In 2017 WHO Director General announced the establishment of a WHO Independent High-Level
Commission on noncommunicable diseases (NCD) as a high-level political tool to achieve
the UN Agenda for sustainable development goals (SDG) and targets in particular target
3.4 “by 2030, reduce by one third premature mortality from NCD through prevention
and treatment, and promote mental health and well-being” (1).
First report published by the Commission in June 2018 “Time to Deliver” (2) indicated
the decline in cardiovascular diseases (CVD) and chronic respiratory diseases (CRD)
mortality. However, the global rate of decline in deaths from NCD (CVD, CRD, cancers
and diabetes) 17% from 2000 and 2015 is still not enough to meet the SDG target 3.4
by 2030. Second meeting of the Commission 2019 identified the challenges to implementation
and recommended WHO to encourage governments to promote meaningful engagement with
civil society for the prevention and control of NCD and promotion of mental health.
It can be accomplished by including the participation of nongovernmental organizations
(NGO) in national platforms through which to coordinate NCD action, with a view towards
encouraging a greater range of voices to be heard, including from those living with
NCD. Commission recommended including civil society meaningfully in WHO governance
(at all levels of the organizations). Multi-stakeholder partnerships and alliances
that mobilize and share knowledge, assess progress, provide services and amplify the
voices and raise awareness about people leaving with and affected by NCD (3).
Global Alliance against Chronic Respiratory Diseases (GARD) is a WHO voluntary alliance
of national and international organizations, institutions, and agencies committed
towards the common goal to reduce the global burden of CRD (4). GARD is a part of
the WHO global work to prevent and control chronic diseases (5).
The vision of GARD “a world where all people breathe freely” is common not only to
CRD but also to CVD certain types of cancer and diabetes. In view of this GARD could
serve as an excellent vehicle to deliver major NCD prevention and control tools to
facilitate achievements of UN SDG. GARD has four strategic directions: advocacy, focused
on raising of the recognition of CRD at global, regional, and country levels and integration
of the prevention and control measures into policies across all government departments,
promotion of partnership, development of national plans on prevention and control
and surveillance focused on supporting WHO in monitoring CRD and their risk factors
to evaluate progress at all levels. They fully correspond to the High Commission recommendations
on accelerating actions to engage civil society in national NCD response through strengthening
advocacy, awareness raising, improving access to care through service delivery, and
accountability. All major international, regional and national organizations, institutions
and agencies focused on reducing the global burden of CRD became GARD members (6).
GARD has a fruitful collaboration with Journal of Thoracic Disease (JTD) on a special
section in this journal. JTD is a multidisciplinary internationally recognized journal
of pulmonologists, cardiologists, oncologists and other specialists.
In order for the strengthening activities of the alliance to meet the specific needs
of countries, national alliances were established (GARD country) with a view to provide
a coordination role and create the necessary momentum to strengthen the national capacity
to face the increasing impact of CRD (4). GARD country activities in particular in
the area of tobacco cessation and studies on traffic related air pollution are common
for major NCD (7).
To preliminary assess the achievements of SDG and demonstrate global mortality trends
from the year 2000 we used the latest available national information on mortality
and its causes submitted to WHO together with the latest available information from
global WHO programmes for causes of deaths of public health importance (8). Only countries
with multiple years of national death registration by cause, sex and age and high
completeness and quality of cause of death assignments were included in our analysis.
Disease specific mortality as age-standardized death rates per 100,000 from 2000 to
2016 with the interim analysis in 2010 has been analysed in 49 countries. Thirty-six
countries (Australia, Austria, Bahamas, Belgium, Brunei Darussalam, Canada, Chile,
Croatia, Czechia, Denmark, Estonia, Finland, France, Germany, Hungary, Iceland, Ireland,
Israel, Italy, Japan, Latvia, Lithuania, Luxemburg, Malta, Netherlands, New Zealand,
Norway, Republic of Korea, Slovakia, Slovenia, Spain, Sweden, Switzerland, Trinidad
and Tobago, United Kingdom, and United States of America) belong to high income countries
(HIC) according to the World Bank classification, and 13 countries (Armenia, Brazil,
Cuba, Grenada, Guatemala, Kyrgyzstan, Mauritius, Mexico, North Macedonia, Republic
of Moldova, Romania, Saint Vincent and the Grenadines, and Uzbekistan) belong to middle
income countries (MIC) (9). GARD has been officially launched or initiated in 19 analysed
countries (42%) (4).
The most visible statistically significant decline in NCD mortality from 2000 to 2016
was achieved for bronchial asthma 54%, stroke 43%, ischaemic heart disease (IHD) 30%
and chronic obstructive pulmonary disease (COPD) 29%.
Lung cancer and diabetes mortality declined by 12% and 8% and these changes were not
statistically significant (
Table 1
,
Figure 1
).
