The Epidemiology and Burden of COPD in Latin America and the Caribbean: Systematic Review and Meta-Analysis

Figures & data

Figure 1.  Flow chart of studies through the systematic review.

Table 1.  Characteristics of included studies

Studies	Study Design, Setting & Country	Participants	Outcome's Measures
Arredondo 2007(36)	Design: Costing. Time series Setting: Mexico. From 1994 to 2005.	Total population NA Age range ≥40 years - no upper limit Outpatient	Cost per ambulatory care without complications
Caballero 2008(21)	Design: Cross-sectional. Setting: Colombia. From February 2003 to May 2004.	Total population: 5539 Age range: 40 - no upper limit. Population based setting Current smokers: 1014 Former smokers: 1672 Exposure to biomass: 1185	Number with GOLD FEV1/FVC ≤ 70%
Campos 2003(43)	Design: Cross sectional. Setting: Brazil. From January 1980 to December 1998.	Total population NA Age lower limits: 65 no upper limit Outpatient and inpatient	COPD definition: ICD Deaths.
Castro 2009(41)	Design: Ecologic time series. Setting: Estado de Rondonia, Brazil. From 1998 to 2005.	Total Population NA Age range: 65, no upper limit. Outpatient and inpatient	COPD definition: ICD Mortality by 100.000
Chatkin 2010(24)	Design: Cross-sectional Setting: Porto Alegre, Brazil. From September 2007 to March 2009.	Total population: 294 Age median: 60 Outpatients Current smokers: 294	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). GOLD1, 2, 3 and 4.
Dias da Costa 2008(33)	Design: Surveillance. Setting: Rio Grande doSul, Brazil. From January1995 to December 2004.	Total population 2578 to 4929 Age range: 20–59 Outpatients	COPD definition: ICD
Dreyse 2008(45)	Design: Cross-sectional. Setting: Chile. From November 2006 to August 2007.	Total population 95 Mean age 68.6 Outpatients.	Number of COPD patients (GOLD FEV1/ FVC ≤ 70%). GOLD-1, 2, 3 and 4. Oxygen cost
Duran 2008(34)	Design: Cross-sectional. Setting: Bogotá, Colombia. From September 2005 to December 2005.	Total population 69 Mean age: 73 Outpatient/inpatient Current smokers: 32	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Oxygen cost Medications (non-antibiotics)
Faganell o 2007(27)	Design: Cohort. Setting: Sao Paulo, Brazil. 2004.	Total Population 120 Age mean 65 Outpatient	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number with exacerbation. Number with exacerbation requiring hospitalization GOLD-1, 2, 3 and 4. Deaths Number of COPD patients that were hospitalized. Number of hospitalizations. Cost oxygen. Bronchodilator cost. Corticosteroid cost
Godoy 2001(30)	Design: Case series. Setting: Rio Grande do Sul, Brazil. From November 1998 to November 1999.	Total Population 1200 Age: >14 years old Inpatient	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Deaths Number of COPD patients that were hospitalized. Number of hospitalizations. Length of hospitalization
Laniado-Laborín 2009(46)	Design: Cross-sectional. Setting: Mexico. From March 2008 to September 2008.	Total population 2293 Age range: 40, no upper limit. Outpatients with risk factors for COPD	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). GOLD-1 2, 3 and 4.
López Varela 2008(32)	Design: Cross-sectional Setting: PLATINO Brazil, Chile, Mexico, Uruguay and Venezuela. From January 2003 to December 2005.	Total population 5315 Age: >40 (mean 57) Population based settings	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Use of resources: tablets, inhalers, nebulizer, syrups, bronchodilator, corticosteroid and medications (non-antibiotics)
Martinez- Gutierrez 2008(38)	Design: Costing. Setting: Santiago, Chile. From October 2004 to April 2005.	Total Population Age mean 68 Outpatient/inpatient Current smokers: 26	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients that were hospitalized. Number of hospitalizations. Number of COPD patients that went to emergency room. Total costs, ambulatory costs, emergency costs, hospitalization costs and medicines costs per month.
Menezes 2004(22)	Design: Cross-sectional Setting: Pelotas, Brazil. From January to March 2001.	Total population: 191 Population based setting Age range: 40–69 Current smokers: 61 Former smokers: 48	Number of persons with GOLD FEV1/FVC ≤ 70%. Number of COPD patients (ERS or LLN). GOLD0, GOLD2
Menezes 2005(25)	Design: Cross-sectional. Setting: Brazil, Sao Paulo. Chile, Santiago. Mexico, Mexico. Uruguay, Montevideo. Venezuela, Caracas. From January 2003 to December 2004.	PLATINO Population based setting
