3.Salvi 9.00 Hespe.pptx

The New Challenges: Chronic Lung Care at Scale.
Management of Respiratory Diseases in India
Dr Sundeep Salvi MD, DNB, PhD(UK), FCCP(USA)
Director
Chest Research Founda9on, Pune, INDIA
ssalvi@crfindia.com
www.crfindia.com
GLOBAL MORTALITY DUE TO
CHRONIC RESPIRATORY DISEASES
Mortality due to Chronic respiratory diseases, Global Health Observatory Data
Repository, World Heath Organisa9on (WHO), viewed 4th November, 2011
Global TB prevalence
hMp://www.worldmapper.org/posters/worldmapper_map228_ver5.pdf
PNEUMONIA DEATHS and PREVALENCE IN CHILDREN < 5 YEARS
Pneumonia Deaths
(India: 35.4 M, Pakistan: 6.7 M, Bangladesh: 4.5 M)
2
0
1
3
120 million children under 5
suffer from Pneumonia / year
8 million require
hospitaliza9on
1.1 million children
die every year
Around 50 million children survive Pneumonias in India/year
Over a period of 10 yrs, 500 million children in SE Asia have survived a Pneumonia
(Theodoratou E et al, PLoS One 2011; e25095)
(Rudan I et al, J Global Health 2013; 3: 1)
GLOBAL SMOKING PREVALENCE
110 million smokers in India
12.1 million female smokers (2nd largest in world a`er USA)
GLOBAL ASTHMA MORTALITY
(h[p://www.worldmapper.org/display_extra.php?selected=459)
Doubling of asthma prevalence in school children over a period of 5
years in some ci9es in India
(Cheraghi M et al, ISRN Public Health 2012; Arccle ID: 361456)
GLOBAL COPD MORTALITY
COPD is the 2nd leading cause of death in India
India and China together cons9tute 65% of all COPD deaths
COPD mortality jumped the queue to become the 3rd leading cause of
all global deaths in 2013, mainly because of rapidly growing COPD
deaths in SE Asia.
(h[p://www.worldmapper.org/display_extra.php?selected=458
)
WHAT AILS
INDIA?
13,250 doctors across
India
-­‐ General Physicians
-­‐ General Prac99oners
-­‐ Pediatricians
888 centers across
India
1st February 2011
204,912 pa9ents
(Manuscript submiMed to Lancet, 2014)
MOST COMMON SYMPTOMS FOR WHICH A PATIENT VISITS A DOCTOR
(NON-­‐SPECIALIST) IN INDIA
(Manuscript submiMed to Lancet, 2013)
Total and gender-­‐wise prevalence of diseases reported
by Primary Care Physicians across India.
Disease
Hypertension
Obstruc9ve Airways Disease
Upper Respiratory Tract Infec9on
Anemia
Diabetes
Complete Data
(204912)
Male (54%)
Female (46%)
Prevalence rate
14.52%
14.51%
12.96%
10.12%
8.85%
Prevalence rate
14.88%
16.31%
13.74%
7.34%
9.17%
Prevalence rate
14.22%
12.22%
12.12%
13.44%
8.55%
Asthma and COPD are among the most common diseases
encountered by primary care physicians in India
Around 3.5 million cases of Asthma and COPD are seen
every day by primary care physicians across India
(Manuscript submiMed to Lancet, 2014)
Alluvial Diagram
Female Genital
Male Genital
Musculoskeletal
Male Genital
Ear
Female Genital
Eye
Eye
Neurological
Ear
Endocrine
Ear
Musculoskeletal
Musculoskeletal
Neurological
Skin
Endocrine
Urological
Diges9ve
Urological
Anemia
Urological
Male Genital
Neurological
Anemia
Skin
Circulatory
Circulatory
Skin
Anemia
Eye
Female Genital
Endocrine
Diges9ve
Diges9ve
Circulatory
Respiratory
Respiratory
Respiratory
0-­‐10 Years
11-­‐20 Years
21-­‐30 Years
31-­‐40 Years
41-­‐50 Years
Age-­‐groups
(Manuscript submiMed to Lancet, 2014)
51-­‐60 Years
Greater than
61 Years
PURE STUDY
(Popula9on Urban Rural
Epidemiology)
Dr Salim Yusuf
Canada
153,996 enrolled
128,152 clean data
38,517 healthy,
Nonsmoker M and F
(17 countries, 628 Urban and Rural communities)
(Duong M et al, Lancet Respiratory Medicine 2014; 1: 599-­‐609)
India, 2014
India, 1977
FEV1 FVC
-­‐20%
-­‐15%
over 35 yrs
(Kamat SR et al, JAPI 1977; 25: 531)
(n = 10,000, 5 ci9es across India)
Healthy adult Indians / S Asians had lung
funccon values that were 35% lower than
age-­‐ and gender-­‐matched Caucasians
(Duong M et al, Lancet Respiratory Medicine 2014; 1: 599)
Peak Expiratory Flow Rate
values among healthy Indians
are 30% lower than Caucasians
(Kodgule R et al, J Postgrad Med 2014;
60(2): 123-­‐129)
GLOBAL AMBIENT AIR POLLUTION
(1600 ci9es from 91 countries)
27 /100 most polluted cices in the world are in India
Delhi – most polluted city in the world
India
627,000 premature deaths
17.8 million DALYs
WHO Report, May 2014
INDOOR AIR POLLUTION
India
1.03 M premature deaths
31.4 million DALYs
6% of the na9onal
burden of disease
(Balakrishnan K, et al, Envir Health Perspect 2014; 122L A6-­‐A7)
INDOOR AIR POLLUTION AS A RISK FACTOR FOR
CHRONIC LUNG DISEASE
70% homes in India use biomass for cooking and hea9ng purposes
Poor lung growth
Respiratory tract infec9ons
Asthma
3
billion
1.1
billion
Smokers
BMF-­‐exposed
COPD
Respiratory tract infec9ons
Lung Cancer
The Lancet 2009 Aug: 374: 733-­‐743
85% of COPD in a
rural popula9on in
India had never
smoked in their life
before.
