Interventions for prevention and control of chronic

respiratory diseases in China

Nan Shan Nan Shan ZhongZhong, M.D., M.D.National GARD Initiator, China

President, Chinese Medical Association

Presented by Professor Huahao Shen, M.D., Ph.D, FCCP

General information

GARD China Network

China Asthma Alliance China COPD Alliance

China GARD AllianceDept of Chronic Disease Management, Ministry of Public Health, China

Chinese Thoracic Society

Country National GARD Initiator

Contact Person in Ministry of Health

National GARD partners National GARD sources of funds

P.R China

Prof. NanShan Zhong

Ms Ling-zhi KongVice-director

Bureau of Chronic Disease Control and Prevention, Ministry of Public Health, People’s Republic

of China

National COPD Alliance

National Asthma Alliance

Chinese PediatricsSociety

Chinese Allergy Society

Chinese Society of Ear, Nose and Throat

RMB 16,000,000(2.1millions US$)

From:BI,GSK, AZ,

RMB 3,000,000(400,000 US$)

From:11th National Five-year Plan Project

Global Alliance against Chronic Respiratory Diseases (GARD)

Summary of Information on Activities at the Country Level

What have we done(Apr 30 , 2006 to present)

• The First China COPD Alliance Meeting and

Second China Asthma Alliance meeting

• New version of China guideline of asthma and

chronic cough

• Training program of physicians in community level

• Knowledge of prevention and management of asthma in the public and media

• Biomass fuel in the pathogenesis of COPD

• Pilot study of early intervention of COPD

management in the community level

• Set up a website in June 2007

(www.chinaasthma.net)

What have we done(Apr 30 , 2006 to present)

Official Website of China Asthma Alliance

www.chinaasthma.net

The Launch Meeting of China COPD Alliance in Guangzhou,

Nov 4, 2006

The Launch Meeting of China Asthma Alliance in Zhenzhou,

June , 2005

Activities on World Asthma Day in big city (Guangzhou)

Activities on World Asthma Day in big city (Guangzhou)

Activities on World Asthma Day in community(Zhejiang)

Professor Nanshan Zhong introduced basic knowledge of Chronic Cough to public

Prevalence and burden of

chronic respiratory diseases

in China

The mortality of top five diseases in some cities and counties 2006 in China

8.946.1Trauma and

poisoning6.132.4Trauma and

poisoning5

13.971.8Cardiovascul

ar disease13.169.3Respiratory diseases

4

16.484.9Respiratory disease17.190.7

Cardiovascula

r disease3

20.4105.0Cerebrovasc

ular disease17.793.7Cerebrovascul

ar disease2

25.1130.2Malignant

tumor27.3144.6Malignant

tumor1

Percentage

%

mortality(1/100,000)

Death Cause

(ICD-10)

Percentage

%

mortality(1/100,000)

Death Cause

(ICD-10)

In CountiesIn CitiesRank

Survey cities:Survey cities:Survey cities:Survey cities: 14 sites from 7 cities (Beijing,

Shanghai, Tianjin, Shenyang, Xi’an, Chongqing,

Guangzhou 2001-2002)

Shanghai

Tianjin

Shenyang

Xi’an

Beijing

Chongqing

Guangzhou

The prevalence of asthma is 0.5%～～～～2.0% in the population in mainland of China.

Prevalence of Asthma in China

Prevalence of COPD in China

• Subjects survey: 24,400 (>40y)

• Response rate: 20245/24400=83%

• Prevalence of COPD:

Male 12.4%

Female 5.1%

Total 8.2%

Prevalence of COPD in China by sex and age

0

5

10

15

20

25

30

40-49years 50-59years 60-69years 70+years

prevalence %

Male Female Total

Mortality

COPD mortality rates per 10,000 population

0

10

20

30

40

50

60

1

9

9

0

1

9

9

1

1

9

9

2

1

9

9

3

1

9

9

4

1

9

9

5

1

9

9

6

1

9

9

7

1

9

9

8

1

9

9

9

2

0

0

0

2

0

0

1

2

0

0

2

2

0

0

3

2

0

0

4

China(M)China(M)China(M)China(M) China(F)China(F)China(F)China(F) HongKong(M)HongKong(M)HongKong(M)HongKong(M) HongKong(F)HongKong(F)HongKong(F)HongKong(F) Aus(M)Aus(M)Aus(M)Aus(M) Aus(F)Aus(F)Aus(F)Aus(F)

