1. … BE IT FURTHER RESOLVED, that the Policy on NCDs shall include benchmarks for ending the Regional State of Health Emergency; … BE IT FURTHER RESOLVED, that the Policy shall provide clear justification for its goals, including clear, accurate and referenced data on NCDs and their impact ; … BE IT FURTHER RESOLVED, that the Regional approach to NCDs shall integrate effectively with other regional, national and local NCD policies and plans;

2. Adaptation & Implementation Policies (Laws, regs, school, govt agency, church, traditional leader policies) USAPI Health Professional Associations Youth Risks (obesity, tobacco, alcohol) Environments Clinical Services Adults Risks Adults Illness (hypertension, diabetes, cholesterol, lung & vascular disease) Primary Care Advocacy Health Education & Promotion Ministers, Secretaries, Directors of Health Hospital Services Outcomes Stroke, dialysis, heart attacks, cancer, amputations, hospitalizations, death Regional Bodies & Mechanisms for Control of NCDs APIL, MCIS, Trad Leaders, Religious Leaders NCD Surveillance & Monitoring Framework & Plans

3. NCD Burden- Impact of Interventions Sources: Franks P, et. al. JAMA, 27(6):737-741. 1993. McGinnis J, et. al. Health Affairs. 21(2) 2002

4. Timeline, USAPI Regional NCD Response, 2010-14

5. THE COMMITMENT: Fifteen Essential Policies for Reversing the Epidemic of Non-Communicable Diseases in PIHOA jurisdictions Risk Factor: Tobacco Commitment 1: Increase taxes on tobacco products (to extent needed to offset costs)* Commitment 2: Pass and enforce model comprehensive smoke-free air acts * Commitment 3: Restrict all forms of tobacco product advertising* Commitment 4: Establish and sustain tobacco cessation programs Risk Factor: Alcohol Commitment 5: Restrict all forms of alcohol advertising* Commitment 6: Restrict access to alcohol* Commitment 7: Increase taxes on alcohol (to extent needed to offset costs)* Risk Factor: Poor Nutrition Commitment 8: Implement policies that reduce salt consumption* Commitment 9:Implement policies that reduce sugar consumption Commitment 10:Implement policies that reduce fat consumption* Commitment 11:Implement policies that promote breastfeeding Commitment 12: Implement policies that promote local foods Risk Factor: Lack of Physical Activity Commitment 13: Develop the built environment to promote physical activity Commitment 14: Promote physical activity in the work place [reconsider] Commitment 15: Promote physical activity in the schools *WHO “Best Buys”

6. NCD Policy Toolkit

7. Regional Road Map for Ending the Epidemic of Non- Communicable Diseases In the United States Affiliated Pacific Islands Version 9 Updated May 22, 2013 1

9. Adaptation & Implementation Policies (Laws, regs, school, govt agency, church, traditional leader policies) Health Leadership Council Roadmap USAPI Professional Associations Youth Risks (obesity, tobacco, alcohol) NCD Policy Commitment Package (includes WHO “Best Buys”) Environments Clinical Services NCD Policy Tool Kit (model laws, regs, policies) Adults Risks Adults Illness (hypertension, diabetes, cholesterol, lung & vascular disease) Primary Care Advocacy Health Education & Promotion Clinical Guidelines, Chronic care delivery systems (WHO PEN, JNC, ADA, etc.) Ministers, Secretaries, Directors of Health Hospital Services Outcomes Stroke, dialysis, heart attacks, cancer, amputations, hospitalizations, death Mechanisms for Control of NCDs Legislators, Exec Branch, Schools,Relig & Trad Leaders NCD Surveillance & Monitoring Framework & Plans

10. 4 major decreases: 1999, 2003, 2005, 2007 Synar Amendment started Cigarette tax increased DMHSA cessation started Natasha Act passed By: Dr. Annette David, SPW & DMHSA PEACE Guam- Youth Tobacco Use

