Introduction
Malta has a publicly funded health care system similar to the one used in the United Kingdom with free health care at the point of delivery for all citizens and registered long term residents. Private health care co-exist along with the public system on a “pay as you use” basis and is mainly used by foreigners and contracted private physicians. The Maltese Ministry of Health is responsible for oversight and regulation purposes besides spear heading campaigns in the health sector. According to Murray & Frenk, Malta has the fifth best health care systems on the world beating developed countries such as the UK, Canada and the US which were ranked 18, 30 and 37 respectively in the same study conducted by the World Health Organization (2010). Waiting times to see a specialist and the quality of health care outcomes such as life expectancy at birth and infant mortality support the better ranking of Malta’s health care system.
Despite its good health system, Malta faces key challenges in the continued delivery of quality health care. Key among these challenges is the rise of lung diseases in particular the Chronic Obstructive Pulmonary Disease (COPD). Currently, COPD is a top five leading cause of chronic morbidity and is projected to rank fifth in burden of disease worldwide by 2020 (Rabe et al., 2007, Atsou et al., 2000). Treatment and management of COPD is expensive and the disease impairs quality of life. This essay provides a comprehensive review of the epidemiology of COPD in Malta. It considers the disease epidemiology, risk factors, prevalence, comparison with other countries, and the steps being taken to address the disease.
COPD Epidemiology
COPD is a term used to describe various chronic lung diseases such as chronic bronchitis and emphysema that lead to limited airflow in the lungs (WHO, 2013). Inflammation and scarring of bronchial tubes reduce air flow in the lungs and increases mucus production. A person with a consistently severe mucus producing cough for most days in a month in two consecutive years is considered to suffer from CPD if no other underlying disease explains the cough (Lung foundation, 2013). Common symptoms of COPD are breathlessness, chronic cough and sputum and a frequent urge to clear the throat. Reduced airflow in the lungs reduces oxygen transfer rates to the blood and people with COPD have a lower tolerance for physical exercises. Sudden onset COPD is rare and is caused by exposure to highly polluted air such as industrial fumes during accidents. A spirometry test which measures how much air a person can inhale and exhale and the ease of air movement in the lungs is the commonly used technique to diagnose COPD (Anto et al., 2001). After diagnosis, the 10 year survival rate is less than 50%. Majority of patients suffering from COPD die of respiratory insufficiency. Since COPD is not curable, treatment and management aims at alleviating pain and controlling the symptoms mainly through the administration of air passage dilators and oxygen therapy.
COPD Risk Factors
Risk factors are conditions whose presence or absence can increase a person’s likelihood of contracting a certain disease. These factors are usually related to the causative agent for a disease. Tobacco smoke including passive exposure is the major cause of COPD with other risk factors being indoor and outdoor air pollution, occupational exposure to dust and chemical vapors and severe respiratory infections during childhood. Prevalence of COPD is correlated with environmental pollution and tobacco use (Anto et al., 2001, Stang et al., 2000). Exposure to particulate pollution in air causes severe COPD that easily kills. Although environmental pollution and air quality is a concern in Malta, smoking is the major cause of COPD. The level of education and the income bracket affects prevalence of COPD. Low income earners and those who have achieved lower education levels are more likely to be affected by COPD than better educated people who earn more (OECD, 2012). This can be explained due to the higher rates of environmental pollution in lower income neighborhoods than high income neighborhoods which have better air quality.
People who suffered respiration infections as children especially below 10 years are more likely to contract COPD later in life than people who had no respiratory infections as children (Cacciottolo & Cordina, 2011). Genetics and inherited characteristics have also been observed to predispose some people to contract COPD. Anto et al., have provided a strong link between certain genetic variations and the increased susceptibility to environmental factors which cause COPD (2001). Research in this are is ongoing a numerous genetic variations have been observed to predispose people to develop COPD in later life. One of these genetic variations is Alpha 1 antitrypsin deficiency which affects up to 20 million people with an extra 116 million carriers world wide (de Serres, 2002). The effect of genetic variations in relation to COPD prevalence in Malta is an area that needs more research as available data is on Europe as a whole rather than Malta as a county. The European Union has been funding research in COPD due to its large burden but available funds are limited.
Prevalence of COPD in Malta
Between 2006 and 2010, the European Health Survey conducted a major health survey in the European Union. The findings were published in 2012 by the Organization of Economic Co-operation and Development (OECD), an international organization that helps governments of member countries to face social, economic and governance challenges. The study indicates a 1.2% self reported prevalence rate of COPD in Malta (OECD, 2012). More women than men are affected by COPD in Malta and prevalence increases with age. The age group of 15-64 years has a prevalence rate of 1% compared to a prevalence rate of 2% for those above 65 years. COPD and Asthma are among the top five killers in Malta. Certain factors have contributed to the high incidence of COPD in Malta compare to other European countries.
The high lifestyle standards in Malta coupled with a smoking legal age of 16 encourages use of tobacco leading to more people being at risk of contracting COPD due to passive exposure to tobacco smoke. Today, tobacco kills at least one person per day in Malta (Dalli, 2012). The tourism industry contributes to encouraging smoking as tourist who smokes for leisure frequent Malta. The low income earners are more likely to take on smoking and this is reflected by the high prevalence rates of COPD among the poor people in Malta (OECD, 2012). In addition, low income earners are more likely to live in areas with higher levels of pollution increasing their risk of exposure. Phenotypic traits are important in explaining the high frequency of COPD in women despite their lower exposure to primary tobacco smoke. High rates of COPD prevalence among those above 65 years results from long term exposure to smoke, exposure to industrial dust and fumes and other occupational hazards. This trend is worrying as geriatric patients have additional health challenges and their reduced immune activities make them more susceptible to infections in the lungs.
