The document describes the Global Research Analytics for Population Health (GRAPH) initiative, which aims to develop universal primary prevention packages for each of the World Health Organization regions. The initiative involves a systematic review of existing peer-reviewed research on primary prevention interventions for the top 10 causes of mortality in each region. Interventions are evaluated for methodological quality and compiled into 21 proposed primary prevention packages, with the goal of providing evidence-based recommendations for population-wide disease prevention globally.

1. Global
Research
Analy0cs
for
Popula0on
Health
(GRAPH):
A
Universal
Primary
Preven0on
Ini0a0ve
Liz
Wartella1,
Sabrina
Hermosilla1
PhD
MIA
MS,
Abdul
El-­‐Sayed1
MD
DPhil
1
Columbia
University
Mailman
School
of
Public
Health,
Department
of
Epidemiology
New
York
City
DISCUSSION
REFERENCES
.
1.
Jamison
DT,
Mosley
WH.
Disease
control
priori0es
in
developing
countries:
health
policy
responses
to
epidemiological
change.
American
journal
of
public
health
1991;81(1):15-­‐22.
2.
Hutubessy
R,
Chisholm
D,
Edejer
TT.
Generalized
cost-­‐effec0veness
analysis
for
na0onal-­‐level
priority-­‐seYng
in
the
health
sector.
Cost
effec0veness
and
resource
alloca0on
2003;1(1):8.
3.
Tengs
TO,
Adams
ME,
Pliskin
JS
et
al.
.
Five-­‐hundred
life-­‐saving
interven0ons
and
their
cost-­‐effec0veness.
Risk
Anal
1995;15(3):369-­‐90.
4.
Higgins
J,
Green
S,
editors.
Cochrane
Handbook
for
Systema0c
Review
of
Interven0ons.
Version
5.1.0
[updated
March
2011]
ed:
The
Cochrane
Collabora0on,
2011.
5.
Guyac
GH,
Oxman
AD,
Vist
GE
et
al.
.
GRADE:
an
emerging
consensus
on
ra0ng
quality
of
evidence
and
strength
of
recommenda0ons.
BMJ
2008;336(7650):
924-­‐6.
6.
Downs
SH,
Black
N.
The
feasibility
of
crea0ng
a
checklist
for
the
assessment
of
the
methodological
quality
both
of
randomised
and
non-­‐randomised
studies
of
health
care
interven0ons.
Journal
of
epidemiology
and
community
health
1998;52(6):377-­‐384.
7.
Wells
G,
Shea
B,
O’connell
D
et
al.
.
The
Newcastle-­‐Ocawa
Scale
(NOS)
for
assessing
the
quality
of
nonrandomised
studies
in
meta-­‐analyses.
2000.
8.
Fitzgerald
A,
Coop
C.
Valida0on
and
modifica0on
of
the
graphical
appraisal
tool
for
epidemiology
(GATE)
for
appraising
systema0c
reviews
in
evidence-­‐based
guideline
development.
Health
Outcomes
Research
in
Medicine
2011;2(1):e51-­‐e59.
9.
Kelly
M,
Morgan
A,
Ellis
S
et
al.
.
Evidence
based
public
health:
a
review
of
the
experience
of
the
Na0onal
Ins0tute
of
Health
and
Clinical
Excellence
(NICE)
of
developing
public
health
guidance
in
England.
Social
science
&
medicine
2010;71(6):1056-­‐1062.
BACKGROUND
• Primary
preven0on
efforts
are
well
recognized
for
their
poten0al
in
preven0ng
disease
and
securing
global
economic
and
social
welfare
if
broadly
implemented.
• There
is
strong
current
advocacy
for
the
inclusion
of
a
popula0on-­‐wide
preven0on
package
as
a
part
of
universal
health
coverage
by
organiza0ons
such
as
the
World
Health
Organiza0on
(“best-­‐buy”
package)
and
by
a
recent
global
health
2035
Lancet
commission
report.
• The
grounding
for
such
recommenda0ons
is
limited
by
a
lack
of
rigorous
evalua0on
of
the
efficacy
of
many
primary
preven0on
ini0a0ves
and
their
methodologies.
Excep0ons
include
the
Disease
Control
Priori0es
in
Developing
Countries
(DCPDC)
project1;
the
WHO-­‐CHOosing
Interven0ons
that
are
Cost-­‐Effec0ve
(WHO-­‐CHOICE)
project2;
and
the
Harvard
Lifesaving
Study3.
OBJECTIVE
METHODS
Step
1:
IdenAfying
Proximal
Modifiable
Risk
Factors
• Reviewed
and
compiled
list
of
top
10
causes
of
death
in
2013
by
WHO
region.
