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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790XOn-line version ISSN 1980-5497

Rev. bras. epidemiol. vol.23  Rio de Janeiro  2020  Epub May 11, 2020

https://doi.org/10.1590/1980-549720200031 

ORIGINAL ARTICLE

Epidemiology and burden of chronic respiratory diseases in Brazil from 1990 to 2017: analysis for the Global Burden of Disease 2017 Study

Epidemiologia e carga das doenças respiratórias crônicas no Brasil de 1990 a 2017: análise do Estudo Global Burden of Disease 2017

IUniversidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Epidemiologia, Porto Alegre, Rio Grande do Sul, Brazil.

IIMcGill University, Department of Epidemiology, Biostatistics and Occupational Health, Montreal, Quebec, Canada.

IIIUniversidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Belo Horizonte, Minas Gerais, Brazil.

IVUniversity of Washington, Division of Allergy and Incetious Diseases, Seattle, Washington, Unitated States of America.


ABSTRACT:

Introduction:

In Brazil, little is known about the trends of chronic respiratory diseases, which was estimated as the third leading cause of deaths in 2017 worldwide.

Methods:

We analyzed Global Burden of Disease (GBD) 2017 estimates for prevalence, incidence, mortality, disability-adjusted life years (DALY), a summary measure of years of life lost (YLLs) and years lived with disability (YLDs), and risk factors attributable to chronic respiratory diseases in Brazil from 1990 to 2017.

Results:

The overall estimates have decreased for all ages and both sexes, and for age-standardized rates. For age-adjusted prevalence, there was a 21% reduction, and nearly 16% reduction for incidence. There was a 42% reduction in mortality for both sexes, though the rate of deaths for men was 30% greater than the rate in women. The increase in the number of DALY was essentially due to the population growth and population ageing. We observed a 34% increase in the absolute number of DALY in Brazil over the study period. The majority of the DALY rates were due to Chronic Obstructive Pulmonary Disease (COPD). For all ages and both sexes, smoking was the main attributable risk factor.

Conclusion:

In Brazil, although mortality, prevalence and incidence for chronic respiratory diseases have decreased over the years, attention should be taken to the DALYs increase. Smoking remained as the main risk factor, despite the significant decrease of tobacco use, reinforcing the need for maintenance of policies and programs directed at its cessation.

Keywords: Respiratory Tract Diseases; Noncommunicable Diseases; Pulmonary Disease, Chronic Obstructive; Global Burden of Disease; Disability-Adjusted Life Years; Brazil

RESUMO:

Introdução:

No Brasil, pouco se sabe sobre as tendências das doenças respiratórias crônicas, que foram estimadas como a terceira principal causa de mortes em 2017 em todo o mundo.

Métodos:

Analisamos as estimativas do Global Burden of Disease (GBD) 2017 para prevalência, incidência, mortalidade, anos de vida ajustados por incapacidade (DALY), uma medida resumida de anos de vida perdidos (YLL) e anos vividos com deficiência (YLD), e fatores de risco atribuíveis a doenças respiratórias crônicas no Brasil, de 1990 a 2017.

Resultados:

As estimativas gerais diminuíram para todas as idades e ambos os sexos, assim como para as taxas padronizadas por idade. Para a prevalência ajustada pela idade, houve uma redução de 21% e, aproximadamente, 16% para a incidência. Houve uma redução de 42% na mortalidade para ambos os sexos, embora a taxa de mortes para homens tenha sido 30% maior do que a taxa para mulheres. O aumento no número de DALY deveu-se ao crescimento e envelhecimento da população. Observamos um aumento de 34% no número absoluto de DALYs no Brasil durante o período do estudo. A maioria das taxas de DALY foi devido a Doença Pulmonar Obstrutiva Crônica (DPOC). Para todas as idades e ambos os sexos, tabagismo foi o principal fator de risco atribuível.

Conclusão:

No Brasil, embora a mortalidade, a prevalência e a incidência de doenças respiratórias crônicas tenham diminuído ao longo dos anos, maior atenção deve ser dada ao aumento dos DALYs. O tabagismo permaneceu como principal fator de risco, apesar da redução significativa do seu uso, reforçando a necessidade de manutenção de políticas e programas direcionados à sua cessação.

