I draw attention to the fact that while committee members have absolute privilege, this privilege does not extend to witnesses. I welcome the delegation from the Irish Thoracic Society and invite its members to make their presentation.
Lung Disease and Related Illnesses: Presentation.
Dr. Neil Brennan
It is nice to be here to present this information to the joint committee. I cannot and will not try to go through all the details supplied in the document in 15 minutes but will provide some background information. I have put together some slides extracted from the document. Members may take notes if they wish. I will concentrate on the summary information rather than the details and point to areas where there are information gaps.
The impetus for the preparation of the document came from a similar document prepared by the British Thoracic Society. The Inhale document closely follows the British document entitled The Burden of Lung Disease. This was deliberate because in Ireland we make many comparisons with the UK system from which we often take our figures. In large parts of the document the data can be directly compared, if needs be. If one does this, even down to the point of costs, one will see there is not a great difference when one compares the cost per head of population in Ireland to that in the United Kingdom.
Four areas are covered in the document, the first of which is mortality. On the common causes of death in Ireland, the slide at the bottom of the first page indicates that respiratory disease accounts for 22% of deaths. Coronary artery disease accounts for a similar percentage. The figures are virtually identical. We regard lung cancer as a respiratory disease. All other cancers account for a figure very close to that for coronary artery disease and respiratory disease. In general, when health statistics are presented, cancer data are taken from the different systems and given separately. However, for someone practising respiratory medicine in a hospital, that is not how the disease presents. Respiratory disease, including lung cancer, presents to chest or general physicians. The investigation of lung cancer is in the domain of respiratory medicine. Nowadays lung cancer is and should be managed by way of a multidisclipinary approach. We are deeply involved in diagnosis. We then pass patients to a thoracic surgeon, medical or radiation oncologist.
The other area where respiratory physicians are often involved is palliation of particular problems such as pleural effusions or where there are more sophisticated modalities. Obviously, we are involved in palliative care. In the United Kingdom respiratory medicine is very much regarded as the team leader in the management of lung cancer. In this country, however, the overall cancer strategy has not tackled lung cancer in terms of organisation at national level. Given that lung cancer is the leading cause of death from cancer in the country, I find it extraordinary as a respiratory physician that it has not been dealt with systematically. There are approximately 7,000 deaths annually from respiratory disease in Ireland, of which nearly 40% are due to pneumonia; one quarter to COPD, chronic obstructive pulmonary disease, mainly cigarette smoking related chronic wheezy chests and emphysema, while respiratory cancers account for nearly one fifth. Apart from a small number of upper airways cancers, the vast bulk are lung cancers.
There has been no decline in mortality rates for respiratory disease, or general cancers, in Ireland in the last 30 years. The data are virtually constant. However, death rates for coronary artery disease have declined substantially in those years. Therefore, as a cause of death, respiratory disease is a static phenomenon in terms of frequency.
Page 2 of the document indicates one very important lung disease factor, namely, the social class differential. In the better-off social classes versus the poorer classes the mortality rates are striking. However, respiratory disease accounts for the biggest discrepancy. For example, in the case of COPD there is a 600% increase in prevalence among socio-economic groups four and five versus socio-economic group one. In the case of tuberculosis, which many might see as small fry in terms of frequency and mortality, its prevalence and mortality rates are excessively oriented towards the poorer social classes. In the case of asthma, noted in the document at a figure of 219% of the excess annual directly standardised mortality rate for the lowest versus the highest social class, the prevalence is slightly higher among the lower socio-economic groups but the social class differential is much less obvious in terms of morbidity as well as mortality.
The top line of the slide I am now showing shows death rates over approximately 20 to 30 years from respiratory disease in Ireland. The two lines closer together across the page are EU and European values. There are one or two points to mention. First, although death rates from lung disease have fallen in Ireland and elsewhere in Europe in the last 20 to 30 years, we consistently have a mortality rate nearly double the European average. We are now where other European countries were 30 years ago in mortality rates from lung disease.
The summary slide is at the bottom of page 3. In Ireland death rates from respiratory disease equal those for coronary artery disease and exceed those for non-respiratory cancer. Ireland has the highest death rate from respiratory disease in western Europe. It is over twice the EU average and nearly twice the European average. Only Kyrgyzstan, Kazakhstan and Turkmenistan have death rates from lung disease which exceed those of the Republic of Ireland. As the burden of heart disease declines, relatively speaking, respiratory disease is accounting for a greater proportion of mortality. It kills one in five. Lung cancer is the single biggest cancer killer in the country. It now kills four women for every five who die from breast cancer and that gap is narrowing. In some countries lung cancer now accounts for more deaths than breast cancer. The number of deaths from occupational lung disease, mainly mesothelioma, is rising. While the absolute numbers are small, it is an increasing problem. I have already referred to social inequality.
Let us move from mortality to morbidity. In Ireland data on the latter are difficult to come by. There are many gaps. The data we have are not as good as those in the UK document, for example. I have picked out a slide at the bottom of page 4. The data are taken from the quarterly national household survey. I am showing an extract from slide 2.2 in the main document. I have simplified it, since the main Inhale document has a great deal of data which are difficult to disentangle.
The age groups at which we are looking are the under-44s. They are young people. The total population in those age groups is given as approximately 500,000. Across the bottom we have the prevalence of long-term illness in thousands. In the 15-24 age group there are nearly 12,000 with chronic respiratory problems. The numbers fall a little going into the higher age groups. One must remember that, particularly in the 15-24 age group, the total number reporting long-term illness is 30,000, meaning that lung disease accounts for a very large proportion of the young people suffering from long-term illness.