• List
organized
by
rela0ve
mortality
burden.
Step
2:
SystemaAc
Review
• Researched
exis0ng
peer
reviewed
and
review
reports
for
all
primary
preven0on
methods
(published
2010-­‐2014)
and
catalogued
in
Medline
(searched
via
PubMed.gov).
• Subcategories
based
on
main
cause
of
death,
49
causes
of
death
and
25
risk
factors
for
causes
of
death.
• From
52,419
cita0ons
ini0ally
screened,
1,388
(2.6%)
rigorous
efficacious
interven0ons
were
iden0fied.
Step
3:
SystemaAc
EvaluaAon:
• Crea0on
of
a
quality
ranking
score
for
interven0ons
informed
by
bias
assessment
tools
from
the
Cochrane
Collabora0on’s
review
process4;
GRADE
quality
assessment
tool5;
Downs
and
Black
scale6;
Newcastle
Ocawa
scale7;
and
NICE
guidelines
for
quality
assessment
(GATE
checklist)8,9.
• Quality
score
range
0
to
17
with
maximum
with
6
points
to
sample
selec0on
and
recruitment,
5
points
to
study
design,
4
points
for
interven0on
assessment,
and
1
for
analy0c
techniques.
Step
4:
IdenAfy
Primary
PrevenAon
Packages
for
Top
10
Causes
of
Mortality
per
WHO
Region
• Iden0fied
and
composed
21
primary
preven0on
packages
(one
for
each
WHO
region),
drawing
on
77
unique
primary
preven0on
interven0on
protocols.
Rigorous
published
interven0on
evalua0ons
not
equally
available
across
WHO
region.
• In
the
final
packages
interven0ons
were
included
that
were
not
published
within
the
region,
when
necessary,
giving
first
priority
to
high
quality
interven0ons
that
were
published
within
the
same
WHO
super-­‐region,
and
if
that
was
not
possible
then
iden0fying
the
most
rigorous
interven0on
for
that
cause
of
death
that
has
been
published,
irrespec0ve
of
the
study
sample
region.
RESULTS
• Iden0fy
a
set
of
evidence-­‐based
primary
preven0on
methods
that
could
be
included
as
part
of
a
universal
health
coverage
plan
in
order
to
achieve
global
health
equity.
FIGURE
1:
Mean
interven0on
quality
score
for
top
10
causes
of
death,
globally
FIGURE
2:
Select
interven0ons
for
top
10
causes
of
death,
globally
• Mean
quality
scores
for
interven0ons
for
top
10
causes
of
death,
globally
are
Cardiovascular
disease:
4.29;
Prematurity
and
low
birth
weight:
5.30;
Ischemic
heart
disease:
5.59;
Cerebrovascular
disease:
5.90;
Trachea
bronchus,
lung
cancers:
6.13;
Chronic
obstruc0ve
pulmonary
disease:6.6;
Diabetes:
5.42;
Road
traffic
accidents:
4.13;
Hypertensive
heart
disease:
4.63;
HIV/AIDS:
5.42
(Figure
1)
• Select
interven0ons
for
top
10
causes
of
death,
globally
are
included
in
Figure
2
• Select
interven0ons
for
top
10
causes
of
death
for
21
WHO
regions
and
primary
preven0on
packages
included
in
forthcoming
report
• Regional
reports
include
the
top
ten
causes
of
death
in
2013,
top
3
interven0ons
per
cause
of
death,
summary
quality
scores,
and
select
interven0on
descrip0ons
• The
global
burden
of
disease
follows
historical
epidemiologic
trend
with
the
distribu0on
of
infec0ous
and
chronic
disease
• The
interven0on
packages
highlight
the
2013
global
and
regional
burdens
of
disease,
the
quality
and
epidemiologic
rigor
of
the
exis0ng
primary
preven0on
interven0ons,
and
where
there
is
a
lack
of
published
interven0ons
and
other
missing
data
• Findings
can
be
used
to
inform
prac00oners,
policy
makers,
donors,
future
research
and
organiza0ons
on
the
poten0al
for
a
popula0on-­‐wide
preven0on
package
as
a
part
of
universal
health
coverage
• Men0oned
here
are
the
global
interven0ons,
and
the
final
report
(forthcoming)
includes
all
regional
packages
and
can
serve
as
evidence
for
a
universal
primary
preven0on
package
with
an
overarching
goal
of
global
health,
economic,
and
social
equity
0
2
4
6
8
10
Quality
score
1.Cardiovascular
disease
2.
