Gerald S. Bloomfi eld, MD, MPH

DGHI,Division of Cardiology,Duke University

September 2013

Non-Communicable Diseases in LMICs:

Myths, Facts and Opportunities

Trends in selected NCDs in LMICsEpidemiologic transitionData challengesApproaches to NCD research in LMICs

OUTLINE

CARDIOVASCULAR DISEASE

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

“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

325 migrants, 267 controls followed for 24 months

SBP changes over 24 months

LUO MIGRATION STUDY

Poulter BMJ 1990

PULMONARY DISEASE

DEATHS DUE TO PULMONARY DISEASE

Devel

oped

199

0

Devel

oped

201

0

Devel

opin

g 19

90

Devel

opin

g 20

100

500000100000015000002000000250000030000003500000

ILDPneumoconiosesAsthmaCOPD

www.healthmetricsandevaluation.org 2013

Adult Smoking Prevalence, 2009

Youth Smoking Prevalence, 2009

Tobacco Control Report from the Region of the Americas 2011

http://www.who.int/tobacco/en/atlas19.pdf

PROPORTION OF PATIENTS WITH COPD WHO ARE NON-SMOKERS

USA

Colom

bia

Braz

il

Chile

Mex

ico

Urugu

ay

Vene

zuel

a0%

20%

40%

60%

80%

100%

Salvi and Barnes. Lancet 2009

www.who.int/ceh/publications/en/map09b.jpg

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

DIABETES AND HIGH BLOOD SUGAR

Health Statistics and Informatics

Leading causes of attributable global mortality and burden of disease, 2004

%

1. High blood pressure

12.82. Tobacco use

8.73. High blood glucose

5.84. Physical inactivity

5.55. Overweight and obesity

4.86. High cholesterol

4.57. Unsafe sex

4.08. Alcohol use

3.89. Childhood underweight

3.810. Indoor smoke from solid fuels

3.3

59 million total global deaths in 2004

%

1. Childhood underweight

5.92. Unsafe sex

4.63. Alcohol use

4.54. Unsafe water, sanitation, hygiene

4.25. High blood pressure

3.76. Tobacco use

3.77. Suboptimal breastfeeding

2.98. High blood glucose

2.79. Indoor smoke from solid fuels

2.710. Overweight and obesity

2.3

1.5 billion total global DALYs in 2004

Attributable Mortality Attributable DALYs

EPICENTERS OF DIABETES

Deaths from diabetes

Hu. Diabetes Care 2011

The Epidemiologic Transition

Description 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

THE PERFECT STORM OF CVD IN LMICS

Gersh et al. EHJ 2010LMICs: low- and middle-income countries

Development Diet

Tobacco

Sedentary lifestyle

Technology

Urbanization

Industry

Projected Deaths by Cause

Beaglehole and Bonita. Lancet 2008

WHERE DO WE GO FROM HERE?

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

CONTEMPORARY CAUSES OF HEART FAILURE IN SSA

Bloomfield et al. Curr Cardiol Reviews 2013

“FLTR” FOR NCDS

Find

Link

Treat

Retain

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

OPTIMIZING LINKAGE AND RETENTIONTO HYPERTENSION CARE:

LARK HYPERTENSION

Oxford Health Alliance 2006

AN OPPORTUNITY FOR PRIMARY PREVENTION

THE GOOD NEWS: PREVENTION WORKS

http://www.ktl.fi

Non-Communicable Diseases in LMICs: Myths, Facts and Opportunities

Gerald S. Bloomfield, MD, MPHDuke Global Health Institute

Division of CardiologyDuke University

THANK YOU