The other interesting point is that, if one examines the data in the more detailed table, one sees that for virtually every other organ system, the prevalence of long-term illness in young people is very low. They rise, particularly when one gets into the 50-60 age group and higher, for example, for heart disease, diabetes, blood pressure, arthritis and so on. With lung disease, the burden is mainly on the younger age group. This means that we have a very large cohort of young people with respiratory disease who will carry it into later life.
If one looks at the data on duration of illness, one sees that, of the 41,000 who report long-term illness, over 12,000 describe their problem as having been present from birth. A further 10,000 describe it as having been present for over ten years. In that group of young people, over half have a disease process ongoing for more than ten years which they will carry for the rest of their lives. Much of it is accounted for by the epidemic of asthma in young people. The second part, showed at the top of page 5, is probably related to the relatively high levels of smoking in the young adult population. Comparative studies with Europe suggest that we do not do very well, particularly for young women. We have the dubious honour of being the only country in that EEC-funded study where the prevalence of smoking among young women exceeds that among young men. The other figure that is worrying is that in the under-44 age group 8% report symptoms of chronic bronchitis which suggests that they are already showing signs of accumulating significant lung damage.
On the cost of lung disease, for the year that I took, 1999, nearly 350,000 working days were lost through incapacity certified as due to lung disease. Obviously, that is an underestimate of the true prevalence since many do not claim benefits for short periods off work. The figure equates to approximately three years of all industrial disputes around that time. I know that it is also related to employment, unemployment and various other matters but it is useful as an index of volume. The other important point about certified incapacity is that the Irish data only show short-term incapacity. When one inquires of the Department of Social and Family Affairs about long-term incapacity, one finds that one cannot get data on why people are on long-term invalidity payments. The system does not record this information. Therefore, there is no way of knowing how many are on long-term incapacity or disability benefit payments in this country because of lung disease, or anything else for that matter.
The most commonly reported long-term illnesses among young people are respiratory system diseases. Lung cancer is the third most common cancer in both men and women. Survival rates for lung cancer are very low. Some 28% survive one year, 10% five years. Tuberculosis remains a significant problem but the incidence is continuing to fall slowly.
Let us turn to the top of page 7 which covers treatment and those availing of services. There are no published data in the public service on visits to general practitioners. The best estimate that I could come up with was that 15% of all GP consultations were due to respiratory disorders. I was corrected by Dr. Michael Boland from the Irish College of General Practitioners at a venue where I presented this figure. He said the figure should be at least 25%. The UK figure is closer to 15% to 20%. Therefore, we are arguing a little but it makes a difference to the costs that I assigned to general practice. The difference between 15% and 25% is significant.
On in-patient care, the data are much better. About 8.6% of all patients have a respiratory diagnosis while almost 10% of all hospital bed days are due to chronic respiratory disease.
At the top of page 8 there is a breakdown of the types of lung disease. When one takes pneumonia and pleurisy which are acute infections and chronic obstructive pulmonary disease, COPD, they account for virtually half of all respiratory admissions. Those figures are important. For example, for COPD there are strategies for early discharge and trying to avoid admissions to hospital given the beds crisis. There is a large number and great scope for transferring patients to a primary care setting as an alternative to how they are managed currently.
On prescriptions used for respiratory disease in general practice, there is a vast number. Over 3.5 million items are prescribed annually. The data are taken from marketing survey information that I received from GlaxoSmithKline. However, the GMS data do not allow one to break down the prescriptions by diagnosis, as I have done. For example, nearly 1 million items are prescribed for asthma each year and over 500,000 for COPD.
In terms of treatment, respiratory disease at 9.4% is the third most common illness responsible for acute admission to hospital, after GIT or gut disorders and circulatory system disorders, which would include coronary heart disease, strokes etc. Respiratory disease is the most common reason for visiting a general practitioner. Chronic obstructive lung disease and pneumonia account for 150,000 bed days a year and drug prescription rates for respiratory disease are among the highest for any organ system. The GMS payout for respiratory drugs is fourth in order of size. The important thing to remember about that figure is that in the GMS (Payments) Board data antibiotics are excluded from the costs for respiratory disease. These represent an important additional cost, obviously.
As regards global costs, on page ten, in terms of assigning costs the top figure in the slide is primary care, which is the general practitioner cost arrived at by consultation rate versus the total payout to GPs. This comes to almost €40 million in a year, which is probably an underestimate if we are talking about 25% versus 15% in terms of visitation rates. Prescribed medication amounts to €77.5 million. That is the GMS (Payments) Board figure for respiratory drugs. The hospital out-patient care figure of €8.1 million is from Deloitte & Touche. The hospital day care valuation€ at 2.2 million is again from Deloitte & Touche and day case numbers. Then there€is about 190 million for hospital in-patient care. Again, this figure is derived from Deloitte & Touche data. It may be seen that by far the largest amount in the pie diagram is accounted for by hospital in-patient care costs and the second largest by drug costs in general practice.
In terms of the global cost of respiratory disease the top item is €316 million, which is taken from the slide above. This is basically the public health service costs. We all know there is a substantial private medicine market in the country. The private health care costs of €72 million approximately has been obtained by courtesy of the Voluntary Health Insurance Board, based on all respiratory disease costs in the private hospitals - both hospital and consultant costs. It also includes the consultant costs for respiratory patients cared for in public hospitals, but not the hospital costs which are separate. It also includes data for over-the-counter costs, as estimated by the Irish Pharmaceutical Healthcare Association. That is almost €72 million.
I have put down €178.5 million for mortality costs. I am going to discuss that in somewhat more detail in the next page because there are important qualifications about that figure. Essentially, the €178.5 million is a conservative figure for mortality costs. The last figure, at €200 million, is for morbidity costs. That figure could virtually be accounted for by asthma alone. Asthma is the only condition for which there have been studies done to cost the economic burden in terms of morbidity costs, loss of employment and earnings etc. There are no really good equivalent data in the Republic of Ireland for COPD, lung cancer or anything like that. The figure of €200 million is extremely conservative. Even at that there is a €0.75 billion cost to the Irish economy for lung disease.