Comparison of COPD Prevalence Rates in Malta with Other Countries
Despite increasing numbers of people being diagnosed with COPD, Malta has the lowest average COPD prevalence rate at 1.2% in the European Union. The average prevalence rate of COPD in the European Union in 2010 was 3.1% with women having an average prevalence rate of 3.5% versus men’s 2.9% (OECD, 2012). This compares well with Malta where more women than men have COPD and contrasts with some European countries such as France and Cyprus where more men than women had COPD. In Europe, Turkey has the highest prevalence rates of COPD at 6.2% while Hungary leads the European Union at 4.7%. In the US, COPD is the third largest cause of death and claimed 124, 477 lives in 2007 (CDCP, 2010). Like in Malta, more American women suffer from COPD compared to men. World wide COPD affects over 160 million people (Halbert, Isonaka, George, & Iqbal, 2003).
COPD Management in Malta
COPD is a leading cause of death in Malta and the Maltese government through the Ministry of Health has set out robust guidelines for the management of COPD. On 9 December 2011, “The Malta Guidelines for the Management of Chronic Obstructive Pulmonary Disease” was launched. The guidelines were prepared in collaboration with the US National Heart, Lung and Blood Institute (NHLBI) as part of the Global Initiative for Chronic Obstructive Lung Disease (GOLD). A consultative and evidence based approach was used to prepare the guidelines so that they can represent a consensus among core health care professionals who practice clinical medicine in Malta (Cacciottolo & Cordina, 2011). The guidelines are not intended to override clinical Judgment but aim at aligning Maltese efforts with global efforts in COPD management. The key milestones in the guidelines are raising awareness, creating more healthy environments especially for poor people, reducing the disease risk factors and preventing disability caused by this chronic disease. Among the recommendations made in the guidelines are changes in health care policy and more stringent regulation of tobacco us, increased investment in research and citizens education about COPD. This approach global approach is important to ensure reduced levels of COPD world wide and to improve quality of life (Currie, 2009). Malta has ratified the WHO framework Convention on Tobacco Control and is a member of Global Alliance against Chronic Respiratory Diseases (GARD). These steps have led to increased government efforts to reduce the burden of COPD and improve air quality to allow people to breathe freely.
COPD is a prevalent disease that is usually diagnosed when it is already more developed because most people mistake its symptoms with those of other lung infections (Busse et al., 2010). Educating the people on the symptoms of COPD will increase awareness and allow for early diagnosis before the disease is more advanced. Brug, Schols, & Mesters recommend for education targeting diet and nutrition as a preventive strategy (2004). Awareness is also aimed at helping people take preventive measures such as quitting smoking and minimizing exposure to polluted air. Training of health care providers to recognize early symptoms of COPD and a community health approach to address COPD challenges among low income earners who are at a higher risk are viable ways which can be used to manage COPD. Health policy reforms are intended to streamline diagnosis and give standardized evidence based responses to COPD. In addition regulations will control air pollution and exposure to passive smoke by regulating smoking in public places and improving occupational health strategies such as use of protective clothing and gas masks in industries. Releasing data on air quality can help people to take necessary precautions to prevent exposure polluted air which is a COPD risk factor. Research in COPD targets better management practices by improving diagnosis and response.
The ministry of Health in Malta has strived to improve the quality of life for COPD patients. Universal health care guarantees access to medical care services and investments in public hospitals have allowed many institutions to have equipments necessary to manage COPD patients. Bronchodilator medications which relax and open air passages in the lungs form an important intervention for management of COPD (Ernst, Gonzalez, Brassard & Suissa, 2007). In addition, antibiotics to treat infections and expectorants to clear mucus in the air passages are recommended by the Malta Ministry of Health.
Limitation of Data used
Data on COPD prevalence in Malta is scarce due to insufficient research especially on historical prevalence rates. Malta has the lowest COPD prevalence rate in European Union and is not classified as a high risk country. The data used is limited to research by WHO and OECD carried out between 2005 and 2010 which was published in 2012. This research covered all members of the European Union making comparisons easier. Additional data was sourced from the government and primary research articles published in peer reviewed journals. This makes the data accurate and reliable and makes this paper to be applicable in various spheres such as policy formulation.
Conclusion
COPD is a top ten leading cause of death in the world and has a high burden on health care systems. Exposure to tobacco smoke and other causative agents inflates the lungs reducing air flow. Patients suffer from breathlessness and have a chronic cough characterized by heavy sputum. Prevalence of COPD is affected by age, education and income bracket, and genetic variation. Malta has one of the best health care systems in the world but COPD has emerged as a serious challenge to the health sector. In Malta, a thriving economy and a low legal smoking age of 16 has encouraged smoking and increased COPD prevalence rates. By 2010, COPD affected 1.2% of Maltese, with more women than men being affected. While the observed prevalence rates in Malta are the Lowest in the European Union, it is worrying to note that COPD prevalence rates have been on an increase. To meet the challenges posed by COPD, the Maltese government through the Ministry of Health has embarked on health policy reforms and educating the citizens. Health policy reforms will streamline management of COPD and align Maltese efforts with the global efforts to combat COPD while education will increase awareness of risk factors and symptoms. When people know the risk factors which can cause COPD, they can take preventive measures such as quitting tobacco to improve their lives. Maltese effort to combat COPD has been partially successive due to low prevalent rates but more strategies are needed to reduce new infections.
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