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i Brian A. Boehlecke Representing ATSScientific Assembly onEnvironmental and Occupational Health American Thoracic Society Philip A. Bromberg, M.D. Representing ATS Board of Directors American Thoracic Society John C. Brooks, M.D. Representing ATS Scientific Assembly on Pediatrics American Thoracic Society Susan Pingleton, M.D. Representing ATS Scientific Assembly onClinical Problems American Thoracic Society Herbert T. Reynolds, M.D. Representing ATS Scientific Assembly on Allergy and Clinical Immunology American Thoracic Society - B67 - Paper: Position Paper on Respiratory Diseases Authors: Laurence S. Farer, M.D., M.P.H. Director, Division of Tuberculosis Control Center for Prevention Services, CDC Project Officer: Carl W. Schieffelbein Public Health Advisor Division of Tu_berculosis Control Center for Prevention Services, CDC William li. Herman, M.D. Medical Epidemiologist Technical and Operational Research Branch Center for Prevention Services, CDC Reviewers: .John B. Bass, Jr., M.D. Representing ATS Scientific Assembly on Microbiology. Tuberculosis and Pulmonary Infections AmericanThoracic Society

EXECIJTIVE SUMMARY Respiratory diseases, including chronic lung diseases, acute respiratory infections, and lung cancer, constitute a tremendous health problem as measured by the number of persons affected, the number of days of productive activity and years of productive life lost, and the direct costs of caring for persons suffering from them. ' Lung diseases 4re a leading cause of death and disability in the United States, causing 1 of every 8 deaths and contributing to an equal number. There are almost 17 million Americans with chronic bronchitis, emphysema, or asthma. More than 100 million cases of inf luenza, pneumonia, and acute bronchitis occur annually. Respiratory diseases account for about 2.5 million hospital discharges, 21 million days of hospital care, and 25 million physician visits per year. The costs for these services exceed t29 billion. Lung diseases account for more workdays lost (over 31 million person-days annually) than any other category of illness. To this economic impact must be added the social costs and human suffering associated with these diseases. The devastating psychosocial and personal economic effects of a chronic, incurable lung disease are obvious. Progressive pulmonary impairment results in decreasing ability of the afflicted person to carry on usual activities of daily living. This may eventually lead to severe limitation of function, with loss of earning capacity and dependency on public assistance. Worry and anxiety may produce intense stress, as the patient and the family face the prospects for the future. As smoking is unquestionably the main cause of chronic lung disease, the single most important thing that can be done to reduce morbidity and mortality from lung disease is to eliminate smoking. COPD and lung cancer are directly related to smoking; asthma and other chronic lung diseases are exacerbated by smoking; and smoking may interact synergistically with occupational exposures, particularly to asbestos, to greatly increase the risks for workers. Although smoking elimination is an obvious intervention with huge potential impact, it presents many controversial policy issues. Among these are those relating to the economics of tobacco growing and marketing, the role of taxes on tobacco as a source of government revenues, the regulation of advertising in a free society, and the propriety of limiting individual rights when smoking is restricted in public places. Behavior modification, which is not easy, is the basis of smoking cessation programs, but the most effective approach to smoking elimination is behavior modification to prevent nonsmokers from starting to smoke. The long-term payoff of this approach will be the prevention of morbidity and premature mortality in people who are now young and whose productive years still lie largely before them, which is undoubtedly more cost-effective than postponing the death of chronically ill older persons through treatment. Other exogenous causes of chronic lung disease are hazardous substances found in the workplace, allergens, and infectious agents. Some lung diseases are hereditary. Many acquired lung diseases are of unknown cause. Acute viral respiratory infections in children may contribute to chronic lung disease later in life. Air pollution probably does not cause, but clearly can exacerbate, chronic lung disease. Other interventions to ameliorate the chronic lung disease problem consist of reducing occupational exposures to hazardous substances; enforcing estabished clean air standards; providing -B68-