On page 11, briefly, the value of a "statistical life" is given. I am not an expert, but I had a long interaction with the department of economics in UCD about this. The value of a statistical life in much health data is costed on what is called the "human capital method", which basically is loss of earnings through time lost from work. However, the EU does not accept that this is a valid method, if one is doing cost-benefit analysis. In other words if one is trying to determine how much money should be invested for what return, then the methodology should be what is called the "willingness to pay" model. If the EU statistical value of a lost life is put at €1.4 million, then the mortality loss in terms of economic cost, for cost-benefit analysis purposes, should be €1.2 billion, that is €1,233 million. There is a philosophical consideration there about how the value of a statistical life is arrived at, in theory. The committee will appreciate, therefore, that given my figure of €178 million, I was not trying to gild the lily or overstate matters. If anything I have grossly understated the figures.
The willingness to pay model has been used in this country in only two areas. It was used as part of the submission from the economics department in UCD in computing the costs of smoking to the economy. The other area in which it was used in practice in this country was in the prevention of hypothermia in elderly people as regards the free fuel scheme.
To summarise the global costs, respiratory disease cost the Irish health service €317 million in 2001. The direct medical costs in total were approximately €390 million and the global cost is at least €0.75 billion and probably considerably more.
Professor Walter McNicholas
I thank the committee for allowing us to make a presentation. As may be seen, I am here as a member of the Irish Thoracic Society. I am also president of the European Respiratory Society. What I would like to do, as a supplement to Dr. Brennan's comments as regards the Irish situation, is to put that data in a European context. As has already been indicated, Ireland has a huge burden of lung disease, both in terms of mortality and morbidity. The European Respiratory Society published a document, The European Lung White Book, which is the first comprehensive survey of respiratory health in Europe. This book makes interesting reading because it highlights a number of facts and figures related to lung disease which are particularly applicable to Ireland. The book is almost unique in the sense that there is no equivalent publication for other chronic organ-related illnesses. As the committee will see from the summary book, the smaller publication, which gives the facts and figures contained in the larger book that members have, the foreword was written by the EU Commissioner for Health and Consumer Protection, Mr. David Byrne. This adds an Irish context to it.
Ireland has the highest death rate from lung disease and accounts for approximately 20% of all cause mortality in this respect. This makes lung disease in Ireland a more prevalent cause of death than heart disease. It is sobering to realise that when one asks a person in the street if he or she has a sense of shortness of breath and what that might relate to, most people are likely to reply, "There must be something wrong with my heart". It is perhaps more likely that symptoms such as that relate to lung disease, however. One of the statistics in the lung white book is that although lung disease represents the most prevalent form of illness in Europe and particularly in Ireland, the consultation rate among physicians in Ireland by patients related to lung disease is among the lowest in Europe.
Although Dr. Brennan said that the most common reason for visiting a GP is respiratory illness, when that is put in the context of the European experience, Ireland is towards the bottom end of the league. That points, almost certainly, to a lack of awareness among the general public of the importance of lung disease. This is one aspect that the European Respiratory Society is focusing on in terms of trying to promote public awareness of lung disease. There is a simple test called "spirometry", which involves blowing in and out of a small machine and this allows airways diseases such as asthma and chronic obstructive lung conditions including emphysema to be detected. This test is hardly every used, however, in general practice. It is relatively infrequently used as part of an assessment of a patient who comes along with a cough or shortness of breath.
The European Respiratory Society is making a major effort to promote the importance of simple tests, such as that to focus on lung diseases. In the Irish context, the statistics relating to mortality, morbidity and the lack of appreciation among the general public of the importance of lung disease give a very clear indication of the need for a health strategy for lung disease. The strategy should focus on awareness among the general public, as well as ensuring that appropriate health care resources are available for managing patients with lung disease. Clearly resources should be targeted primarily at the primary care sector, because patients with the early stage of lung disease can be identified. They can be moved on with appropriate resources to secondary and tertiary health care services.
The European Respiratory Society is very active at European Union level and established an office in Brussels, which has been in existence for the past 18 months, to focus specifically on political and public awareness of the importance of lung disease. It is very gratifying to see the results of such efforts and the growing appreciation of the importance of lung disease at European Union and Commission level, for example, in Brussels last November, the launch of the White Book on Lung Disease was hosted by several MEPs from different countries and Commissioner Byrne attended and spoke at it.
Recent EU documents on chronic illness focus on the economic and personal cost of disease, with increasing emphasis on respiratory disease and the White Book on Lung Disease is frequently cited as an important reference document. We have had some successes, the most notable success in Ireland is the workplace ban on smoking. As president of the European Respiratory Society, I am very much aware of the impact of measures such as this at European level. It is clear that the workplace smoking ban has been major news throughout Europe. A similar ban was introduced in Norway on 1 June 2004 and several European countries are now examining the feasibility of introducing a similar ban in their respective countries. The European Respiratory Society regards this as such an important development that the Minister for Health and Children, Deputy Martin has been invited to its annual congress in Glasgow to accept a special award from the society. The Minister has accepted the invitation to attend the annual congress of the society.
Dr. James Hayes
I thank my colleagues, Dr. Niall Brennan and Professor Walter McNicholas. To summarise, the Irish Thoracic Society believes the time is opportune to consider a strategy for dealing with respiratory disease. As Professor McNicholas alluded to, the workplace ban on smoking has been introduced with great success, and through the offices of Dr. Niall Brennan and the European Respiratory Society, we have excellent data to show the impact that respiratory conditions have on the health of the nation and its economy.