Brazil	Sao Paulo, Brazil. From January 2003 to June 2003.	Total population: 1000 Mean age: 55 Outpatient BMI ≤ 25: 19% BMI ≤ 18: 50% BMI≥30: 13.2% Current smokers: 34 Former smokers: 24 Average pack/ year: 15.8. Biomass: 25.	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients (ERS or LLN). Number of COPD patients (ATS). Gold 0, 1, 2, 3 and 4.
Chile	Santiago, Chile. From January 2004 to December 2004.	Total population: 1208 Mean age: 57 Outpatient BMI ≤ 25:20.7% BMI≤ 18: 50% BMI≥30: 14.4% Current smokers: 38 Former smokers: 31 Average pack/ year: 16.9 Biomass: 34.	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients (ERS or LLN). Number of COPD patients (ATS). Gold 0, 1, 2, 3 and 4.
Mexico	Mexico, Mexico. From January 2003 to December 2004.	Total population: 1063 Outpatient Mean age: 56 BMI ≤ 25: 14.6% BMI≤ 18: 28.6% BMI≥30: 4.3% Current smokers: 6 Former smokers: 10 Average pack/year: 7.8 Biomass: 7	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients (ERS or LLN). Number of COPD patients (ATS). Gold 0, 1, 2, 3 and 4.
Uruguay	Montevideo, Uruguay. From June 2003 to June 2004.	Total population: 943 Mean age: 60 Outpatient BMI ≤ 25: 23.7% BMI≤ 18: 26.7% BMI≥30: 15% Current smokers: 41 Former smokers: 42 Average pack/year: 19.7 Biomass:40	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients (ERS or LLN). Number of COPD patients (ATS). Gold 0, 1, 2, 3 and 4.
Venezuela	Caracas, Venezuela. From June 2004 to December 2004.	Total population: 1357 Mean age: 55.1 Outpatient BMI ≤ 25: 15.1 BMI≤ 18: 22.7 BMI≥30: 9.6 Current smokers: 25 Former smokers: 27 Average pack/year: 12.1 Biomass: 24	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of COPD patients (ERS or LLN). Number of COPD patients (ATS). Gold 0, 1, 2, 3 and 4.
Miravitlles 2003(31)	Design: Costanalysis. Setting: Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela. From June 2001 to June 2004.	Outpatient/inpatient	Ambulatory costs, emergency costs, hospitalization costs and medications cost per month. Cost of Failure, cost of exacerbations, percent Failure.
Miravitlles 2008(35)	Design: Cross-sectional Setting: Argentina and Ecuador. From January 2001 to December 2001.	Total Population 833 Age: >40 Outpatient/ inpatient BMI average: 25.5 Current smokers: 42 Average pack year: 45 Biomass: 63	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of exacerbation. Number of hospitalization. Number of hospitalization requiring ICU. Number of emergency room visits. Outpatient visits per year. Exacerbations due to infectious causes.
Montes de Oca 2009(44)	Design: Prevalence study. Setting: PLATINO Brazil, Chile, Mexico, Uruguay and Venezuela	Total population 5314 Population based setting	PLATINO outcomes related to health status categories (Excellent, Very good, Good, Fair, Poor)
Perez 2007(37)	Design: Cost analysis. Setting: From January 2004 to December 2004.	Outpatient/inpatient	Total costs and ambulatory costs per month.
Ramírez- Venegas 2006(28)	Design: Cases series. Setting: Mexico, Ciudad de Mexico. From January 1996 to December 2003.	Total population 481 Mean age: 69 Outpatient smokers/biomass exposure	COPD definition: ERS Number of persons with GOLD FEV1/FVC≤70%. GOLD-1, 2, 3 and 4. Deaths. Oxygen (cost).
Reynales- Shigematsu 2005(39)	Design: Cost analysis. Setting: Mexico.	Total population xxx Age Outpatient/inpatient	Ambulatory costs, medical specialty consult costs, emergency costs, hospitalization costs and intensive care unit.
Reynales- Shigematsu 2006(40)	Design: Cost analysis. Setting: Mexico. From Juneb2001 to June 2004.	Total population xxx Age xxx Outpatient/inpatient Current smokers: 223 Former smokers: 85	COPD definition: ICD 10. Length of ICU. Total costs, ambulatory costs, emergency costs, hospitalization costs and intensive care unit costs per month.
Rico-Mendez 2005(29)	Design: RCT Setting: Mexico, Mexico. From January 1991 to December 2001. Primary care/Tertiary care.	Total population 87 Age (mean 58) Outpatient/inpatient	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). Number of exacerbation Gold 2 and 3. Deaths Number of hospitalization. Length of hospitalization
Seemungal 2008(47)	Design: Prospective Cross-sectional. Setting: Trinidad and Tobago.	Total population: 720 Mean Age: 50 Inpatients Current smokers: 45 Former smokers: 34	Number of COPD patients (GOLD FEV1/FVC ≤ 70%). GOLD-1, 2, 3 and 4.
Sívori 2001(42)	Design: Cross-sectional. Setting: Tucuman, Argentina. From January 1980 to December1998	Outpatient/inpatient	Mortality by 100.000
Toyoshima 2005(48)	Design: Surveillance. Setting: Sao Paulo, Brazil. From January 1995 to December 2000.	Total population: 206764 Inpatient Age range: > 65	COPD definition: ICD Number of persons with exacerbation requiring hospitalization.

