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Appendix B International Studies of Cardiovascular Disease and Chronic Obstructive Lung Disease HEART DISEASE AMIS Plus Registry (Switzerland). This nationwide prospective registry included patients hospitalized with an acute coronary syndrome (ACS) between 1997 and 2006 in academic and nonacademic hospitals throughout Switzerland (n ~20,000 patients). ARIAM (Analysis of Delay in AMI) Project. This registry included all patients hospitalized with an ACS at 119 Spanish hospitals between 1995 and 2001. A total of 17,761 patients were admitted to participating ICU’s/CCU’s with acute myocardial infarction (AMI). Canadian Cardiovascular Outcomes Research Team—Quebec. The study sample consisted of patients admitted with a first AMI from the 18 administrative regions of Quebec between 1988 and 1995. This study was performed to examine regional variation in the management of patients hospitalized with AMI throughout Quebec; more than 76,000 patients were included in the computerized database. CARMELA (Cardiovascular Risk Factor Multiple Evaluation in Latin America). Cross-sectional study that was carried out in adults between the ages of 25–64 years who resided in major cities in 7 Latin American countries. This study was designed to examine the prevalence of several cardiovascular disease (CVD) risk factors and common carotid artery intima-media thickness. Copenhagen City Heart Study. This study, which has been performed in the Danish general population since the early 1980s, was a prospective study of more than 10,000 individuals between the ages of 30–70 years who were randomly selected from the city of Copenhagen and were subsequently followed over time for the development of fatal and nonfatal CVD events. EUROASPIRE (European Action on Secondary Prevention Through Intervention to Reduce Events) Surveys. The first EUROASPIRE Survey was conducted in 1995/1996 and was carried out in hospitals in 9 European countries in patients < 80 years of age with coronary heart disease (CHD). Subsequent surveys were carried out in 1999/2000 and 2006/2007. In the last survey, patients with CHD from 76 centers in 22 countries throughout Europe were included. 175

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176 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES EuroHeartSurvey ACS. Study was performed in clusters of academic and nonacademic hospitals treating patients with an ACS (AMI or unstable angina) in 25 countries throughout Europe and the Mediterranean basin (total n ~10,000) during 2000/2001. European Physical Activity Surveillance System (EUPASS). Designed to monitor physical activity and its deter- minants in random population samples of adults ≥ 18 years from 8 European Union member states (Belgium, Finland, France, Germany, Italy, Netherlands, Spain, United Kingdom). This project was funded by the Health Monitoring Programme of the European Commission. French USIC (Unité de Soins Intensits Coronaires) Project. This was a nationwide registry of patients hospital- ized with AMI during a 1-month period in 1995 and 2000. Patients between the ages of 30–89 years comprised the study sample. The total sample size was 4,347, and participating ICUs represented more than 80% of those treating patients with AMI in France. Heart of Soweto Study. This investigation studied persons presenting to a large tertiary care clinic in Soweto, South Africa, over a 1-year period (2006) with either incident or prevalent CVD (n = 4,162). This registry included predominantly black Africans who presented to the Chris Hani Baragwanath Hospital, which provides cardiac care to residents of Soweto and surrounding communities. Hellenic Multicenter Study of Acute Myocardial Infarction. This registry included consecutive patients hospital- ized with an AMI (n = 7,433) during a 1-year period (1993/1994) at 76 (out of a total of 86) hospitals throughout Greece. International Network of Field Sites With Continuous Demographic Evaluation of Populations and Their Health (INDEPTH). This international network includes 34 health and demographic surveillance systems in 17 low and middle-income countries designed to identify the magnitude of non-communicable diseases in these countries. Of these, 23 sites are in Africa, 10 sites are in Asia, and 1 is in Oceania. Risk factor surveys are being carried out in selected study sites to compile baseline data for purposes of subsequent intervention trials. Italian National Register of Major Coronary Events: Attack Rates in Different Areas of the Country. National register initiated in Italy at the end of the 1990s designed to develop surveillance of fatal and nonfatal coronary events in the general Italian population aged 35–74 years using MONICA criteria. Italian Network for Obesity and Cardiovascular Disease Surveillance: A Pilot Project. Pilot project implemented in 2006 to evaluate the feasibility of a surveillance network for CVD and obesity in Italian men and women aged 35–74 years. The study lasted 2 years and involved 40 general practitioners from the Italian Association of General Practitioners throughout Italy. Maximal Individual Therapy in Acute Myocardial Infarction (MITRA Registry). This study enrolled all persons with new onset diabetes from 1972 on at the Laxa Primary Health Care Center in Orebro County, Sweden. A total of 776 incident cases of diabetes reported to this health care center through 2001 were included in this register. MONICA (Monitoring Trends and Determinants in Cardiovascular Disease). This was a large multinational study that was designed to monitor trends in fatal and nonfatal CHD and strokes, and trends in CVD risk factors, in men and women aged 25–64 years from 38 populations in 21 countries between the mid-1980s and mid-1990s. Myocardial Ischaemia National Audit Project (MINAP). This study included all acute care hospitals in England and Wales (n = 229) treating patients with an ACS. Data were prospectively collected at participating hospitals between 2003 and 2005. More than 100,000 patients were included in this large multisite observational study.

