title: Prevalence of chronic obstructive pulmonary disease and variation in risk factors across four geographically diverse resource-limited settings in Peru.
abstract: BACKGROUND
  It is unclear how geographic and social diversity affects the prevalence of chronic obstructive pulmonary disease (COPD). We sought to characterize the prevalence of COPD and identify risk factors across four settings in Peru with varying degrees of urbanization, altitude, and biomass fuel use.
  
  
  METHODS
  We collected sociodemographics, clinical history, and post-bronchodilator spirometry in a randomly selected, age-, sex- and site-stratified, population-based sample of 2,957 adults aged ≥35 years (median age was 54.8 years and 49.3% were men) from four resource-poor settings: Lima, Tumbes, urban and rural Puno. We defined COPD as a post-bronchodilator FEV1/FVC < 70%.
  
  
  RESULTS
  Overall prevalence of COPD was 6.0% (95% CI 5.1%-6.8%) but with marked variation across sites: 3.6% in semi-urban Tumbes, 6.1% in urban Puno, 6.2% in Lima, and 9.9% in rural Puno (p < 0.001). Population attributable risks (PARs) of COPD due to smoking ≥10 pack-years were less than 10% for all sites, consistent with a low prevalence of daily smoking (3.3%). Rather, we found that PARs of COPD varied by setting. In Lima, for example, the highest PARs were attributed to post-treatment tuberculosis (16% and 22% for men and women, respectively). In rural Puno, daily biomass fuel for cooking among women was associated with COPD (prevalence ratio 2.22, 95% CI 1.02-4.81) and the PAR of COPD due to daily exposure to biomass fuel smoke was 55%.
  
  
  CONCLUSIONS
  The burden of COPD in Peru was not uniform and, unlike other settings, was not predominantly explained by tobacco smoking. This study emphasizes the role of biomass fuel use, and highlights pulmonary tuberculosis as an often neglected risk factor in endemic areas.
authors.affiliation: Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave Suite 9121, Baltimore, MD, 21205, USA. djagana1@jhmi.edu.|Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA. djagana1@jhmi.edu.
authors.forename: Devan
authors.initials: D
authors.lastname: Jaganath
authors.affiliation: CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru. jaime.miranda@upch.pe.|Departamento de Medicina, Escuela de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru. jaime.miranda@upch.pe.
authors.forename: J Jaime
authors.initials: JJ
authors.lastname: Miranda
authors.affiliation: Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA. gilmanbob@gmail.com.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Gilman
authors.affiliation: Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave Suite 9121, Baltimore, MD, 21205, USA. rwise@jhmi.edu.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wise
authors.affiliation: Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave Suite 9121, Baltimore, MD, 21205, USA. gdiette@jhmi.edu.
authors.forename: Gregory B
authors.initials: GB
authors.lastname: Diette
authors.affiliation: Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave Suite 9121, Baltimore, MD, 21205, USA. chooper5@jhmi.edu.
authors.forename: Catherine H
authors.initials: CH
authors.lastname: Miele
authors.affiliation: CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru. antonio.bernabe@upch.pe.
authors.forename: Antonio
authors.initials: A
authors.lastname: Bernabe-Ortiz
authors.affiliation: Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave Suite 9121, Baltimore, MD, 21205, USA. wcheckl1@jhmi.edu.
authors.forename: William
authors.initials: W
authors.lastname: Checkley
mesh_terms: D000328:Adult; D000368:Aged; D000531:Altitude; D018533:Biomass; D005260:Female; D005541:Forced Expiratory Volume; D005579:Fossil Fuels; D006801:Humans; D008137:Longitudinal Studies; D008168:Lung / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010568:Peru / Q000453:epidemiology; D011237:Predictive Value of Tests; D015995:Prevalence; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000453:epidemiology* / Q000503:physiopathology; D012111:Residence Characteristics; D018570:Risk Assessment; D012307:Risk Factors; D012423:Rural Health; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D013147:Spirometry; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000453:epidemiology; D014504:Urban Health; D014507:Urbanization; D014797:Vital Capacity
chemical_list: D005579:Fossil Fuels