The Global Alliance against Chronic Respiratory Diseases

1
The Global Alliance against Chronic Respiratory
Diseases
Dr Nikolai Khaltaev"Global lung health in
2000's"Antalya, Turkey, 25 26 April 2007
2
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

3
The global burden of chronic respiratory diseases
4
Did you know??
4 000 000 PEOPLE DIED FROM CHRONIC RESPIRATORY
DISEASES IN 2005
5
Some widespread misunderstandings about chronic
respiratory diseases - and the reality
6
Some widespread misunderstandings about chronic
respiratory diseases - and the reality
7
Chronic respiratory diseases worldwide
Main chronic diseases include

• Cardiovascular diseases mainly heart disease and
  stroke
• Cancer
• Chronic respiratory diseases
• Diabetes

8
Chronic respiratory diseases worldwide
Hundreds of millions of people have chronic
respiratory diseases,

• 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.

9
Chronic respiratory diseases in Turkey
In Turkey, chronic respiratory diseases accounted
for 6 of all deaths or 26 220 deaths in 2002.
10
What are the causes of chronic respiratory
diseases?
11
Burden of Major Respiratory Conditions
Condition
DALYs
Deaths


Lower Respiratory Infections
6.6 5.8
COPD
4.8 1.9
Tuberculosis
2.8 2.4
Bronchus
Lung/
2.2 0.8
/Trachea Cancer
Asthma
0.4 1.0
Total
16.8 11.9
Source World Health Report 2003
DALYs Disability-Adjusted Life-Years
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What are DALYs?
age (years)
13
Increasing Burden of Diseases and
Injuries Change in Rank Order of DALYs
DALYs Disability Adjusted Life Years
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Chronic obstructive pulmonary disease (COPD)

• "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

15
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

16
World map COPD - Deaths / 1000 year 2000
17
World map COPD DALYs / 1000 year 2000
18
Prevalence of COPD in Europe
19
Risk factors
Passive smoking "Keep it funny, Keep it smoke
free" Anti smoke campaign, The Netherlands
20
The relative importance of Tobacco Smoke and
other risk factors relevant for COPD
Opposite patterns in different geographic areas
EUROPE versus AFRICA
Source World Health Report 2002
21
EUROPE Disease burden (DALYs) in 2000
attributable to selected risk factors
22
AFRICA Disease burden (DALYs) in 2000
attributable to selected risk factors
23
Risks are increasing burden of disease
attributable to tobacco ( DALYs in each
subregion)
24
Risks are increasing burden of disease
attributable to indoor smoke from solid fuels (
DALYs in each subregion)
25
Risks are increasing burden of disease
attributable to urban air pollution ( DALYs in
each subregion)
26
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.

27
Global Burden of Asthma 2004
28
Global Burden of Asthma 2004
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Global Burden of Asthma 2004
30
WHO global approach to control Chronic
Respiratory Diseases
31
Framework Convention on Tobacco Control (FCTC)
As for 17 December 2004 47 countries
have ratified 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)
32
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.

33
Framework Convention on Tobacco Control (FCTC)

• 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.

34
WHO/NHLBI
WHO/ARIA
2001
1995
One of the first examples of worldwide used
disease-specific guidelines and the 1st one on
Asthma Project coordinators Nikolai Khaltaev
(WHO) Claude Lenfant (NHLBI)
Including adaptation to developing countries
EBM low drug cost affordable for most patients
WHO essential list of drugs
35
WHO/NHLBI
2001
The first worldwide used guidelines on COPD
NHLBI/WHO Workshop Report Global Strategy for
the Diagnosis, Management, and Prevention of
COPD. Scientific information and recommendations
for COPD programs.
36
Practical Approach to Lung health
2003
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.
Targets Improve diagnostic strategies, reduce
inappropriate care, foster cost reduction
strategies, savings in antibiotic usage
and increase appropriate CS usage Tested in 15
different countries
Source WHO/STB
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A new way to prevent and control chronic
respiratory diseases
Global Alliance against Chronic Respiratory
Diseases
39

• 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

40
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.