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177 APPENDIX B National Hospital Discharge Register (Sweden). This national registry was established in 1996 and linked hospital discharge data with a national mortality registry of all fatal and nonfatal cases of AMI occurring in Sweden between 1987 and 1995. A total of ~354,000 cases of AMI in adults 30–89 years occurred over this period. PREVENCION Study (Peru). This study was designed to determine the prevalence of CVD and its risk factors in the adult population of Arequipa, Peru, the second largest city in Peru. It is one of the first population-based studies of CVD in Latin America. Purwarejo (Indonesia) Demographic Surveillance Site. Using the WHO STEPwise protocol for surveillance, this study examined risk factors for CVD in nearly 3,000 women aged 15–74 years at the Purwarejo (Indonesia) Demographic Surveillance Site in 2001. REACH Registry (REduction of Atherothrombosis for Continued Health). This is a prospective registry designed to provide up to 4 years of clinical follow-up of ~68,000 outpatients from approximately 5,000 sites in 44 countries in men ≥ 45 years with either CAD, CVD, PAD, or who had at least 3 coronary risk factors present. REGICOR (Registi: Fironi del COR). Population-based study designed to examine the prevalence of CVD risk factors, as well as the incidence and death rates associated with CHD, in the province of Gerona, Spain, in persons 25–74 years old. The reference population was composed of 189 towns and nearly 510,000 inhabitants. This study was carried out in 1995/1996. Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (Riks-HIA) (updated and renamed to SWEDE-HEART). This investigation collects information on patients admitted to the ICUs of participating hospitals with AMI throughout Sweden. The registry started in 1995, with 19 participating hospitals, and has increased gradually over time to include 70 of 78 hospitals throughout Sweden. This registry has been recently updated and renamed to include patients admitted with an ACS to 71 of 74 hospitals throughout Sweden (SWEDE-HEART). Sino-MONICA Project. This population-based study compared the CVD risk factor profile of persons from dif - ferent race ethnicities residing in Ontario, Canada, over the period 1996–2007. Statistics Canada National Health Survey. This was a 7-year study designed to monitor trends and determinants of CVD in geographically defined populations residing in different parts of China between 1987 and 1993. Adults between the ages of 35–64 years were targeted for this population-based surveillance system. Survey of Acute Myocardial Infarction and Ischaema (SAMII) in the United Kingdom. The original sampling frame for this study was all 248 acute nonteaching U.K. hospitals serving a population of approximately 42 mil - lion people. A random sample of 118 hospitals was selected, and of these, 94 (80%) provided data on patients hospitalized with an ACS during the mid-1990s. Thai Acute Coronary Syndrome Registry (TACSR). This registry included consecutive patients with an ACS enrolled from 17 medical centers in Bangkok and other regions in Thailand between 2002 and 2005. In this registry, 5,537 patients had a discharge diagnosis of an ACS. World Health Organization STEPwise Approach to Surveillance of Noncommunicable Disease Risk Factors (STEPS). The STEP program is a standardized method for collecting, analyzing, and disseminating data on chronic disease risk factors and stroke in low and middle income countries. A secondary goal of the STEPS program is to help countries build and strengthen their capacity to conduct surveillance in men and women aged 25–64 years.

