PublicHealthStrategic

Frameworkfor
COPDPrevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Adult and Community Health
Suggested Citation:CentersforDiseaseControlandPrevention.PublicHealthStrategicFramework
forCOPDPrevention.Atlanta,GA:CentersforDiseaseControlandPrevention;2011.
Availableatwww.cdc.gov/copd
Disclaimer: Tefndingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarily
representtheofcialpositionoftheCentersforDiseaseControlandPrevention.
Introduction
Inthespringof2010,theCentersforDiseaseControlandPrevention(CDC)andseveral
partnersembarkedonanintensiveprocesstoexaminethecurrentstateofknowledge
regardingchronicobstructivepulmonarydisease(COPD)prevention.Teprocessincluded
identifyingpublichealthgapsandgeneratingasetofgoalsthatwoulddefnetheuniquerole
andcontributionsofpublichealthinthepreventionandcontrolofCOPD.Tisworkgroup
representedotherfederalagencies,academia,thehealthcaresector,nationalorganizations,and
otherCOPDstakeholders.Tepurposeofthisreportistoprovideaframeworkthatcouldbe
usedbythepublichealthcommunitytoaddressCOPDasanimportantpublichealthissue.
Background
Approximately,12millionAmericanshavebeendiagnosedwithCOPD,butatleastanother
12millionAmericansmaybeundiagnosed(1).COPDreferstoagroupofchronicdiseases,
includingemphysemaandchronicbronchitis,thatimpairthefowofairinthelungsandmake
breathingdifcult.WhileCOPDdeathratesarehigheramongmenthanwomen,overthe
past20years,thenumberofCOPDdeathsamongU.S.womenhasincreasedmuchfasterthan
thoseamongmen(13).COPDdeathratesarealsohigheramongwhitesthanamongAfrican
Americansorpersonsofotherraces(13),andinsomestates,includingIdahoandIndiana
(3).Inaddition,womenhadmoreCOPDhospitalizationsthanmenandmoreemergency
departmentvisits(1,2,4).
Prevention
Approximately75%ofCOPDcasesareattributedtocigarettesmoking(5).Occupation-related
exposuresmayaccountforanother15%ofCOPDcases(6)andgeneticfactors,asthma,
respiratoryinfections,andindoorandoutdoorexposurestoairpollutantsalsoplayarole
(6,7).Tus,COPDlargelycanbeprevented.PreventionofCOPDbeginswithreducingand/
oreliminatingsmokinginitiationamongteenagersandyoungadultsandencouragingtobacco
cessationamongcurrentsmokers.Morethan20millionworkersintheUnitedStateshavebeen
exposedtogases,vapors,fumes,andduststhatmaycauseCOPD(6).Publichealthprograms
andpoliciesthatfocusontobacco-usepreventionandcessation,reducingoccupational
exposuretodustsandchemicals,andreducingotherindoorandoutdoorairpollutantsare
criticallyimportant.Earlytreatmentandcontrolofasthmamayalsopreventthedevelopment
ofCOPD.
1

Diagnosis
CommonsymptomsofCOPDincludeshortnessofbreath,cough,phlegm,andwheezing.As
manyasone-halfofallpersonswithsymptomsofCOPDhavenotbeendiagnosedbecause
thesesignsareofenattributedtoagingornormalsmokerssymptoms.Adefnitivediagnosis
ofCOPDinvolvesmeasuringlungfunctionusingspirometry,whichisanoninvasiveoutpatient
procedure.
Treatment
OnceCOPDhasbeendiagnosed,goalsoftreatmentandmanagementincluderelieving
symptoms;preventingandtreatingdiseaseprogression,complications,andexacerbations;
improvingexercisetolerance,dailyactivity,andhealthstatus;monitoringnutritionalneeds;
andreducingprematuremortality(8).Managementshouldincludesmokingcessationand
abstinence;limitingexposuretosecondhandsmoke,dusts,fumes,andgases;pharmacological
treatmentwithbronchodilatorsandcorticosteroids;supplementaloxygentherapy;pulmonary
rehabilitation;collaborativeself-management;andsurgery(8).Clearly,efortstowardpatient
andprofessionaleducationshouldcontinuetofocusonpromotingtreatmentmodalitiesfor
personswithCOPDaswellaspersonsatriskforCOPD.
PublicHealthGoals
Teworkgroupidentifedfourgoalsthatweregroundedinthefollowingpublichealthareas:
(1)surveillanceandevaluation:improvecollection,analysis,dissemination,andreportingof
COPD-relatedpublichealthdata;(2)publichealthresearchandpreventionstrategies:improve
understandingofCOPDdevelopment,prevention,andtreatment;(3)programsandpolicies:
increaseefectivecollaborationamongstakeholderswithCOPD-relatedinterests;and(4)
communication:heightenawarenessofCOPDamongabroadspectrumofstakeholdersand
decisionmakers(Table1).Toaccomplishthesegoals,theworkgroupproposedthefollowing
objectives,strategies,andactionsbasedonadetailed,scientifcrationale.
2