Prematurity
3.Ischemic
heart
disease
4.
CVD
5.
Trachea,
bronchus,
lung
cancers
6.
COPD
7.
Diabetes
8.
Road
traffic
accidents
9.
Hypertensive
heart
disease
10.
HIV/AIDS
TABLE
1:
Top
10
Causes
of
death
by
global
region,
Global
Burden
of
Disease,
2013
!!
Causes!
Region! 1! 2! 3! 4! 5! 6! 7! 8! 9! 10!
North!America,!High!Income! A! C! E! K! G! F! D! B! H! I!
Asia!Pacific,!High!Income! A! F! D! B! E! C! G! I! L! M!
Australasia! A! N! C! E! G! K! F! D! B! O!
Europe,!Central! A! C! D! E! F! K! G! I! N! P!
Europe,!Western! A! C! E! D! K! F! G! B! I! O!
Europe,!Eastern! A! C! D! L! E! H! B! K! F! I!
Oceania! O! N! B! A! G! C! F! H! E! Q!
Asia,!East! A! D! E! C! I! F! H! G! B! R!
Asia,!Central! A! C! D! B! N! F! I! H! E! G!
Asia,!Southeast! A! B! D! C! G! F! O! H! I! E!
Asia,!South! B! A! F! C! E! S! D! H! G! J!
Latin!America,!Andean! B! A! N! F! H! G! C! T! D! E!
Latin!America,!Central! A! G! B! C! H! U! F! T! L! D!
Latin!America,!Tropical! A! B! C! G! F! D! H! U! E! L!
Latin!America,!Southern! A! F! C! B! N! G! E! D! H! K!
Caribbean! A! B! N! C! G! D! F! H! I! E!
North!Africa!and!Middle!East! A! B! C! G! D! F! H! E! I! V!
SubVSaharan!Africa,!Central! B! F! W! A! N! J! Q! S! V! G!
SubVSaharan!Africa,!Eastern! B! J! A! W! F! S! Q! N! H! X!
SubVSaharan!Africa,!Southern! B! J! A! N! F! G! D! H! S! X!
SubVSaharan!Africa,!Western! B! W! S! H! F! J! A! N! V! G!
Global! A! B! C! D! E! F! G! H! I! J!
A
Cardiovascular
Disease
B
Prematurity
and
low
birth
weight
C
Ischemic
heart
disease
D
Cerebrovascular
disease
E
Trachea,
bronchus,
lung
cancers
F
Chronic
obstruc0ve
pulmonary
disease
G
Diabetes
H
Road
traffic
accidents
I
Hypertensive
heart
disease
J
HIV/AIDS
K
Neurodegenera0ve
disorder
L
Self-­‐inflicted
injuries
M
Stomach
cancer
N
Birth
asphyxia
and
birth
trauma
O
Colon
and
rectum
cancers
P
Inflammatory
heart
disease
Q
Diarrheal
diseases
R
Hepa00s
S
Neonatal
infec0ons
T
Renal
disease
U
Violence
V
Congenital
disease
W
Malaria
X
Tuberculosis
1.
Cardiovascular
disease
Meuormin
or
intensive
lifestyle
change
Diet
program
(protein)
Lifestyle
counseling
2.
Prematurity
and
lower
birth
weight
Mul0ple
micronutrient
supplementa0on
Micronutrient
supplementa0on,
daily
in
healthy
women
Mebendazole
3.
Ischemic
heart
disease
Clopidogrel
Exercise
promo0onal
campaign
Rehabilita0on
with
family
support
4.
Cerebrovascular
disease
Weight-­‐bearing
exercise
program
Health
belief
model
based
mo0va0on
Tailored
dietary
advice
and
educa0on
5.
Trachea,
bronchus,
and
lung
cancers
Nurse
consulta0on
and
self-­‐help
manual
Mo0va0onal
interviewing
State
cigarece
taxes
6.
Chronic
obstruc0ve
pulmonary
disease
Azithromycin
Tiotropium
Smoking
cessa0on,
doctor
consulta0on
7.
Diabetes
Meuormin
Tailored
dietary
advice
and
educa0on
Pioglitazone
8.
Road
traffic
accidents
Driving
educa0on
session
Helmet
promo0on,
cyclists
Designated
driver
program
9.
Hypertensive
heart
disease
Familial
risk
assessment
Nurse
care
management
Losartan-­‐based
hypertensive
treatment
10.
HIV/AIDS
Mo0va0onal
interviewing
Mo0va0onal
incen0ves
Familial
HIV
risk
reduc0on
in
adolescents