Palavras-chave: Doenças Respiratórias; Doenças não Transmissíveis; Doença Pulmonar Obstrutiva Crônica; Carga Global da Doença; Anos de Vida Ajustados pela Incapacidade; Brasil

INTRODUCTION

Chronic respiratory diseases are defined as a group of diseases that affect the lung and its structures1. These conditions, mainly consisting of chronic obstructive pulmonary disease (COPD) and asthma, have different epidemiologic profiles and sequelae depending on the age and other characteristics of those affected1,2,3,4.

Previous epidemiological estimates for chronic respiratory diseases have considerable heterogeneity worldwide, in part due to differences in study design. As a result, the estimates are not comparable, especially considering inequalities between high- and low-income countries4,5. Recently, the methods to assess aggregate data have improved, and it is now possible to evaluate and compare estimates and correct for sources of measurement bias6. In fact, the Global Burden of Disease Study (GBD), first published over 10 years ago and with regular updates to its estimates, has brought transparency and improvement to global health estimates7.

In Brazil, population-based studies have contributed to estimating the impact of chronic respiratory diseases. The Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) provided estimates for COPD8,9,10,11, while the National Health Survey (PNS) has estimated the prevalence of asthma and COPD, as well as the degree to which these conditions limit everyday activities12. Another important contribution to Brazilian estimates was provided by the Brazilian National Household Survey (PNAD)13.

Beyond the population-based studies, data on health-care conditions other than prevalence are provided by the Ministry of Health in which the main population-based information systems (with respective acronyms in Portuguese) are Mortality Information System (SIM), Live-Birth Information System (SINASC), Primary Care Information System (SIAB); Hospital Information System (SIH); Ambulatory Care Information System (SIA); and National System of Notifiable Events (SINAN)14. Brazilian estimates for chronic respiratory diseases, although available from these different sources, have not been aggregated so far, hampering the assessment of the burden of these conditions.

Previous studies using GBD results have demonstrated health improvements in the Brazilian population, including reduction in mortality due to chronic respiratory diseases15,16. Nevertheless, to our knowledge, publications showing the behavior of such conditions over the years are still missing. To address these data gaps, we evaluate the prevalence, incidence, mortality, and burden due to chronic respiratory diseases in Brazil, as well as the risk factors to which these conditions are attributable, based on GBD estimates from 1990 to 2017.

METHODS

This is a descriptive study analyzing the epidemiology profile of chronic respiratory diseases in Brazil from 1990 to 2017. The estimates were extracted from the Institute for Health Metrics and Evaluation’s (IHME) data visualizations tools17, which show results from GBD. The GBD 2017 utilized a range of data resources and uses statistical methods to aggregate data, adjust bias, and create new covariates for each group of metrics. This section provides a brief overview of GBD methodology, which has been published elsewhere6,18,19,20.

The main source of data for causes of death in Brazil is the SIM21. For the GBD, known as garbage codes22, causes that cannot be considered underlying causes of death (or causes that are implausible for other reasons) are redistributed to other underlying causes of deaths using a variety of methods. Once the garbage coded deaths have been redistributed the causes of death database is used as an input for the Cause of Death Ensemble modelling (CODEm) tool to estimate the cause of deaths18.

For estimates of prevalence, incidence, and years lived with disability (YLDs) GBD uses the DisMod-MR 2.1 tool23, which utilizes Bayesian meta-regression. In Brazil, the source data for nonfatal health outcomes and covariates used to compute these estimates are mainly from SIH, survey data and other epidemiologic studies, such as the PLATINO, PNS and Brazil Surveillance System of Risk Factors for Chronic Diseases by Telephone Interviews (Vigitel)8,24,25.

