The Global Alliance against Chronic Respiratory Diseases

Global Alliance against Chronic Respiratory Diseaseswww.who.int/gard

The Global Alliance against Chronic Respiratory Diseases

Dr Nikolai Khaltaev"Global lung health in 2000's"

Antalya, Turkey, 25 – 26 April 2007


Overview

• The global burden of chronic respiratory diseases– Chronic obstructive pulmonary disease (COPD)

– Asthma

• WHO global approach to control chronic respiratory diseases

• The Global Alliance against Chronic Respiratory Diseases (GARD): a new way to prevent and control chronic respiratory diseases

• GARD country activities


The global burden of chronic respiratory diseases


Did you know??

4 000 000 PEOPLE

DIED FROM CHRONIC

RESPIRATORY DISEASES

IN 2005


Some widespread misunderstandings about chronic respiratory diseases - and the reality

87% OF CHRONIC RESPIRATORY DISEASES DEATHS OCCUR IN LOW & MIDDLE INCOME COUNTRIES

REALITY

MISUNDERSTANDING

CHRONIC RESPIRATORY DISEASES MAINLY AFFECT HIGH INCOME COUNTRIES

Upper middle income

countries 5%

Lower middle income countries

48%

Low income countries

34%

High income countries

13%

Projected global distribution of chronic respiratory disease deaths By World Bank income group, all ages, 2005


CHRONIC RESPIRATORY DISEASES AFFECT WOMEN AND MEN ALMOST EQUALLY

REALITY

MISUNDERSTANDING

CHRONIC RESPIRATORY DISEASES MAINLY AFFECT MEN

Projected global distribution of chronic respiratory disease deaths all ages, 2005

men52%

women48%

Some widespread misunderstandings about chronic respiratory diseases - and the reality


Chronic respiratory diseases worldwide

Cardiovascular diseases mainly heart disease and stroke

Cancer Chronic respiratory diseases Diabetes

Main chronic diseases include:


Chronic respiratory diseases worldwide

• including 300 million people with asthma, • 80 million people with moderate to severe chronic obstructive pulmonary disease (COPD)• and millions of others with mild COPD, allergic rhinitis, and other chronic respiratory diseases, which are often undiagnosed.

Hundreds of millions of people have chronic respiratory diseases,


Chronic respiratory diseases in Turkey

In Turkey, chronic respiratory diseases accounted for 6% of all deaths or 26 220 deaths in 2002.


What are the causes of chronic respiratory diseases?


Burden of Major Respiratory Conditions

Source: World Health Report 2003

DALYs*

%

Bronchus /Trachea Cancer

Condition Deaths

%Lower Respiratory Infections 6.6 5.8

COPD 4.8 1.9

Tuberculosis 2.8 2.4

Lung/ 2.2 0.8

Asthma 0.4 1.0

Total 16.8 11.9

*DALYs = Disability-Adjusted Life-Years


What are DALYs?

age (years)

DisabilityAdjustedLifeYears

One DALY: one lost year of “healthy” life

DALY = YLD + YLL

55 65 75

COPDonset death

expecteddeath

YLLYears of Life LostYears of Life

with Disability

YLD50


Increasing Burden of Diseases and Injuries:Change in Rank Order of DALYs*

*DALYs: Disability Adjusted Life Years

*DALYs = Disability-Adjusted Life-Years Source: WHO Evidence, Information and Policy, 2005


"When I was 16 years old, my primary doctor told me that smoking would help me lose weight, so every time I started a diet, I also started to smoke.

Now I am an invisible picture of COPD disability. I am not yet using oxygen, but I know that day will come. I am unable to do many of the things I love. I cannot dance. I cannot do my own food shopping. I cannot take long walks along the river at sunset with my husband."

Elaine L. Ackley, 58 years, New York, United States of America

Chronic obstructive pulmonary disease (COPD)


Burden of COPD

• COPD is a major cause of morbidity, death and disability

• The main cause for developing COPD is tobacco smoking

• COPD is not just simply a "smoker's cough", but a disease that kills per year 3 million people worldwide

• Despite its ease of diagnosis, COPD remains an under-diagnosed disease, chiefly in its milder and more treatable form


World map COPD - Deaths / 1000 year 2000

<6.2 .6.2-9.7

9.7-15.7

18.1-19.919.9-22.1

35.5-38.122.1-35.5

15.7-18.1

>38.1no data


<0.100.10-0.790.80-2.192.20-2.592.60-3.493.50-3.893.90-4.399

>6.704.40-6.69

no data*DALYs: disability-adjusted life year

World map COPD – DALYs* / 1000 year 2000


Prevalence of COPD in Europe


Risk factors

Passive smoking

"Keep it funny, Keep it smoke free"

