Epidemiology of bronchiectasis in the UK: Findings from the British lung foundation’s ‘Respiratory health of the nation’ project

Open ArchivePublished:September 17, 2019DOI:https://doi.org/10.1016/j.rmed.2019.09.012

      Highlights

      • The prevalence and incidence of bronchiectasis in the UK is increasing in line with global estimates.
      • Prevalence is higher in less-deprived subjects.
      • Mortality is rising with a 3% annual increase in mortality between 2001 and 7.

      Abstract

      Key findings of this national survey of non-cystic fibrosis bronchiectasis epidemiology were that its prevalence, incidence and mortality have all increased over recent years; we estimate that around 212,000 people are currently living with bronchiectasis in the UK, very much higher than commonly quoted figures. Bronchiectasis is more common in females than males; 60% of diagnoses are made in the over-70 age group. Regional differences in prevalence, incidence, mortality, and hospital admission were identified. An intriguing finding was that bronchiectasis is more commonly diagnosed in the least deprived sections of the population, in contrast to other respiratory disorders.

      Keywords

      1. Introduction

      As part of its 30th anniversary activities the British Lung Foundation commissioned a survey of the epidemiology of respiratory disease in the UK covering the period 2004–2012/13 [
      ]. Findings pertaining to non-cystic fibrosis bronchiectasis are presented here.

      2. Methods

      Prevalence and incidence rates were estimated from The Health Improvement Network (THIN) records for 2004–13; this general practice database represents ~ 5% of the population and is based on physician diagnoses as recorded in electronic primary care medical records. The data were scaled up using population estimates to produce estimated total figures for the UK population. Whole population numbers were produced by calculating the sum of the expected numbers in each region, broken down by age and sex, estimated by multiplying the relevant rate by the Office for National Statistics population estimates for each subgroup in each year; region-specific estimates are standardised against the full registered THIN population in each year. 95% Confidence Intervals (CIs) for unstandardized rates were estimated as for simple proportions; CIs for standardised estimates were obtained using the Tiwari modified gamma method [
      • Tiwari R.C.
      • Clegg L.X.
      • Zou Z.
      Efficient interval estimation for age-adjusted cancer rates.
      ]. The Townsend deprivation index (assigned at full postcode level) was used to estimate the impact of social deprivation on prevalence and incidence. Mortality data were obtained from the Office for National Statistics for England and Wales, the General Register Office for Scotland and the Northern Ireland Statistics and Research Agency. Age-standardised mortality ratios by region were calculated separately for males and females over the five-year period 2008–2013. The WHO Europe Hospital Morbidity Database was used to analyse total hospital admissions. Regional variations in hospital admissions were produced by looking at age-standardised emergency hospital admissions ratios; the sources for these were the relevant government agencies for England, Scotland, Wales and Northern Ireland. Our findings were compared with previously published data.

      3. Results

      For full tabulated data see the Supplementary File (online only). An estimated 211,598 (C.I. 207,135–216,019) people in the UK were living with bronchiectasis in 2012. From 2008 to 2012 prevalence increased by 20%, with the number of people estimated to be living with bronchiectasis going up by ~40,000. In 2012, 379 (370–387) females and 281 (273–289) males per 100,000 had bronchiectasis.
      More women than men had the condition throughout the years 2004–12; around 35% more women than men are diagnosed with bronchiectasis each year. Approximately 60% of bronchiectasis diagnoses are made in people aged over 70.
      A higher proportion of people have bronchiectasis in the West Midlands than elsewhere in the UK, and a lower proportion in the South East of England. This was seen throughout the years 2004–12.
      Intriguingly, and in contrast to other lung diseases, figures for 2004–12 show that the chances of being diagnosed with bronchiectasis are lowest in the most deprived sections of the population and increase with reducing deprivation.
      In recent years, there has been an increase in the rate of first diagnoses of bronchiectasis in primary care. 33 (31–35) people per 100,000 were newly diagnosed in 2012, up from 20 (19–22) per 100,000 in 2004.
      In 2012, 1567 people in the UK were recorded as dying from bronchiectasis (0.3% of all deaths and 1.4% of deaths from lung disease), up from 1150 in 2008. 123 were aged 15–64 and 1444 were aged 65 and above; no deaths from bronchiectasis were recorded in the age range >28 days–14yrs. In 2012, of the 1567 people who died from bronchiectasis, 661 were males and 906 were females. There were higher mortality rates in the North East, the North West, the East Midlands, the West Midlands and the South East of England than in the UK generally. There were notably lower death rates in the East of England, London and the South West than in the UK generally. The death rate in Scotland was slightly lower, and in Northern Ireland slightly higher, than for the UK as a whole.
      During the period 2008–12 there were 32,365 admissions to UK hospitals for bronchiectasis (12,539 males and 19,826 females). There were higher rates of emergency admission in Northern Ireland, and in the North East, North West, Yorkshire and the Humber, and East Midlands regions of England than in the UK as a whole. Admission rates were notably lower in the South East and South West of England, and in Scotland and Wales, compared with the UK generally.