In conjunction with the planned restructuring of the health services, we wish to see a parallel strategy for respiratory medicine. We believe the strategy should begin from the bottom up, with a combination of public education, better screening at primary care level and rapid access to hospitals as appropriate. We believe that model has been very successfully applied to the cardiovascular strategy. In our view, the reason the cardiovascular strategy functions very well is that it focuses on primary rather secondary care in the detection and management of patients. We believe a parallel model could be developed for patients with respiratory diseases and we hope that it should be possible to do so in the not too distant future.
We thank the members of the committee for listening to the presentations which we hope will have an impact. We believe this is the best opportunity we have to lead the way in this area in Europe.
I thank those who made the presentations and hope they will address the following issues. Dr. Hayes suggests that a strategy to deal with respiratory diseases similar to the cardiovascular strategy should be developed. Has such an approach been discussed with the Department of Health and Children and what has been its response?
Is there a reason for the rate of increase in the presentation of asthma in Ireland? One would expect that today's young people would enjoy better health than previous generations. However, is there a reason for the increasing prevalence of asthma? The statistics are very revealing, but from my experience elderly people who are ill generally die from pneumonia and will Dr. Hayes put this in context?
We will bank the questions. Deputy Gormley is next.
I welcome the delegation and thank it for the presentation, which I found very interesting, on developing a strategy for the treatment and palliation of respiratory diseases. However, I would have liked to hear more on the root causes of these diseases. Smoking has been alluded to but we know there has been an increase in outdoor and indoor air pollution. A study was conducted in Switzerland a number of years ago which showed that three times as many people die from the effects of air pollution from cars as die in car accidents. This is something fundamental. I have studied and campaigned on the air pollution in Dublin, on the emissions of PM10s, PM2.5s, volatile organic compounds and benzene, all of which are carcinogenic. One may argue the case, and I note that Dr. Hayes looks doubtful about what I am saying, but I would like to hear his comment on the matter.
There are root causes for the increase. If we are to develop a strategy, will we talk about these factors? When we mention the increase in asthma relating to indoor air pollution, one of the factors is that our houses are well insulated so we have less ventilation. Would it be part of a strategy to advise people to ventilate their houses better?
I believe it was Professor McNicholas who spoke about spirometry. I do not think that it is often used, although I have gone to a doctor that has used it. How is lung cancer prevented through diagnosis? By the time diagnosis occurs, it seems to be far too late from the figures given. Once one has it, one is basically a gonner. What would the professor recommend people to do to get an early diagnosis that perhaps might stop it in its tracks? Could I have the witnesses' comments on the situation at Peamount Hospital? I would like to hear their views because Dr. Luke Clancy, who has been a long time campaigner on air pollution in the city, believes that Peamount should remain the centre for dealing with TB.
I want to comment on the value of statistical life. Economics is truly a dismal science, although one can get different views. I remember when we spoke about air pollution in Dublin, there were various analyses done. At the time people felt that it cost a lot of money. On the other hand the coal industry produced a booklet telling us that people were not dying from air pollution in the city, but rather hypothermia as they were not using enough coal. I also remember an economist stating that air pollution was a culling exercise as it killed people at an earlier age so that they would not use up all the resources of our hospitals later on. In the view of the witnesses, is it a fact that unless we deal with this, we will use up huge resources in the future? Let us go back to the root causes and see how we can deal with this in its tracks.
I must declare an interest in view of Deputy Gormley's question on Peamount Hospital. I am on the board of the hospital and Dr. Clancy has taken the board to court and received a financial settlement. I thank the witnesses for their comprehensive presentations, although they were depressing. I draw no comfort from the fact that we are ahead of Turkmenistan regarding respiratory disease. There are a few things that we can do in public policy which might be important.
It is important that we know why people are on long-term benefit because respiratory diseases are very important in that. I was taken by Dr. Brennan's comment on preventing hypothermia in the elderly. We do not think often enough about that when we talk about public policy on the elderly. Professor McNicholas spoke about trying to get awareness about respiratory disease. Spirometry is very simple as the professor pointed out. Perhaps general practitioners could be encouraged to include that when taking people's blood pressure and so forth. These are not major changes that might in fact be of some help.
The smoking rates for young people are very worrying. I remember the first time that the incidence of lung cancer exceeded the death rate of breast cancer. It was in Tower Hamlets and Dr. Wendy Savage produced those figures about ten years ago. To see it elsewhere is very worrying. One can only hope that the smoking ban helps with this. The witnesses also mentioned young people with chronic chest disease. Is our high incidence of cystic fibrosis important? When I was practising medicine, everyone with cystic fibrosis died before the age of 12 or 13. Now people have it in their twenties. Is that important in our high rate? Like everyone else I share the concern about the rise in asthma, but no one has an answer to that. I am sure that ventilation and air pollution is important.
There is a shortage of respiratory physicians in the country. Is there also a shortage of oncologists to work with you? Is this a factor in the disappointing treatment for lung cancer in the country?
Dr. Hayes
There are many in-depth questions that may require detailed answers. In the first instance, we are in discussions with the Department of Health and Children but we are in the exploratory phase. We are hoping that we will be able to start the process rolling and meet the Minister and the Secretary General of the Department. We hope that we can count on the support of the committee in developing the strategy.
The whole area surrounding environmental lung disease is difficult to disentangle from the different data and the quality of the data that appears. One has to be very careful about what the researchers are trying to do, what are the questions they ask and how do they answer them. There are a number of studies that have shown an increased death rate from all causes, both respiratory and cardiovascular, from high levels of air pollution. There have been a number of studies in North America and Europe that have shown this. The change from the high particulate air pollution to the low particulate, especially regarding sulphur dioxide, seems to have had a permissive effect in the development of asthma. In other words, we have moved from the 1950s pea-soup London type problems of recurring chest infections and bronchitis, to a superficially cleaner environment. However, in terms of the particulate matter, there are equal amounts of it but at a smaller particle size which allows for the particle to get further into the lung. Some people feel that this has a permissive effect. The current thinking on this does not suggest a causal relationship, but merely an aggravating relationship. There is conflicting data on this depending on whether one looks at sensitisation and asthma. Developing an allergic response to something does not necessarily mean one will contract asthma. According to laboratory data, there seems to be permissive effect on ozone, nitrates and sulphur dioxide in becoming sensitised to a specific allergen. We do not seem to be able to make a complete jump to saying that there is an absolute causal relationship between environmental air pollution and the cause of asthma.
