Mortality Among Persons With Both Asthma and Chronic Obstructive Pulmonary Disease Aged ≥25 Years, by Industry and Occupation

United States, 1999-2016

Katelynn E. Dodd, MPH; John Wood, MS; Jacek M. Mazurek, MD, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(22):670-679. 

In This Article

Abstract and Introduction

Introduction

Patients with asthma typically have chronic airway inflammation, variable airflow limitation, and intermittent respiratory symptoms; patients with chronic obstructive pulmonary disease (COPD) often have fixed airflow limitation and persistent respiratory symptoms. Some patients exhibit features suggesting that they have both conditions, which is termed asthma-COPD overlap. These patients have been reported to have worse health outcomes than do those with asthma or COPD alone.[1] To describe mortality among persons aged ≥25 years with asthma-COPD overlap, CDC analyzed 1999–2016 National Vital Statistics multiple-cause-of-death mortality data* extracted from the National Occupational Mortality System (NOMS), which included industry and occupation information collected from 26 states§ for the years 1999, 2003, 2004, and 2007–2014. Age-adjusted death rates per one million persons and proportionate mortality ratios (PMRs)** were calculated. During 1999–2016, 6,738 male decedents (age-adjusted rate per million = 4.30) and 12,028 female decedents (5.59) had both asthma and COPD assigned on their death certificate as the underlying or contributing cause of death. The annual age-adjusted death rate per million among decedents with asthma-COPD overlap declined from 6.70 in 1999 to 3.01 in 2016 (p<0.05) for men and from 7.71 in 1999 to 4.01 in 2016 (p<0.05) for women. Among adults aged 25–64 years, asthma-COPD overlap PMRs, by industry, were significantly elevated among nonpaid workers, nonworkers, and persons working at home for both men (1.72) and women (1.40) and among male food, beverage, and tobacco products workers (2.64). By occupation, asthma-COPD overlap PMRs were significantly elevated among both men (1.98) and women (1.79) who were unemployed, had never worked, or were disabled workers and among women bartenders (3.28) and homemakers (1.34). The association between asthma-COPD overlap mortality and nonworking status among adults aged 25–64 years suggests that asthma-COPD overlap might be associated with substantial morbidity. Increased risk for asthma-COPD overlap mortality among adults in certain industries and occupations suggests targets for public health interventions (e.g., elimination of or removal from exposures, engineering controls, and workplace smoke-free policies) to prevent asthma and COPD in and out of the workplace.

For this report, 1999–2016 National Vital Statistics System's multiple-cause-of-death data extracted from NOMS were analyzed. Decedents with asthma-COPD overlap were identified using the International Classification of Diseases, Tenth Revision codes from death certificates for which both asthma and COPD†† were listed as the underlying or contributing cause of death. Death rates per million persons aged ≥25 years were assessed by sex and year and were age-adjusted using the 2000 U.S. Census standard population. Time trends in log-transformed age-adjusted mortality rates were assessed in Joinpoint software§§ by performing a sequence of permutation tests using Monte Carlo sampling and the Bonferroni correction for multiple testing. Information on industry and occupation, coded by the National Institute for Occupational Safety and Health using the U.S. Census 2000 Industry and Occupation Classification System, was available from 26 states for the years 1999, 2003, 2004, and 2007–2014.¶¶ PMRs, relative to the expected number of decedents with asthma-COPD overlap, and 95% confidence intervals (CIs) were generated by industry and occupation for men and women and adjusted for 5-year age groups and race. Joinpoint (version 4.7.0.0; National Cancer Institute) and SAS software (version 9.4; SAS Institute) were used to conduct all statistical analyses.

During 1999–2016, among U.S. decedents aged ≥25 years, a total of 4,689,828 had COPD and 164,731 had asthma assigned on their death certificate as the underlying or contributing cause of death. Among these decedents, 18,766 had both asthma and COPD assigned as the underlying or contributing cause of death (6,738 among men and 12,028 among women). The overall death rate among those with asthma-COPD overlap was 5.03 per million persons (4.30 among men and 5.59 among women). The annual age-adjusted death rate per million for men declined from 6.70 in 1999 to 3.01 in 2016 (annual percent change [APC] = –4.82%; p<0.05) and for women declined from 7.71 in 1999 to 4.01 in 2016 (APC = –3.63%; p<0.05) (Figure).

Figure.

