Implementing a National NCD Program Population Based and High Risk Approaches to Prevention and Control of NCDs/CVD Dr Shanthi Mendis MBBS MD FRCP FACC Coordinator Chronic Disease Prevention and Management World Health Organization Geneva, Switzerland

Modifiable causative risk factors Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol Noncommunicable diseases Heart disease and stroke  Diabetes Cancer Chronic lung disease Prioritization and Integration

Total number of deaths in the world 90% of premature deaths from NCDs occur in low- and middle-income countries Source: 10 million 15 million 20 million 25 million High-income countries Upper middle-income Lower middle-income 0.6M 0.5M 3.3M 2.3M 10.2M 3.3 M 3.0M 5.9M 6.8 M 3.7M 13.6M 1.1M 0.9M Total number of deaths in the world 5 million 0 million 30 million Low-income countries Group III - Injuries Low-income countries Group II – Other deaths from noncommunicable diseases Group II – Premature deaths from noncommunicable diseases (below the age of 60), which are preventable Group I – Communicable diseases, maternal, perinatal and nutritional conditions

Cardiovascular Diseases - CVD contributes 29% of global deaths - 88% of the global CVD burden is in LMICs -Total CVD deaths 17.1 million - 12.9 million deaths ( CHD /CeVD 7/6 ) due to atherosclerotic disease

Global mortality cardiovascular diseases 29% (17 million) Communicable maternal infant All other Non communicable diseases Cancer 13% 16% 40% Diabetes 29% (17 million) 2% Look at potential contribution of effective 2 P to the overall CVD epidmic cardiovascular diseases ( Three quarters of the burden in LMIC) 5 5

Cardiovascular mortality trends In high income countries CV mortality is declining In middle income countries CV mortality is high and rising In low income countries CV mortality will rise.

Prevention and Control of NCD Evidence based interventions for primary and secondary prevention are available Together they have been responsible for the decline of CVD seen in many developed countries Implementation is key

Implementation Barriers Resources Political commitment Capacity Competing issues Demands Interests Implementation Barriers

Implementation key issues Prioritization Integration Evidence based Cost effectiveness Feasibility Impact Implementation research Monitoring effectiveness Implementation key issues

Synergism of population-wide and high risk strategies Mendis S 2005

Per capita expenditure on health (International dollars ) Expenditure Number of countries 33 25 72 24 19 18 Less than 50 $ 50 – 99 100-499 500-999 1000-1999 >2000

Few risk factors account for the global burden of cardiovascular disease

Blood pressure, stroke and IHD 8.00 8.00 4.00 4.00 2.00 Relative Risk & 95% CI 2.00 1.00 1.00 0.50 Stroke 0.50 IHD (-10 mmHg = - 42%) (-10mmHg = - 24%) 0.25 0.25 110 120 130 140 150 160 170 110 120 130 140 150 160 170 Usual SBP (mmHg) Usual SBP (mmHg) APCSC J Hypertens, 2003

Political messaging High health care budgets Health care budgets will rapidly increase Resources for other areas (education), suffer Lost productivity due sickness Lost productivity due to premature mortality Cobenefits

Overarching Integrated NCD Policy and National Action Plans

Cost effectiveness “highly cost-effective” intervention is defined as one that generates an extra year of healthy life for a cost below the gross domestic product per person.

CVD and salt Positive association between salt and BP Significant relationship between the rise in BP with age and salt intake Systematic review (17 trials HBP and 11 trials with NBP) Correlation between magnitude of salt reduction and BP reduction within the range 3-12 gm/day Intensive interventions reduce BP significantly (DASH trial) Individual efforts work in the short term, more difficult in the long-term (0.6 mm Hg diastolic, 1.1 mm Hg systolic)

CVD and Trans-fat Trans-fats (unsaturated fatty acids with that contain one or more isolated (non conjugated )double bonds in a trans configuration Formed during partial hydrogenation of liquid vegetable oils resulting in semi solid fats used in margarines, cooking oils and bakery products Stability during frying and long shelf life Consumption may be 4.5 – 7 gms per day, 2-3% of total calories Conclusive evidence that trans-fats increases the risk of CHD