COPD: Chronic obstructive pulmonary disease, GOLD: Global Initiative for Chronic Obstructive Lung Disease, ERS: European Respiratory Society, LLN: lower limit of normal, FEV1: forced expiratory volume in 1 s, FVC: forced vital capacity, ATS: American Thoracic Society, ICD: International Classification of Diseases, BMI: Body mass index, ICU: intensive care unit, RCT: Randomized controlled trial; NA Not Available.

Table 2.  Risk of Bias of included studies by quality items*

Studies	Study Design	Sampling method	Participants’ selection	Variable measurement	Conflict of interest	Summary Risk of Bias
Arredondo 2007(36)	Cost analysis	Non probabilistic	High	Moderate	Low	High
Caballero 2008(21)	Cross-sectional	Probabilistic	Low	Low	Low	Low
Campos 2003(43)	Cross-sectional	Non probabilistic	Low	Low	Low	Low
Castro 2009(41)	Time series	Non probabilistic	Low	Moderate	Low	Moderate
Chatkin 2010(24)	Cross-sectional	Non probabilistic	High	High	Low	High
Dias da Costa 2008(33)	Surveillance	Probabilistic	Low	Low	Low	Low
Dreyse 2008(45)	cross sectional	Non probabilistic	High	Low	Low	High
Duran 2008(34)	Cross-sectional	Non probabilistic	High	High	Low	High
Faganello 2007(27)	Cohort	Non probabilistic	High	Low	Low	High
Godoy 2001(30)	Case series	Non probabilistic	High	High	Low	High
Laniado-Laborín 2009(46)	cross sectional	Unclear	High	High	Low	High
López Varela 2008(32)	Cross-sectional	Probabilistic	Low	Low	Low	Low
Martinez- Gutierrez 2008(38)	Cost analysis	Non probabilistic	Moderate	Low	Low	Moderate
Menezes 2004(22)	Cross-sectional	Probabilistic	Low	Low	Low	Low
Menezes 2005(25)	Cross-sectional	Probabilistic	Low	Low	Low	Low
Miravitlles 2003 (31)	Cost analysis	Non probabilistic	Moderate	Moderate	Low	Moderate
Miravitlles 2008(35)	Cross-sectional	Non Probabilistic	High	Low	Low	High
Montes de Oca 2009(44)	prevalence study	Probabilistic	Low	Low	Low	Low
Perez 2007(37)	Cost analysis	Non Probabilistic	Moderate	Low	Low	Moderate
Ramírez- Venegas 2006(28)	Case series	Non Probabilistic	High	Low	Low	High
Reynales-Shigematsu 2005(39)	cost analysis	Non probabilistic	High	High	Low	High
Reynales-Shigematsu 2006(40)	Cost analysis	Non probabilistic	Moderate	Low	Low	Moderate
Rico-Mendez 2005(29)	RCT	Non probabilistic	Moderate	Low	Unclear	Low
Seemungal 2008(47)	Cross-sectional	Non probabilistic	High	Low	Low	High
Sívori 2001(42)	Cross-sectional	Census	Low	Moderate	Low	High
Toyoshima 2005(48)	Surveillance	Non Probabilistic	Low	Low	Low	Low

