1. Hypertension- A Global Problem & A National Challenge Professor Tazeen H Jafar Duke-National University of Singapore & Aga Khan University, Karachi, Pakistan

2. Disclosures: None

3. Overview Global burden of NCD and attributable risk factors –esp high BP Trends Impact on national economies Leading causes of mortality and attributable risk factors in Pakistan Challenges with control of BP in resource poor communities Funding for NCDs Effectiveness and cost effectiveness of successful BP control strategies- focus on health systems COBRA RCT (urban) (investigator experience) Other RCTs Global health challenges: integrated models of care focused on hypertension with other chronic diseases and other health services-way forward

4. WHO 2008 Global Trend and Forecasts in Major Causes of Death

5. Attributable Risk Factors in 21 regions: Global Burden of Disease 2010 Lancet 2012

6. Projected Increase in Number of People with Hypertension 1.5 Billion with Hypertension by 2025 Kearney P at al Lancet, 9455, 2005, 217 - 223

7. Attributable Risk Factors for Premature Deaths from CVD, Cancer & Respiratory Diseases in Pakistan Jafar TH Lancet 2013

8. Trends in Hypertension and Obesity in Pakistan Ezatti M, Lancet 2011

9. Estimates of Effects of Heart Disease, Diabetes and Stroke on the Economy Lancet 2007

10. Poverty Rates World Bank 2010

11. Global age-standardized coronary heart disease (CHD) mortality rates in men and women Cooney M T et al. Circulation 2010;122:300-310

12. Associations of reduction in blood pressure with risk reduction for total major cardiovascular events for adults aged <65 and ≥65 BMJ 2008;336:1121-1123

13. Control of Blood Pressure and Risk Attenuation Trial- Factorial, Cluster, RCT 12 Clusters n = 17,850 6 clusters Home Health Education Age > 40 years with hypertension n = 840 Age > 40 years with hypertension n = 840 3 clusters (control) Usual Care Hypertension Management 3 clusters (Trained GP alone) Special Care Hypertension Management 3 clusters (HHE alone) Usual Care Hypertension Management 3 clusters (combined) Special Care Hypertension Management 6 clusters No Home Health Education Jafar TH et al Annals of Int Med 2009

14. Home Health Education-modeled on piggy-backing on publically funded Lady Health Workers Programme Providing education in home setting on:  Nutrition (low saturated fats, more fruits and vege, low salt, maintain ideal body weight)  Physical activity  Smoking cessation  Medication adherence Culturally sensitive Behavior Change Communications (BCC) techniques  Nutritionists, epidemiologists, clinicians 1 CHW=250 households

15. GP training: Private contractors- front line care providers Training in appropriate therapy of hypertension using low cost high quality drugs  case studies  cardiologists, nephrologists, and pharmacologists GP from the same communities as subjects Aim to train 2/3 rd of all GPs in communities randomized to trained GP intervention Do not force/insist subjects to switch to trained GP: real life or practical model Annual session over 1 day Certificate of training

16. COBRA Outcomes- Change in Systolic Blood Pressure Levels among Randomized Groups Treatment GroupnDecline in SBP in mm Hg (95% CI)** p-value Home Health Education + Trained GP 332 10.2 (8.0, 12.4) 0.001 Home Health Education only348 5.5 (3.4, 7.6) Trained GP only335 5.4 (3.2, 7.5) No Intervention326 4.6 (2.5, 6.7) **Means and 95% CI are calculated using analysis of variance in mixed models accounting for clustering and adjusted for age, sex, and baseline systolic BP. Interaction p for trained GP and HHE=0.003 Jafar TH et al Ann Intern Med 2009

17. Cost per CVD DALYs SAVED Benefit in CVD DALYs saved annually Cost per CVD DALYs averted annually based on Intervention Cost for policy maker *Cost per CVD DALYs annually saved based on cost difference at societal level *Cost per CVD DALYs averted annually based on probabilistic sensitivity analysis at societal level 20%115 12261208 16%144 15321510 12%192 20432014 10%230 24512416 Jafar TH et al Circulation 2011

18. Implications for other low-resource settings Example in low income communities in the US-  cost-effective in Georgia, US, where BP control rates of 68% were achieved with per-capita expenditure of $7.8 (Anderson GF et al N Engl J Med. 2007;356(3):209-211). Other emerging countries:  Train the trainers intervention for BP control in Kyrgyzstan  Potential for up-scaling Urban health mission in India Bare foot doctors in China Promatoras in Mexico HIV programs in Africa and SE Asia

19. Score Chart for CVD Risk Stratification

20. UMPIRE TRIAL- Multiple Fixed Dose Combination Pill a Treatment effect: relative risk for adherence and mean difference for blood pressure, cholesterol measures, and creatinine b Self-reported use of antiplatelet, statin, and2 blood pressure–lowering drugs. JAMA.JAMA. 2013 Sep 4;310(9):918-29.

21. Integrated Primary Care Strategies to Reduce High Blood Pressure- A Cluster Randomized Trial in Rural Bangladesh, Pakistan, and Sri Lanka MRC/Wellcome Trust/Dfid UK

22. Priority Interventions for NCDs Beaglehole R. et al Lancet 2010

23. UN High Level Meeting on NCD in 2011 and subsequent targets Reduce premature NCD mortality by 25% from 2010 to 2025 – 65 th World Health Assembly 2012 (94 countries)  CVD, respiratory disease, diabetes, cancer WHO proposes to address risk factors to achieve these goal 25 By 25

26. Call to Action-Hypertension control integrated with overall NCD Prevention & Control Powerful advocacy –UN High-Level meeting Sept 18, 19, 2011- MDG, National Health Policy Inter-sectoral approach- Education, Food & Safety Standards, Tobacco Control Unit, Nutrition Unit, Agriculture & Trade, Municipal Planning, Road Safety & Transportation Department, and media Public—private partnerships with emphasis on eliminating inequities in social determinants and improving HTN/NCD care Create synergies with other disease prevention and treatment efforts (HIV/AIDs, MCNH, ID) National strategy and policy-HTN/NCD prevention and detection has to filter down as an integrated health system Implement well coordinated evidence based HTN/NCD care- monitor performance Subsidization of pharmaceutical cost Investment in Research (esp epidemiological and health systems) by govt, NGOs, and industry

27. www.duke-nus.edu.sg Thank You