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Gerald S. Bloomfield, MD, MPH
DGHI,Division of Cardiology,Duke University
September 2013
Non-Communicable Diseases in LMICs:
Myths, Facts and Opportunities
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Trends in selected NCDs in LMICsEpidemiologic transitionData challengesApproaches to NCD research in LMICs
OUTLINE
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CARDIOVASCULAR DISEASE
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Common CVDs: Rheumatic, infectious, pericardial, high BP
Heart failure is endemic in SSA Dilated cardiomyopathy: 48% of admissions Causes: RHD, Hypertension, Peripartum, Idiopathic
Coronary heart disease “distinctly rare”Diagnostic limitations
Lack of specialized investigations Viral, nutritional, familial, alcohol, immune, ischemia
68% of ‘idiopathic’ can be mislabeled
CLASSIC TEACHING ON CARDIOVASCULAR DISEASES IN SSA
RHD = Rheumatic Heart Disease Watkins and Mayosi. Cardiovascular Journal of Africa 2009BP = blood pressure Oyoo and Ogola. East African medical journal 1999
Mokhobo. S Afr Med J 1980
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“Africans are immune to heart/coronary disease”
Ancient Egypt1370 BC
Heavy Heart is a Bad Heart
Kenya.2 years, 1800 patients. 0% HTN, arteriosclerosis
Uganda.2 years0% HTN
Kalahari San. No increase in BP with age
No change in BP with age
Prev. HTN
Ghana 13% Nigeria 25% Lesotho 7%
History of chronic CVD in Africa
1920s 1941 1960 1970s
1976-81901
Uganda. N= 1500“High tension pulses not often met with”
1958-72: 8-11% admissions due to CVD
1980-90s
40% hospital admissions with any CVD
2010:CVD is the 2nd most common cause of death in SSA
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325 migrants, 267 controls followed for 24 months
SBP changes over 24 months
LUO MIGRATION STUDY
Poulter BMJ 1990
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PULMONARY DISEASE
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DEATHS DUE TO PULMONARY DISEASE
Develo
ped 1
990
Develo
ped 2
010
Develo
ping 1
990
Develo
ping 2
010
0500000
100000015000002000000250000030000003500000
ILDPneumoconiosesAsthmaCOPD
www.healthmetricsandevaluation.org 2013
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Adult Smoking Prevalence, 2009
Youth Smoking Prevalence, 2009
Tobacco Control Report from the Region of the Americas 2011
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http://www.who.int/tobacco/en/atlas19.pdf
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PROPORTION OF PATIENTS WITH COPD WHO ARE NON-SMOKERS
USA
Colombia
Brazil
Chile
Mexico
Urugua
y
Vene
zuela
0%
20%
40%
60%
80%
100%
Salvi and Barnes. Lancet 2009
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www.who.int/ceh/publications/en/map09b.jpg
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85% of all global particulate exposure occurs indoors
HAP levels are typically higher than developed world standards for ambient air quality
EPA Standard: 150 micrograms/cubed meter Households with HAP:
300-3000 During cooking 30,000 50x more carbon
monoxide
HOUSEHOLD AIR POLLUTION
HAP in Nigeriahttp://magazine.uchicago.edu/1102/investigations/indoor_air_pollution.shtml
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DIABETES AND HIGH BLOOD SUGAR
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Health Statistics and Informatics
Leading causes of attributable global mortality and burden of disease, 2004
%
1. High blood pressure 12.8
2. Tobacco use8.7
3. High blood glucose 5.8
4. Physical inactivity 5.5
5. Overweight and obesity 4.8
6. High cholesterol 4.5
7. Unsafe sex 4.0
8. Alcohol use3.8
9. Childhood underweight 3.8
10. Indoor smoke from solid fuels 3.3
59 million total global deaths in 2004
%
1. Childhood underweight 5.9
2. Unsafe sex4.6
3. Alcohol use4.5
4. Unsafe water, sanitation, hygiene 4.2
5. High blood pressure3.7
6. Tobacco use3.7
7. Suboptimal breastfeeding 2.9
8. High blood glucose 2.7
9. Indoor smoke from solid fuels 2.7
10. Overweight and obesity 2.3
1.5 billion total global DALYs in 2004
Attributable Mortality Attributable DALYs
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EPICENTERS OF DIABETES
Deaths from diabetes
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Hu. Diabetes Care 2011
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The Epidemiologic TransitionDescription Life
Expectancy% deaths from CV
Dominant CVDs
Stage 1 Pestilence and Famine
•Malnutrition•Infectious diseases
35 years <10 •Infectious (RHD)•Nutritional
Stage 2 Receding pandemics
•Improved nutrition and public health•Chronic disease•Hypertension
50 years 10-35 •Infectious (RHD)•Stroke-haemorrhagic
Stage 3 Degenerative and man-made diseases
•High fat and caloric intake•Tobacco use•Chronic diseases > infectious, malnutrition
>60 years 35-65 •Ischemic heart disease (IHD)•Stroke – haemorrhagic, ischaemic
Stage 4 Delayed degenerative diseases
•Leading causes of mortality CV and cancer deaths•Prevention and treatment delays onset•Age-adjusted CV death reduced
>70 years 40-50 •IHD•Stroke – ischaemic•CHF
From Gersh et al. European Heart Journal 2010
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THE PERFECT STORM OF CVD IN LMICS
Gersh et al. EHJ 2010LMICs: low- and middle-income countries
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Development Diet
Tobacco
Sedentary lifestyle
Technology
Urbanization
Industry
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Projected Deaths by Cause
Beaglehole and Bonita. Lancet 2008
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WHERE DO WE GO FROM HERE?
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1980-87 1987-94 1994-2000
2000-080%
10%20%30%40%50%60%70%80%90%
100%
West AfricaSouthern AfricaEast AfricaNigeriaSouth Africa
PERCENT OF CVD STUDIES FROM SSA BY COUNTRY/REGION, 1980-2008
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CONTEMPORARY CAUSES OF HEART FAILURE IN SSA
Bloomfield et al. Curr Cardiol Reviews 2013
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“FLTR” FOR NCDS
FindLinkTreatRetain
HOSPITAL
HOSPITAL
Health Center
Dispensary
COMMUNITY
COMMUNITY
Current scenario
Proposed scenario
Optimizing Linkage and Retention to Hypertension Care in Kenya: LARK Hypertension Study. Slide courtesy of R. Vedanthan, Mt. Sinai
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OPTIMIZING LINKAGE AND RETENTIONTO HYPERTENSION CARE:
LARK HYPERTENSION
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Oxford Health Alliance 2006
AN OPPORTUNITY FOR PRIMARY PREVENTION
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THE GOOD NEWS: PREVENTION WORKS
http://www.ktl.fi
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Non-Communicable Diseases in LMICs: Myths, Facts and Opportunities
Gerald S. Bloomfield, MD, MPHDuke Global Health Institute
Division of CardiologyDuke University
THANK YOU