Table 1
Dynamics of major non-communicable diseases mortality 2000–2016
Diseases
2000
2010
2016
Chronic respiratory disease
COPD
25.6±13.9
19.7±8.8
18.2±7.5
Asthma
2.94±3.01
1.67±1.84
1.34±1.43
Cardiovascular disease
Ischaemic heart disease
150.4±83.7
119.8±86.7
105.7±78.6
Stroke
76.4±45.6
53.9±36.6
43.7±31.0
Lung cancer, diabetes
Lung cancer
25.4±10.0
24.1±9.5
22.4±8.6
Diabetes mellitus
25.3±31.6
24.6±34.2
23.4±31.0
COPD, chronic obstructive pulmonary disease.
Figure 1
Age-standardized NCD mortality rate per 100,000 population in selected countries,
both sexes, 2000–2016. NCD, noncommunicable diseases.
We analysed prevalence of tobacco smoking, obesity and raised blood pressure (RBP)*
*
The percentage of the population 18 years and older having systolic blood pressure
(BP) ≥140 mmHg and /or diastolic BP ≥90 mmHg.
in the countries for the same period of time from 2000 to 2015 (10). Prevalence of
tobacco smoking gradually declined in 84% of countries, did not change in 9% and increased
only in 7%. Good progress has been achieved in declining RBP. Fifty-five percent of
countries demonstrated declining prevalence of RBP, 24% no changes and 20% increasing
prevalence of the RBP. Regretfully obesity**
**
The percentage of the population 18 years and older having a body mass index ≥30 kg/m2,
the percentage of the population ≥10 years who are more than 2 standard deviation
(SD) above the median of the WHO growth reference for children and adolescents.
prevalence was increasing in all countries.
Highest among all NCD decline of asthma mortality is closely associated with the activities
of the first global CRD programme initiated by WHO and the US-based National Heart
Lung and Blood Institute (NHLBI) called Global Initiative on Asthma (GINA) (11) later
transformed to NGO and one of the GARD founders. GINA played a key role in promoting
asthma management and prevention worldwide. Annual World Asthma Day 5th May initiated
by WHO in 1998 disseminated GINA recommendations in all WHO regions. Tobacco cessation
and other life style modifications along with asthma management always remain key
messages of this global campaign. GINA initiative was well implemented in all analysed
GARD countries and globally and no doubt contributed to major NCD risk factors control,
in particular smoking.
WHO international guidelines dealing specifically with RBP was published in 1999 (12)
and had a global distribution and implementation in collaboration with WHO, national
and international partners in the area of CVD. In the past decades, WHO has included
diagnosis and management of hypertension in a total cardiovascular risk approach as
part of the WHO Package of Essential NCD interventions 2007, 2010 and 2013 (PEN) (13).
Annual WHO World Hypertension Day regularly shared country and partner experience
in implementing hypertension programmes.
Percentage of IHD and COPD decline well corresponds to SDG 3.4 and our task is to
maintain and further improve these dynamics.
CVD and in particular IHD and atherosclerosis prevention and control approach and
initiatives have a long history and became a basis for NCD community-based prevention
and control. Pioneering epidemiological Framingham Heart Study initiated in 1948–1950
focused on hypertension and CVD had a dramatic contribution to the risk factors conception
and based on this preventive approach (14). Community-based North Karelia intervention
programmes demonstrated success of the country wide CVD and major NCD prevention programme
and further proved the modern risk factors conception and integrated approach for
NCD prevention based on the commonality of risk factors (15).
Multiple WHO global, regional and national prevention and control programmes have
dramatically improved awareness about healthy life style, surveillance, and management
of atherosclerosis and IHD. It has become evident that most premature deaths due to
CVD can be avoided with combination of the live style modification interventions to
prevent disease, early treatment to avert death during acute events (heart attacks
and stroke) and regular treatment to prevent recurrent events and to prolong the lives
of people with prior CVD. Reduction in burden and mortality from CVD in HIC reflects
a combined impact of population interventions to reduce risk factors based on the
life-style modifications and treatment (16).
Success in COPD decline is closely associated with GARD and GARD partners activities
in particular with initiated by WHO and the US-based NHLBI Global Initiative for COPD
GOLD (17). Launched in 2001 GOLD like GINA became one of the GARD founders and brought
COPD to the attention of governments, public health officials, health care workers
and the general public. GOLD promoted concerted efforts by all involved in health
care to increase awareness and control of this major NCD. Life style modifications
in particular smoking control implemented by GOLD are common for all major NCD and
are intensively promoted during annual World COPD Day 18 November. COPD and CVD often
coexist in one patient therefore commonality in management is obvious. Decreased pulmonary
function in COPD is closely associated with an increased risk of congestive CVD. A
large proportion of patients with mild and moderated COPD die due to CVD, which is
much more likely than deaths in the same group due to respiratory insufficiency. COPD
patients have a higher rate of hospitalization and death, the cause of which are IHD,
stroke and congestive heart failure (17).