`N I I I I I I I I I I I I I to the public and to health professionals on how to prevent lung disease; educating patients and health care providers about clinical management and treatment of chronic lung diseases, including self-help skills; and assuring access to health care, including home health care, for chronic lung disease patients. For most patients, these interventions can enhance functional ability and help them to cope with chronic illness, but, in general, once the manifestations of disease are present, the course of the process cannot be substantially altered. An exception is tuberculosis, once an incurable, highly fatal lung disease which is now curable and preventable. The effort to control it provides an example of how tools can be applied to control a disease, even as better ones continue to be sought, and it is a model for the potential control of other diseases, such as asthma, for which there is no cure or primary prevention, but which is amenable to interventions which could substantially affect morbidity, health care costs, absenteeism, and quality of life. However, for much chronic lung disease, major advances in control will depend on new insights into therapy and prevention which can only be acquired through continued research. I I I N ~ - B69 - L.rY O .~ PV ~.J ~. I

t t sttznQszQz TABLE 1: 5ummary of NeRative Impact ResultlnR from the Health Problem Health Problem Area: Re9pf}'atory Diseases NEGATIVE IMPACT RESULTING FROM THE HEALTH f'ROBLFM SPECIFIC IfEALTH PROBLEM Number of Deaths Number of Years Lost Before e 65 Number of Number of Hospital Disability D_ays Da~s 2 Cost Associated with each specific flealth Probl_em COPD & Allied Conditions 53,159 Zero 4.736000 263 m (3) Occu?ational Lung Diseases 1 1,422 N/A 57,000 (4) Asthma 2,891 18,791 2 059 000 1 (3) Tuberculosis 1,978 6,107 527.000 6 5 (3) Cystic fibrosis 505 23,230 164,000 N A (4) Ac~ionchjolitis N/A N A N A Interstitial lung disease N/A N/A 70.000 (4) $17.0 million Sarcoidosis 364 N/A 104,000 N/A (4) $27.7 million (1) Excludes lung cancer (2) Includes estimate of restricted activity days, bed days, and loss of work days (3) Includes direct and indirect cost estimates (4) Includes only direct cost estimates N/A Information not available

j m M M M M M M -M i S -i MAR a M M i M at TAR1.F. 2: Sumwnry of Nee.tlve lwpact tAxlch Could be 1¢educed or E11.1nnted Through I.ple.MOnt.tlon of thc totervcntlon Strate6tea Ile.lth Problea Area: Reepiratory Dtecasep SPECIFIC IIF.nLTII PROOLIN INTERVENTION STRAT[CT NEGArtVL' IMPACT UIIICII COULD DE R7:1)UCED OR ELIMINATEO TIIn0UG11 IMPLF.II£NTATION OF T11E IItTF.RVF.NTION STRATECC Dcath• Ycwr• of Li[c Lnst flospitnl Dayo Dls.bllltY Da a Cost Nun,bcr 2 Tut.1 _Nue.ber (_2_To_talj_ N~~mbcr_ Z Totnl Nu~.hor Z 1'ntn N~e I T Tn COPD L/1111ed [.Ond iC10M Eli~nate a 42.527 (80%) Not appllcable 3,788,000 (80Z) 261,046,400 (80I) $5.2 billion (80I Occupational Lung Di e Elirminate exposure 1,422,(100Z) Informatlon not available 57,000 (100%) Infor.eatlon not available $15.6 tmillion ( seas Asthma Kedlcal care INTENSIVE HEDICA HANAGEMF}7T OF TNES COPrDTTIOHS SH 6E ABLE TO SIIDST TIALI.T REDUCE Tuberculosis " ^ Others « n 7L L C ,i7~~~.lJC. LC,i7~~~.lJC. - B71 - ~

-Respiratory: Years <65 Lost and Deaths ~ ~~.. v 120 -, 100~ COPD El Years <65 Lost ® Deaths L= I ksn I !,~ n F~ Occup. Asthma Cystic Other TB Fibrosis Resp. r60 LZZZfi0Sz0Z

Respiratory: Hospital Days & Direct Costs URf,QSZQZ COPD ® ® Occup. Rsthma Cystic Other Fibrosis Resp. TB ~ 0 (/I ~ ~ ~