Another metric used by GBD is the disability-adjusted life year (DALY). The DALY measures premature mortality and incapacity due to disease simultaneously20,26, as the sum of years of life lost (YLLs) and years lived with disability (YLDs). YLLs are computed by multiplying the number of deaths from chronic respiratory diseases in each age group by the reference life expectancy at the average age of death for those who die in that age group19. YLDs are calculated by multiplying chronic respiratory diseases sequelae prevalence by their disability weights in age-, sex-, and year-specific strata, in the presence of more than one disability condition was used the comorbidity correction (COMO), to adjust the estimates27. The disability estimates and weights presented by GBD were obtained from population-based surveys of countries around the world19.

The ICD-10 codes for causes of death due to chronic respiratory diseases used by GBD were:

  • asthma: J45-J46.9;

  • COPD: J41-J44.9;

  • pneumoconiosis: J60-J63.8, J65-J65.0, J92.0;

  • interstitial lung disease and pulmonary sarcoidosis: D86-D86.2, D86.9, J84-J84.9;

  • other chronic respiratory diseases: G47.3, J30-J35.9, J37-J39.9, J66-J68.9, J70, J70.8-J70.9, J82, J91-J92, J92.9.

ICD-9 codes was also used but only for estimates up to 199518,23.

All metrics are estimated using 95% uncertainty intervals (95% UI), in which every estimate is calculated 1,000 times, assuming the time sampling from distributions rather than point estimates for data inputs, data transformations and model choice. The 95th uncertainty interval is determined by the 25th and 975th value of the 1,000 ordered values18.

To understand the factors associated with the change in DALYs between 1990 and 2017, we used decomposition according to the Das Gupta method28. This analysis uses the estimated percent changes due specifically to growth in total population, population ageing, and change in DALY rates29. We also assess the DALYs attributable to risk factors for chronic respiratory diseases according to GBD classification, which include air pollution, occupational risks, tobacco, and high body-mass index.

We conducted this study using exclusively public secondary data available from GBD17. All procedures described followed the ethical principles of Resolution no. 466/2012 of the National Council of Health.

RESULTS

There was a decrease in both prevalence and incidence rates of chronic respiratory diseases in Brazil over the last 27 years. Figure 1 depicts changes in patterns of prevalence (Panel A) and incidence (Panel B) from 1990 to 2017. The overall estimates have decreased for all ages and both sexes, and for age-standardized rates. A slight reduction in prevalence was observed for all ages, from 9,226.7 (95% UI = 8,136.6 - 10,367.3) prevalent cases per 100,000 in 1990 to 8,025.3 (95% UI = 7,312.0 - 8,775.5) prevalent cases per 100,000 in 2017, which represented a reduction of approximately 13%. For incidence, the estimates have reduced gradually over the period, with a reduction of nearly 16% for age-standardized and both sexes. The differences between estimates for women and men are also demonstrated in Figure 1. Across all years the estimated incidence and prevalence are larger in women than men. While there has been a gradual decrease for both sexes in prevalence, the incidence has been steady for women since 2005.

Figure 1. Epidemiology and burden of chronic respiratory diseases in Brazil from 1990 to 2017: analysis for the Global Burden of Diseases 2017: (A) prevalence rate of chronic respiratory diseases by sex age-standardized and for all ages between 1990 and 2017; (B) incidence rate of chronic respiratory diseases by sex age-standardized and for all ages between 1990 and 2017. 

The mortality estimates for all ages, as well as age-standardized rates by sex, are presented in Figure 2. An absolute increase of deaths due to chronic respiratory diseases was observed for both women and men, for all ages, between 1990 and 2017. When adjusted by age, however, an absolute decrease of nearly 42% for both sexes were observed, even though the rate of deaths for men, 44.1 deaths per 100,000 (95% UI = 42.9 - 45.3) was 30% greater than the mortality rate for women (26.6 deaths per 100,000; 95% UI = 25.7 - 27.5) in 2017.

Figure 2. The mortality rate due to chronic respiratory diseases for all ages and age-standardized by sex, between 1990 and 2017. 

Concerning DALYs, Table 1 shows the decomposition of the number of DALYs between 1990 and 2017. The population growth accounted for an increase of 42%, ageing of the population for an increase of 64%, and change in the underlying age- and sex-standardized rates of DALYs for a decrease of 71%, representing an overall increase of 34% in DALY rate due to chronic respiratory diseases over the period.

