PREVENTING CHRONIC DISEASE DEATHS: TARGETING CVD WILL MEET 75% OF GLOBAL GOAL
Lancet 2007; 370:1929-2062


Questa serie di articoli pubblicati da Lancet riguardanti l'impatto e la gestione delle patologie croniche fornisce l'evidenza che la mortalità e i costi correlati a queste malattie possono essere ridotte attraverso intereventi di prevenzione rivolti alla popolazione e in particolare ai gruppi maggiormente a rischio.

L'uso di una terapia multifarmaco per prevenire le patologie cardiovascolari in individui ad alto rischio in Paesi a basso- e medio-reddito può evitare 18 milioni di morti in 10 anni. Questo approccio, che comporterebbe solo un modesto incremento della spesa sanitaria di poco più di $1 per persone l'anno, consentirebbe di raggiungere l'obiettivo globale della riduzione dei tassi di patologie croniche in un decennio. Un articolo su effetti e costi sanitari della prevenzione delle malattie cardiovascolari in 23 paesi selezionati è stato pubblicato su Lancet [1], insieme ad altri quattro articoli sui costi correlati alle patologie croniche [2], l'applicazione degli interventi per la prevenzione delle malattie croniche [3], i costi di queste strategie [4] e una "chiamata all'azione" [5].
Le malattie croniche sono la principale causa di disabilità e morte. Nel 2005 è stato stabilito l'obiettivo globale di ridurre i tassi di mortalità per malattie croniche del 2% ogni anno, allo scopo di evitare 36 milioni di morti in tutto il mondo entro il 2015, producendo notevoli benefici economici. Nei 23 Paesi scelti per la ricerca, l'obiettivo è prevenire 24 milioni di morti; questi stati sono stati selezionati perché rispondono di circa l'80% della mortalità totale per malattie croniche nelle nazioni sviluppate.
La serie di articoli fornisce l'evidenza che l'obiettivo globale è ottenibile con alcuni interventi diretti all'intera popolazione e agli individui ad alto-rischio.

[1] PREVENTION OF CARDIOVASCULAR DISEASE IN HIGH-RISK INDIVIDUALS IN LOW-INCOME AND MIDDLE-INCOME COUNTRIES: HEALTH EFFECTS AND COSTS
Lim SS, Gaziano TA, Gakidou E, et al.
Lancet 2007; 370:2054-62
ABSTRACT
In 2005, a global goal of reducing chronic disease death rates by an additional 2% per year was established. Scaling up coverage of evidence-based interventions to prevent cardiovascular disease in high-risk individuals in low-income and middle-income countries could play a major part in reaching this goal. We aimed to estimate the number of deaths that could be averted and the financial cost of scaling up, above current coverage levels, a multidrug regimen for prevention of cardiovascular disease (a statin, aspirin, and two blood-pressure-lowering medicines) in 23 such countries. Identification of individuals was limited to those already accessing health services, and treatment eligibility was based on the presence of existing cardiovascular disease or absolute risk of cardiovascular disease by use of easily measurable risk factors. Over a 10-year period, scaling up this multidrug regimen could avert 17.9 million deaths from cardiovascular disease (95% uncertainty interval 7.4 million-25.7 million). 56% of deaths averted would be in those younger than 70 years, with more deaths averted in women than in men owing to larger absolute numbers of women at older ages. The 10-year financial cost would be US$47 billion ($33 billion-$61 billion) or an average yearly cost per head of $1.08 ($0.75-1.40), ranging from $0.43 to $0.90 across low-income countries and from $0.54 to $2.93 across middle-income countries. This package could effectively meet three-quarters of the proposed global goal with a moderate increase in health expenditure.

[2] THE BURDEN AND COSTS OF CHRONIC DISEASES IN LOW-INCOME AND MIDDLE-INCOME COUNTRIES
Abegunde DO, Mathers CD, Adam T, et al.
Lancet 2007; 370:1929-38
ABSTRACT
This paper estimates the disease burden and loss of economic output associated with chronic diseases-mainly cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes-in 23 selected countries which account for around 80% of the total burden of chronic disease mortality in developing countries. In these 23 selected low-income and middle-income countries, chronic diseases were responsible for 50% of the total disease burden in 2005. For 15 of the selected countries where death registration data are available, the estimated age-standardised death rates for chronic diseases in 2005 were 54% higher for men and 86% higher for women than those for men and women in high-income countries. If nothing is done to reduce the risk of chronic diseases, an estimated US$84 billion of economic production will be lost from heart disease, stroke, and diabetes alone in these 23 countries between 2006 and 2015. Achievement of a global goal for chronic disease prevention and control-an additional 2% yearly reduction in chronic disease death rates over the next 10 years-would avert 24 million deaths in these countries, and would save an estimated $8 billion, which is almost 10% of the projected loss in national income over the next 10 years.

