NSM-NCD2013 Symposium 1 - Non-communicable Diseases in Asean - Current Situation and Future Prospect
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NSM-NCD2013 Symposium 1 - Non-communicable Diseases in Asean - Current Situation and Future Prospect

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By Prof Dato' Khalid Yusoff

By Prof Dato' Khalid Yusoff

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NSM-NCD2013 Symposium 1 - Non-communicable Diseases in Asean - Current Situation and Future Prospect NSM-NCD2013 Symposium 1 - Non-communicable Diseases in Asean - Current Situation and Future Prospect Document Transcript

  • 4/15/20131Noncommunicable diseases in ASEAN:Current situation, future prospectsKhalid YusoffUniversiti Teknologi MARAMalaysiaFigure 4Source: The Lancet 2012; 379:413-431 (DOI:10.1016/S0140-6736(12)60034-8)Terms and ConditionsThe Tropics
  • 4/15/20132Tropical Countries – tropical diseases:A legacy….MalariaTuberculosisLeprosyWaterborne diseasesParasitic diseasesHIV/AIDSDengue……… Tropical diseasesHigh infant / maternity mortalityFigure 2Trends in global malaria deaths by age and geographical region, 1980 to 2010 CJL Murray, et al.The Lancet 2012; 379:413-431Terms and Conditio
  • 4/15/20133Malaria in MalaysiaDeaths of adults due to MalariaNumber of deaths (cummulative probability of deaths per 1000 pop)1980 1990 2000 2010Madagascar 2232 (41.3) 4806 (67.6) 7149 (77.5) 14,200 (128.2)Malawi 1106 ( 28.8) 4670 (78.3) 4933 (60.0) 48,476 (51.8)Malaysia 175 (2.1) 88 (0.8) 43 (0.3) 20 (0.1)Mali 3106 (68.7) 3690 (71.7) 6416 (99.1) 10,424 (128.9)CRL Murray, et al. Lancet 2012; 392: 413 - 433Lopez, et.al, Lancet, 2006
  • 4/15/20134Lopez, et.al, Lancet, 2006WHO, 2005
  • 4/15/2013510 Leading Risk Factors for Death: WorldRisk Factor Deaths (millions) Percentage of Total1. High blood pressure 7.5 12.82. Tobacco use 5.1 8.73. High blood glucose level 3.4 5.84. Physical inactivity 3.2 5.55. Overweight and obesity 2.8 4.86. High cholesterol level 2.6 4.57. Unsafe sex 2.4 4.08. Alcohol use 2.3 3.89’. Childhood underweight 2.1 3.810 Indoor smoke from solid fuels 2.0 3.3 WHO, 200910 Leading Risk Factors for Death: LICRisk Factor Deaths (millions) Percentage of Total1. Childhood underweight 2.0 7.82. High blood pressure 2.0 7.53. Unsafe sex 1.7 6.64. Unsafe water and poor nutritionand hygiene1.6 6.15. High blood glucose 1.3 4.96. Indoor smoke from solid fuels 1.3 4.87. Tobacco use 1.0 3.98. Physical inactivity 1.0 3.89’. Suboptimal breast-feeding 1.0 3.710. High cholesterol level 0.9 3.4 WHO, 2009
  • 4/15/2013610 Leading Risk Factors for Death: MICRisk Factor Deaths (millions) Percentage of Total1. High blood pressure 4.2 17.22. Tobacco use 2.6 10.83. Overweight and obesity 1.6 6.74. Physical inactivity 1.6 6.65. Alcohol use 1.6 6.46. High blood glucose 1.3 6.37. High cholesterol level 1.3 5.28. Low fruit and vegetable intake 0.9 3.99’. Indoor smoke from solid fuels 0.7 2.810. Urban outdoor air pollution 0.7 2.822% of global NCD deaths occur in the 11 SEA countries; 8 million deaths per year.34% of NCD deaths in SEA < 60 y.o (cf. 25% globally)21% increase in NCD deaths over the next 10 yearsWHO, 2011
