age groups, the reverse was
true. Among people age 5 to 64 years, females were hospitalized
for asthma at an age-adjusted rate of 14.8 per 10,000,
compared with 8.5 per 10,000 for males. Among people
age 65 years and older, females had a rate of hospitalization
for asthma about 2 1/2 times the rate for males (27.9
per 10,000 for females, compared with 11.8 per 10,000
for males). The targets for these three age groups (younger
than 5 years, 5 to 64, 65 years and older) from youngest
to oldest are, respectively, 25.0, 7.7, and 11.0 per
10,000 (Objs. 24-2a, -2b, -2c).
The proportion of people with asthma who experience
activity limitations decreased from 10.2 percent in 1997
to 7.9 percent in 2002. Over that time span, the decrease
was from 14.2 to 9.1 percent for non-Hispanic blacks
and from 10.2 to 6.5 percent for Hispanics. Of people
with asthma in 2002, 6.1 percent of men and 9.1 percent
of women had such limitations, as did 13.6 percent of
the poor and 22.8 percent of persons with disabilities.
The target is 10 percent (Obj. 24-4). From 1997 to 2002,
none of the changes in the proportion of people who experience
activity limitations from asthma was statistically significant.
In general, activity limitations both in 2002 and in
1997 were higher among non-Hispanic blacks compared with
other racial and ethnic groups, among females compared
with males, and among the poor compared with middle-/high-income
persons.
Among people who have asthma, an average of 18 days
(age-adjusted) of school or work were lost because of
the disease in 2002, with no significant differences
among racial and ethnic groups or between males and females.
A target has not yet been determined (Obj. 24-5). In
1999, 13.8 percent of persons with asthma (age-adjusted)
received formal patient education to help in managing
their condition, up from 8.4 percent in 1998. No notable
differences were evident among racial and ethnic groups.
However, females received more formal education compared
with males, both in 1998 and 1999. Furthermore, the increase
to 16.4 percent among females in 1999 from 9.1 percent
in 1998 is a significant step toward achieving the target
of 30 percent (Obj. 24-6). Among blacks, 17.5 percent
(age-adjusted) received such education in 1999—an
increase from 11.2 percent in 1998—as did 16.4
percent of females, compared with 9.6 percent of males.
Chronic Obstructive Pulmonary Disease—Chronic
obstructive pulmonary disease (COPD) imposes an estimated
annual burden of approximately 8 million physician and
outpatient visits, 1.5 million hospital emergency visits,
726,000 hospitalizations, and 119,000 deaths. It is the
fourth leading cause of death in the United States. While
approximately 10 million adults reported having physician-diagnosed
COPD according to the most recent data available, 24
million adults have evidence of impaired lung function.
This serious degree of under-diagnosis and identification
of persons with COPD reflects the low utilization of
spirometry to identify persons with diminished lung function.
Reduced lung function is particularly common among smokers.
The death rate from COPD in the United States increased
greatly during the 1980s and most of the 1990s. From
1980 to 2000, the death rate from COPD among women age
45 years and older tripled, whereas the corresponding
rate for males increased 15 percent. The overall increase
from 1980 to 2000 was 67 percent. In more recent years,
the age-adjusted COPD death rate in people age 45 years
and older decreased from 123.9 per 100,000 in 1999 to
119.4 per 100,000 in 2001. This change reflects the compounding
of a sharp decrease for males over this time period—from
163.1 to 150.3 per 100,000—together with no significant
change for females, among whom the 2001 age-adjusted
death rate was 101.0 per 100,000. The decline in the
death rate held true for all racial groups for whom data
were available. Among those groups, the age-adjusted
death rate for COPD in 2001 was highest for non-Hispanic
whites, at 129.6 per 100,000—a reflection of current
smoking patterns. The target is 60.0 deaths per 100,000
(Obj. 24-10).
For the total population, the age-adjusted proportion
of people age 45 and older who experienced activity limitations
due to COPD was 2.5 percent in 2002, the same as in 1997. Of three racial and ethnic groups for whom data were
available, the lowest proportion in this category was
recorded for Hispanics in 2002—1.4 percent—compared
with 2.5 percent for non-Hispanic blacks and 2.6 percent
for non-Hispanic whites. Activity limitations of this
kind were experienced by 5.7 percent of the poor in this
age group in 2002—a proportion more than three
times that for persons of middle/high income. The target
is 1.5 percent (Obj. 24-9).
Key Challenges and Current Strategies
In the presentations that followed the data overview,
the principal themes were introduced by representatives
of the two co-lead agencies—Barbara Alving of NIH’s
National Heart, Lung, and Blood Institute (NHLBI), Sheila
Newton of NIH’s National Institute of Environmental
Health Sciences (NIEHS), Marshall Plaut of NIH’s
National Institute of Allergy and Infectious Diseases
(NIAID), and Stephen Redd of CDC’s National Center
for Environmental Health. These agency representatives
and other participants in the review identified a number
of obstacles to achieving the objectives and discussed
activities under way to meet these challenges, including
the following:
Maternal asthma is an important risk factor
in the development of asthma in children, but the maternal
factors conferring this risk are not yet known.