*Control confounding, Design-specific bias, and Statistical methods bias were not applicable items of the risk of bias tool for descriptive, non comparative studies.

The e-Appendix-2 Risk of Bias Tool provide details about classifications used in this table.

Figure 2.  Proportion Meta-analysis of COPD prevalence in general population.

Figure 3.  Proportion Meta-analysis of COPD prevalence by age group.

Figure 4.  Proportion Meta-analysis of COPD prevalence by sex.

Table 3.  The general population and at risk population* GOLD-specific prevalence

		General population		At risk population
COPD status	GOLD	# persons (# studies)	Prevalence (95% CI)	# persons (# studies)	Prevalence (95% CI)
No COPD	GOLD-0	5762 (6)	21.8% (16.8% to 27.1%)	—	—
	GOLD-1	5571 (5)	8.8% (6.3% to 12.1%)	3013 (2)	2.5% (0.3% to 6.3%)
	GOLD-2	5762 (6)	4.8% (3.3% to 6.6%)	3013 (2)	9.4% (8.4% to 10.5%)
COPD	GOLD-3	5571 (5)	0.7% (0.5% to 0.9%)	3013 (2)	6.2% (4.4% to 8.3%)
	GOLD-4	5762 (6)	0.2% (0.1% to 0.3%)	3013 (2)	2.4% (0.9% to 4.4%)
	GOLD 1–4	11301 (7)	13.4% (10.1% to 17.1%)	3013 (2)	20.7% (19.3% to 22.2%)

*COPD in at-risk populations, defined by the presence of smoking, indoor pollution from biomass cooking or occupational dusts and chemicals.

COPD: Chronic obstructive pulmonary disease, GOLD-0 (chronic cough and sputum with normal spirometry) was eliminated in 2009; GOLD-1 (Mild) defined as FEV₁ ≥80% predicted, sometimes chronic cough and sputum; GOLD-2 (Moderate) defined as 50% ≤ FEV₁ <80% predicted, with shortness of breath; GOLD-3 (Severe) defined as 30% ≤ FEV₁ <50% predicted; and GOLD-4 (Very severe) defined as FEV₁ <30% predicted or FEV₁ <50% predicted plus chronic respiratory failure.