Burden

Burden of Chronic Respiratory Diseases in China

A survey from 6 cities in China

The burden of a patient with COPD per year:

Direct medical costs: 11,000 RMB (1410 US$)

Indirect medical costs: 3,400 RMB (436 US$)

Days lost from work: 17 days

Data from Professor Quanying He

Burden of Chronic Respiratory Diseases in China

Average hospitalization expenditure in 132 patients with COPD

during 1998-2004

Year Cases Averag hospitalization expenditure

1998-1999 38 1820 (RMB)

(233 US$)

2000-2001 44 2988

2002-2004* 50 4640#(RMB)

(595 US$)

# compared with 1998-1999, P<0.01

Risk factors of COPD in China

Environmental factors leading to COPD

• Smoking

• Occupational exposure

• Biomass fuels

• Body mass index (BMI)

• Respiratory infections

• Others(Host factors )

Comparison of COPD Prevalence in

Smoker And Non-smoker

Male:OR=1.6(1.4Male:OR=1.6(1.4Male:OR=1.6(1.4Male:OR=1.6(1.4----1.9) Female:OR=2.7(2.21.9) Female:OR=2.7(2.21.9) Female:OR=2.7(2.21.9) Female:OR=2.7(2.2----3.9) Total:OR=1.9(1.73.9) Total:OR=1.9(1.73.9) Total:OR=1.9(1.73.9) Total:OR=1.9(1.7----2.2)2.2)2.2)2.2)

13.6

11.0

13.2

8.8

4.4

5.1

0.0

5.0

10.0

15.0

male female total

%

smoking never-smoking

Effects of tobacco smoking on lung function in subjects with COPD

-350

-300

-250

-200

-150

-100

-50

0

2002.9 2004.3 2005.3 2006.3 2007.3

不吸烟不吸烟不吸烟不吸烟

干预前戒烟干预前戒烟干预前戒烟干预前戒烟

干预期戒烟干预期戒烟干预期戒烟干预期戒烟

现吸烟现吸烟现吸烟现吸烟

• Post hoc analysis, adjusting for gender, age, childhood

respiratory infection, family history and body mass index

P=0.001

年月

Accumulative decline

in FEV1(ml）

non-smokers

ex-smokers before in

Ex- smokers after in

Current smokers

Y,M

Mean annual decline in FEV1（（（（ml/yr））））

COPD and Smoking (2005)

Liwang (Guangzhou) Yunyan (Shaoguan)

(n=1818) (n=1468)

38.4%38.4%38.4%38.4%35.1%35.1%35.1%35.1%Total

0.5%0.5%87.5%9.5%73.4%Smoker

12.0%7.4%Total

7.1%7.1%18.3%3.0%13.8%COPD

F(n=828)

M(n=640)

F(n=1088)

M(n=730)

Liu SM, Zhong NS, et al. Thorax 2007, on line

Fuel For Cooking in the last two Decade

69.3%0.7%Biomass

18.1%－

Biomass

+

Coal

10.9%0.7%Coal

－2.8%Electric

0.1%95.5%Gas

Yunyan (Shaoguan)Liwan (Guangzhou)

Liu SM, Zhong NS, et al. Thorax 2007, on line

Indoor Biomass Combustion

Liu SM, Zhong NS, et al. Thorax 2007, on line

Only SO2 was significantly associated with the prevalence of non-smoking female COPD subjects (p=0.036)

Conclusion• Prevalence of COPD in females in the rural area was

significantly correlated with family history, childhood respiratory

infection and biomass combustion.