Environmental exposure can be an important factor
in asthma severity. Working as part of the National Cooperative
Inner-City Asthma Study, funded by NIAID, investigators
found that children in inner-city areas who were allergic
to cockroach allergen and exposed to high levels of it
had more than 3 times the rate of hospitalizations per
year as children who were not exposed. Data from the
related Inner-City Asthma Study, funded by NIAID and
NIEHS, show that an environmental intervention targeted
to reducing exposure of inner-city children with asthma
to cockroach and other indoor allergens and to tobacco
smoke substantially reduces asthma morbidity.
The total estimated cost of COPD in 2002 was
$32.1 billion, including $18 billion in direct costs
and $14.1 billion in indirect costs. COPD is projected
to be the third leading cause of death for both males
and females by the year 2020.
Among the factors associated with the greater
prevalence of asthma in women are higher levels of overweight,
more severe physiological effects from smoking, and generally
narrower airways.
An estimated 70 million people in the United
States suffer from sleep problems, nearly 60 percent
on a chronic basis. Approximately 18 million adults have
obstructive sleep apnea (i.e., sleep-disordered breathing),
but less than 50 percent are being diagnosed and treated.
The National Asthma Education and Prevention
Program (NAEPP), begun in 1989, is responsible for coordinating
research translation activities among Federal agencies
and among other national organizations.
-
A primary responsibility of NAEPP is to provide
ongoing monitoring of the asthma scientific literature
to identify areas of research or controversy where
there is new, compelling, and strong evidence that
could warrant a change to the current clinical practice
recommendations for diagnosing and treating asthma.
A core patient education booklet is expected to be
released in the fall of 2004 that will dovetail with
the NAEPP Guidelines for the Diagnosis and Management
of Asthma, portions of which were updated in
2002.
Beginning in 1998, NHLBI has stimulated action
and support for community-based asthma programs through
the building of asthma coalitions, of which there are
more than 200 today.
NHLBI is sponsoring a genome-wide search to identify
all the various genes that confer susceptibility to asthma.
Early findings from these studies confirm that multiple
genes may be involved in asthma and that they may vary
among racial and ethnic groups. In addition, NHLBI is
supporting pharmacogenetics research to explore how genetically
determined factors may influence individual response
to pharmacologic therapy.
-
CDC’s National Asthma Control Program was
created in 1999 to support the respiratory disease
goals and objectives of Healthy People 2010.
To improve asthma surveillance and promote scientifically
validated interventions, CDC implemented 11 asthma-tracking
projects, 48 asthma interventions, and 33 partnership
activities in 2003. To conduct school health-related
asthma-control programs, the agency also developed
partnerships with six urban school districts, one
state education agency, and six nongovernmental organizations.
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Environmental Justice: Partnerships to Address
Ethical Challenges in Environmental Health is
an initiative of NIEHS to support projects that promote
public understanding of the social, ethical, and
legal implications of conducting environmental health
research involving human subjects in areas such as
gene-environment interactions, environmental health
hazards, and disease susceptibility.
The NIEHS program of Health Disparities Research
supports interdisciplinary research to elucidate how
the interaction of physical exposures and the social
environment contributes to health disparities. Several
studies focus on high-risk, socioeconomically disadvantaged
children living in inner cities.
NHLBI’S National Center on Sleep Disorders
Research conducts and supports research and coordinates
the Federal Government’s efforts to improve communication
among scientists, policymakers, and healthcare professionals
to accelerate the speed of scientific discovery and dissemination
of findings about sleep disorders.
Approaches for Consideration
Participants in the review made the following suggestions
for steps to enable further progress toward achievement
of the objectives for Respiratory Diseases:
Improve the surveillance of asthma by making
data available quickly enough and in fine enough geographic
resolution for optimal program planning and evaluation.
Encourage elementary and secondary schools to
institute comprehensive asthma management programs.
Increase research aimed at identifying relevant
environmental exposures and the mechanisms by which they
may cause and aggravate asthma.
Seek to elevate fitness levels of asthma and
COPD patients by encouraging them to exercise to the
extent possible with careful management by physicians
and other healthcare professionals.
Take greater advantage of opportunities to partner
with organizations that promote programs to help people
quit smoking, the cause of at least 15 percent of COPD.
-
In the quest to reduce COPD morbidity and mortality,
stress to healthcare providers the importance of
using spirometry for accurate diagnosis and assessment
of disease severity, administering influenza and
pneumococcal vaccines, using bronchodilators for
symptomatic relief, and managing exacerbations aggressively.
To guide development of new therapeutic drugs,
expand research to (1) characterize the molecular and
cellular processes involved in the initiation and progression
of COPD and (2) identify biomarkers reflecting disease
activity; these biomarkers can be used for testing the
efficacy of putative therapies.
Encourage interested entities to collect national
population-based prevalence data for sleep-disordered
breathing, which independent surveys have confirmed is
under-diagnosed in the United States.
Contacts for information about Healthy
People 2010 focus area 24Respiratory Diseases:
- Centers for Disease Control and Prevention—Stephen
Redd, scr1@cdc.gov
- Office of Disease Prevention and Health Promotion
(coordinator of the Progress Reviews)—Emmeline
Ochiai (liaison to the focus area 24 workgroup),
eochiai@osophs.dhhs.gov
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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