There is a relationship between indoor air pollution, which refers to volatile organic chemicals and house dust-mites or even cockroaches in North America. There is also data which suggests that allergen levels are important in terms of whether or not a family susceptible to allergies will develop asthma. As in all matters, there is also conflicting data. Some believe that if a family susceptible to allergies has a cat, instead of getting rid of it they should get a second cat. In this way, their immune systems may be overloaded thereby reducing the amount of asthma within the family. It is a controversial theory. Dr. Thomas Platts-Mill, a North American doctor spearheading research in this area, has produced data which suggests this course of action. This sort of desensitisation approach is popular in North America but not so much in this part of the world.
There is also the "dirt" theory, which is somewhat similar. Data from the UK suggests that if children are exposed to a significant number of respiratory tract infections during early childhood it may result in a lesser number of people with chronic asthma. This theory has not been proven. It has been demonstrated in epidemiological studies but not proven to be of great significance in clinical practice. Epidemiological studies comprise observational data in that one collects a range of data and attempts to make sense of it. This is different from experimental data where one intervenes and observes any outcome. Studies have been carried out on the effect of lactobacillus on susceptible families. In some cases, lactobacillus reduced the rate of eczema. However it did not reduce the rate of asthma.
These are fascinating areas of study. One of the greatest contradictions is that in the UK, which probably has the best data, the highest prevalence of asthma is in Norfolk which has clean country air and less traffic. There is a constant interplay between genetics, environment, allergens, and critical periods of exposure which are important. There is a whole range of factors. Studies continue to show that encouraging mothers of families susceptible to allergies to breast-feed leads to a reduction in early childhood years of wheeze and asthma. Certain respiratory tract infections are more likely to result in a wheezy child who may develop asthmatic symptoms for a number of years. These symptoms may not continue into adulthood, but they cause many problems in terms of school absences.
Prevention is a significant problem. We should all strive for clean environments within our home, workplace and outdoors. That should be a general principle. None of us would have a problem with that.
On the matter of cystic fibrosis, it is genetic. The incidence rate in Ireland is one in 1,800. We seem to have a high carry rate for the recessive gene which causes the condition. That is unlucky. Our incidence rate is high, probably the highest in Europe. Improved facilities for looking after patients with cystic fibrosis means that someone born today with the condition should live for 40 to 45 years. This increase in life expectancy will result in an increased burden because patients with cystic fibrosis require multidisciplinary treatment, especially in terms of respiratory help. The number of patients with cystic fibrosis will increase significantly over the next generation.
We believe there is a problem regarding the number of respiratory physicians and oncologists. Patients with acute respiratory disease should not be admitted to a hospital which does not have a respiratory physician. There are well documented protocols for treating patients with respiratory disease. There is data which suggests, in terms of morbidity and mortality, that it is worthwhile seeing a respiratory physician if one has a respiratory disease.
The situation regarding oncologists is probably not as well-developed as it should be. The strategy to deal with cancer has resulted in a number of appointments of oncologists around the country. However, this strategy is in the early developmental stages. We are all aware of the issues concerning cancer strategy development with regard to radiation, oncology and other matters. We are not discussing these today. However they are part and parcel of the development of oncology services within Ireland. Patients with lung cancer will need to see medical oncologists as well as radiation oncologists to a much greater extent. Ireland has one of the lowest access rates to radiation oncology for lung cancer patients in Europe. It is shameful. The access rate varies somewhat from area to area in that the further one is from a local centre the more difficult it is to access the service. As regards lung cancer, one of the reasons we have such a poor mortality rate is that most lung cancer patients present at stage 3b, the inoperable stage. A figure of 9% five-year survival was listed in the last national cancer strategy. This means only 9% of patients who present with lung cancer will be alive in five years' time. That compares to a figure of 70% for breast cancer. The data differs greatly. The figure is approximately 50% for bowel or colon cancer. In North America, the figure for lung cancer is 15% to 16% five-year survival and 86% for breast cancer. In terms of respiratory disease mortality rates Ireland is at the point where Europe was in 1970. In terms of cancer we are also where North America was in 1970. Dr. Brennan may have more answers and he may also wish to comment on issues within his area.
Dr. Brennan
Deputy Neville asked about pneumonia as a common cause of death. Pneumonia is often put on death certificates. One could get into a discussion about what is written on death certificates. Not everybody has an autopsy. There is a certain leeway regarding the cause of death included in certificates. Pneumonia will always be a relatively common cause of death. I take the Deputy's point that we all must die. The mortality figures are the tip of the iceberg. I am also concerned about the large morbidity figures relating to respiratory infections. The mortality rate is skewed towards the elderly population and people with co-existing disorders. However, if one takes pneumonia and respiratory tract infections as a diagnosis the data shows large numbers of children are admitted to paediatric hospitals with pneumonia. In terms of morbidity, pneumonia is a big issue. It has a significant mortality rate of up to 20%. Many lay people would think such a figure very serious and it is. However, the important issue is to prevent avoidable mortality. Leaving aside cases where people also have a severe or terminal disease, pneumonia should be treatable and curable. I understand the philosophy behind that assertion.
Deputy Gormley mentioned root causes and cigarette smoking. Cigarette smoking is a major cause. However we have already alluded to cystic fibrosis which has genetic factors. There are probably genetic factors in asthma also. Obesity is another common problem that is in the news at the moment.