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178 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES CHRONIC LUNG DISEASE Asthma, Chronic Bronchitis, and Respiratory Symptoms Among Adult Estonians and Non-Estonians (FinEsS-study). In the mid-1990s, a postal questionnaire survey was carried out for purposes of assessing differ- ences in the prevalence of asthma, chronic bronchitis, and symptoms of respiratory disease in various population groups residing in Estonia. Based on self-reported responses to a standardized questionnaire, the prevalence of physician-diagnosed asthma was approximately 2.0%, whereas the prevalence of physician-diagnosed chronic bronchitis was 10.5%. Asthma and COPD in Southern Finland. The data for this study were derived from a random sample of 4,300 men and women aged 18–65 years who were living in Southern Finland in 1996. Based on the responses to sev - eral standardized questionnaires, the prevalence of asthma was 5.3% whereas the frequency of COPD was 3.6%. BOLD (Burden of Obstructive Lung Disease). This international study was designed to assess the prevalence of chronic obstructive pulmonary disease (COPD) and its predisposing factors and determine whether variation in these endpoints existed between participating sites. Individuals residing in major cities (e.g., Manila, Philippines; Cape Town, South Africa) from 12 countries participated in this multinational prevalence study of COPD. Adult participants ≥ 40 years (n = 9,425) were selected by a random sampling design. These individuals underwent spirometry testing and completed various questionnaires about their respiratory symptoms, health status, and exposure to risk factors for COPD. China COPD Prevalence Study. For purposes of providing insights into the prevalence of COPD in China, a population-based epidemiologic study of COPD was conducted in 7 provinces/cities throughout China over a 2-year period beginning during the fall of 2002. Trained interviewers used a standardized questionnaire from the BOLD Study to assess COPD and respiratory symptoms, and subjects underwent spirometry examination. More than 20,000 individuals completed spirometry testing. Chronic Bronchitis Among French Adults. This study assessed the prevalence of symptoms suggestive of chronic bronchitis in a large sample of the French population that consisted of more than 14,000 persons aged ≥ 25 years. The prevalence of chronic bronchitis was 4.1% based on participants’ responses to a mailed questionnaire. Chronic Bronchitis in South African Adults. This was a large national household survey of adults living in South Africa in 1998 designed to determine the prevalence and predictors of chronic bronchitis. A working definition of chronic bronchitis was utilized and peak expiratory flow was assessed. In the 5,671 men studied, the prevalence of chronic bronchitis (2.3%) was slightly lower than the prevalence of chronic bronchitis in women (n = 8,155; 2.8%). In multivariable adjusted models, several sociodemographic and lifestyle factors were associated with chronic bronchitis. Comparative Study of Respiratory Symptoms and Diseases Between Northern Sweden and Northern Finland: the FinEsS Study. This study examined the prevalence rates of respiratory symptoms, asthma, and chronic bronchi - tis in residents of Norrbotten providence, Sweden and Lapland region, Finland, using standardized questions about respiratory symptoms and pulmonary diseases. Questionnaires were completed by 7,014 residents of Norrbotten and by 6,633 residents of Finnish Lapland. Physician-diagnosed chronic bronchitis was reported by approximately 4% of the Swedish population and by 3% of Finnish residents. The rates of other respiratory conditions (e.g., chronic cough, sputum production) were also reported. COPD Among Canadians. Data from 7,210 individuals aged 35–64 years who participated in the National Population Health Survey of Canadians in 1994/1995 were utilized to assess the prevalence of chronic bronchitis/ emphysema in Canadians. Based on an individual’s response to a single question about whether COPD had ever been diagnosed by a health professional, the prevalence of COPD was approximately 2.4% in men and 3.8% in

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179 APPENDIX B women. Advanced age, history of allergies, low income, high BMI, and being either a current or ex-smoker were significantly associated with the presence of bronchitis/emphysema. European Community Respiratory Health Study (ECRHS). This study examined the prevalence rates of asthma and allergic disease in young adults between the ages of 20–44 years in several European countries using a stan - dardized protocol. This multicenter, multinational study began collecting baseline data in 1990, and a subsequent follow-up study, ECRHS II, was carried out between 1998 and 2002. A total of 56 centers from 25 countries took part in the baseline data collection activities of this study. Guangzhou [China] Biobank Cohort Study. The Guangzhou Biobank Cohort Study includes older (≥ 50 years) adult residents of Guangzhou, China, who underwent measurement of their lung function under standardized condi- tions in the mid-2000s. A total of more than 8,000 healthy community-dwelling participants underwent spirometry testing, and the prevalence rates of prior TB and