Table 1. Decomposition analysis of the change in the number of disability-adjusted life years (DALY) (thousands) due to chronic respiratory diseases from 1990 to 2017 as being due to total population growth, population ageing, and changes in age-, sex-specific DALY rates. 

Values
1990 DALYs 1,601,765.14
DALYs expected with 2017 population, 1990 population age structure, 1990 DALY rates 2,270,590.00
DALYs expected with 2017 population, 2017 population age structure, 1990 DALY rates 3,288,766.00
2017 DALYs 2,146,048.00
Median percent change from 1990 due to population growth 42%
Median percent change from 1990 due to population ageing 64%
Median percent change from 1990 due to change in DALY rates -71%
Median percent change from 1990 to 2017 (Total) 34%

Figure 3 graphically represents the DALYs rate increase according to age range. The DALY rates due to asthma were greater for those younger than 20 years old, peaked in those aged 5 to 9 years, and then decreased until 20 years old. From 30 years old, the rates for COPD gradually rise, with a slight increase of interstitial lung diseases and asthma observed for those aged more than 60 years.

Figure 3. Disability-adjusted life-years (DALY) rates due to chronic respiratory diseases by condition and age range, both sexes, Brazil, 2017. 

Finally, the rates of risk-attributable DALYs due to chronic respiratory diseases are shown in Figure 4. For all ages, smoking was the main risk factor. For male population, the disability due to smoking markedly decreased between 1990 and 2017, from 462.2 (95% UI = 423.4 - 501.4) DALYs per 100,000 persons to 389.4 (95% UI = 349.9 - 428.8) DALYs per 100,000 persons, the same not occurring for female population, which reduction was roughly 7% when compared with 19% for men. The male population also was more affected by occupational particulate matter, without reduction occurring over the years, 140.4 (95% UI = 115.3 - 166.4) and 138.6 (95%UI = 113.2 - 163.8) in 1990 and 2017, respectively. Household air pollution from solid fuels, which similarly affected men and women in 1990, 101.6 (95% UI = 60.0 - 143.7) DALYs per 100,000 men and 103.8 (95% UI = 65.0 - 139.7) DALYs per 100,000 women, had its rates replaced by ambient particulate matter pollution for both sexes in 2017.

Figure 4. (A) All-ages Disability-Adjusted Life Years (DALY) rates due to chronic respiratory diseases attributable to ten risk factors, for women and men, Brazil, 1990. (B) All-ages DALY rates due to chronic respiratory diseases attributable to ten risk factors, for women and men, Brazil, 2017 

DISCUSSION

Prevalence, incidence and mortality rates of chronic respiratory diseases have been decreasing in Brazil. Despite these improvements, the burden, shown by the DALY rates decomposition, has still risen mainly due to population growth and ageing, possibly associated with the epidemiological transition towards non-communicable diseases (NCD) and the ageing process in Brazil, accelerated after 200016. Herein, COPD appeared as the chronic respiratory disease responsible for the growth of DALY with increasing age, a trend that was expected considering the profile of such diseases. Smoking is the main risk factor associated with DALY. The difference observed between sexes is notable and deserves attention.

The profile of respiratory conditions is in line with Brazilian estimates8,12,24, in which asthma and COPD have higher prevalence than other chronic respiratory conditions, similar to other countries2,30,31. Prevalence and incidence decreased for all-ages and age-standardized and, though decreasing for both sexes, estimates were higher for females. In general, the disease’s occurrence is more frequent in women than in men, likely explained by the greater opportunity of women to receive a diagnosis when compared to men32,33,34, whose preventive search for medical care is historically lower. Consequently, men have lower prevalence of diseases, not because of their better health condition, but mostly because they do not access the health care system. In this regard, policies to improve healthcare engagement for men have been created in Brazil35. Additionally, we highlight the high percentage of the population with COPD and other chronic respiratory conditions without proper diagnosis11, which means we are probably underestimating such diseases.