Goal1:SurveillanceandEvaluation
Improvecollection,analysis,dissemination,andreportingofCOPD-relatedpublichealthdata.
Objectives
Adaptandexpandcurrentnationalpopulation-basedsurveillancesystemssuchasthe
BehavioralRiskFactorSurveillanceSystem(BRFSS,state-based,self-reporteddata),
NationalHealthandNutritionExaminationSurvey(NHANES,nationaldatacollection
involvingacombinationofinterviews,spirometry,andphysicalexaminations),andthe
NationalHealthInterviewSurvey(NHIS,national,self-reporteddata)toincludemore
COPD-relatedinformation.
Adaptandexpandcurrentnationalhealthcaresurveillancesystems(healthcaresystem-
basedsurveys)toincludeCOPD-relatedinformation.
AnalyzeandreportCOPD-relevantdatafromthesesurveys.
Rationale
OngoingdatacollectionisrequiredtoassessthenationsprogresstowardHealthyPeople
2020COPDobjectiveswhichincludes:(1)Reduceactivitylimitationsamongadultswith
chronicobstructivepulmonarydisease(COPD);(2)Reducedeathsfromchronicobstructive
pulmonarydisease(COPD)amongadults;(3)Reducehospitalizationsforchronicobstructive
pulmonarydisease(COPD);and(4)(Developmental)Increasetheproportionofadultswith
abnormallungfunctionwhoseunderlyingobstructivediseasehasbeendiagnosed.Current
population-basedsurveysalreadycapturesomeinformationrelatedtoCOPDsuchassmoking
prevalence,medicalcareutilization,andprevalenceofchronichealthconditions.However,
COPD-relatedtopicscouldbeanalyzedmoreextensivelyincurrentsurveillancesystemsand
newquestionscouldbeaddedtoexistingsurveys.Duetothedesignsandperiodicrevisions
ofthesesurveys,adaptingoraddingnewquestionsrelatedtoCOPDtoexistingsurveyswould
bemoretime-andcost-efcientthancreatingnewsurveillancesystemsspecifcallyfocusedon
COPD.
3


Strategy 1: Maximize use of currently available data.
Potential actions include:
AnalyzingcurrentlyavailabledatarelevanttoCOPDinexistingsurveys(BRFSS,
NHANES,NHIS,etc.);
PublishinghighprofleCDCreportsonCOPD-relatedtopics;
Developingacomprehensivereportofinformation(e.g.,surveillancesummary)across
surveysregardingCOPDevery4years;
PresentinginformationoncurrentCOPD-relatedNHANESsurveydataaddressing
occupationalriskfactors.
Strategy 2: Develop and initiate new data collection within existing surveys.
Potential actions include:
AddingnewquestionsrelatedtoCOPDtoexistingsurveys;
Developingandtestingnewquestionsforreliabilityandvalidity,asneeded;
RefningthedefnitionofCOPDinexistingsurveillancesystemsbyaddingthe
termsCOPDandchronicobstructivepulmonarydiseasetothecurrentlyused
emphysemaandchronicbronchitisterms;
Addingnewquestionsonoccupationalandenvironmentalexposures;
Includingnewqueriesongeneticsandfamilyhistory;
Insertingnewquestionsrelatedtoasthma;
Promotingcollaborationsbetweenfederalagenciestodevelopandimplement
standardizedCOPD-relatedquestions.
4

