World Lung Day: impact of “the big 5 lung diseases” in the context of COVID-19

The Forum of International Respiratory Societies (FIRS) is celebrating World Lung Day on September 25, 2022, with the theme “Lung Health for All.” Lung health is vital throughout the lifespan, but acute and chronic respiratory diseases (CRDs) are a clear threat to life, health, and productive human activity as clearly experienced during the COVID-19 pandemic. Respiratory diseases are associated with high morbidity, risk of mortality, and health care direct and indirect costs due to persistent symptoms, activity limitation, and intermittent exacerbations requiring acute care. They affect people in all countries, but disproportionally in low- and middle-income countries (LMICs) where resources for research, prevention, and management are scarce. It is imperative that resources devoted to acute and chronic respiratory diseases become a top priority in global decision-making in the health sector.

FIRS published the 3rd edition of the Global Impact of Respiratory Diseases report in 2021 emphasizing the five major lung diseases, the ‘‘Big Five,” which include asthma, chronic obstructive pulmonary disease (COPD), acute lower respiratory tract infections, lung cancer, and tuberculosis (TB). These diseases are among the most common causes of illness, disability, and death worldwide (1). In 2019, respiratory disease comprised three of the top 10 causes of death according to the World Health Organization (WHO), leading to more than 8 million deaths annually (2).

The spectrum of respiratory disease ranges from acute illness, such as pneumonia or lower respiratory tract infection, to chronic diseases such as COPD. Pneumonia remains one of the commonest causes of acute illness and of mortality globally, responsible for more than 2.5 million deaths in 2019 (3), and is a leading cause of death among children younger than 5 years outside the neonatal period and adults older than 65 years (4). Further, due to COVID-19, the number of adults developing respiratory disease/pneumonia with associated mortality due to SARS-CoV-2 increased exponentially, particularly in those with underlying comorbidities (5) claiming the lives of more than 6.3 million people, largely from respiratory causes (6). TB may also present with acute pneumonia, especially in children and in areas with high TB rates. More than 10 million people developed TB and 1.5 million died in 2020, making it the most common lethal infectious disease next to the COVID-19 pandemic (7). Such acute respiratory infections and other genetic-environmental interactions may also be associated with the development of chronic respiratory disease, with childhood illness setting a developmental trajectory for impaired health (8).

Chronic respiratory diseases are important contributors to the burden of noncommunicable diseases (NCDs). In 2017, an estimated 544.9 million (95% CI: 506.9–584.9) individuals worldwide had a chronic respiratory diseases (CRDs; 9). Nearly 200 million people, or 4% of the world’s population, have COPD, and 3.2 million die of it each year (10, 11), making it the third leading cause of death worldwide. Asthma is the most common CRD globally and the most common chronic disease in children worldwide, affecting 262.4 million people in 2019, with LMICs contributing 96% of global asthma-related deaths and 84% of global disability-adjusted life-years (10). Lung cancer kills 1.8 million people each year and is the deadliest of all cancers (12). These numbers are probably an underestimate of the true burden of respiratory diseases due to a lack of diagnostic tools and lack of access to care with substantial underreporting in LMICs. In addition, in LMICs the high burden of potentially noxious exposures, health system constraints, and social and political contexts negatively impact health and health outcomes.

Although much of the burden is preventable or treatable with available interventions, these diseases have received less attention than other prominent NCDs such as cardiovascular disease, diabetes, or cancer. Strong health systems that are capable of providing effective and efficient services across the life-course will be key in the prevention and management of acute and CRDs. Primary prevention of acute respiratory disease through immunization and optimizing other preventive strategies [such as adequate nutrition, control of human immunodeficiency virus (HIV), and reduction in tobacco smoke exposure or air pollution] and appropriate treatment of pneumonia are important to prevent and manage acute illness. Prevention of CRDs in LMICs will require attention to in utero and early childhood exposures, in particular adequate nutrition, living conditions, adequate asthma, and infection control, which will determine the trajectory of lung development and health over the course of an individual’s lifespan health (8). This is compounded by the fact that at least 2.4 billion people are exposed to indoor air pollution (13), 90% of all people breathe outdoor air that exceeds WHO guideline limits, especially in LMICs, and more than 1.3 billion are exposed to tobacco smoke (14). Reduction in these exposures is crucial to reducing the global burden of respiratory disease.