Number of asthma and chronic obstructive pulmonary disease (COPD) overlap deaths* and age-adjusted asthma-COPD overlap death rates among decedents aged ≥25 years, by sex — United States, 1999–2016
*Decedents with International Classification of Diseases, Tenth Revision codes for asthma: J45.0 (predominantly allergic asthma), J45.1 (nonallergic asthma), J45.8 (mixed asthma), J45.9 (asthma, unspecified), J46 (status asthmaticus); and COPD: J40 (bronchitis, not specified as acute or chronic), J41.0 (simple chronic bronchitis), J41.1 (mucopurulent chronic bronchitis), J41.8 (mixed simple and mucopurulent chronic bronchitis), J42 (unspecified chronic bronchitis), J43.0 (MacLeod's syndrome), J43.1 (panlobular emphysema), J43.2 (centrilobular emphysema), J43.8 (other emphysema), J43.9 (emphysema, unspecified), J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection), J44.1 (chronic obstructive pulmonary disease with acute exacerbation, unspecified), J44.8 (other specified chronic obstructive pulmonary disease), J44.9 (chronic obstructive pulmonary disease, unspecified) assigned as the underlying cause of death (i.e., the disease or injury which initiated the chain of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury) or as a contributing cause of death.
Age-adjusted death rates per million persons were calculated by applying age-specific death rates to the 2000 U.S. Census standard population age distribution. https://wonder.cdc.gov/wonder/help/mcd.html#Age-AdjustedRates.

Among persons aged 25–64 years in 26 states during 1999, 2003, 2004, and 2007–2014, industry and occupation data were available for 784 (99.1%) of 791 decedents with asthma-COPD overlap (314 [99.4%] of 316 men and 470 [98.9%] of 475 women). By industry, asthma-COPD overlap PMRs were significantly elevated among nonpaid workers, nonworkers, and persons working at home for both men (1.72) and women (1.40) and among male food, beverage, and tobacco products workers (2.64) (Table 1). By occupation, asthma-COPD overlap PMRs were significantly elevated among men (1.98) and women (1.79) who were unemployed, never worked, or were disabled workers and among women bartenders (3.28) and homemakers (1.34) (Table 2).

Among persons aged ≥65 years, industry and occupation data were available for 1,908 (98.3%) of 1,941 decedents with asthma-COPD overlap (624 [99.5%] of 627 men and 1,284 [97.7%] of 1,314 women). Asthma-COPD overlap PMRs were significantly elevated among men in certain industries (e.g., computer and electronic products [2.58]; lumber, wood products, and furniture [2.53]; agriculture, forestry, fishing and hunting [1.82]; beverage manufacturing [3.15]; and miscellaneous manufacturing [1.39)] and among women in private households (1.69), furniture and home furnishings stores (2.99), and unspecified food industries (3.72) (Table 1). By occupation, asthma-COPD overlap PMRs were significantly elevated among men in fishing, hunting, and forestry (3.78); farmers and farm managers (1.62); laborers and material movers (1.54); carpenters (1.68); and industrial production managers (2.23) and among women production workers (1.66) and waitresses (1.70) (Table 2).

*https://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm.
Guidelines for reporting industry and occupation on death certificates instruct recorders to report decedent's "kind of business/industry" and "usual occupation" (i.e., "the type of job the individual was engaged in for most of his or her working life").
§Colorado, Florida, Georgia, Hawaii, Idaho, Indiana, Kansas, Kentucky, Louisiana, Michigan, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, and Wisconsin. States represent the state where the death took place, not necessarily where the decedent had resided.
Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. Census standard population age distribution. https://wonder.cdc.gov/wonder/help/mcd.html#Age-AdjustedRates.
**PMR was defined as the observed number of deaths from asthma-COPD overlap in a specified industry or occupation, divided by the expected number of deaths from asthma-COPD overlap. The expected number of deaths was the total number of deaths in industry or occupation of interest multiplied by a proportion defined as the number of asthma-COPD overlap deaths in all industries or occupations, divided by the total number of deaths in all industries or occupations. The asthma-COPD overlap PMRs were internally adjusted by 5-year age groups, sex, and race. CIs were calculated assuming Poisson distribution of the data. A PMR >1.0 indicates that there were more deaths associated with the condition in a specified occupation or industry than expected; a PMR <1.0 indicates that there were fewer deaths associated with the condition in a specified occupation or industry than expected.
†† International Classification of Diseases, Tenth Revision codes for asthma: J45.0 (predominantly allergic asthma), J45.1 (nonallergic asthma), J45.8 (mixed asthma), J45.9 (asthma, unspecified), J46 (status asthmaticus); and COPD: J40 (bronchitis, not specified as acute or chronic), J41.0 (simple chronic bronchitis), J41.1 (mucopurulent chronic bronchitis), J41.8 (mixed simple and mucopurulent chronic bronchitis), J42 (unspecified chronic bronchitis), J43.0 (MacLeod's syndrome), J43.1 (panlobular emphysema), J43.2 (centrilobular emphysema), J43.8 (other emphysema), J43.9 (emphysema, unspecified), J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection), J44.1 (chronic obstructive pulmonary disease with acute exacerbation, unspecified), J44.8 (other specified chronic obstructive pulmonary disease), J44.9 (chronic obstructive pulmonary disease, unspecified).
§§ https://surveillance.cancer.gov/joinpoint/.
¶¶ https://www.cdc.gov/niosh/topics/noms/default.html.

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