Strategy 3: Improve the ability of federal agencies to collect, analyze, and report
health care data from electronic health records (EHR).
Potential actions include:
Supporting the development of uniform EHR defnitions of COPD;
Supporting collection of clinical measures and risk factors for COPD including
occupation, family history, genetics, and smoking as part of EHRs;
Developing templates for collection of clinical data;
Developing standard COPD-related measurements (i.e., as determined by theNational
Committee for Quality Assurances Healthcare Effectiveness Data and Information Set
and the National Quality Forum) in EHRs for the Centers for Medicare & Medicaid
Services, Health Resources and Services Administration, Department of Veterans
Affairs, and the U.S. Department of Defense;
Developing partnerships with health care delivery systems for pilot projects using
EHRs to collect COPD information (including large city, small town, and rural patient
populations);
Developing standards for accessing spirometry data through EHRs;
Developing a standard format for reporting of spirometry results;
Developing and testing quality-of-care measures, including spirometry, to confrm
COPD diagnosis.
Strategy 4: Encourage the involvement of the appropriate organizations in the
development of surveillance case defnitions for COPD and to initiate COPD
surveillance.
Potential actions include:
DevelopingaconsensusstatementwiththeCouncilofStateandTerritorial
Epidemiologistsonsurveillancecasedefnitions;
Developingsurveillancetemplatesforpartnerorganizations.
5
Goal2:PublicHealthResearchandPreventionStrategies
ImproveunderstandingofCOPDdevelopment,prevention,andtreatment.
Objective
Supportandconductepidemiologicandappliedpreventionresearchthatexploresrisk
factors,prevention,andtreatmentofCOPD.
Rationale
COPD,althoughpreventableandtreatable,isnotcurrentlycurable.Tus,theprimary
preventionofCOPDremainsacriticalactionforpublichealth.NewinvestigationsintoCOPD
riskfactorscouldexploreoccupationalhazards,environmentalexposures,genetics,family
history,andco-morbidconditionssuchasasthma.Investigationofpropertrainingandclinical
useofspirometryandevidence-basedtreatmentmodalitiesisalsowarranted.
Strategy 1: Conduct assessment of COPD environmental risk factors in addition
to smoking and occupational exposures.
Potential actions include:
Conductingepidemiologicinvestigationstotrackpossibleenvironmentalcausesand
riskfactors;
DevelopingformalpartnershipswiththeEnvironmentalProtectionAgencyandother
institutionstopromoteresearchonambientairpollutionasaCOPDriskfactor;
PublishinganalysisforriskfactorsofCOPD.
6
Strategy 2: Assess current health care practices, including the proper use of
spirometry, regarding the diagnosis and treatment of COPD and COPDs
relationship to asthma and other co-morbid conditions such as cardiovascular
disease, stroke, depression, musculoskeletal disease, osteoporosis, and diabetes.
Potential actions include:
AnalyzingandpublishingCOPD-relatedhealthcarepracticeandtreatmentdatafrom
nationalhealthcaresurveysandotheravailabledatasets;
IdentifyinginformationgapsintheareasofthediagnosisandtreatmentofCOPD.
Strategy 3: Identify specifc public health research needs for COPD prevention.
Potential actions include:
Conveningabroad-basedworkinggroupofkeystakeholderstoidentifyprevention
researchneedsandprioritiesandtopublishareport;
Collaboratingwithpublicandprivatesectorhealthcarepartnerstoencouragenew
preventionresearchactivities.
7
Goal3:ProgramsandPolicies
IncreaseefectivecollaborationamongstakeholderswithCOPD-relatedinterests.
Objective
Increaseprevention-andpolicy-relatedcollaborationamongpartnerorganizations
interestedinCOPD-relatedconcernssuchastobacco,asthma,andoccupationalhealth.
Rationale
Extensiveprogramsforthepublic,healthcareprofessionals,andprovidersystemsalready
existtopreventandtreattheconsequencesoftobaccouse.However,tobaccocontrolprograms
maynotbeawareofthelateststatisticsandtreatmentsforspecifctobacco-relatedillnesses,
includingCOPD.Inturn,COPDstakeholders,practitioners,anddecisionmakersmaynot
beawareofcurrentpublichealthefortsintobaccocontrol.Terearealsoextensivenetworks
ofhealthcareprofessionals,stakeholders,andotherconstituentsforco-morbiddiseases
andconditionsofCOPDsuchasasthma,heartdisease,stroke,anddiabetes.Manystates
haveconductedstateCOPDsummitsandformedCOPDcoalitions,andeitherhaveorare
developingstateCOPDactionplans.
Strategy 1: Enhance the collaboration between tobacco control programs and
COPD-related programs at national, state, and local levels.
Potential actions include:
EncouragingtobaccocontrolandCOPDpartnersinteractionstoaddressprogrammatic
andpolicyissuesrelatedtobothsmokingandCOPD;
IdentifyingthenumberofstatesthathaveCOPDactionplans;
Increasingthenumberofstatesthathaveactionplansandprovidingconnectionstostate
tobaccocontrolplans;
SupportingcollaborationbetweenstatetobaccocontrolandCOPDprogramstodevelop
bestpracticesandbuildtemplatesforCOPDactionplans,includingimplementation
strategies;
EstablishingregularstatetobaccocontrolandCOPDliaisonactivities;
Conductingmeetingsamongappropriatepartnerstoexploreopportunitiesfor
complementaryactivitiesbetweentobaccocontrolandCOPDprograms;
IdentifyingaCOPDcontactforeachstatehealthdepartment;
IdentifyingspeakersonrelevantCOPDtopicsfortobacco-relatedconferencesatthe
8