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Before GARD lack of coordination, competition
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WHO calls for a global and coordinated effortto
fight Chronic Respiratory Diseases
43
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
44
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
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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
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GARD Vision

• A world where all people breathe freely

47
GARD Goal and Objective

• Goal
• To reduce the global burden of chronic
  respiratory diseases
• Objective
• To 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.

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Participants
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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
50
A global alliance working at country level

• GARD focuses on the needs of countries
• and fosters country-specific initiatives tailored
  to local conditions.

51
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.
52
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

53
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

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Prerequisites

• The situation of chronic respiratory disease
  surveillance, prevention and control programme in
  the country is analysed.
• The Ministry of Health is informed about GARD
  Country and invited to be involved in its
  development.
• WHO Regional Office and WHO Representative are
  informed about GARD Country and invited to be
  involved in its development.

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Situation analysis

• GARD runs pilot projects on surveillance of
  chronic respiratory diseases at primary health
  care level
• Georgia
• Russian Federation
• Cape Verde
• Philippines

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in Georgia
Firstly, patients fill in a WHO questionnaire on
symptoms of chronic respiratory diseases,
environmental exposure and smoking habits
Secondly, patients are screened by doing a
spirometry test that measures the lung capacity
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. in Ryazan, Russian Federation
A patient is screened by doing a spirometry test
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in Cape Verde and the Philippines

• Cape 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
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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

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Involvement of the Ministry of Health

• 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
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Involvement of the Ministry of Health

• Brazil
• Meeting with Dr Luis Fernando Sampaio,
• Director of Primary Care, Ministry of Health
• April 2006

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Involvement of the Ministry of Health

• 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".

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Steps to develop a GARD Country

1. Agreeing on a definition of Alliance
2. Nominating a GARD Country Coordinator
3. Identifying other partners
4. Running an exploratory workshop
5. Defining the Terms of Reference
6. Defining the structure
7. Identifying outcomes

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1. Agreeing on a definition of Alliance

PROPOSED DEFINITION
GARD COUNTRY
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)
that invites new inputs from various interested
parties
who commit to work collaboratively towards a
common goal.
in order to strengthen the national capacity to
face the increasing impact of CRD.
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2. Nominating a GARD Country Coordinator
Ministry of Health GARD Country initiator Core
group of interested parties ENDORSE
WHO on behalf of GARD Executive
Committee NOMINATES
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

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Faces of GARD Country Coordinators

• Prof Paulo Camargos
• GARD coordinator Brazil

Prof Tamaz Maglakelidze GARD coordinator Georgia
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3. Identifying other potential partners
GARD Country Coordinator shall make an inventory
of the various interested parties

• 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

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Identifying partners outside Ministry of Health
Multilateral Bilateral Agencies
Educational Sector
Professional Associations
Communities, churches, religious leaders
Patient Groups
Private sector, media
CRD and public health experts
Related Ministries
NGOs
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4. Running an exploratory workshop
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

• 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

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Exploratory workshop in Brazil, April 2006
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Exploratory workshop for Eastern European
Countries, Poland, 23-24 March 2007
4
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5. Defining the Terms of Reference

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

• General Purpose to reduce the burden of CRD at
  national level
• Technical Objectives different according to the
  products of GARD action plan that best suit the
  country
• 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

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Raising greater awareness on chronic respiratory
diseases in China
The Launch Meeting of China COPD Alliance in
Guangzhou, 4 November 2006
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Raising greater awareness on chronic respiratory
diseases in China
The Launch Meeting of Asthma Alliance in
Zhengzhou, Henan 4 June 2005
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Running intervention projects

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

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in Brazil
Brazil (Belo Horizonte) Programme Criança que
Chia (Wheezing Child)
Brazil (Bahia) Pilot project on control of
severe asthma
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in Tunisia

• 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

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6. Defining the structure
A proposal
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
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GARD Brazil Council
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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
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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

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Overview of GARD in countries
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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

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