Table 4.  COPD hospitalization rate by age group and gender*

Country	Age, gender group	COPD hospitalization/1,000 hospitalizations	N° of hospitalizations
Brazil	40–49 years, both sex	12.4 [10.2–14.7]	14900000
	50–59 years, both sex	30.1 [24.8–36.0]	13200000
	60–69 years, both sex	53.5 [44.7–63.4]	12600000
	70–79 years, both sex	69.1 [59.5–79.6]	10700000
	80 years or more, both sex	69.1 [59.8–79.0]	6354655
	All ages, females	12.8 [11.5–14.2]	93000000
	All ages, males	23.7 [20.9–26.7]	60100000
Mexico	45–64 years, female	8.6 [8.2–9.0]	2636696
	45–64 years, male	18.0 [11.4–26.2]	1716265
	45-64, both sex	8.9 [8.3–9.4]	4623275
	65 years or more, female	36.0 [34.2–37.9]	2022789
	65 years or more, male	40.1 [37.4–42.6]	1848543
	65 years or more, both sex	38.1 [36.0–40.4]	3848947

*Meta-analysis of Brazilian and Mexican ministerial databases considering all years of follow-up (5 to 13 years).

Arredondo A, Carrillo C, Zuniga A. Economic burden of expected epidemiological changes in diseases related to tobacco, Mexico. Rev Saude Publica 2007 Aug; 41(4):523–529. PubMed PMID: 17589749.

 PubMed Web of Science ®Google Scholar

Caballero A, Torres-Duque CA, Jaramillo C, Prevalence of COPD in five Colombian cities situated at low, medium, and high altitude (PREPOCOL study). Chest 2008 Feb; 133(2):343–349. PubMed PMID: 2008090792.

 PubMed Web of Science ®Google Scholar

Campos HS. Mortalidade por DPOC no Brasil, 1980-1998. Pulmão RJ 2003; 12(4):217–225. PubMed PMID: 401665.

 Google Scholar

Castro HA, Goncalves KS, Hacon SS. Trend of mortality from respiratory disease in elderly and the forest fires in the state of Rondonia/Brazil - period between 1998 and 2005. [Portuguese]. Ciencia Saude Coletiva 2009; 14(6):2083–2090. PubMed PMID: 0020069176.

 PubMed Web of Science ®Google Scholar

Chatkin G, Chatkin JM, Aued G, Evaluation of the exhaled carbon monoxide levels in smokers with COPD. J Bras Pneumol 2010 Jun; 36(3):332–338. PubMed PMID: 20625671.

 PubMed Web of Science ®Google Scholar

Dias-da-Costa JS, De Borba LG, Pinho MN, Quality of primary care as measured by preventable hospitalizations in the South of Brazil. [Portuguese] Qualidade da atencao basica mediante internacoes evitaveis no Sul do Brasil. Cadernos de Saude Publica 2008; (7):1699–1707. PubMed PMID: 18670693.

 PubMed Web of Science ®Google Scholar

Dreyse DJ, Lisboa BC, Pinto RC, Características clínicas y funcionales según género de pacientes con enfermedad pulmonar obstructiva crónica. Rev Chil Enferm Respir 2008; (2):95–100.

 Google Scholar

Duran D, Vargas OC. Stable copd management in relation to the GOLD: Experience at a university hospital. Colombia Medica 2008; (4):328–345. PubMed PMID: 2009177981.

 Web of Science ®Google Scholar

Faganello MM. Fatores associados à ocorrência de exacerbação em pacientes com DPOC. Botucatu: s.n; 2007.

 Google Scholar

Godoy DVd, Dal Zotto C, Bellicanta J, Doenças respiratórias como causa de internações hospitalares de pacientes do Sistema Unico de Saúde num serviço terciário de clínica médica na região nordeste do Rio Grande do Sul. J Pneumol 2001; 27(4):193–198. PubMed PMID: 339742.

 Google Scholar

Laniado-Laborin R, Rendon A, Bauerle O. High copd prevalence in mexico: A prevalence study. CHEST Journal. 2009;136(4_MeetingAbstracts):90S–S.

 Google Scholar

Lopez Varela MV, Muino A, Perez Padilla R, Treatment of chronic obstructive pulmonary disease in 5 Latin American Cities: The PLATINO study. [Spanish]. Arch Bronconeumol 2008 Feb; 44(2):58–64. PubMed PMID: 2008233735.