nationalandstatelevel;likewise,identifyingspeakersonrelevanttobaccotopicsfor
COPDconferences.
Strategy 2: Develop a national COPD action plan.
Potential actions include:
Analyzing existing state COPD action plans to identify best practices;
Convening a meeting of a broad group of stakeholders to develop a national action plan;
Preparing and circulating the draft action plan to relevant agencies and partners;
Publishing and initiating the fnal action plan;
Supporting areport on COPD from the Task Force on Community Preventive Services.
Strategy 3: Support workplace programs and policies that reduce the risk of
COPD.
Potential actions include:
Supportingthedevelopmentofworkplacepoliciesregardingtopicssuchas
Indoorsmoke-freepolicy;
Campus(indoor/outdoor)smoke-freepolicy;
Insurancecoverageforevidenced-basedsmokingcessationtreatments;
Strongworkerprotectionandrespiratoryprotectionprograms,including
surveillance;
Workplaceindoorairqualityassurancepolicy;
Resourcesforhealthriskappraisalswithaccompanyingworkplacecoachingand
treatmentinterventions;
Resourcesforworkplacescreeningprogramsforat-riskworkersandfamilies;
Providingeducationandconsultationtoemployersinvarioustypesofworkplace
locations.
9
Goal4:Communication
HeightenawarenessofCOPDinthefollowinggroups:peoplewithCOPDandtheirfamilies,
peoplewithCOPDriskfactors,healthprofessionals(especiallyprimarycareproviders),
providersystems,media,decisionmakers,policymakers,andthepublic.
Objective
ImproveawarenessofthewarningsignsforCOPD,theriskfactorsforCOPD,andthe
factthatCOPDispreventableandtreatable.
Rationale
AwarenessofCOPDprevention,treatmentoptions,andtheseriousnessofitsconsequences
remainslowamongmostAmericans.
Strategy 1: Collaborate with appropriate partners to develop educational
resources for people with COPD, people with COPD risk factors, families,
health professionals (especially primary care providers), provider systems,
media, decision makers, policy makers, and the public.
Potential actions include:
Identifyingandconductingmeetingswithappropriatepartnerstodevelopandpromote
targetededucationalapproachesfortheaudienceslistedintheCommunicationgoal;
Identifyingandevaluatingexistingprograms;
Preparingandpilottestingeducationalapproachesindiferentaudiences;
Initiatingeducationactivities;
Evaluatingeducationactivitiesusingbothprocessandoutcomemeasures;
Expandingpartnershipstoincludeadditionaladvocatessuchaswomensgroups,seniors,
unions,andfaith-basedorganizations;
Developingaphasedplantocollaboratewithpartnersonaddressingthekeyaudiences.
10
Strategy 2: Collaborate with professional health organizations to communicate
current standards of diagnosis, including spirometry use, and treatment options
for COPD.
Potential actions include:
Assessingcurrenteducationalactivitiesandinitiativesusingevidence-basedstandards;
Collaboratingwithpublichealthandhealthprofessionpartnerstodevelopcontinuing
educationandtrainingactivitiesforprofessionalaudiences,especiallyprimarycare
providers.
Conclusion
TefourgoalsoutlinedinthisCOPDpublichealthactionplanshouldhelpwiththeongoing
andfuturedevelopmentofhealthinitiativestopreventandcontrolCOPD.Additionally,the
frameworkwillincreasetheawarenessofCOPDasanimportantpublichealthissue.
11