Reduce Trans-fat Denmark, Canada, France, USA, Russia (labelling and regulation) Argentina, Chile, Brazil , Paraguay, Uruguay Significant reduction is feasible Total elimination should be the goal Less than 2% in cooking oils and <5% in other foods

Cost to implement the package of interventions (US$ per person per year, 2005) Asaria et al, Lancet 2007;370:2044-2053

Tobacco control Implementing four key elements of the WHO FCTC (tax increases, comprehensive legislation creating smoke-free environments, Warnings and bans on advertising etc ) Saves 5.5 million deaths, 25 m DALYs averted (half the burden ) Cost of implementing all four interventions <USD 0.40 per person per year in LMIC

Other interventions Taxation of alcoholic beverages and restricting their availability. DALYs averted approx. 10 million (one fifth of burden) Reduce salt intake of food 5 m DALYs averted (one third of burden) Others been worked out

Primary Care Interventions Reducing cardiovascular risk of people including those with diabetes above a 30% CVR with counseling and multidrug regimen (60 m DALYs averted ; about one third the burden) Using total CV risk approach

WHO PEN Guidance Priorities Integration Interventions Assessment Costs/Resource planning Technologies Medicines Training Protocols Evaluation

Scope Tobacco cessation Promotion of healthy diet/ physical activity Diabetes Cardiovascular risk (HBP/ HBC ) Prevention of kidney disease Cerebrovascular disease Coronary heart disease Asthma Chronic obst. Pulmonary Dis. Early detection of cancer Cancer pain care Rheumatic heart disease

Integrated protocols- what is new? One protocol to - REDUCE CARDIOVASCULAR RISK Prevent myocardial infarction Prevent stroke Prevent renal disease Prevent congestive cardiac failure Prevent diabetes complications

WHO/ISH charts Screen for risk of heart attacks and strokes G E   MALE FEMALE SBP Non-Smoker Smoker 180 160 70 140 120 60 50 40 4 5 6 7 8 Cholesterol WHO/ISH charts Screen for risk of heart attacks and strokes Using simple variables Age Smoking Sex Blood pressure Blood cholesterol Blood sugar Intervene based on risk and affordability

Equipment and tests core list Urine protein Test for blood sugar Test for blood cholesterol BPMD PEF meter Weighing machine / tape

Medicines core list Aspirin Thiazides CCB ACEI BB Statin Insulin Metformin Salbutamol Beclometasone

WHO PEN ; How to………tools Assess capacity Plan / Cost Equipment / Medicines lists Integrated protocols (guideline) Safety - Strict referral criteria Training materials Tools for self management /adherence Community engagement tools Health information system- clinical record Quality assessment tools Monitoring and evaluation

Noncommunicable diseases and PHC Prevent / protect Detect cases early Diagnose and treat Treat emergencies Improve adherence Follow up cases Reduce complications Reduce admissions Reduce costs Prevent premature death

Affordable technology for PHC BPMD field tested by WHO Solar powered BPMD Affordable technology for PHC BPMD field tested by WHO Accurate Low cost semiautomatic Used by non-physicians THANK YOU

WHO PEN Best buys in NCD health interventions Keeping it as simple as possible Equity- First step to universal coverage of NCD interventions

Monitoring Mortality Risk factors Implementation of Policies Primary care system

Monitoring Mortality Death between ages 30 and 70 years from major NCDs X per cent decline in overall and case specific mortality

Tobacco Prevalence of current daily tobacco smoking among adults aged 15+ years. Target: ? 30 per cent relative reduction in prevalence of current daily tobacco smoking among adults aged 15+ years.

Risk factors Prevalence of diabetes ( ? 10% reduction in the prevalence) Prevalence raised BP (? 20% relative reduction in prevalence) Prevalence of raised lipids (? 20% relative reduction in prevalence )

Prevention of heart attacks and strokes Percentage of adult population with a 10 year cardiovascular risk (fatal and nonfatal cardiovascular events), above 20%, managed through combination therapy ( multiple drug treatment and counseling). Target: Fraction of adult population with CVR above 20% not covered by combination therapy reduced by 50 per cent

National Plan Make an impact on a rising epidemic Prioritize Estimate Implement Measure

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