[3] SCALING UP INTERVENTIONS FOR CHRONIC DISEASE PREVENTION: THE EVIDENCE
Gaziano TA, Galea G, Reddy KS
Lancet 2007; 370:1939-46
ABSTRACT
Interventions to prevent morbidity and mortality from chronic diseases need to be cost effective and financially feasible in countries of low or middle income before recommendations for their scale-up can be made. We review the cost-effectiveness estimates on policy interventions (both population-based and personal) that are likely to lead to substantial reductions in chronic diseases--in particular, cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We reviewed data from regions of low, middle, and high income, where available, as well as the evidence for making policy interventions where available effectiveness or cost-effectiveness data are lacking. The results confirm that the cost-effectiveness evidence for tobacco control measures, salt reduction, and the use of multidrug regimens for patients with high-risk cardiovascular disease strongly supports the feasibility of the scale-up of these interventions. Further assessment to determine the best national policies to achieve reductions in consumption of saturated and trans fat--chemically hydrogenated plant oils--could eventually lead to substantial reductions in cardiovascular disease. Finally, we review evidence for policy implementation in areas of strong causality or highly probable benefit--eg, changes in personal interventions for diabetes reduction, restructuring of health systems, and wider policy decisions.

[4] CHRONIC DISEASE PREVENTION: HEALTH EFFECTS AND FINANCIAL COSTS OF STRATEGIES TO REDUCE SALT INTAKE AND CONTROL TOBACCO USE
Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R
Lancet 2007; 370:2044-53
ABSTRACT
In 2005, WHO set a global goal to reduce rates of death from chronic (non-communicable) disease by an additional 2% every year. To this end, we investigated how many deaths could potentially be averted over 10 years by implementation of selected population-based interventions, and calculated the financial costs of their implementation. We selected two interventions: to reduce salt intake in the population by 15% and to implement four key elements of the WHO Framework Convention on Tobacco Control (FCTC). We used methods from the WHO Comparative Risk Assessment project to estimate shifts in the distribution of risk factors associated with salt intake and tobacco use, and to model the effects on chronic disease mortality for 23 countries that account for 80% of chronic disease burden in the developing world. We showed that, over 10 years (2006-2015), 13.8 million deaths could be averted by implementation of these interventions, at a cost of less than US$0.40 per person per year in low-income and lower middle-income countries, and US$0.50-1.00 per person per year in upper middle-income countries (as of 2005). These two population-based intervention strategies could therefore substantially reduce mortality from chronic diseases, and make a major (and affordable) contribution towards achievement of the global goal to prevent and control chronic diseases.

[5] PREVENTION OF CHRONIC DISEASES: A CALL TO ACTION
Beaglehole R, Ebrahim S, Reddy S, et al.
Lancet 2007; 370:2152-7
ABSTRACT
Chronic (non-communicable) diseases--principally cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes--are leading causes of death and disability but are surprisingly neglected elements of the global-health agenda. They are underappreciated as development issues and underestimated as diseases with profound economic effects. Achievement of the global goal for prevention and control of chronic diseases would avert 36 million deaths by 2015 and would have major economic benefits. The main challenge for achievement of the global goal is to show that it can be reached in a cost-effective manner with existing interventions. This series of papers in The Lancet provides evidence that this goal is not only possible but also realistic with a small set of interventions directed towards whole populations and individuals who are at high risk. The total yearly cost of the interventions in 23 low-income and middle-income countries is about US$5.8 billion (as of 2005). In this final paper in the Series we call for a serious and sustained worldwide effort to prevent and control chronic diseases in the context of a general strengthening of health systems. Urgent action is needed by WHO, the World Bank, regional banks and development agencies, foundations, national governments, civil society, non-governmental organisations, the private sector including the pharmaceutical industry, and academics. We have established the Chronic Disease Action Group to encourage, support, and monitor action on the implementation of evidence-based efforts to promote global, regional, and national action to prevent and control chronic diseases.