Straying slightly into Dr. McNicholas's territory, this document does not mention sleep apnoea because there are no official statistics on it. I got most of my data from statutory bodies. Sleep apnoea is part of respiratory medicine and has significant mortality rates. It causes road accident deaths and is obesity related. There are other things besides smoking. There are genetic factors and obesity. Air pollution has already been discussed and it is a factor.
There are enormous problems associated with lung cancer and its early diagnosis. There are international groups within the respiratory fraternity exploring the possibility of screening systems and CT screening. There is a certain amount of controversy about whether it will reduce mortality or early diagnosis will make people appear to live longer. In future considerable advances will be made in selecting high risk populations for screening.
Another influencing factor will be the increasing effectiveness of chemotherapy regimes, particularly for non-small cell lung cancer. If we have better chemotherapy modalities then the benefit of more active screening programmes will become more important. It is a mobile area and over the next decade it will undergo significant change.
The national cancer register produced data on lung cancer and its treatment. There were concerns about the low referral for chemotherapy, low surgical rates and that almost 50% of sufferers were not offered specific treatments. The data reflects the fact that in many areas of the country there are few, if any, respiratory physicians and limited or difficult access to oncology. I have already mentioned this. I come from Cork and we have all of the modalities to treat lung cancer in the city but I would have serious reservations about how they are organised. A co-ordinated multidisciplinary approach to lung cancer is needed. This has been driven in the UK. A study was conducted in the UK several years ago which had a major political fallout when it showed major discrepancies in geographical areas between operation and treatment rates. We have the same problem here. We need a strategy and leadership to make everyone act together. The public must be made aware that a lung cancer sufferer can avail of a range of treatment options. We also need more respiratory physicians and oncologists.
Professor McNicholas
My colleagues have replied to most of the questions. I shall make some broad comments. Deputy Neville's challenge is legitimate in the sense that we must all die of something. In reality we are here concerned with premature mortality. There is no doubt that people die young from chronic lung disease. When a person dies at 70 years from pneumonia he or she probably had underlying chronic lung disease. If the latter had been picked up in their 40s and 50s it could have been treated and the pneumonia might never have developed. Equally, as Dr. Brennan indicated, dying at the age of 70 from a treatable condition such an pneumonia is entirely inappropriate. Yes, we must die at some stage but we are focusing on premature mortality here.
My presentation stressed the importance of the early detection of chronic lung disease. Early detection should form the central focus of a lung strategy in terms of public awareness, etc. A detection strategy can contribute substantially to the overall health level of the Irish community. It has quality of life, public health and major economic implications. I have already indicated in my presentation that the most common reason for absence at work due to acute ill health is respiratory disease. The most common cause of absences from work due to sickness is chronic obstructive lung disease. It can be detected early but, unfortunately, it is not due to a lack of awareness and resources. Simple measures could make a huge difference.
Lung cancer figures are extremely bleak. American data clearly indicate that the early detection of lung cancer increases survival rates. We do not have early detection systems for lung cancer here. Smokers should seek medical help if they have a cough that will not go away. I am not talking about a smoker's morning cough. A chest X-ray is another detection measure. These are very simple measures.
Greater awareness is also needed. Once the disease is suspected there should be rapid access to diagnostic modalities. There should also be rapid access to the specific diagnosis through a test called bronchoscopy. It is absolutely frustrating for a doctor trying to fasttrack a patient with an abnormal chest X-ray into the diagnostic system. It is very difficult to get treatment for these patients given the lack of resources in our acute hospitals. A lung health strategy could make a major contribution.
I welcome members of the delegation and thank them for a frank and informative presentation. I want to mention two issues that, to our shame as politicians, we have allowed develop. Of the approximately 7,158 deaths from lung disease, 1,943 or 26%, were the result of COPD in 1999. I am worried that there is a 605% increase in the prevalence of COPD in the lowest socio-economic groups versus the highest socio-economic group. That the problem has not been addressed is a huge reflection on us and the medical system. Every day we see people living with these conditions but something can be done. Cigarette smoking has caused 90% of these cases.
Members of the delegation have indicated that simple measures are required. Will an extra tariff on cigarettes ensure that the people in the lowest socio-economic groups cannot afford them? We have spent so much time, energy and finance on road traffic safety. More than five times the number of people killed on our roads have died from cigarette smoking. Is enough being done? Can the delegation suggest measures to curb cigarette smoking? I am amazed at the different mortality rates for the lowest and highest social classes. As politicians we should be ashamed that we have allowed this discrepancy to develop.
Like my colleagues I thank the delegation for its informative presentation. My two teenage daughters smoke and the delegation has frightened the daylight out of me. The statistics for Kurdistan and so on is no consolation - I will go home terrified.
Now that Britain is thinking of imposing a smoking ban, I would say the iron is hot. It is an opportune moment for your society to get stuck in. I know your talks are just at the embryo stage but they will be developed. Perhaps our committee can keep a watching brief on this matter and push it as much as possible. The figures we have been given this morning are a shame and there is no great public awareness of how dangerous and common are lung diseases.
I have two questions for Professor McNicholas. Would he X-ray teenage smokers who have a persistent cough? Dr. Hayes said there will be an increase in the number of children presenting with CF in the future. I am trying to put this question in a non-political way. Would he see the use of stem cell research having a role in preventing an increase in the disease? Given the little I know about the disease, it appears to be heartbreaking for the parents, the children themselves and the wider families of children with CF. It is shocking to think there could be an increase in the disease. I am heartened to hear that one's lifespan could now reach into the forties because I thought it was in the late twenties. I am 44 years of age and I would be terrified to think I might die today. It is very young for one's life to end at the age of 44.