Concerning mortality estimates, a decrease in mortality rates since 1990 was shown. A similar trend was observed for cardiovascular disease (CVD)36, but not for diabetes37, two important NCDs in our country. The overall mortality rates have fallen for both populations, though men remained the most affected by NCDs, including chronic respiratory conditions16,18. Remarkably, the difference in mortality between male and female estimates have been around 40%, and are always higher for men. The health disparities between sexes have been broadly discussed for other conditions16,38,39,40 and seem to follow the same pattern as those for asthma or COPD. Several hypotheses have been proposed for the greater rates of mortality in men. They are involved in more violent situations, use alcohol and other drugs more often, and have greater exposure to traffic and work accidents34. Previous studies have described that men present later to medical care32,34, often presenting with overall poor self-care35 which might be a driver of the higher mortality rates. The Brazilian National Policy of Comprehensive Men’s Health Care (in Portuguese, Política Nacional de Atenção Integral à Saúde do Homem - PNAISH)35, although carrying in-depth discussions about masculinity and health and other social issues (not addressed by our study), aimed to improve the promotion, prevention, protection, treatment and recovery of men diseases and illnesses, a starting point in tackling such disparities in healthcare attention for men.

Related to the burden of chronic respiratory diseases, the PNS 2013, to our knowledge, was the first study that assessed the burden of disease in the Brazilian population showing a severe degree of limitation for daily activities for people with either asthma or COPD (16 and 10%, respectively)12. In order to express the total burden that the loss of health imposes on the population over the years, through our study we presented the DALY rates which sum YLL to YLD estimates41. If strategies of control and management are not properly provided, the increase of DALYs due to ageing and population growth will impact all levels of the health system. In Brazil, the access to the healthcare system is low for the poorest people with important disparities depending on the region of the country42, and, although access to medication is high, it is not free of charge for these diseases43,44,45. Social inequalities aggravate health problems and the population over 40 years old continues to face a high degree of burden. Concerning these issues and the current lack of improvements and investments in health16,38,46, attention must be taken to avoid the burden caused by chronic respiratory conditions from becoming worse, considering the advances in estimates showed since 1990. In this sense, such indicators could be incorporated and used for decision making, whether improvements in policies to prevent and offer a better quality of life for this population are still missing.

Regarding the risk factors for chronic respiratory diseases in Brazil, we show that smoking represented the main factor in increasing the number of DALYs. Indeed, tobacco smoking is a common risk factor for many NCDs and as such the World Health Organization (WHO) and the Global Alliance against Chronic Respiratory Diseases (GARD) has initiatives to reduce tobacco consumption. Other initiatives work on issues directly related to respiratory conditions, such as medication access and reduction in occupational and allergenic exposure47,48. In Brazil, initiatives to tackle NCDs emphasize the efforts to improve policies to reduce tobacco use49. The National Tobacco Control Program (PNCT)50 and all tobacco control policies are internationally recognized due to their impact on tobacco use prevalence, decreasing roughly 60% from 1998 to 201351. According to results from VIGITEL52, the reduction has occurred in every sex, age, level of education and region of Brazilian strata. Secondhand smoke which figured as a leading risk factor for DALY rates in 1990 has also decreased according to VIGITEL, an important result considering its effects as triggers for chronic respiratory diseases, especially in children53. Indeed, several measures, including the ban on advertising in the 2000s, adherence to the WHO Framework Convention on Tobacco Control in 2006, and laws that established and regulated tobacco-free environments are examples to be pursued. Also, regulation has promoted the increase of warningsand anti-smoking images on product packaging, increased taxes and defined the minimum price for their marketing, among others, representing multifaceted interventions to effectively reduce tobacco consumption. Our study represents one more source of information that highlights the importance of policies for tobacco control. There is a current discussion in Brazil evaluating reduced taxation of cigarettes manufactured in our country54. If such policy change is enacted, it may not only lead to a worsening of health estimates, such as those presented in this study, but also reduce the likelihood of reaching, or even surpassing the target of reducing tobacco consumption by 30%, according to the Global Action Plan for the Prevention and Control of NCDs49,52.

