Burden of Chronic Obstructive Pulmonary Disease and its Determinants among Patients Reporting to a Primary Health Facility in North India

ABBREVIATIONS USED IN THIS ARTICLE

COPD = Chronic obstructive pulmonary disease; CHC = Community Health Centre; DALYs = Disability adjusted life years; GATS = Global adult tobacco survey; GOLD = Global initiative for chronic obstructive lung disease; LPG = Liquefied petroleum gas; NFHS-5 = National family health survey-5; NCDs = Non-communicable diseases; OPD = Outpatients department; SOB = Shortness of breath; WHO = World Health Organization.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable chronic lung disease that affects both men and women worldwide. It is the third leading cause of death worldwide, causing 3.23 million deaths in 2019. In low- and middle-income countries, 90% of COPD deaths occur in those under 70 years of age.¹ The current estimates from the Global Burden of Disease study report 2019 state that low-income and middle-income countries account for 62.6% of the global burden of COPD and lung cancer.² With the increasing prevalence of smoking in developing countries and the aging population in developed nations, the prevalence of COPD is expected to rise over the next 40 years. By 2060, there may be more than 5.4 million deaths due to COPD and related conditions.³ In India, the prevalence of COPD ranges between 6.5 and 7.7% in rural and up to 9.9% in urban India.⁴ World Health Organization (WHO) reported that the prevalence of COPD ranges between 4 and 20% in Indian adults.⁵ As of 2016, COPD is India’s second largest cause of the five leading causes of mortality and morbidity.⁶ Disability adjusted life years (DALYs) due to COPD increased by 36.3% from 1990 to 2016, becoming India’s second leading cause of DALYs.^7,8

India is a large country consisting of people with different sociodemographic profiles and diverse cultural practices; the risk factors are also likely to be different in different regions. Tobacco smoking, including second-hand smoke, is the primary risk factor for COPD. Besides this, indoor air pollution from using biomass fuel for cooking and heating, occupational dust, chemicals, and frequent childhood infection are other important risk factors for developing the disease. National family health survey-5 (NFHS-5) reports only fifty-nine percent of households use clean fuel for cooking in India; only 43.2% of households in rural and 89.7% in urban areas use clean fuel for cooking. Female tobacco use is 10.5% in rural and 5.5% in urban areas. Similarly, tobacco use by males is 42.7% in rural and 28.8% in urban areas.⁹

In Himachal Pradesh, according to the findings of the Indian Council of Medical Research and Public Health Foundation of India, COPD ranks second in terms of years of life lost; moreover, it constitutes 7.7% of the total disease burden due to non-communicable diseases (NCDs).⁶ About 90% of the population in Himachal Pradesh resides in rural areas with a high prevalence of smoking and biomass usage. Global adult tobacco survey (GATS) has reported the prevalence of smoking tobacco in Himachal Pradesh as 14.2%.¹⁰ Due to cold terrain, biomass is used as fuel not only for cooking but also for heating purposes. NFHS-5 data for the state has documented that in a rural area, 44.5% of households use clean fuel for cooking, while 94.7% of urban households use clean fuel for cooking.¹¹

Primary healthcare physicians are essential in detecting and managing COPD as they manage most patients in the early stages. Unfortunately, COPD is often misdiagnosed and under-assessed in clinical practice. A failure to appreciate the disease severity and the onset of the respiratory disability is common because of the poor availability of spirometry assessment of lung functions.¹² The patient should be subjected to post-bronchodilator Spirometry according to Global Initiative of Lung Disease (GOLD guidelines) for confirmation of the diagnosis of COPD and its further management, but a guideline-directed strategy is rarely adopted.¹³

Hence, this study was planned to determine the frequency, severity, and risk factors associated with COPD using spirometry for diagnosis and staging of severity of COPD among the patients reporting to the Outpatient Department of a Primary Health Care Facility Community Health Centre, Mashobra District Shimla, Himachal Pradesh.

MATERIALS AND METHODS

RESULTS

Seven hundred and eight patients presented to the OPD during the study duration with respiratory symptoms. A total of 107 (15.1%) patients ≥40 years of age were enrolled in the study based on symptoms and/or risk factors as laid down in GOLD guidelines among patients attending OPD (Fig. 1).

DISCUSSION

Our study found that the proportion of spirometry-confirmed COPD was 38.3% (41/107). Out of 41 COPD patients, only 17 (41%) got spirometry done in the past. About 16/41 (39%) of COPD patients were told by a healthcare provider that they had COPD. It is widely known that COPD is often misdiagnosed and under-assessed in clinical practice.¹⁶ Under diagnosis of COPD is a global phenomenon, with 10–95% of cases of COPD remaining under-diagnosed. Underutilization of spirometry is the strongest predictor for an incorrect diagnosis of COPD.¹⁷ An average clinician in India frequently ignores COPD as simple bronchitis or asthma. In primary care settings, due to the non-availability of spirometry assessment of lung functions, there is a failure to diagnose COPD.¹²

About 57% (61/107) of study participants were currently on medication for their breathing problems (including medication for nasal congestion), constituting 56% of non-COPD patients. This highlighted the phenomenon of COPD over diagnosis followed by overtreatment. It has been reiterated that the GOLD Guidelines for managing COPD are available for different levels of health care in India, but a guideline-directed strategy is rarely adopted.¹²

The proportion of spirometry-confirmed COPD was 38.3% in this study. Sandelowsky et al. reported spirometry confirmed COPD at 27%, Stafyla et al. and 17.8% in a study conducted in Greece.^16,18 In contrast to our study, Mandke et al. in Gujarat, reported a prevalence of 14.1%, Sinha et al. 10.1%, and a study in Kashmir reported a prevalence of 16.1%.^19–21 The higher proportion of COPD patients in the current study (38.3%) may be due to methodological differences, as our study was done in a primary healthcare facility and was not community-based and the patients suffering from respiratory symptoms were presenting to the outpatient department for treatment of their respiratory complaints.