Anti smoke campaign, The Netherlands


The relative importance of Tobacco Smokeand other risk factors relevant for COPD

Opposite patterns in different geographic areas

EUROPE versus AFRICASource: World Health Report 2002


0 5000 10000 15000 20000

Indoor smoke from solid fuels Unsafe water, sanitation, and hygiene

Underweight Childhood sexual abuse

Urban air pollution Occupational risk factors for injury

Iron deficiency Unsafe sex

Lead exposure Illicit drugs

Physical inactivity Fruit and vegetable intake

High Body Mass IndexCholesterol

Alcohol Tobacco

Blood pressure

Number of Disability-Adjusted Life Years (000s)

Tobacco

Urban airpollution

EUROPEDisease burden (DALYs) in 2000 attributable to selected risk factors


AFRICADisease burden (DALYs) in 2000 attributable to selected risk factors

Lead exposure

0 10000 20000 30000 40000 50000 60000 70000

Fruit and vegetable intake Occupational risk factors for injury

Global climate change Unsafe health care injections

Cholesterol Tobacco

Lack of contraception Blood pressure

Alcohol Iron deficiency

Indoor smoke from solid fuels Zinc deficiency

Vitamin A deficiency Unsafe water, sanitation, and hygiene

Underweight Unsafe sex

Number of Disability-Adjusted Life Years (000s)

Tobacco

Indoor air pollution


Risks are increasing: burden of disease attributable to tobacco (% DALYs in each subregion)

Source: World Health Report, 2002



Risks are increasing: burden of disease attributable to indoor smoke from solid fuels (% DALYs in each subregion)



Risks are increasing: burden of disease attributable to urban air pollution (% DALYs in each subregion)


Burden of asthma• Asthma is not just a public health

problem for high income countries: it occurs in all countries regardless of level of development. Over 80% of asthma deaths occurs in low and lower-middle income countries.

• Asthma deaths will increase by almost 20% in the next 10 years if urgent action is not taken.

• According to WHO estimates, 300 million people suffer from asthma and 255 000 people died of asthma in 2005.

• Asthma is the most common chronic disease among children.


Global Burden of Asthma 2004






WHO global approach to control Chronic Respiratory Diseases


As for 17 December 2004: 47 countries haveratified the treaty. On 27 February 2005:

the FCTC has entered into force and has become an International law.

Today the FCTC has 146 parties(16 April 2007)

Framework Convention on Tobacco Control (FCTC)


• Taxes – tax and price measures are an important way of reducing tobacco consumption, particularly in young people, and requires signatories to consider public health objectives when implementing tax and price policies on tobacco products.

• Labelling – The text requires that at least 30 per cent of the display area on tobacco product packaging is taken up by clear health warnings in the form of text, pictures or a combination of the two. Packaging and labelling requirements also prohibit misleading language such as “light”, “mild” or “low tar”.

• Advertising –The final text requires parties to move towards a comprehensive ban within five years of the convention entering into force.



• Liability – Parties to the convention are encouraged to pursue legislative action to hold the tobacco industry liable for costs related to tobacco use.

• Financing – Parties are required to provide financial support to their national tobacco control programmes. A number of countries and development agencies, have already pledged their commitment to include tobacco control as a development priority.

• Other issues - The text also requires countries to promote treatment programmes to help people stop smoking and education to prevent people from starting, to prohibit sales of tobacco products to minors, and to limit public exposure to second-hand smoke.



WHO/NHLBI

One of the first examples of worldwide used disease-specific guidelinesand the 1st one on Asthma

Project coordinatorsNikolai Khaltaev (WHO)Claude Lenfant (NHLBI)

1995

WHO/ARIA

Including adaptation to developing countries:

EBMlow drug cost affordable for most patients

WHO essential list of drugs

2001


WHO/NHLBI

The first worldwide used guidelines

on COPD

2001

NHLBI/WHO Workshop Report: Global Strategy for the Diagnosis,

Management, and Prevention of COPD. Scientific information and

recommendations for COPD programs.


Practical Approach to Lung health

A primary health care strategy for a coordinated and standardized approach for an integrated management of the patient with respiratory symptoms in countries with epidemiological transition.

