A major new publication from the European Respiratory Society (ERS) ahead of its annual congress (Barcelona, 7 Sept 2013), shows that lung conditions are responsible for 1 in 10 of all deaths across Europe, with deaths due to lung cancer and COPD predicted to rise over the coming decades.
The European Lung White Book is a comprehensive publication that provides burden, cost and risk factor information for a range of respiratory diseases, drawing on the latest available research and statistics to provide a resource for health care professionals, politicians, and the public. The White Book estimates that direct and indirect costs due to lung conditions total at least a staggering 390 billion Euros per year; even this sum is an underestimate due to there being limited or no data available on costs for some lung conditions.
The proportion of deaths due to respiratory disease is higher among the 28 countries of the European Union (EU28) – representing 1 in 8 of all deaths (12.5% of total deaths, 661 000 deaths annually) – than among the remainder of the WHO Europe region countries (that include the countries of central Europe closer to Asia), where it is 7.5% (292 000 deaths annually). Each year in the EU28 countries, lung diseases cause two-thirds of a million deaths, and at least 6 million hospital admissions, accounting for over 43 million in-patient bed-days. Four respiratory disease categories appear in the global top 10 causes of mortality, together accounting for one in six deaths as well as one in 10 disability-adjusted life-years lost. These are lung cancer, COPD, lower respiratory tract infections (including pneumonia), and tuberculosis. Smoking and respiratory infections are major causes of the burden of lung disease in Europe, and are potentially preventable.
Among the wealthy countries of Western/Northern/Southern Europe, Belgium and Denmark have the highest mortality from respiratory diseases, at 117 deaths per 100,000 population followed by Ireland (114) and the UK (112). However, the proportion of total deaths attributed to a lung condition is highest in the UK and Ireland. The White Book shows that while tobacco smoking rates in these high-death rate countries such as Denmark and the UK have fallen substantially since the 1970s, the long-term effects of those high smoking rates from years gone by continue to manifest in cases of lung cancer and COPD today. By contrast Finland, with its highly active programme targeting respiratory illness, has the lowest death rate from respiratory conditions (54 per 100,000). Other countries with low mortality include Sweden (56) and Cyprus (57). Around half of respiratory disease deaths across all European countries are due to lung cancer or COPD, with others caused by a variety of conditions including pneumonia, lung fibrosis, tuberculosis and influenza.
In European countries where detailed data are available, 7% of hospital admissions result from respiratory causes. The pattern of hospital admissions does not, however, exactly match the pattern of mortality. Thus, while some high-mortality countries (such as Belgium, Hungary, Ireland and Romania) also have relatively high respiratory admission rates, there are countries with high mortality but below-average admission rates (such as the UK), and others with low or average mortality rates but high admission rates (for example, Austria and Lithuania). This variation could reflect a variety of issues including reporting differences, and differences in quality of community care preventing some hospital admissions (there are many cases of COPD, for example, that are almost exclusively cared for in the community and never reach hospital).
A chapter of the White book dedicated to the economic burden of respiratory diseases explains that the total average health and societal cost per case of lung cancer is 364,213 Euros, while for tuberculosis it is 86,217 Euros (averaged across all forms of the disease including multi-drug resistant and extensively drug resistant forms). On the other hand, the costs of COPD, at 6,147 Euros per case per year, and asthma, at 7,443 Euros per year, accrue over many years, and represent an even greater socioeconomic burden because they are so common. The data also shows that at least half the total socioeconomic costs of respiratory disease can be attributed to smoking.
The White book concludes that the burden of lung disease in Europe remains as large today as it was at the turn of the millennium, and is likely to remain so for at least the next 20 years. In the next two decades, the proportion of deaths caused by respiratory disease in Europe is likely to remain stable, with variations in different diseases balancing out the overall effect on mortality. A decrease in deaths from lung infections will be accompanied by a rise in lung cancer and COPD mortality. Prof. Francesco Blasi, ERS President, says: "By 2030, the WHO estimates that the four major potentially fatal respiratory diseases (pneumonia, tuberculosis, lung cancer and COPD) will account for about one in five deaths worldwide, compared to one-sixth of all deaths globally in 2008. Within the WHO European Region, the proportion is expected to remain stable at about one-tenth of all deaths, with an increase in COPD and lung cancer deaths balancing a decline in deaths from lower respiratory infections and tuberculosis."
However, trends in conditions such as asthma are more difficult to predict. Prof. Blasi says: "Although asthma causes few deaths, it is an important cause of disability. There are no well-informed projections of the future burden of asthma, but in many European countries the prevalence of childhood wheezing increased between the late 1990s and the early 2000s, and asthma is likely to remain a major burden on European societies for decades to come."
The increase has been attributed to ill-understood factors in the "western" lifestyle and improving socioeconomic conditions in many eastern European countries may be accompanied by an increase in the prevalence of asthma.
He concludes: "Both the prevention and treatment of lung diseases will need to be improved if their impact on longevity, quality of life of individuals and economic burden on society, are to be reduced in Europe and worldwide."
Preventive measures are available for many respiratory conditions but they need to be employed more effectively and more widely. The most obvious preventable cause is smoking. To combat its effects the World Health Organization in 2005 launched the wide ranging Framework Convention for Tobacco Control (FCTC): although most European countries and the EU have ratified the convention, a minority still have to do so and in several others implementation by government has been inadequate due to commercial, fiscal and other pressures. Another important contributor to respiratory disease and disability is poor air quality and in many countries the standards for both outdoor and indoor air fall short of those recommended by WHO. Finally, more attention should be given to preventing and controlling respiratory infections: by more effective immunisation programmes for those conditions in which effective vaccines are available, by more careful use of antibiotics and by Europe-wide monitoring of the resistance patterns to antibiotics used in treatment of tuberculosis, pneumonia and other respiratory infections.
The White Book also underlines a critical lack of national capacity to collect, interpret and use comparable data accurately and transparently across different sectors and between countries. "Since formulation of optimal policy demands accurate and up to date information, it is of paramount importance that all European governments improve and standardise surveillance and data collection relating to respiratory diseases as a top priority and a matter of urgency," concludes Prof. Blasi.