11. USAPI NCD Core Surveillance Indicators TobaccoAlco hol ↑BMI Diseases (adult) Deaths (30-69 years) Cigs- youthCigs- adultChew- YouthChew- adultYouthAdultYouthAdultHTNDM↑CholesterolAll Cause CardiovascularCancerDiabetesChronic Lung Am Samoa↓N↓↑NNNNN CNMI↓N↓N↓N↑↑↑N↓ FSM Chuuk Kosrae Pohnpei YapNNNNN↓N↓N Guam↓↓↑N↓NNNNNN↑N↑↑↑ Palau↑N↓N↓NNN↑↑↑NN RMI↑↓↑↓N ↓ = Improved (rate decreased) N= No change ↑ = Worse (rate increased) Blank= Not enough data

12. Out of 144 measurements: 14=improved, 15=worse, 33=no change, 82=not enough data USAPI NCD Core Surveillance Indicators TobaccoAlco hol ↑BMI Diseases (adult) Deaths (30-69 years) Cigs- youthCigs- adultChew- YouthChew- adultYouthAdultYouthAdultHTNDM↑CholesterolAll Cause CardiovascularCancerDiabetesChronic Lung Am Samoa↓N↓↑NNNNN CNMI↓N↓N↓N↑↑↑N↓ FSM Chuuk Kosrae Pohnpei YapNNNNN↓N↓N Guam↓↓↑N↓NNNNNN↑N↑↑↑ Palau↑N↓N↓NNN↑↑↑NN RMI↑↓↑↓N

13. Take Home Messages Some progress, especially tobacco and alcohol Need to do much better overall Many gaps in surveillance picture, because: At jurisdiction level- > No clear delegation of responsibility at jurisdiction level > Lack of NCD surveillance plans at jurisdiction level At regional level- > Surveillance activities initiated by variety of TA agencies > Very long turn-around time for analysis of some surveys > Vital stats problems

14. Addressing the Gaps- Jurisdiction Level > Clear identification of surveillance teams in your jurisdiction > Nominate members to attend May Palau EpiTech Workshop (or hold similar activity in your jurisdiction) - Jurisdiction-level NCD Surveillance Plan - Technical work to harmonize CDC with WHO stuff - Credited Epi course delivery > Encourage/require enrollment of team members in EpiTech certificate program (for credit!)

15. NCD SURVEILLANCE STYLES- Your Choices: WHO- NCD STEPS - Comparisons across Pacific - Fits well with MANA - Face-to-face survey -Does not fit as easily with CDC programs/HP2020 -Costs to come from country budgets -Analysis support not completely established -Not very flexible CDC- BRFSS - Comparisons with US - Fits well with CDC/HP2020 -Stable external funding -Good analysis support -Flexible -Telephone survey -Does not fit as well with MANA -Not as good for Pacific comparisons BOTH -Comparisons with both US and Pacific -More burden on Depts of Health -Survey fatigue -Difficult to monitor trends

16. NCD SURVEILLANCE STYLES  (Creating another choice) Harmonizing WHO with CDC Styles - Adapt BRFSS (and YRBS) to meet WHO needs as well as US program needs - physical measures - fit with new WHO NCD Surveillance Framework - Secretariats to work more closely to harmonize technical assistance

17. Addressing the Gaps- PIHOA Board Communique to CDC NCDPHP to request: > Assist to provide Epi TA/place epidemiologist in region > BRFSS & YRBS funding support > Adapt BRFSS and YRBS > Help support delivery of EpiTech and Pacific FETP Asking WHO to assist with harmonization of BRFSS & YRBS, and harmonizing TA > ? Formal communique

18. Regional Surveillance TA Entities PPHSN (Pacific Public Health Surveillance Network) - Outbreak prone diseases PHIN (Public Health Information Network) - HIS planning Brisbane Accord Group -Vital stats SAMHSA -Behav Health HIV-STITB, Etc,etc. Counterparts Frameworks Training program Surveillance plans Off-island trips Counterparts Frameworks Training program Surveillance plans Off-island trips Counterparts Frameworks Training program Surveillance plans Off-island trips