FIRS calls on all governments, communities, health-care professionals, and individuals to promote the achievable and effective preventive measures that have reduced tobacco consumption in many countries. The health benefits of clean air policies are far-reaching, and legislation and political action on clean air, as well as public awareness, are all important steps in preventing respiratory diseases. Reduction in tobacco smoking, including e-cigarettes and heat-not-burn devices, and improvement in air quality, which includes a reduction in second-hand tobacco smoke, indoor air pollution, and unhealthy public and workplace air, impact in decreasing deaths and hospitalizations for cardiovascular and pulmonary diseases. The respiratory societies of the world believe that everyone has the right to breathe clean air (15), and lawmakers should enforce clean air standards in all countries. Global warming and related climate emissions can affect respiratory health directly (heat waves and extreme weather events such as hurricanes and cyclones) or indirectly (increasing air pollutants, wildfire activity, pollens, and molds, as well as by promoting vectors for transmission of infectious diseases). Policies that reduce air pollution from fossil fuel combustion offer a “win-win” strategy for both climate and health, immediately lowering the disease burden from air pollution while also mitigating climate change.

The COVID 19 pandemic caused an interruption in childhood and adult immunization, tuberculosis, asthma, COPD, and cancer programs, reversing gains achieved until then and leading to patients seeking care with the more advanced diseases once face-to-face consultations were reinstituted. Reducing poverty, strengthening immunization programs, and providing greater availability and equitable access to immunizations including pneumococcal, influenza, Haemophilus influenzae type b, pertussis, Bacillus Calmette-Guérin (BCG); respiratory syncytial virus (RSV), and SARS-CoV-2 vaccines must be a priority worldwide to prevent infections, in particular in LMICs. The pandemic has also enhanced the importance of viral pneumonia and the need for appropriate etiologic diagnosis to avoid overuse of antibiotics, the emergence of Clostridioides difficile, and antibiotic resistance.

Effective training of healthcare professionals and ensuring the availability of appropriate diagnostic tools and medications are key to improve respiratory health. Without awareness and importance of respiratory diseases, an early and accurate diagnosis will not be pursued and inappropriate and delayed therapies will impact negatively on the prognosis of many of the “Big Five” and other respiratory diseases. Development of a core curriculum for clinical respiratory training including community workers, nurses, physiotherapists, and nonspecialist and specialist doctors with broader access to clinical and research-focused respiratory education and training platforms including open access journals, affordable online courses, and virtual and in-person workshops or consultations are needed.

FIRS and several other stakeholders are working together in collaboration with WHO looking at the barriers and solutions to improve long-term access and affordability of WHO-essential medicines (16, 17) and oxygen for people living with respiratory diseases globally. There is a need to develop local and applicable clinical guidance and implementation tools that address the needs of local healthcare providers and ensure that the WHO essential medicines list is aligned with current evidence to treat acute and chronic respiratory diseases. There is a need to optimize nonpharmacological CRD management tools, including self-management tools, nutrition, pulmonary rehabilitation, airway clearance tools, and smoking cessation programs. We hope that in the near future we may progress toward improving access for CRD medicines, with a World Health Assembly (WHA) resolution, similar to the advances seen for diabetes and cancer, and provide a more universal health coverage to reduce the burden of CRDs worldwide.

Another daunting issue is that despite having a correct diagnosis, access to affordable, safe, and quality-assured treatments is not assured worldwide. Immunization and tuberculosis programs sponsored by WHO and collaborating organizations are being rerouted post the pandemic, but a vital need exists for better access to basic and effective affordable medicines for asthma, COPD, lung cancer, and pulmonary infections. Control of the global lung cancer epidemic will require concerted efforts at achieving primary prevention, promoting early detection through screening, addressing the drivers of disparities that exist in both early detection and treatment, and ensuring access to effective treatment for all, including novel therapies

Finally, research in respiratory diseases is the hope for today and the promise for tomorrow. Basic, clinical, and population-based research is critical to improve the prevention, diagnosis, and management of respiratory diseases and their long-term sequalae. Measures developed from the research must be cost-effective and widely applicable. Increased funding to support respiratory research with key indicators for the future planning, monitoring, and evaluation of CRD interventions is needed to strengthen lung health in the future.

Despite these challenges, we must be encouraged by our progress in reducing the impact of respiratory diseases, in particular in the “big five,” over the last few decades. Investments in research and public health have paid dividends, as prepandemic evidence revealed decreasing rates and deaths of pneumonia, TB, and asthma, as well as reduced tobacco use in certain nations. However, the dire toll of the COVID-19 pandemic has highlighted the need for multisectoral collaborations to strengthen and expand global public health, research, and healthcare systems.

On World Lung Day 2022, we must continue moving forward to build equitable capacity, infrastructure, and resources needed to manage and prevent the next worldwide emergency, be it a pandemic or a climate catastrophe, while also addressing inequity and the existing large burden of acute and chronic respiratory diseases through available, effective interventions to reach “Lung Health for All.”

DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the authors.

AUTHOR CONTRIBUTIONS

M.C., S.M.L., and H.J.Z. drafted manuscript; M.C. edited and revised manuscript; M.C. approved final version of manuscript.