1. 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

2. 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

3. 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

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

5. 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

6. 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.

7. 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

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

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

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

11. Per capita expenditure on health (International dollars )
Expenditure Number of countries 33 25 72 24 19 18
Less than 50 $
50 – 99
>2000

12. Few risk factors account for the global burden of cardiovascular disease

13. 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

14. 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

15. Overarching Integrated NCD Policy and National Action Plans

16. 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.

17. 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)

18. 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

19. 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

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

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. WHO/ISH charts Screen for risk of heart attacks and strokesG 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

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

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

30. 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

31. 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

32. 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

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

34. Monitoring Mortality Risk factors Implementation of Policies
Primary care system

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

36. 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.

37. 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 )

38. 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

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

40. Thank you