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Noncommunicable diseases in ASEAN: Current situation, future prospects

Khalid Yusoff

Universiti Teknologi MARA

Malaysia

Figure 4

Source: The Lancet 2012; 379:413-431 (DOI:10.1016/S0140-6736(12)60034-8)

Terms and Conditions

The Tropics

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Tropical Countries – tropical diseases: A legacy….

Malaria Tuberculosis Leprosy Waterborne diseases Parasitic diseases HIV/AIDS Dengue ……… Tropical diseases High infant / maternity mortality

Figure 2

Trends in global malaria deaths by age and geographical region, 1980 to 2010 CJL Murray, et al.The Lancet 2012; 379:413-431

Terms and Conditio

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Malaria in Malaysia Deaths of adults due to Malaria

Number of deaths (cummulative probability of deaths per 1000 pop)

1980 1990 2000 2010

Madagascar 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 - 433

Lopez, et.al, Lancet, 2006

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Lopez, et.al, Lancet, 2006

WHO, 2005

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10 Leading Risk Factors for Death: World

Risk Factor Deaths (millions) Percentage of Total

1. High blood pressure 7.5 12.8

2. Tobacco use 5.1 8.7

3. High blood glucose level 3.4 5.8

4. Physical inactivity 3.2 5.5

5. Overweight and obesity 2.8 4.8

6. High cholesterol level 2.6 4.5

7. Unsafe sex 2.4 4.0

8. Alcohol use 2.3 3.8

9’. Childhood underweight 2.1 3.8

10 Indoor smoke from solid fuels 2.0 3.3 WHO, 2009

10 Leading Risk Factors for Death: LIC

Risk Factor Deaths (millions) Percentage of Total

1. Childhood underweight 2.0 7.8

2. High blood pressure 2.0 7.5

3. Unsafe sex 1.7 6.6

4. Unsafe water and poor nutrition and hygiene

1.6 6.1

5. High blood glucose 1.3 4.9

6. Indoor smoke from solid fuels 1.3 4.8

7. Tobacco use 1.0 3.9

8. Physical inactivity 1.0 3.8

9’. Suboptimal breast-feeding 1.0 3.7

10. High cholesterol level 0.9 3.4 WHO, 2009

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10 Leading Risk Factors for Death: MIC

Risk Factor Deaths (millions) Percentage of Total

1. High blood pressure 4.2 17.2

2. Tobacco use 2.6 10.8

3. Overweight and obesity 1.6 6.7

4. Physical inactivity 1.6 6.6

5. Alcohol use 1.6 6.4

6. High blood glucose 1.3 6.3

7. High cholesterol level 1.3 5.2

8. Low fruit and vegetable intake 0.9 3.9

9’. Indoor smoke from solid fuels 0.7 2.8

10. Urban outdoor air pollution 0.7 2.8

22% 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 years WHO, 2011

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Total Cardiovascular Disease : Deaths

Government Hospital 1985 - 2000

6205

6058

5959

6221

6336

6574

6475

6535

6352

6715 7071

7249 7496

7307

7559

7812

Ischaemic Heart Disease Mortality Rate in Malaysia

Disease 1998 1999 2000

Ischaemic heart

disease

8.89 9.19 10.18

Source : Malaysia’s Health 2001

IHD Mortality rate in Government Hospitals per 100 000 population is increasing

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Association of risk factors with acute myocardial infarction in men and women after adjustment for age, sex, and geographic region

Yusuf et.al., Lancet 2004

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The Raub Heart Study

Prevalence of Hypertension, Diabetes and Obesity 1993 1998 Males Hypertension 26.2 30.6 Diabetes 4.4 4.7 Obesity 3.1 5.2 Overweight 17.7 30.9 Females Hypertension 29.4 31.7 Diabetes 3.5 7.5 Obesity 10.5 12.3 Overweight 25.3 31.1

Nawawi, J CVR 2002

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PURE / REDISCOVER Studies:

Community profiling of coronary risk factors -

Urban – rural ‘divide’, impact of urbanisation

Ketereh Jeli

Pekan

Morib

KL & SA Total: 12294 Urban: 6390 Rural: 5904 Males: 5369

Females: 6925

Sibu

Raub

K. Marudu

PURE / REDISCOVER Studies Prevalences of Risk Factors by 2012

RISK FACTORS N=12,234 Overall Males Females Urban Rural

Hypertension N=11,742 (95.5%)

50.0 51.7 46.7 45.9 49.6

Diabetes (FG > 7.0 mmol/L)

N= 10091 (82.1%)

15.5 17.7 13.9 17.0 13.8

Hyperlipidaemia (TC > 6.5 mmo/l)

N= 10,294 (83.3%)

30.8 31.8 30.0 34.6 26.3

Low HDL ( < 1.0 mmol/L)

N= 10169 (83.1 %)

23.1 33.8 15.1 20.3 26.4

Body mass index N=11,691 (95.1%)

Overweight (BMI: 23.0 – 27.49) Obesity (BMI >27.0)

38.3 33.6

42.2 30.1

35.3 36.3

40.2 36.7

36.2 30.3

Waist-Hip ratio, N= 11671 (94.9%)

males > 0.9, females > 0.8

66.2 60.1 70.8 66.4 65.9

Smoking, N = 11,464 (93.2%)

Current Previous

13.0 11.1

27.0 22.2

2.3 2.5

10.7 10.7

15.5 11.5

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Projection of Risk Factor Burden

Note: Based on NHMS2 1996. Prevalence rate increase proportionately.