The proportion of COPD patients significantly increased with age (p = 0.02). More men had COPD than women (p = 0.01). Studies worldwide have also observed a male preponderance in the prevalence of COPD. A study conducted by Sandelowsky et al. in Sweden reported the prevalence of COPD among those aged 55–75 as 43% (p < 0.001), and men had more COPD cases.¹⁷ Similar findings were reported by Salvi et al. in Pune, Sinha et al. in Delhi, and studies from different parts of the world.^2,20,22–24 High prevalence in a male could be due to different lifestyles and genetic predispositions, but more likely due to smoking habits, which are more common in males.

We observed that COPD cases increased with the increase in biomass exposure though the difference was insignificant. However, a study by Mahesh et al. found a positive correlation between biomass exposure and the development of chronic bronchitis in Pune.²⁵ This difference could be because of the selection of study participants, as this study was conducted among women only and the majority of our study population was male. Aggarwal N et al. in Haryana also reported a significant association between biomass exposure and COPD (p = 0.04).²⁶ The reason for this may be that people residing in this particular area were using biomass generally in winter seasons only. Liquefied petroleum gas (LPG) is usually used for cooking in summer. So the exposure to biomass cannot be precisely quantified. Moreover, it was not a continuous exposure. In our study, it was found that exposure to dusty jobs (p = 0.5) and exposure to second hand smoke were not significantly associated with the development of COPD (p > 0.5) as also reported by Aggarwal N et al.²⁶

Our study revealed that current smokers and ex-smokers had more chances of developing severe disease than non-smokers (p = 0.04). We also found a significant association in terms of pack years of tobacco smoking with the severity of COPD (p = 0.008). It was also observed that the mean pack-years of smoking were different among varied stages of COPD and had a significant association with the severe form of COPD (p < 0.001). Our findings concord with the study conducted by Mrinmoy et al. and Pandolfi et al., where they found that the mean pack year of smoking increased with the severity of the disease.^27,28 However, Soni and Jain in Maharashtra found no association with the quantity of tobacco smoked.²⁹

Risk factors, i.e., advancing age, male sex, exposure to biomass, and exposure to dusty jobs, were not significantly related to the severity of COPD. These findings aligned with the results of Pandolfi et al. and Soni NA and Jain.^28,29 On univariate analysis, it was found that age ≥60 years (OR 2.4 CI 1.01–5.9), male gender (2.8 CI 1.2–6.7), smoking status (12.5 CI 4.5–34.2), ≥20 pack years tobacco smoked (29.9 CI 10.2–88.0) by participants and biomass index ≥60 (2.7 CI 1.2–6.4) were having higher odds of developing COPD. Similar findings were observed by Sinha et al.²⁰ On multivariate analysis; it was observed that intensity of smoking ≥20 pack years of tobacco is independently associated with COPD. However, our study findings regarding age, gender, smoking status, and biomass exposure were not independently associated with the severity of COPD. Another study by Sandelowsky et al.¹⁸ and Mejza et al.³⁰ reported a significant association between smoking status and the quantity of tobacco smoked with COPD.

The strength of our study is the objective criteria used for diagnosing COPD in a peripheral health facility and the availability of a pulmonary medicine specialist at the peripheral health facility to establish a COPD diagnosis.

Our study had certain limitations because we used a fixed ratio to define obstruction, such as FEV1/FVC post-bronchodilator <70%. Ideally, a lower limit of normal should be used. In addition, this study is hospital-based; the present study could not elicit the true prevalence in a random population of an important but often neglected NCD in the form of COPD.

CONCLUSION

Standard guidelines like GOLD guidelines may be percolated in peripheral health institutes so that all COPD patients are managed according to standards. Diagnostic facilities need to be improved in peripheral health institutes. It would be emphasized to competent health authorities in the state health department to provide spirometry firstly at district headquarters and subsequently in peripheral health institutes so that COPD could be picked up at the primary health care level. Since smoking is a significant risk factor for the development of COPD, behavior change communication activity against smoking may be an upsurge at the peripheral healthcare facility level. The prominent ranking of COPD among the four leading causes of DALYs in age groups 50 years and above also emphasizes the continuing need for tobacco-control measures.² Early diagnosis of undiagnosed COPD may act as a deterrent to smoking also.³¹ This will help to decrease the enormity of the burden from COPD-related morbidity and mortality and make progress toward the United Nations 2030 Agenda for Sustainable Development.

SUPPLEMENTARY MATERIAL

All the supplementary materials are available online on the website of “https://www.ijcdas.com/”.

ORCID

Anupam Parashar https://orcid.org/0000-0002-6723-7972

Malay Sarkar https://orcid.org/0000-0002-2644-2750

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