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4/15/2013
1
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
4/15/2013
2
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
4/15/2013
3
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
4/15/2013
4
Lopez, et.al, Lancet, 2006
WHO, 2005
4/15/2013
5
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
4/15/2013
6
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
4/15/2013
7
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
4/15/2013
8
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
4/15/2013
9
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
4/15/2013
10
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
4/15/2013
11
21
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)
4/15/2013
12
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
4/15/2013
13
WHO Fact Sheet, 2011
WHO Fact Sheet, 2011
4/15/2013
14
WHO Fact Sheet, 2011
WHO Fact Sheet, 2011
4/15/2013
15
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%
4/15/2013
16
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
4/15/2013
17
• 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
4/15/2013
18
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
4/15/2013
19
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
4/15/2013
20
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
4/15/2013
21
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
4/15/2013
22
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
4/15/2013
23
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
4/15/2013
24
4/15/2013
25

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

  • 1. 4/15/2013 1 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
  • 2. 4/15/2013 2 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
  • 3. 4/15/2013 3 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
  • 5. 4/15/2013 5 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
  • 6. 4/15/2013 6 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
  • 7. 4/15/2013 7 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
  • 8. 4/15/2013 8 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
  • 9. 4/15/2013 9 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
  • 10. 4/15/2013 10 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
  • 11. 4/15/2013 11 21 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)
  • 12. 4/15/2013 12 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
  • 13. 4/15/2013 13 WHO Fact Sheet, 2011 WHO Fact Sheet, 2011
  • 14. 4/15/2013 14 WHO Fact Sheet, 2011 WHO Fact Sheet, 2011
  • 15. 4/15/2013 15 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%
  • 16. 4/15/2013 16 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
  • 17. 4/15/2013 17 • 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
  • 18. 4/15/2013 18 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
  • 19. 4/15/2013 19 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
  • 20. 4/15/2013 20 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
  • 21. 4/15/2013 21 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
  • 22. 4/15/2013 22 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
  • 23. 4/15/2013 23 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