• Indoor biomass combustion was an important risk factor of

COPD in females in the rural area

• Biomass combustion (or occupational exposure) and smoking

possess a synergistic effect on COPD prevalence

Liu SM, Zhong NS, et al. Thorax 2007, on line

Interventions for prevention

and control of chronic

respiratory diseases

in China

Community intervention for COPD

• 1410 patients (aged above 40) with confirmed COPD in Liwan, Guangzhou

P＝0.121Χ

2＝7.292

36.1%40.0%% lost to follow

up

436 cases436 casesMar 2007

683 cases727 casesSept 2002

Control Intervened

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Community intervention

• Health education

• Consultation

• Archives

management

• Routine therapy

• Tobacco cessation

• Knowledge on

prevention &

treatment

• Reduction of indoor

and outdoor air

pollution

• Sabutamol +

Ipratropin Inhalation

• Hazards of tobacco

• Quitting steps

(nicotine replacement)

• Helps to set up

ventilating facilities

• Voluntary consultation

• TV, broadcasts

• Bulletins

• Lectures

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Intervention outcomes

0.11711.1%2.1%% COPD mortality

0.0038.3%21.8%% tobacco cessation

0.0193.2%5.7%% improvement of occupation environment

0.00219.1%26.6%% improvement of outdoor environment

<0.00182.2%92.3%% awareness of tobacco hazards

<0.00121.8%77.1%% COPD awareness

<0.00126.1%78.9%% attendance to health education

P valueControlIntervened

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Overall outcome of community intervention(FEV1)

-350

-300

-250

-200

-150

-100

-50

0

2002.9 2004.3 2005.3 2006.3 2007.3

干预社区干预社区干预社区干预社区

对照社区对照社区对照社区对照社区

Y,M

P<0.001

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Intervened

Control

Accumulative decline

in FEV1(ml）

Overall outcome of community intervention(FVC)

-350

-300

-250

-200

-150

-100

-50

0

2002.9 2004.3 2005.3 2006.3 2007.3

干预社区干预社区干预社区干预社区

对照社区对照社区对照社区对照社区

Y,M

P=0.017

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Intervened

Control

Accumulative decline

in FVC(ml）

Overall outcome of community intervention(FEV1/FVC)

-5

-4.5

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

2002.9 2004.3 2005.3 2006.3 2007.3

干预社区干预社区干预社区干预社区

对照社区对照社区对照社区对照社区

Y,M

P<0.001

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Intervened

Control

Accumulative decline

in FEV1/FVC(%）

Conclusion

•Community intervention may lead to:

−Effective reduction of COPD risk factors

−Significantly less decline in lung function

Zhou YM, Zhong NS, et al. AJRCCM 2007, in pres

Zhou et al Respirology 2006; 11: 603

A study of low-dose, slow-release theophylline in

the treatment of COPD for 1 year

• 110 COPD patients(61.0±10.5yrs) in

Guangdong.

• 100 mg slow release theophylline bd versus

placebo in a parallel design for one year.

• 85 (77 %) completed the study.

Mean changes from baseline in pre-bronchodilator and post-bronchodilator lung functions in ITT and PP population

Zhou et al Respirology 2006; 11: 603

Time to first exacerbation

theophylline

placebo

Time of the first acute exacerbation

Conclusion

Low-dose, slow release oral theophylline is

effective and well-tolerated in long-term treatment

of stable COPD.

Recent plans (Asthma)

• A second ARIA survey on asthma control in China

• A survey of common allergen in patients with asthma and allergic rhinitis

• Dissemination of GINA Guidelines

• Training program of physicians in community level

• Knowledge of prevention and management of asthma in the public and media

• Development of a simplified guideline available for the rural area (cost-effective)

• Boycott false medicine

Recent plans (COPD)

• Review the China Guidelines for management of

COPD

• Complete the nationwide survey of COPD

prevalence

• Nationwide study of normal lung function values

• To sum up a pilot study of early intervention of

COPD (a 13-year study)