  • 4/15/20137Total Cardiovascular Disease : DeathsGovernment Hospital 1985 - 20006205605859596221633665746475653563526715707172497496730775597812Ischaemic Heart Disease Mortality Rate inMalaysiaDisease 1998 1999 2000Ischaemicheartdisease8.89 9.19 10.18Source : Malaysia’s Health 2001IHD Mortality rate in Government Hospitals per 100 000population is increasing
  • 4/15/20138Association of risk factors with acute myocardial infarction in menand women after adjustment for age, sex, and geographic regionYusuf et.al., Lancet 2004
  • 4/15/20139The RaubHeart StudyPrevalence of Hypertension,Diabetes and Obesity1993 1998MalesHypertension 26.2 30.6Diabetes 4.4 4.7Obesity 3.1 5.2Overweight 17.7 30.9FemalesHypertension 29.4 31.7Diabetes 3.5 7.5Obesity 10.5 12.3Overweight 25.3 31.1Nawawi, J CVR 2002
  • 4/15/201310PURE / REDISCOVER Studies:Community profiling of coronary risk factors -Urban – rural ‘divide’, impact of urbanisationKeterehJeliPekanMoribKL & SA Total: 12294Urban: 6390Rural: 5904Males: 5369Females: 6925SibuRaubK. MaruduPURE / REDISCOVER StudiesPrevalences of Risk Factors by 2012RISK FACTORS N=12,234 Overall Males Females Urban RuralHypertensionN=11,742 (95.5%)50.0 51.7 46.7 45.9 49.6Diabetes (FG > 7.0 mmol/L)N= 10091 (82.1%)15.5 17.7 13.9 17.0 13.8Hyperlipidaemia (TC > 6.5 mmo/l)N= 10,294 (83.3%)30.8 31.8 30.0 34.6 26.3Low HDL ( < 1.0 mmol/L)N= 10169 (83.1 %)23.1 33.8 15.1 20.3 26.4Body mass index N=11,691 (95.1%)Overweight (BMI: 23.0 – 27.49)Obesity (BMI >27.0)38.333.642.230.135.336.340.236.736.230.3Waist-Hip ratio, N= 11671 (94.9%)males > 0.9, females > 0.866.2 60.1 70.8 66.4 65.9Smoking, N = 11,464 (93.2%)CurrentPrevious13.011.127.022.22.32.510.710.715.511.5
  • 4/15/20131121Projection of Risk Factor BurdenNote: Based on NHMS2 1996. Prevalence rate increase proportionately.DiseaseBurden1996NHMS22002 2006 2010 2020HPT 2,190,504(29.9%)3,476,435(39.5%)4,383,450(45.9%)5,226,300(52.3%)8,126,100(68.3%)DM 608,000(8.3%)836,200(9.5%)983,650(10.3%)1,109,200(11.1%)1,558,600(13.1%)THE RISING EPIDEMIC OF HYPERTENSIONNational Health Morbidity & Mortality Surveys I, II & III (1986-2006)
  • 4/15/201312Figure 1. Global mortality and burden of cardiovascular disease and major risk factors for people aged30 years Kaplan et.al, Lancet 2006Figure 7. Risk of acute myocardial infarction associated with self-reported hypertension, overall and by regionafter adjustment for age, sex, and smokingYusuf et.al., Lancet 2004
  • 4/15/201313WHO Fact Sheet, 2011WHO Fact Sheet, 2011
  • 4/15/201314WHO Fact Sheet, 2011WHO Fact Sheet, 2011
  • 4/15/201315WHO Fact Sheet, 2011AWARENESS,TREATMENT & CONTROLOF HYPERTENSION0%5%10%15%20%25%30%35%40%Awareness Treatment Control33%23%26%36%32%26%NHMS IINHMS IIINational Health Morbidity Surveys (NHMS) II (1996) & III (2006)NHMS III: OVERALL RATE OF CONTROL OF HT IS 8.2%
  • 4/15/201316BP Control among hypertensivesPts > 18 yrs from 23 centresPre-JNC-7 Post-JNC-7 p value(Jun 98 – Mar 03) (Dec 03-Apr 06)N 15,359 2,012Mean age (yrs) 61.5 62.3Females (%) 56.2 65.0Hyperlipidaemia 52.4 59.5 <0.0001Diabetes 22.1 27.0 <0.0001BP control (%) 39.3 53.2 <0.0001BP control w DM 16.7 29.2 <0.0001No Rx 21.4 6.4Monotherapy 45.8 36.7Dual therapy 23.2 37.3>Triple therapy 9.6 19.6Diuretics 24.8 32.9 <0.0001Beta-blockers 22.0 25.4 0.0007ACE inhibitors 21.9 23.6 NSCaCBs 20.9 23.6 NSFixed dose combo 10.1 26.7 <0.0001Jackson, et al. AHA Circ 2006; 114: II - 828Periera M, et al. JH 2009;27:963-5