TargetsImprove diagnostic strategies, reduce inappropriate care, foster cost reduction strategies, savings in antibiotic usage andincrease appropriate CS usageTested in 15 different countries

2003

Source : WHO/STB


STEP

SuRF

FCTC

Prevention ofAllergy andAllergic AsthmaBased on the WHO/WAO Meeting on thePrevention of Allergy and Allergic AsthmaGeneva,8-9 January 2002

WHO/MNC/CRA/03.2


A new way to prevent and control chronic respiratory diseases

Global Alliance against Chronic Respiratory Diseases


The enormous human suffering caused by chronic respiratory diseases (CRD) has been recognized by the

53rd World Health Assembly (May 2000) which requested the Director General to:

• To continue giving priority to prevention and control of noncommunicable diseases, including CRD, with special emphasis on developing countries and other deprived populations;

• To coordinate, in collaboration with the international community, global partnerships and alliances for resource mobilization, advocacy, capacity building and collaborative research


What is the value added of this new way?

The value added of developing an alliance with specialized national and international NGOs is to:

• To share responsibilities and building on each partner's expertise

• To combine the partners' strengths and knowledge, thereby achieving results that no one partner could attain alone.

• To improve coordination between existing governmental and nongovernmental programmes, which avoids duplication of efforts and wasting of resources.


Before GARD = lack of coordination, competition


WHO calls for a global and coordinated effortto fight Chronic Respiratory Diseases


GARD Global Launch, 28 March 2006, Beijing, People's Republic of China

"GARD will provide an effective form in which health care workers, institutions and governments from all countries may jointly work to mobilize the entire population in efforts to prevent and control chronic respiratory diseases".

Dr Longde Wang Vice Minister of Health, People's

Republic of China


GARD“I am happy to hear that the Global Alliance against Chronic Respiratory Diseases is now in place as a global team. As a team, each member will contribute his or her unique strengths, just like in football. Together, the Alliance's teamwork will provide help to the hundreds of millions of people who suffer from chronic respiratory diseases, including those in my country who do not have access to essential treatments.”

Pele, soccer legend


GARD

"Reaching a major goal like conquering chronic respiratory diseases is similar to a marathon run: it's a big effort but with energy, knowledge, support and the will to win, it can be done. I am convinced that the Global Alliance for Respiratory Diseases will win the battle against chronic respiratory disease, which kills four million people a year"

Rosa Mota, former Portuguese marathon runner and Olympic champion


GARD VisionA world where all people breathe freely


GoalTo reduce the global burden of chronic respiratory diseases

ObjectiveTo initiate a comprehensive approach to fight chronic respiratory diseases through:

• developing a standard way of obtaining relevant data on chronic respiratory disease risk factors;

• encouraging countries to implement health promotion and chronic disease prevention policies; and

• making recommendations of simple strategies for management of chronic respiratory diseases.

GARD Goal and Objective


June 2004

WHOACAAIALATARIAATS EAACIEFAERSFILHAFIRSGA2LENGINAGOLD NHLBIWAOWHO-CC DU

15

Jan 2005

WHOAAAAIAAAFACAAIARIAATSEAACIEFAERSFILHAFIRSGA2LENGINAGOLDICCINTERASMAKAFNHLBIWAOWHO-CC DUWHO-CC UCMWONCA

21

March 2007WHOAAA (D. Vervloet, France)AAAAI (E. Simon, CAN)AAAF (R. Pawankar, JAP)ACAAI (M. Blaiss, USA)AIMAR (C. Donner, ITA)ALAT (C. Luna, ARG)ALLERG.O.S (P. Demoly, FRA)APAACI (T. Fukuda, JAP)APRS (Y. Fukuchi, JAP)ARIA (J. Bousquet, FRA)ATS (P. Wagner, USA)CCM (D. Greco, ITA)CNR-INMM (G. Rasi, ITA)DLHA (DK)EAACI (U. Wahn, GER)ECARF (T. Zuberbier, GER)EFA (S. Palkonen, FIN)ERS (R. Dahl, DK)FEMTEC (U. Solimene, ITA)FILHA R. Kauppinen, FIN)FIRS (A. Turnbull, SWI)GA2LEN (P. Van Cauwenberge, BEL)