Other risk factors, such as ambient air pollution and occupational particulate matter should be mentioned. It is interesting to observe the transition among risk factors related to DALY rates from 1990 to 2017. While occupational particulate matter exhibited higher and similar rates in both years for men, in 2017 a slight increase was observed for women. In turn, ambient particulate matter pollution presented an important change, with increased rates shown in 2017. The opposite occurred for household air pollution which dropped in 2017. These results were somewhat expected, considering industrialization, migration from rural to urban areas and all environmental changes that occurred in the last few years in Brazil. According to the World Bank, Brazil is classified as an upper-middle-income economy, with industrialization increasing in recent years. Ambient and household pollution exposure are concerns for overall health conditions and targets of action by the WHO55. Pollution affects the respiratory system and has been demonstrated to not only increase the incidence of chronic respiratory diseases, but also impact those with pre-existing conditions, regardless of age56. Our results suggest an increasing burden relating air pollution and occupational exposure, the latter increasing for the female population. Thus, initiatives in this regard should be prioritized in order to understand the reasons why existing policies are not effectively reducing such burden and apply the right initiatives in reducing their impact.

This study has some limitations worth discussing. The first is related to issues with the ICD codes for COPD, ICD-10 codes J41 to J44.9. There is difficulty in differentiating ordinary chronic bronchitis from obstructive chronic bronchitis, meaning that we may overestimate COPD if we assume that all chronic bronchitis is COPD. The same misclassification of this diagnosis may happen with emphysema, as not every patient with this condition has COPD. Second, for other chronic respiratory conditions, it is not clear which acute conditions are being included, such as ICD-10 J37-J39.9, J39.0 and J39.1; these are acute pharyngeal and retropharyngeal abscesses that may increase the number of cases within this class. ICD-10 J68 and J90 also include acute cases. Finally, GBD uses statistical methods and aggregate data. The estimates can be over- or underestimated depending on the source, in order to account for this the uncertainty interval is provided, which reflects the quality of the input data and modeling process.

In summary, our study demonstrated that the prevalence and incidence of chronic respiratory diseases, according to GBD 2017 estimates, decreased in Brazil between 1990 and 2017, with the same result for mortality rates and overall disease burden. The difference in mortality rates between men and women draws attention to the need to address these conditions for both populations. Population growth and ageing and their impact on this burden should be a concern as the disability due to COPD is related to these components. It is no surprise that smoking tobacco is the main factor related to the disability; this demonstrates that policies need to further restrict its access. We hope these results can support strategies to assist in the continuous monitoring of these conditions and the use of resources for their management.

ACKNOWLEDGMENTS

Lisiane F. L. and Ewerton C. thank the CAPES for the doctoral scholarship grant. We acknowledge Dr. Marcelo B. Gazzana for reviewing the classification of the diseases and Darrah McCracken, Pauline Kim, Adrienne Chew of the IHME, University of Washington, for their manuscript reviews and writing support. We are grateful to Dr. Bruce Duncan for presenting and supporting this project. Finally, we express thanks to the Bill & Melinda Gates Foundation.

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Financial support: This study was financed in part by the Coordenação deAperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 (Lisiane F. L., Ewerton C. and Augusto B. B. received the doctoral scholarship grant). Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) - (Deborah C. M. received a scholarship of productivity), TED 125/2017 (FNS - Secretaria de Vigilância em Saúde).

Received: September 25, 2019; Revised: December 11, 2019; Accepted: December 16, 2019

Corresponding author: Lisiane Freitas Leal. 3,755 Cote Ste- Catherine, suite H-455, Montreal, QC H3T 1E2, Canada. E-mail: lisianeleal@gmail.com

Conflicts of interests: nothing to declare

Authors’ contribution: Lisiane F. Leal and Ewerton C.: article design, analysis, writing, and critical review of the manuscript. Augusto B. Bidinotto, Daniel Sganzerla, Rogério B. Borges: analysis and critical review of the manuscript. Deborah C. Malta, Kevin Ikuta, Tatiane da S. D. Pizzol: writing, and critical review of the manuscript.

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