Special attention should be paid to pulmonary rehabilitation (PR) which is the most
effective intervention to improve the quality of life in COPD patients and integrated
component of the disease management strategy. PR can reduce readmission and mortality
in patients (17). PR becomes crucial now in coronavirus (COVID) epidemic for the millions
of post-COVID patients since respiratory illness is the dominant clinical manifestation
of coronavirus disease 2019 (COVID-19), a highly infectious respiratory tract disease
which can cause respiratory, physical, and psychological dysfunction in patients.
Therefore, PR is important for both admitted and discharged patients with COVID-19
(18).
CVD involvement of COVID-19 patients occurs much less commonly. Acute cardiac injury,
defined as significant elevation of cardiac troponins, is the most commonly reported
cardiac abnormality. It occurs in approximately 8–12% of all patients along with the
heart failure, circulatory shock, cardiomyopathy, arrhythmia, and vascular thrombosis.
Nonetheless, it has been shown that the presence of pre-existing CVD and development
of acute cardiac injury are associated with significantly worse outcome in these patients
(19).
Lung cancer and diabetes mortality dynamics differs from CVD and CRD picture. We have
chosen lung cancer out of 24 different forms of cancer registered in the WHO mortality
report (8) since it’s a most common lethal neoplasm in the world with very poor prognosis
(20). Smoking plays a key role in lung cancer development but it may also occur in
people who have never smoke, other risk factors impact should be also considered in
this case such as passive exposure to tobacco smoke, biomass fuel, diesel exhaust,
radon, asbestos and other environmental and workplace carcinogens. Cancer patients
in general and those suffering from lung cancer in particular are a vulnerable group
in COVID-19 era. Different types of lung cancer treatments (chemotherapy, radiation
therapy and immunotherapy) may also influence the risk of infection. Lung cancer patients
require frequent radiologic study follow ups which may be affected by COVID-19 pandemic.
COVID-19 related incidental radiologic findings can appear in routinely scheduled
radiology tests, which may be difficult to interpret. Cancer treatment also induces
pneumonitis with similar radiologic features like in acute COVID-19 pneumonia and
leads to a wrong diagnosis (21).
According to various estimates, excess weight and obesity are closely linked with
type 2 diabetes. Practically no changes of diabetes mortality in our case were observed
with growing prevalence of obesity. In the current COVID-19 pandemic situation, diabetes
has become a serious health concern as it is one of the most frequent comorbidities
in people with COVID-19 with prevalence from 7% to 30%. Diabetics infected with COVID-19
have a higher rate of hospital admission compared to non-diabetics, severe pneumonia,
and higher mortality. Recent evidence has shown that COVID-19 is also capable of causing
direct damage to the pancreas that could increase hyperglycaemia and even induce the
onset of diabetes in previously non-diabetic subjects (22). Diabetes care has been
severely shattered due to the pandemic. In view of the above new WHO Global Compact
was launched to speed up action to tackle diabetes and provide a much-needed boost
to efforts to prevent diabetes and bring treatment to all who need it. “It is the
only major NCD for which the risk of dying early is going up, rather than down” said
Dr. Tedros Ghebreyesus WHO Director General. GARD representatives along with other
UN agencies, civil society partners and representatives of the private sector took
part in the launch (23).
Our analysis has shown that the most visible decline seen for asthma and RBP is associated
with declining smoking prevalence and promotion of global management programmes. Gradually
increasing prevalence of obesity does not prevent these declines.
Air pollution reduction and clean air strategy could help to maintain and further
improve CRD management and prevention. Life style modifications besides tobacco use
like decreasing salt consumption, increasing fruits and vegetables intake, decreasing
saturated and trans fats consumption, limited use of alcohol and elevated level of
physical activity and effective obesity control have a great potential for further
decline of CVD.
Since lung cancer has a very poor prognosis, in order to achieve better results in
cancer mortality along with early detection, more efforts should be concentrated on
strengthening tobacco cessation, clean air and diet actions.
Since overweight and obesity control remain a big challenge in majority of countries,
diet and physical activity along with adequate management remain the key elements
in the current strategy for diabetes control and decreasing diabetes mortality. Further
decline in smoking prevalence will have an additional positive effect (24). Association
of diabetes mortality with air pollution is interesting and perspective since air
pollution affects nearly every organ in the body, causing or contributing to many
illnesses, in view of this GARD role in clean air policy is crucial. Last GARD General
Assembly was dedicated to air pollution and proper recommendations concerning NCD
prevention have been made (25).
GARD has always been active in global life style modification activities like, World
No Tobacco Day, World Health Day and many others. The focus of the No Tobacco Day
2019 for instance was “tobacco and lung health”. The campaign aimed to increase awareness
on the negative impact that tobacco has on people’s lung health from cancer to CRD
or CVD and on the fundamental role lungs play for the health and well-being of all
people. In view of the COVID-19 pandemic GARD considered the potential impact of the
COVID-19 on accomplishment of the SDG during the global webinar conference (26).
Supplementary
The article’s supplementary files as
10.21037/jtd-21-857