 PubMed Web of Science ®Google Scholar

Martínez-Gutiérrez MS, Vanegas L J, Reveco U S, Estudio piloto: costos directos atribuibles al tabaquismo en dos hospitales de Santiago. Rev méd Chile 2008; 136(10):1281–1287. PubMed PMID: 503895.

 PubMedGoogle Scholar

Menezes A, Macedo SC, Gigante DP, Prevalence and risk factors for chronic obstructive pulmonary disease according to symptoms and spirometry. COPD 2004; 1(2):173–179. PubMed PMID: 17136985.

 PubMedGoogle Scholar

Menezes AMB, Perez-Padilla R, Jardim JRB, Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): A prevalence study. Lancet 2005 Nov 26;366(9500):1875–1881. PubMed PMID: 2005536833.

 PubMed Web of Science ®Google Scholar

Miravitlles M, Jardim JR, Zitto T, [Pharmacoeconomic study of antibiotic therapy for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease in Latin America]. Arch Bronconeumol 2003 Dec; 39(12):549–553. PubMed PMID: 14636491.

 PubMed Web of Science ®Google Scholar

Miravitlles M, Murio C, Tirado-Conde G, Geographic differences in clinical characteristics and management of COPD: The EPOCA study. Inter J COPD 2008; 3(4):803–814. PubMed PMID: 2009077581.

 Google Scholar

Montes de Oca M, Talamo C, Halbert RJ, Frequency of self-reported COPD exacerbation and airflow obstruction in five latin American cities: The Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study. Chest 2009; 136(1):71–78. PubMed PMID: 2009370476.

 PubMed Web of Science ®Google Scholar

Pérez N, Murillo R, Pinzón C, Costos de la atención médica del cáncer de pulmón, la EPOC y el IAM atribuibles al consumo de tabaco en Colombia (proyecto multicéntrico de la OPS). Rev Colomb Cancerol 2007; 11(4):241–249. PubMed PMID: 493088.

 Google Scholar

Ramirez-Venegas A, Sansores RH, Perez-Padilla R, Survival of patients with chronic obstructive pulmonary disease due to biomass smoke and tobacco. Am J Respir Crit Care Med 2006 Feb 15; 173(4):393–397. PubMed PMID: 16322646.

 PubMed Web of Science ®Google Scholar

Reynales-Shigematsu LM, Juarez-Marquez SA, Valdes-Salgado R. Costs of medical care attributable to tobacco consumption at the Mexican Institute of Social Security (IMSS), Morelos. [Spanish]. Salud Publica de Mexico 2005 Nov; 47(6):451–457. PubMed PMID: 2006064805.

 PubMed Web of Science ®Google Scholar

Reynales-Shigematsu LM, Rodriguez-Bolanos Rde L, Jimenez JA, [Health care costs attributable to tobacco consumption on a national level in the Mexican Social Security Institute]. Salud Publica Mex 2006; 48 Suppl 1:S48–64. PubMed PMID: 17684689.

 PubMedGoogle Scholar

Rico-Méndez FG, Barquera S, Múgica-Hernández JJ, [Survival in a cohort of patients with chronic obstructive pulmonary disease: comparison between primary and tertiary levels of care]. Archivos de bronconeumología [Internet] 2005; (5):[260–266 pp.]. Available from: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/146/CN-00522146/frame.html.

 Google Scholar

Seemungal T, Harrinarine R, Rios M, Obstructive lung disease in acute medical patients. West Ind Med J 2008; (1):7–13. PubMed PMID: 19565931.

 PubMed Web of Science ®Google Scholar

Sivori M, Saenz CB, Posse CR. Mortalidad por asma y enfermedad pulmonar obstructiva crónica en Argentina en el periodo 1980–1998. Medicina (BAires) 2001; 61(5, pt.1):513–521. PubMed PMID: 299672.

 PubMedGoogle Scholar

Toyoshima MTK, Ito GM, Gouveia N. Morbidade por doencas respiratórias em pacientes hospitalizados em São Paulo/SP. Revista da Associação Médica Brasileira (1992) 2005; 51(4):209–213. PubMed PMID: 411208.

 PubMedGoogle Scholar