References
1. AmericanLungAssociation.TrendsinCOPD(emphysemaandchronicbronchitis):
morbidityandmortality.February2010.[cited2010Dec30].Availableathttp://www.
lungusa.org/fnding-cures/our-research/trend-reports/copd-trend-report.pdf.
2. CentersforDiseaseControlandPrevention.Chronicobstructivepulmonarydisease
surveillanceUnitedStates,19712000.MMWR2002;51(SS-6):116.
3. CentersforDiseaseControlandPrevention.Deathsfromchronicobstructivepulmonary
diseaseUnitedStates,20002005.MMWR2008;57(45):12291232.
4. BrownDW,CrofJB,GreenlundKJ,GilesWH.Trendsinhospitalizationwithchronic
obstructivepulmonarydiseaseUnitedStates,19902005.COPD2010;7(1):5962.
5. CentersforDiseaseControlandPrevention.Smoking-attributablemortality,yearsof
potentiallifelostandproductivitylossesUnitedStates,20002004.MMWR2008;
57(45):12261228.
6. AmericanToracicSociety.AmericanToracicSocietystatement:occupational
contributiontotheburdenofairwaydisease.AmJRespirCritCareMed2003;167:787
797.[cited2010Dec30].Availableathttp://www.cdc.gov/niosh/nas/RDRP/appendices/
chapter4/a4-50.pdf.
7. CentersforDiseaseControlandPrevention.Chronicobstructivepulmonarydisease
(COPD).[cited2010Dec30].Availableat:http://www.cdc.gov/copd/.
8. NationalHeart,Lung,andBloodInstitute.COPDLearnMoreBreatheBettercampaign.
[cited2010Dec30].Availableathttp://www.nhlbi.nih.gov/health/public/lung/copd/index.
htm.

12

Table 1. Primary Goals and Strategies for the Public Health Framework for
COPD Prevention
Goal 1: Surveillance and Evaluation
Improvecollection,analysis,dissemination,andreportingofCOPD-relateddata.
Strategy1
Maximizeuseofcurrentlyavailabledata.
Strategy2
Developandinitiatenewdatacollectionwithinexistingsurveys.
Strategy3 Improvetheabilityoffederalagenciestocollect,analyze,andreport
healthcaredatafromelectronichealthrecords.
Strategy4 Encouragetheappropriateorganizationstodevelopsurveillancecase
defnitionsforCODandtoinitiateCOPDsurveillance.
Goal 2: Public Health Research and Prevention Strategies
ImproveunderstandingofCOPDdevelopment,preventionandtreatment.
Strategy1 ConductassessmentofCOPDenvironmentalriskfactorsinadditionto
smokingandoccupationalexposures.
Strategy2 Assesscurrenthealthcarepracticesregardingthediagnosisand
treatmentofCOPDandCOPDsrelationshiptoasthmaandother
co-morbidconditionssuchascardiovasculardisease,stroke,depression,
musculoskeletaldisease,osteoporosis,anddiabetes.
Strategy3
IdentifyspecifcpublichealthresearchneedsforCOPDprevention.
Goal 3: Programs and Policies
IncreaseefectivecollaborationamongstakeholderswithCOPD-relatedinterests.
Strategy1 EnhancethecollaborationbetweentobaccocontrolprogramsandCOPD-
relatedprogramsatnational,state,andlocallevels.
Strategy2
DevelopanationalCOPDactionplan.
Strategy3
SupportworkplaceprogramsandpoliciesthatreducetheriskofCOPD.
Goal 4: Communication
HeightenawarenessofCOPDinthefollowinggroups:peoplewithCOPDandtheirfamilies,
peoplewithCOPDriskfactors,healthprofessionals(especiallyprimarycareproviders),
providersystems,media,decisionmakers,policymakers,andthepublic.
Strategy1 Collaboratewithappropriatepartnerstodevelopeducationalresources
forpeoplewithCOPD,peoplewithCOPDriskfactors,families,health
professionals,providersystems,media,decisionmakers,policymakers,
andthepublic.
Strategy2 Collaboratewithprofessionalhealthorganizationstocommunicate
currentstandardsofdiagnosis,includingspirometryuse,andtreatment
optionsforCOPD.
13