I thank the delegation for it's presentation. On the question of prevention, what can be done to deal with what was so eloquently addressed in the presentation? To get back to the ancient "baddie", tuberculosis, it is just about 60 years since this country was rife with tuberculosis and entire communities and families were wiped out. Long-stay institutions were riddled with the disease. As someone who worked in a long-stay institution for a number of years, I was disappointed to find that in the last few years - I have left the profession for approximately seven years - there were occasional incidents of tuberculosis. I was always very concerned and tried to find out the reason for the return of the disease.
It is also true to say that there is a significant increase in tuberculosis in African countries. Are we doing enough in the area of prevention and is sufficient screening being carried out? Should we go back to the old days when the X-ray unit called to schools and people were X-rayed? Senator Feeney's concern is legitimate. One member of my family smokes. Dr. Fintan Howell of ASH told this committee recently that addiction to heroin is not as great as addiction to nicotine. This has been proved in the case of well known personalities throughout the world, some of whom are no longer with us. I wonder why.
We talk about housewives who must vacuum carpets each day. There is a view, whether it is correct or otherwise, that carpets are not as healthy as wooden floors. There is a significant decrease in the number of houses using carpet covering. I do not know why, but it is the case. Are practising farmers sufficiently aware of the health risks involved in working in the hay shed, whether moving bales of straw or whatever? Are farmers aware that if they do not take proper precautions they could develop farmer's lung? There is a practice in some countries, including Canada, whereby roads are sprayed in dry conditions to keep down the dust. This country is not famous for dry conditions, nevertheless, in the past six or eight weeks, there have been such conditions. Is this a consideration?
Plumbers may develop pulmonary fibrosis. I regret to say that a member of my family, who was a plumber in Canada, was diagnosed with the condition idiopathic pulmonary fibrosis, which means it is not known what caused it. What precautions should members of that trade take when carrying out their duties? We could go on and on.
Is enough known about prevention? I have covered a few examples. Everyone has responsibility for their own health. They also have a responsibility and obligations towards others, which is why the smoking ban is so welcome. This is an enforced responsibility on smokers to take account of those who do not smoke. I regret to say this must be the case.
Bovine tuberculosis has been around for a long time. Has enough been done to eradicate it?
Have any studies been carried out on the respiratory health of the nation due to the introduction of smokeless fuel? I am old enough to remember the pea soup fogs in London. Is there a place for the return of mass X-rays? It was abolished some years ago because we were told TB was a thing of the past. We all know it is coming back, albeit in the older generation rather than the younger generation. Is the sleep apnoea syndrome an under-diagnosed problem in Ireland?
Dr. Hayes
We have another few matters to address and we will try to deal with as many as possible. A number of members asked about smoking and prevention. There is data to indicate that if cigarettes are more expensive, people will buy fewer of them and smoke less. However, members will be aware of cigarette smuggling, therefore, if the price goes above a certain threshold it will encourage smuggling. There is a threshold beyond which it would probably not make much difference. The biggest factor is probably parental smoking. I believe that if parents smoke it is much more likely their children will smoke.
Our main focus in this area is on education, both in primary and secondary schools. What Dr. Fintan Howell said at an previous committee meeting is correct. Once youngsters get beyond the age of 18 to 20 years, the chance of them taking up significant cigarette smoking is low. This is seen in the manner in which many cigarette companies pitch their advertising, or in how they have done so in the past in an effort to get youngsters to start smoking at 13 or 14 years of age. The pitch is similar in Third World countries. If we can get children through secondary school without them taking up smoking, the chance is small that they will take it up thereafter. We see that as the main factor.
The smoking cessation programmes that started on the back of the cardiovascular strategy have been relatively successful, although probably not as co-ordinated as they should be. They work and should also be available to a greater degree within the primary care sector. Although the data on their effect has been somewhat negative, I believe that the severity of many of the current lung conditions, albeit that they are directly related to cigarette smoking, is related to the total number of cigarettes smoked in the person's lifetime - a simplistic approach to a complex issue. Therefore, stopping smoking for five years is useful. It is useful for one year if a person smokes 20 to 40 cigarettes a day. If people fall off the non-smoking regime once or twice, this does not mean they cannot get back on to it, no more than with any addiction.
Somebody asked about a "watching brief". We would be grateful if the committee could keep a watching brief and for any support it can give us in developing our strategy. We would be happy to return again if the committee felt this would be useful.
On the issues of cystic fibrosis and stem cell research, the current data suggests we have genotype and can, if we have the search facilities, know the genes that occur in cystic fibrosis. Groups in France can pick up approximately 99% of all genetic factors that might be important in cystic fibrosis. We do not see stem cell research as particularly useful at present with regard to correcting the abnormality because it is a specific conducting problem which occurs in a specific part of the cell. There may be other ways to deal with this. Unfortunately, some of the work worth looking at, that of instilling the gene into the person with cystic fibrosis, was unsuccessful. Work is continuing in the area and that may well be the way forward.
The number of children with cystic fibrosis may not necessarily be on the increase. I alluded to the fact that the number of children who will survive into adulthood has increased. Therefore, the burden, for want of a better word, on the health services will be greater as those people attend the centres where they are looked after.
In the area of pulmonary tuberculosis, specific instances have arisen in other countries of multi-drug resistant TB. Most TB is catered for as an outpatient service by the consultant respiratory physician, as appropriate. I believe there has been a fall off in contact tracing. Even though our instance of TB is small, it is approximately twice that in Northern Ireland despite a similar backdrop in terms of risk, etc. The only differences we can see for the fall off are the funding available and the organisational skills available for the administration of contact tracing. We should have a national strategy on the management of TB and contact tracing should be incorporated into it. We need more facilities in terms of directly observed therapies for those patients who are not good at complying with their medication and for checking patients who do not attend clinics. This will be part of a strategy we will outline today.