airflow obstruction in this cohort were assessed. IBERPOC Study in Spain. This population-based study was carried out in 7 different geographic areas of Spain for purposes of assessing the prevalence of COPD and its risk factors. Fieldwork was performed in 1996/1997, and personal interviews and spirometry were carried out in approximately 4,000 men and women aged 40–69 years. The prevalence rates of COPD were considerably higher in men (14%) than in women (4%). Geographic variation in the prevalence rates of COPD was also reported among the 7 population settings. Meta Analysis of COPD Prevalence Surveys. This publication was a meta-analysis of surveys examining the prevalence of COPD in persons ≥ 40 years. The authors identified 101 overall prevalence estimates of COPD from 28 different countries. Estimates were provided of COPD, of chronic bronchitis alone, and of emphysema alone. MIDSPAN Studies. The MIDSPAN studies consisted of a number of occupational and general health studies that began in the 1960s and included nearly 30,000 people from Scotland and the United Kingdom. These studies were based in factories and other workplaces in Scotland, in a general population residing in a Hebridean island (Tiree), and two additional studies were carried out in residents of the towns of Paisley and Renfrew. Lung function testing and cardiorespiratory health status was performed in each of the MIDSPAN study sites. PLATINO (Latin American Project for the Investigation of Obstructive Lung Disease). This study, which was carried out in population samples in residents of five major cities in Latin America (Sao Paulo, Brazil; Santiago, Chile; Mexico City, Mexico; Montevideo, Uruguay; and Caracas, Venezuela), examined the prevalence rates of COPD and associated mortality. This study began in 2002 and employed a 2-stage sampling strategy for identifying population samples of adults > 40 years old. These individuals completed several study questionnaires and under- went spirometry testing. Approximately 5,500 men and women participated in this cross-sectional prevalence study. Prevalence and Correlates of Airway Obstruction in South Korean Adults. A cross-sectional population-based study of residents of Ansan City, near Seoul, South Korea, was carried out in men and women ≥ 18 years. Inter- views and physical examinations were carried out with study participants, including pulmonary function tests. The prevalence rates of airway obstruction were reported for men (17.0%) and for women (5.6%). Prevalence and Risk Factors for Chronic Bronchitis in Pelotas, Brazil. A population-based cross-sectional survey was carried out among adult residents of an urban area (Pelotas) of southern Brazil during the winter of 1990. A total of 1,053 individuals aged ≥ 40 years participated in this survey and 12.7% were classified as having chronic bronchitis based on findings from a standardized questionnaire. Low family income and level of education, current cigarette smoking, and a history of major respiratory illnesses were associated with chronic bronchitis. Prevalence and Treatment of Chronic Airways Obstruction in U.K. Adults. A mailed questionnaire was sent to middle-aged (≥ 45 years) white men and women residing in central Manchester, UK, in the early 1990s. In the

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180 A NATIONWIDE FRAMEWORK FOR SURVEILLANCE OF CARDIOVASCULAR AND CHRONIC LUNG DISEASES surveyed inner-city population (n = 723), the prevalence of asthma/bronchitis was assessed whereas chronic airways obstruction was assessed by pulmonary function tests in a sample of respondents. Prevalence of Respiratory Symptoms in Northern and Central Italy (Po Delta and Pisa Study). Four cross- sectional general population surveys were carried out in residents of Northern and Central Italy between the late 1980s and early 1990s for purposes of assessing the frequency of respiratory symptoms and pulmonary disease in populations living in an urban and in a rural area that were characterized by different levels of outdoor air pollution. Respiratory Symptoms in Elderly Chinese Living in Hong Kong. In the early 1990s, an age stratified sample of elderly (≥ 70 years) Chinese men and women was studied (n = 2,032). Standardized questionnaires about participants’ lung health were completed, and the prevalence of various respiratory symptoms as well as several pulmonary diseases was assessed. Swiss Study of Air Pollution and Lung Diseases in Adults (SAPALDIA). This is a multicenter cohort study that has examined the association between exposure to air pollutants and respiratory symptoms in adults residing in 8 areas throughout Switzerland. This study was initiated in 1991, and nearly 10,000 subjects completed a standard - ized baseline questionnaire on respiratory health and attended a health examination. Trends in COPD in U.K. Women and Men. Data from the Group Practice Research Database (GPRD) were used for purposes of examining trends in the prevalence of COPD in British residents between 1990 and 1997. The GPRD is a large computerized database that included data from more than 3 million patients who had been seen in more than 500 primary care practices. Over the period under study, the annual prevalence rates of COPD increased in women (0.8% 1990; 1.4% 1997) as well as in men (1.3% 1990; 1.6% 1997).