COPDWorkgroupMeetingParticipants
Paul Billings
AmericanLungAssociation
VicePresident,NationalPolicyandAdvocacy
Gary Ewart
AmericanToracicSociety
DirectorofGovernmentRelations
Winston Liao
NCDepartmentofHealthandHumanServices
Epidemiologist
DivisionofPublicHealth,AsthmaProgram
Ann Malarcher, PhD, MSPH
NationalCenterforChronicDiseasePreventionandHealthPromotion
SeniorScientifcAdvisor
OfceonSmokingandHealth
David Mannino, MD - COPD Workgroup Chair
UniversityofKentucky
ProfessorofMedicine
CollegeofPublicHealth
DepartmentofPreventiveMedicineandEnvironmentalHealth
Roy Pleasants II, PharmD
DukeUniversitySchoolofMedicine
AssociateProfessor,DivisionofPharmacyPractice
PulmonaryMedicine
Antonello Punturieri, MD, PhD
NationalHeart,Lung,andBloodInstitute
ProgramDirector
DivisionofLungDiseases
Eileen Storey, MD, MPH
NationalInstituteforOccupationalSafety&Health
ActingChief,SurveillanceBranch
DivisionofRespiratoryDiseaseStudies,CDC
John Walsh
Alpha-1Foundation
David Weissman, MD
NationalInstituteforOccupationalSafety&Health
Director
DivisionofRespiratoryDiseaseStudies,CDC
14

GalleryObservers
Centers for Disease Control and Prevention (CDC)
JanetCrof,PhD
GeraldineS.Perry,DrPH,RD
LetitiaPresley-Cantrell,PhD,MEd
StephanieL.Sturgis,MPH
National Institute for Occupational Safety & Health (NIOSH)
EvaHnizdo,PhD
CaseyChosewood,MD
Alpha-1 Foundation
MiriamODay
SeniorDirectorofPublicPolicy
Alpha-1Foundation
COPD Learn More Breathe Better Campaign
RosyMcGillan
PorterNovelliProjectManager
15

ExternalReviewers
David H. Au, MD MS
AssociateProfessor
PulmonaryandCriticalCareMedicine
UniversityofWashingtonandInvestigator
HealthServicesResearchandDevelopment
VAPugetSoundHealthCareSystem
A. Sonia Buist, MD, PhD
ProfessorofMedicine,Physiology&Pharmacology
PublicHealthandPreventiveMedicine
DivisionofPulmonaryandCriticalCareMedicine
OregonHealth&ScienceUniversity
David B. Coultas, MD
PhysicianinChief/ChairProf
DepartmentofMedicine
UniversityofTexasHealthScienceCenteratTyler
Jerry A. Krishnan, MD, PhD
AssociateProfessorofMedicineandHealthStudies
Director,AsthmaandCOPDCenter
Director,RefractoryObstructiveLungDisordersClinic
UniversityofChicagoMedicalCenter
Jonathan Samet, MD, MS
ProfessorandFloraL.TorntonChair
DepartmentofPreventiveMedicine
KeckSchoolofMedicine
Director,InstituteforGlobalHealth
UniversityofSouthernCalifornia
Byron Tomashow, MD
ClinicalProfessorofMedicine,DivisionofPulmonary,AllergyandCriticalCareMedicine
MedicalDirector,Jo-AnnF.LeBuhnCenter
BoardChairman,COPDFoundation
ColumbiaUniversity,CollegeofPhysiciansandSurgeons
Barbara P. Yawn, MD, MSc, FAAFP
DirectorofResearch,OlmstedMedicalCenter
AdjunctProfessor,FamilyandCommunityHealth
UniversityofMinnesota
16
CS220390