The issue of the house dust mite is controversial. I alluded previously to the role of an allergen in asthma and the difficulty in getting rid of it. Some data suggest that thresholds of allergen exist above which a high-risk family should not go. However, it is difficult for this to be measured because the house dust mite resides not only in the carpet but also on the curtains and soft furnishings. People who are into allergen avoidance must be quite obsessive about it in the sense that they will have to work hard to rid their house of the house dust mite.
The issue of occupational lung disease, which would probably include farmers and plumbers, involves general dust control. Enough is not being done about occupational lung disease here. Vast improvements have taken place on the back of EU regulations. Other parts of the world have more developed services in occupational health. The problem here is that occupational health, as in other countries, tends to be available for larger companies such as the Civil Service, the ESB, Bank of Ireland, etc. However, many of our workers work in smaller industries, for example farmers, paint sprayers etc, and often do not have enough information on the chemicals they use and the problems they can cause if not handled in the proper manner. This is my personal view on what is a specific interest of mine. The biggest problem for farmers is no longer farmer's lung because most farmers have switched from hay to silage. Farmer's lung is not currently a major problem although other organic compounds can cause equivalent diseases in other industries and we see the odd patient with farmer's lung. That type of disease has other causes and probably the area is not well enough controlled.
People need to take more control over dust in general. Dust in any form, organic or inorganic, is associated with a slight reduction in lung function over time. Many studies have shown this and that its effect is increased if it is added to cigarette smoking or to other chemical agents in the workplace. It may be simplistic to say that it just wears out the lungs a little more, but that is probably the easiest way to look at it.
Most countries have eradicated bovine TB, but we still have areas where it occurs and come across sporadic cases of human bovine TB. I discussed this with a colleague who returned from North America who has expertise in the area of TB and he says that he would never see some of the cases I see here. More needs to be done to eradicate bovine TB. We do not need to reintroduce mass X-rays to detect TB or early lung cancer as the incidence of TB is not high enough to require that and it would not be as effective as before. For lung cancer, plain chest X-ray screening, in the absence of symptoms, has not been shown to be of great value.
Smokeless fuel data is available and Professor Clancy followed up the changes that have occurred in hospital admissions in Dublin since the changeover to smokeless fuel. There is no doubt that it has made a significant difference to hospital admissions for patients with COPD, chest infections and pneumonia. I will not say anything about sleep apnoea.
Professor McNicholas
I will respond to the specific questions addressed to me. Senator Feeney asked about a teenager with a cough and whether that person should have a chest X-ray. Any person with a persistent unexplained cough should be investigated. One of the sad features of medicine as it is practised in many areas is that people who come in with a cough are given an antibiotic and if the cough does not go away, they are given another. Unfortunately, this is one of the reasons serious lung problems develop which if they had been assessed earlier, might have been corrected. In a teenage smoker who develops a persistent cough, asthma is probably the number one possibility.
Consideration should be given as to why the person has the cough. It is probably not simply because the person is smoking. This is one of the difficulties we face which is why I have been stressing the importance of an awareness campaign in an overall strategy to try and deal with these issues.
Senator Feeney asked about sleep apnoea. This is an area in which I have a particular interest. I am director of the national referral centre for this disorder in St. Vincent's Hospital. It is a disorder with a prevalence of approximately 4% of the adult male population and 2% of the adult female population, yet the resources available in this country to diagnose and treat the condition are quite rudimentary. That is a great shame because research exists which shows very clearly that patients with untreated sleep apnoea are anywhere up to ten times more likely to have a road traffic accident due to being sleepy. Statistics compiled in the UK show that somewhere between 20% and 25% of all serious motorway accidents on the M1 are related to sleepiness. It is a highly prevalent disorder which in prevalence league tables is second only to asthma, yet the facilities in this country would be rudimentary in comparison to any other western European country. For example, our waiting lists in St. Vincent's are running in excess of two years. This is in a situation where people with this condition are at risk of having a driving accident because of sleepiness yet they must wait two years to have the condition assessed and treated. It is an appalling vista.
Equally, there are very clear statistics which show that sleep apnoea is a major contributing factor to cardiovascular disease. Up to half our patients with sleep apnoea have high blood pressure. We have done studies and have submitted a paper for publication in one of the American journals comparing the long-term outcome of patients with sleep apnoea successfully treated to those who have not been treated. The death rate from cardiovascular disease among untreated sleep apnoea patients is eight times higher than those who are treated. The answer to the Senator's question is "Yes". We have inadequate resources and there is an inadequate appreciation of this disorder in Ireland. This issue should be addressed urgently.
Dr. Brennan
Professor McNicholas knows that Dr. Bredin, who works in Cork University Hospital, and I, who works in the Mercy Hospital, have been trying to set up a sleep service in Cork and have one of sorts. There are significant problems with resources and major problems recruiting technicians to staff a laboratory. Part of the reason why an overall strategy is required is that if one raises awareness of issues such as occupational workplace asthma and sleep apnoea with an information campaign, then the resources must be in place to be able to deal with what is identified. An overall approach is required to tackle this issue and to put all the pieces together to make it work.
Professor McNicholas
At an earlier stage I used to be happy to accept invitations from the media to talk about sleep apnoea. I have become much less happy to do so for the simple reason that for weeks afterwards, the telephone in my office hops with people phoning in saying they think their husband or wife has this condition and asking for an appointment. This is in a situation with waiting lists of two years and then the telephone starts hopping and it is difficult to know what to do. Unfortunately I have now reached the stage where I have become very reluctant to accept invitations to do a newspaper or other media-related interviews.
I thank Dr. Hayes, Dr. Brennan and Professor McNicholas for their excellent presentation. I will take up Senator Feeney's suggestion that the committee hold a watching brief on developments. I can safely say we will be inviting you back in the near future.
The joint committee adjourned at 11.25 a.m. sine die.