45

GINA (P. O’Byrne, CAN)GOLD (L. Fabbri, ITA)ICC (L. Grouse, USA)INTERASMA (I. Ansotegui, SPA)IPCRG (A. Ostrem, UK)IPRAIS (J. Warner, UK)IUATLD (N. Billo, FRA)KAF (Y. Kim, KOR)KTL (P. Puska, FIN)NHLBI (B. Alving, USA)PSA (M. Kowalski, POL)RSP (A. Chuchalin, RUS)SIMER (G. D'Amato, ITA)SFAIC (G.Pauli, FRA)SPAIC (M. Morais de Almeida)SPLF (B. Housset, FRA)TTS (A. Kocabas, TUR)TNSACI (O. Kalayci, TUR)WAO (C. Baena-Cagnani, ARG)WHO-CC DU (S. Makino, JAP)WHO-CC GU (G. Joos, BEL)WONCA (A. Loh, SIN)

Oct 2002

WHOEFA

2

Jan 2003

WHOEFAARIA

3

Participants


GARD is part of WHO's work to prevent and control chronic diseases

Comprehensive and integrated action is the means to prevent and control chronic diseases


• GARD focuses on the needs of countries

• and fosters country-specific initiatives tailored to local conditions.

A global alliance working at country level


Desired outcome at country level: initiated or upgraded

programme on surveillance, prevention and control of chronic respiratory diseases

HOW?

Approach:Alliances against Chronic Respiratory Diseases

are established at country level (GARD Country), in order for the activities of the Alliance to meet the specific needs of countries.


What does GARD Country do?

1. Coordinating already existing activities and exchanging relevant information

2. Analysing the situation of chronic respiratory diseases in the country

3. Raising greater awareness on chronic respiratory diseases and their risk factors

4. Running intervention projects on chronic respiratory diseases prevention and control

5. Generating political commitment


Who guides the process to explore and build GARD Country?

• GARD Country Initiator is a person or an organization that develops the initial idea and takes the first step in formulating the apporach of building an alliance at country level

• The Core Group of interested parties is a group of interested parties which gathers with GARD Country Initiator


1. The situation of chronic respiratory disease surveillance, prevention and control programme in the country is analysed.

2. The Ministry of Health is informed about GARD Country and invited to be involved in its development.

3. WHO Regional Office and WHO Representative are informed about GARD Country and invited to be involved in its development.

Prerequisites


Situation analysis…

GARD runs pilot projects on surveillance of chronic respiratory diseases at primary health care level

– Georgia– Russian Federation– Cape Verde– Philippines


Secondly, patients are screened by doing a spirometry test that

measures the lung capacity

Firstly, patients fill in a WHO questionnaire on symptoms of chronic respiratory diseases, environmental exposure and

smoking habits

… in Georgia


A patient is screened by doing a spirometry test

…. in Ryazan, Russian Federation


…in Cape Verde and the PhilippinesCape Verde (Praia and Sao Vincente): data on the prevalence of CRD have been collected and are being processed

Philippines (Guimaras): data on the prevalence of CRD have been collected and are being processed


Involvement of the Ministry of Health

• Poland:GARD Symposium for Eastern European countries under auspices of Professor Zbigniew Religa, Minister of Health, Republic of Poland, Zakopane, Poland, 23-24 March 2007



• Algeria: Meeting between GARD Chairman and Minister of Health, Dr Amar Tou, Alger, 23 July 2006

• Turkey: participation of GARD initiator in a meeting on chronic diseases organized by the Ministry of Health, Istanbul, 16 January 2007

GARD Focal Point appointed within the Ministry of Health


• Brazil:Meeting with Dr Luis Fernando Sampaio, Director of Primary Care, Ministry of HealthApril 2006



• China: Dr Longde Wang, Vice Minister of Health, opening GARD Global Launch, 28 March 2006, Beijing

"GARD will provide an effective form in which health care workers, institutions and governments from all countries may jointly work to mobilize the entire population in efforts to prevent and control chronic respiratory diseases".



Steps to develop a GARD Country

1. Agreeing on a definition of Alliance2. Nominating a GARD Country Coordinator3. Identifying other partners4. Running an exploratory workshop5. Defining the Terms of Reference6. Defining the structure7. Identifying outcomes


1. Agreeing on a definition of Alliance

GARD Country shall act as a coordination and creation of a momentum

A strategic alliance

between organizations drawn from different sectors of societies(government, business, NGOs)

who commit to work collaboratively towards a common goal.

that invites new inputs from various interested parties

in order to strengthen the national capacity to face the increasing impact of CRD.