Chest 2010; 138(1): 3-­‐6
Salvi SS, Barnes PJ.
Risk factors for COPD
-­‐ Poor socioeconomic
status
-­‐ Farming
-­‐ Post TB lung disease
-­‐ Chronic poorly
treated asthma
Levels of indoor PM2.5 (mg/m3) while burning
one mosquito coil
Door + Window
closed
Window open +
Door Closed
Window +
Door open
End of exp.
Baseline
WHO safety
standards
• 15 billion coils sold every year (Asia, South America, Africa)
• 2 billion people exposed worldwide
• Pyrethrins, wood powder, binders, oxidants
(SaLvi D, Manuscript under preparacon )
Pune city, India
2003 – 2.9%
2008 – 5.4%
2.5% = 25 million new cases
OR (CI)
Family history
7.2 (5.1–10.1)
Caesarian delivery
4.0 (2.8-­‐5.6)
Absence of separate
kitchen at home
2.4 (1.4-­‐3.9)
Home proximity to
main road (<75m)
2.4 (1.6-­‐3.5)
Damp walls at home
2.3 (1.8-­‐3.6)
Paracetamol, Indoor Air Pollucon,
Mosquito coils, Diwali fire-­‐works
(Cheraghi M et al, ISRN Public Health 2012; 361456)
(Times of India, 5th May 2009)
The AP-­‐AIM survey
Australia
China
Hong Kong
India
Korea
Malaysia
Singapore
Taiwan
Thailand
84,000 households screened
AIM:
To explore asthma-­‐related
pa9ent percep9ons,
behaviors, presenta9on
paMerns, and trends in
management in the Asia
Pacific Region
≈3,600 households with
asthma pa9ent ≥12 yrs of age
≈400 households per
country/region
52 Ques9ons
Adults/Children (12-­‐17yrs)
Current Asthma ∆ by doctor
Or Used Asthma medica9ons
Or Experienced Asthma
symptoms during past 1 year
Telephone / Face-­‐to-­‐face
general health
pa9ent astudes
diagnosis/history
symptoms
treatments
8 DOMAINS
exacerba9ons
pa9ent burden
disease management
Pacent reported asthma triggers
India
(Salvi S et al, Journal Assoc, Physicians India, Submi[ed 2014)
Pacent percepcon of Asthma Control
Not controlled at
all, 2%
Poorly controlled,
7%
GINA assessment of Asthma Control
Completely
controlled, 2%
Uncontrolled,
40%
Well controlled,
29%
Partly controlled ,
60%
Somewhat
controlled, 60%
0% controlled asthma
Proporcon of pacents who missed
work or school due to asthma
No,
22%
Yes,
78%
78% missed school or
work due to asthma
SUMMARY and CONCLUSIONS
• An es9mated 100 million people in India suffer from Chronic
Respiratory diseases, a large number of which remain undiagnosed,
under-­‐diagnosed, un-­‐treated or wrongly treated.
• Risk factors for chronic lung disease in India are unique and very
different from the developed world.
• Most knowledge needed to diagnose and treat these pa9ents are
imported from the western world, which are not necessary to India.
Knowledge genera9on needs to take place in India.
• There are inadequate numbers of well trained doctors to tackle this
huge and growing problem
• Policy makers in India are liMle aware about the size and growing
burden of this problem.
• What India really needs is ………
India needs a
RESPIRATORY REVOLUTION
Conflicts of Interest:
I serve as Interna9onal Advisory Board Member of Cipla Ltd., Lupin,
Novar9s, MSD and Boehringer Ingelheim and have received
Honoraria for giving talks
THANK YOU
ssalvi@crfindia.com
www.crfindia.com