  • 4/15/201317• Blood pressure is the biggest global risk factor fordisease, followed by tobacco, alcohol, and poordiet.Richard HortonLancet 2012; 380: 2053 -54Future prospects?• NCDs are dominating health-care needs in SEA• Health systems are currently ill-equipped totackle NCDs• Lack of access to affordable medicines andhealth-care servicesWHO, 2011
  • 4/15/201318New approaches to controlling HT• Polypill• Task shifting- GACD grant from Grand Challenges Canada:Malaysia (UiTM and Ministry of Health), Columbia, McMaster andToronto Universities, LSH&TM (HOPE-4 Study; 50 communities )• Identifying individuals with hypertension:community screening and programmesFord, et.al., NEJM 2007
  • 4/15/201319Epidemics – treated by town plannersand sociologists!• Plaques of Europe, ‘Black death’London: 1603, 1625, 1665Yersinia pestisRodents esp rats• Rheumatic fever - rheumatic heart diseaseControlled before advent of effective antibiotics- better housing, less congestion, less slums, improvesewerage, increase natural lighting, better nutrition, cleanwater, better hygiene, ….‘25 by 25’ NCD GoalTen targets:• Blood pressure control• Tobacco smoking cessation• Salt intake reduction• Increase in physical activity• Obesity control• Reduction in fat intake• Reduction in alcohol consumption• Reduction in total cholesterol• Availability of generic drugs and basic technologies• Availability of drug therapy to prevent heart attacks andstrokes
  • 4/15/201320Choice of targets depend on…• Strong scientific basis• Sensitivity to change• Major impact on NCD mortality• Achievable with cost-effective interventions• Assessing progressBeaglehole, et al. 2012Chose: Cigarette smoking, salt reduction, multi-drugtherapy, alcohol reduction and physical inactivityWhat would it be for SEA?Cooney, et alJACC 2009
  • 4/15/201321A turning point….• Epidemiologic transition• Need good data… not just recording whathappens but anticipate what can happen andtest ways to best handle the future• Overcome silo’s, be interdependent; create anAlliance across the SEAR?• Reach-out: Communicate with the public andengage institutions (MOH, IHLs, politicians,…)• Prepare appropriate work forceThank youAcknowledgements: PURE REDISCOVER Team,Ministry of Higher Education, Ministry of HealthMinistry of Science, Technology and Innovation
  • 4/15/201322Cost of Managing Stroke• Per admission treating stroke (withoutcomplications)* - RM3,420• Per admission treating stroke (with minorcomplications) - RM4,276• Per admission treating stroke (withmajor complications) - RM6,129• Managing stroke in 2010 – at leastRM101.6 MillionMinistry of Health stats
  • 4/15/201323Cost of Managing ESRD• The cost of dialysis in MOH facility, per patientper year in 2005 - RM33,000• The total cost to the country to treathypertensive patients that needed dialysis inyear 2011 - RM318.3 millionMinistry of Health statsLIMIC have 5% of the finances to deal with 80% ofthe burden of cancer- Knaul, et a. Harvard Global Equity Initiative 2012: 3 - 28
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