Disease Burden

1996 NHMS2

2002 2006 2010 2020

HPT 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 HYPERTENSION

National Health Morbidity & Mortality Surveys I, II & III (1986-2006)

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Figure 1. Global mortality and burden of cardiovascular disease and major risk factors for people aged

30 years

Kaplan et.al, Lancet 2006

Figure 7. Risk of acute myocardial infarction associated with self-reported hypertension, overall and by region

after adjustment for age, sex, and smoking

Yusuf et.al., Lancet 2004

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WHO Fact Sheet, 2011

WHO Fact Sheet, 2011

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WHO Fact Sheet, 2011

WHO Fact Sheet, 2011

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WHO Fact Sheet, 2011

AWARENESS, TREATMENT & CONTROL OF HYPERTENSION

0%

5%

10%

15%

20%

25%

30%

35%

40%

Awareness Treatment Control

33%

23% 26%

36%

32%

26%

NHMS II

NHMS III

National Health Morbidity Surveys (NHMS) II (1996) & III (2006)

NHMS III: OVERALL RATE OF CONTROL OF HT IS 8.2%

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BP Control among hypertensives Pts > 18 yrs from 23 centres

Pre-JNC-7 Post-JNC-7 p value (Jun 98 – Mar 03) (Dec 03-Apr 06)

N 15,359 2,012 Mean age (yrs) 61.5 62.3 Females (%) 56.2 65.0 Hyperlipidaemia 52.4 59.5 <0.0001 Diabetes 22.1 27.0 <0.0001 BP control (%) 39.3 53.2 <0.0001 BP control w DM 16.7 29.2 <0.0001 No Rx 21.4 6.4 Monotherapy 45.8 36.7 Dual therapy 23.2 37.3 >Triple therapy 9.6 19.6 Diuretics 24.8 32.9 <0.0001 Beta-blockers 22.0 25.4 0.0007 ACE inhibitors 21.9 23.6 NS CaCBs 20.9 23.6 NS Fixed dose combo 10.1 26.7 <0.0001

Jackson, et al. AHA Circ 2006; 114: II - 828

Periera M, et al. JH 2009;27:963-5

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• Blood pressure is the biggest global risk factor for disease, followed by tobacco, alcohol, and poor diet.

Richard Horton

Lancet 2012; 380: 2053 -54

Future prospects?

• NCDs are dominating health-care needs in SEA

• Health systems are currently ill-equipped to tackle NCDs

• Lack of access to affordable medicines and health-care services

WHO, 2011

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New approaches to controlling HT

• Polypill

• Task shifting - GACD grant from Grand Challenges Canada:

Malaysia (UiTM and Ministry of Health), Columbia, McMaster and Toronto Universities, LSH&TM (HOPE-4 Study; 50 communities )

• Identifying individuals with hypertension:

community screening and programmes

Ford, et.al., NEJM 2007

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Epidemics – treated by town planners and sociologists!

• Plaques of Europe, ‘Black death’

London: 1603, 1625, 1665

Yersinia pestis

Rodents esp rats

• Rheumatic fever - rheumatic heart disease

Controlled before advent of effective antibiotics

- better housing, less congestion, less slums, improve sewerage, increase natural lighting, better nutrition, clean water, better hygiene, ….

‘25 by 25’ NCD Goal Ten 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 and strokes

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Choice of targets depend on…

• Strong scientific basis

• Sensitivity to change

• Major impact on NCD mortality

• Achievable with cost-effective interventions

• Assessing progress

Beaglehole, et al. 2012

Chose: Cigarette smoking, salt reduction, multi-drug therapy, alcohol reduction and physical inactivity

What would it be for SEA?

Cooney, et al JACC 2009

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A turning point…. • Epidemiologic transition

• Need good data… not just recording what happens but anticipate what can happen and test ways to best handle the future

• Overcome silo’s, be interdependent; create an Alliance across the SEAR?

• Reach-out: Communicate with the public and engage institutions (MOH, IHLs, politicians,…)

• Prepare appropriate work force

Thank you

Acknowledgements: PURE REDISCOVER Team,

Ministry of Higher Education, Ministry of Health Ministry of Science, Technology and Innovation

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Cost of Managing Stroke

• Per admission treating stroke (without complications)* - RM3,420

• Per admission treating stroke (with minor complications) - RM4,276

• Per admission treating stroke (with major complications) - RM6,129

• Managing stroke in 2010 – at least RM101.6 Million

Ministry of Health stats

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Cost of Managing ESRD

• The cost of dialysis in MOH facility, per patient per year in 2005 - RM33,000

• The total cost to the country to treat hypertensive patients that needed dialysis in year 2011 - RM318.3 million

Ministry of Health stats

LIMIC have 5% of the finances to deal with 80% of the burden of cancer

- Knaul, et a. Harvard Global Equity Initiative 2012: 3 - 28

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