      4. Discussion

      Our estimate of 211,598 people in the UK living with bronchiectasis is very considerably higher than official estimates; the UK National Health Service states that around 5 in every 1000 adults in the UK have the condition’ []. Given a UK adult population of approximately 52 million [], this would give a prevalence of ~50,000. The difference is not accounted for by inclusion of children in our figures, as there were only an estimated 4638 subjects <18yr. Other research published recently broadly agrees with our findings, and suggests that bronchiectasis prevalence in the UK could even be in excess of 300,000 [
      • Quint J.
      • Millett E.
      • Joshi M.
      • et al.
      Changes in the incidence, prevalence and mortality of bronchiectasis in the UK from 2004 to 2013: a population-based cohort study.
      ]. More research is required to confirm the number of people living with the condition, and to determine whether bronchiectasis is becoming more common, or being diagnosed more accurately (or both); as a general comment, the quality of diagnosis and the extent of misdiagnosis in surveys like this are unknown.
      Truly assessing incidence and prevalence at a population level is complex given the current disease definition requires both clinical symptoms and imaging (high resolution computerised tomography) changes [
      • Quint J.K.
      • Smith M.P.
      Paediatric and adult bronchiectasis: diagnosis, disease burden and prognosis.
      ]. However, globally there has been a shift, with bronchiectasis in children under 5 and those over 75 at increased risk of disease in particular [
      • King P.T.
      The pathophysiology of bronchiectasis.
      ]. In addition, there appears to be a steady increasing prevalence [
      • Seitz A.E.
      • Olivier K.N.
      • Adjemian J.
      • Holland S.M.
      • Prevots D.R.
      Trends in bronchiectasis among medicare beneficiaries in the United States, 2000 to 2007.
      ,
      • Ringshausen F.C.
      • de Roux A.
      • Diel R.
      • Hohmann D.
      • Welte T.
      • Rademacher J.
      Bronchiectasis in Germany: a population‐based estimation of disease prevalence.
      ,
      • Monteagudo M.
      • Rodriguez‐Blanco T.
      • Barrecheguren M.
      • Simonet P.
      • Miravitlles M.
      Prevalence and incidence of bronchiectasis in Catalonia, Spain: a population‐based study.
      ]. A recent worldwide review suggested that increasing incidence and prevalence might be largely associated with a globally ageing population [
      • Chandrasekaran R.
      • Mac Aogáin M.
      • Chalmers J.
      • et al.
      Geographic variation in the aetiology, epidemiology and microbiology of bronchiectasis.
      ].
      The reasons for prevalence of the condition being more frequent in less-deprived subjects could include better access to diagnostic services in this group, more deprived people being labelled as having COPD rather than bronchiectasis, and higher mortality among the most deprived. However, most information on bronchiectasis comes from registry studies, from which the patient population may be more severe or not as generalisable as those captured from using routine data. This may also be the reason for the inverse association seen with socioeconomic status and bronchiectasis incidence.
      Our finding that mortality from the disease is increasing is in line with the findings of Roberts and Hubbard of a 3% annual increase in mortality between 2001 and 7 [
      • Roberts H.
      • Hubbard R.
      Trends in bronchiectasis mortality in England and Wales.
      ]. Prognosis is disease severity and co‐morbidity dependent and in a tertiary referral centre in the UK, male gender, age, respiratory function and Pseudomonas aeruginosa were all found to be independently associated with mortality [
      • Loebinger M.R.
      • Wells A.U.
      • Hansell D.M.
      • et al.
      Mortality in bronchiectasis: a long term study assessing the factors influencing survival.
      ].

      5. Conclusions

      Bronchiectasis represents a considerably larger than appreciated, and increasing burden on UK health services [
      • Navaratnam V.
      • Millett E.
      • Hurst J.
      • et al.
      The increasing secondary care burden of bronchiectasis in England.
      ].

      Contributors

      NJCS and JQ contributed to the conception and design of the article. JG contributed to the analysis of the data. All authors contributed to the interpretation of data and drafting of the manuscript, and gave approval for this version to be submitted for publication.

      Funding

      The Respiratory Health of the Nation project was funded by the British Lung Foundation .

      Conflicts of interest

      JQ's research group has received funding from The Health Foundation, MRC, Wellcome Trust, BLF, GSK, Insmed, AstraZeneca, Bayer, Chiesi, IQVIA and Boehringer Ingelheim for other projects, none of which relate to this work. JQ has received funds from AstraZeneca, GSK, Chiesi, Bayer, Teva and Boehringer Ingelheim for Advisory Board participation or travel. NS, IJ, and JG have no competing interests to declare.

      Patient consent and ethics approval

      Not required. The use of THIN data for the original Respiratory Health of the Nation project was approved by the THIN Scientific Review Committee.

      Acknowledgments

      We are grateful to Professor David Strachan, St George's Hospital, London UK, who led the team working on the ‘Respiratory Health of the Nation’ project; to him and to Professor Richard Hubbard (University of Nottingham, UK) for their comments on the draft manuscript; and to Michael Laffan (British Lung Foundation, UK) for his work on the project and the presentation of the data.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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