PROPOSED DEFINITION GARD COUNTRY


2. Nominating a GARD Country Coordinator

• International recognition of his/her capabilities in surveillance, prevention and control of CRD

• Entrusted by Ministry of Health, GARD Country initiator and other interested parties

• Committed to the public health system of the country• Good communication and diplomatic skills

GARD Country Coordinator

WHO on behalf of GARD Executive Committee

NOMINATES

Ministry of Health

GARD Country initiator

Core group of interested parties

ENDORSE


Faces of GARD Country Coordinators

Prof Paulo Camargos GARD coordinator Brazil

Prof Tamaz MaglakelidzeGARD coordinator Georgia


3. Identifying other potential partners

Within Ministry of Health:• Between specific programmes on chronic respiratory diseases• Between supporting programmes, services, departments at national and regional

level: – Human Resources Development Department – Health Statistics Department– Health Finance Department– Drug Control Department– Health Education Programme– Health Care Reforms– Environmental Health Unit

GARD Country Coordinator shall make an inventory of the various interested parties:

Related Ministries

CRD and public health

experts

Professional Associations

Patient Groups

NGOs

Educational Sector

Multilateral Bilateral Agencies

Communities, churches, religious leaders

Private sector, media

Identifying partners

outside Ministry of Health


4. Running an exploratory workshop

• a vision for the alliance is agreed upon• the purpose and shared objectives of the alliance are agreed• the interest and expected benefit of each single partners are identified• the resources and competencies that each partner could bring to the alliance are

mapped• roles and responsibilities of each partner are decided• project ideas are that could be carried out collaboratively are outlined• options for management mechanisms are explored

The country coordinator and the Ministry of Health focal point call a workshop with the core group of interested parties and the short listed potential partners.

During this workshop:


Exploratory workshop in Brazil, April 2006


Exploratory workshop for Eastern European Countries, Poland, 23-24 March 2007

4


A sub-committee is appointed by GARD Country Coordinator to draft the Terms of Reference of GARD Country

5. Defining the Terms of Reference

a. General Purpose: to reduce the burden of CRD at national levelb. Technical Objectives: different according to the products of GARD

action plan that best suit the countryc. In general:

Coordinating existing activities related to CRD Exchanging relevant information Raising greater awareness on CRD and their risk factors as well as on

prevention and treatment Running intervention projects on CRD surveillance, prevention and control Generating political commitment at country level Raising additional resources


The Launch Meeting of China COPD Alliance in Guangzhou,

4 November 2006

Raising greater awareness on chronic respiratory diseases in China


The Launch Meeting of Asthma Alliance in Zhengzhou, Henan

4 June 2005

Raising greater awareness on chronic respiratory diseases in China


Running intervention projects

GARD has started to run intervention projects on chronic respiratory diseases prevention and control:– Brazil– Tunisia


… in Brazil

Brazil (Bahia): Pilot project on control of severe asthma

Brazil (Belo Horizonte): Programme Criança que Chia (Wheezing Child)


… in Tunisia

TUNISIATUNISIA

WHOWHO

GA

RD

GA

RD

PALPAL

Tunisia (since 2002): Pilot project on control of CRD:• Practical Approach to Lung Health (PAL) implemented• Increased diagnosis• Reduction of prescription of antibiotics• Reduction of medication costs per patient


6. Defining the structure

GAR

D C

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Cou

ncil

GAR

D Co

untry

Pl

anni

ng G

roup

GAR

D Co

untry

se

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Plenary body of all GARD Country partners

Chaired by GARD Country Coordinator

It supports GARD Country and assists the partners

Managed by GARD Country Coordinator

Driving force of the Alliance

Composed of partners elected by the Council

A proposal:


GARD Brazil Council


7. Identifying outcomes• Are you doing things right?• What have you learnt from building the alliance?• Has the alliance been effective to achieve its aims?• Have the partners all benefited from their involvement?• How much has GARD Country achieved in the country (process and

output)?• Has GARD Country brought any change in CRD surveillance,

prevention and control in he country (outcome)?

If not, EXIT STRATEGY


Overview

• A global alliance working at country level• Who guides the process?• Prerequisites to develop an alliance at country

level• Steps to develop an alliance at country level• Current activities countries


Overview of GARD in countries


• Pilot projects in:– Algeria– Brazil– Cape Verde– China– Georgia– Republic of Korea– Philippines– Russian Federation– Tunisia– Turkey

• Other interested countries:– Argentina– Bulgaria– France– Greece– Italy– Kazakhstan– Norway– Paraguay– Poland – Portugal– South Africa– Vietnam

Overview of GARD in countries


Documents

The Global Alliance against Chronic Respiratory Diseases