Articles
Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis

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Summary

Background

There is a scarcity of published data on the global prevalence of obstructive sleep apnoea, a disorder associated with major neurocognitive and cardiovascular sequelae. We used publicly available data and contacted key opinion leaders to estimate the global prevalence of obstructive sleep apnoea.

Methods

We searched PubMed and Embase to identify published studies reporting the prevalence of obstructive sleep apnoea based on objective testing methods. A conversion algorithm was created for studies that did not use the American Academy of Sleep Medicine (AASM) 2012 scoring criteria to identify obstructive sleep apnoea, allowing determination of an equivalent apnoea-hypopnoea index (AHI) for publications that used different criteria. The presence of symptoms was not specifically analysed because of scarce information about symptoms in the reference studies and population data. Prevalence estimates for obstructive sleep apnoea across studies using different diagnostic criteria were standardised with a newly developed algorithm. Countries without obstructive sleep apnoea prevalence data were matched to a similar country with available prevalence data; population similarity was based on the population body-mass index, race, and geographical proximity. The primary outcome was prevalence of obstructive sleep apnoea based on AASM 2012 diagnostic criteria in individuals aged 30–69 years (as this age group generally had available data in the published studies and related to information from the UN for all countries).

Findings

Reliable prevalence data for obstructive sleep apnoea were available for 16 countries, from 17 studies. Using AASM 2012 diagnostic criteria and AHI threshold values of five or more events per h and 15 or more events per h, we estimated that 936 million (95% CI 903–970) adults aged 30–69 years (men and women) have mild to severe obstructive sleep apnoea and 425 million (399–450) adults aged 30–69 years have moderate to severe obstructive sleep apnoea globally. The number of affected individuals was highest in China, followed by the USA, Brazil, and India.

Interpretation

To our knowledge, this is the first study to report global prevalence of obstructive sleep apnoea; with almost 1 billion people affected, and with prevalence exceeding 50% in some countries, effective diagnostic and treatment strategies are needed to minimise the negative health impacts and to maximise cost-effectiveness.

Funding

ResMed.

Introduction

Obstructive sleep apnoea is a common disorder that can present with or without symptoms and is accompanied by major neurocognitive and cardiovascular sequelae.1, 2, 3 At present, care of patients with obstructive sleep apnoea varies by country and depends on a patient's symptoms. In well resourced settings, considerable efforts are being made to diagnose and treat individuals with obstructive sleep apnoea, but available data suggest that most cases of obstructive sleep apnoea remain undiagnosed and untreated, even in developed countries. In developing countries, there is generally little awareness of obstructive sleep apnoea, and diagnostic and treatment options are often not available or have not been adapted for resource-poor settings.4 Because of the multifactorial and social consequences of obstructive sleep apnoea, the disorder is associated with a high economic and societal burden. In 2015, the cost of diagnosing and treating obstructive sleep apnoea in the USA was approximately US$12·4 billion.5 The global cost of diagnosing and treating obstructive sleep apnoea has not been estimated because information about global prevalence is required first.

Evidence suggests that obstructive sleep apnoea is an important contributor to poor health outcomes and that treatment of this condition is generally beneficial in minimising the associated adverse clinical outcomes and improving sleep-related quality of life.6 Thus, focusing on effective treatment of obstructive sleep apnoea might be one approach for reducing associated health-care costs and the negative impact of the condition, such as the cognitive impact of sleepiness.7, 8 Additionally, given the shift in focus from issues around malnutrition and basic hygiene towards chronic health conditions, such as the obesity pandemic and its associated metabolic complications,9, 10, 11, 12 the ageing population demographic,13 and the association between obstructive sleep apnoea and various non-communicable diseases,14 obstructive sleep apnoea is likely to be a rising global problem over the coming years.15, 16

Research in context

Evidence before this study

Despite increasing recognition of obstructive sleep apnoea as a contributor to poor health outcomes, our literature searches identified a scarcity of data about global prevalence of obstructive sleep apnoea. We searched PubMed and Embase using search terms of “adult”, “sleep disordered breathing”, “sleep apnoea”, “sleep apnoea syndrome”, “obstructive”, “prevalence”, and “population”, with no limits on timeframe nor any language restrictions. The original search was done in April, 2017, and then rechecked in February, 2019 (no new papers were identified in the second search). Relevant and local prevalence data are important to facilitate implementation of effective and efficient strategies for diagnosis and management of obstructive sleep apnoea.

Added value of this study

To the best of our knowledge, this is the first study to report a global estimate of obstructive sleep apnoea prevalence and to estimate the number of individuals affected by this condition worldwide. Nearly 1 billion adults aged 30–69 years worldwide were estimated to have obstructive sleep apnoea, with and without symptoms, based on an apnoea-hypopnoea index (AHI) cutoff value of five or more events per h, with 425 million (>45%) of these individuals having an AHI of 15 or more events per h (defined as a moderate to severe disorder requiring treatment). Wide geographical variation exists in the prevalence of obstructive sleep apnoea, with prevalence exceeding 50% in some countries.

Implications of all the available evidence

Given the high burden of obstructive sleep apnoea worldwide, health-care systems need to adopt effective diagnostic and management strategies so that the negative health impacts of obstructive sleep apnoea can be minimised.

Planning for effective diagnosis and management strategies requires accurate and country-specific estimates of disease prevalence. In 2007, WHO estimated that more than 100 million individuals were affected by obstructive sleep apnoea worldwide,17 but this estimate was acknowledged to be only an approximation based on data available at the time. In this study we used a new approach and the latest publicly available data to estimate the global prevalence of obstructive sleep apnoea. We aimed to estimate the total number of affected individuals around the world and the proportion of those with moderate or severe obstructive sleep apnoea because positive airway pressure is recommended in all patients with excessive sleepiness, impaired sleep-related quality of life, and comorbid hypertension, which are more likely with an apnoea-hypopnoea index (AHI) of 15 or more events per h.18 The aim of our analysis was to raise awareness of the global burden of obstructive sleep apnoea by providing data to help guide strategies and health policies to address this important health and societal problem, and to highlight substantial gaps in rigorously assessed obstructive sleep apnoea prevalence data that are currently unavailable for much of the global population. These gaps should be of great concern because of the wide-ranging negative sequelae of obstructive sleep apnoea.

Section snippets

Search strategy and selection criteria

We searched PubMed and Embase to identify prevalence studies of obstructive sleep apnoea done in the general or community population, in adults (aged 18 years and older), where obstructive sleep apnoea was measured objectively with a sleep study. We selected general population prevalence studies rather than those done in selected groups on the basis of concomitant diseases or those done in clinical settings where referral bias could be an important limitation. Only studies that used objective

Results

17 articles were included in the analyses (table 2).23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39 Reliable prevalence estimates were obtained on the basis of available data for 16 of 193 countries in the world; prevalence estimates for the remaining countries were extrapolated as described above.

Using an AHI criterion of five or more events per h and the AASM 2012 criteria, an estimated 936 million (95% CI 903–970) individuals aged 30–69 years (men and women) worldwide were

Discussion

Our estimates suggest that nearly 1 billion adults aged 30–69 years worldwide could have obstructive sleep apnoea, and the number of people with moderate to severe obstructive sleep apnoea, for which treatment is generally recommended, is estimated to be almost 425 million. To the best of our knowledge, this analysis represents the first set of global estimates of the prevalence of obstructive sleep apnoea.

Based on the published literature and by matching countries based on population

Data sharing

All data included in this study are available in the public domain. Specific requests or questions should be submitted to the corresponding author for consideration.

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