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The Global Alliance against CRD GARD: rationale and objectives of a novel WHO initiative Nikolai Khaltaev, MD Chronic Respiratory Diseases Team World Health Organization Geneva, Switzerland. 8 th Annual Congress of the Turkish Thoracic Society April, 2005. photo: US EPA. OUTLINE.

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  1. The Global Alliance against CRD GARD: rationale and objectives of a novel WHO initiative Nikolai Khaltaev, MD Chronic Respiratory Diseases TeamWorld Health OrganizationGeneva, Switzerland 8th Annual Congress of the Turkish Thoracic Society April, 2005 photo: US EPA

  2. OUTLINE 1. WHO and its mandate 2. CRD, a public health priority for the WHA 3. GARD: an ambitious idea 4. GARD: programs against CRD 5. Present status of GARD

  3. WHO HQ – Geneva (CH)

  4. 6 Regional Offices 192 Countries with >75 WHO Representatives

  5. WHO is a UN specialized Agency which is controlled by the Countries and is serving the Countries 192 countries = 192 Ministries of Health WORLD HEALTH ASSEMBLY (annual mtg on May in Geneva) WHO deliver to countries

  6. WHO CORE FUNCTIONS • Articulate policy & advocacy • Manage information (knowledge) • Provide technical & policy support to countries • Develop national & global partnerships • Develop norms & standards • Stimulate development of new technologies, tools and guidelines

  7. OUTLINE 1. WHO and its mandate 2. CRD, a public health priority for the WHA 3. GARD: an ambitious idea 4. GARD: programs against CRD 5. Present status of GARD

  8. Respiratory diseases in MIC & Transition Countries communicable tbc, pneumoina, etc. % % changes in: demographics, HCSs schooling, income, tobacco XXth XXIth non-communicable asthma, COPD, lung cancer

  9. Burden of Major Respiratory Conditions Condition Deaths DALYs % % Lower Respiratory Infections 6.6 5.8 COPD 4.8 1.9 Tuberculosis 2.8 2.4 Lung/ Bronchus /Trachea Cancer 2.2 0.8 Asthma 0.41.0 Total 16.8 11.9 source: World Health Report 2003

  10. Increasing burden of noncommunicable diseases and injuries change in rank order of DALYs for the 15 leading causes (baseline scenario) 1999 2020 1.Acute lower respiratory infections 2. HIV/AIDS 3. Perinatal conditions 4. Diarrhoeal diseases 5. Unipolar major depression 6. Ischaemic heart disease 7. Cerebrovascular disease 8. Malaria 9. Road traffic injuries 10. COPD 11. Congenital abnormalities 12. Tuberculosis 13. Falls 14. Measles 15. Anaemias 1. Ischaemic heart disease 2. Unipolar major depression 3. Road traffic injuries 4. Cerebrovascular disease 5. COPD 6. Lower respiratory infections 7. Tuberculosis 8. War 9. Diarrhoeal diseases 10. HIV 11. Perinatal conditions 12. Violence 13. Congenital abnormalities 14. Self-inflicted injuries 15. Trachea, bronchus and lung cancers DALY = Disability-adjusted life year Source: WHO Evidence, Information and Policy, 2000

  11. COPD

  12. epidemiological transition = rise of life expectancy IF in the absence of reduction of exposure to smoke, occupational hazards, indoor & outdoor pollution = Rise of COPD e.g.: 45 to 65 Behavioral & Environmental Risk Factors COPD

  13. because of epidemiological transition the generation(s) exposed to pneumonia & TB & malnutrition in infancy-adolescence but surviving more will develop more COPD than the previous and the next generation(s) COPD

  14. DALYs Disability Adjusted Life Years One DALY: one lost year of “healthy” life DALY = YLD + YLL COPD onset expected death death 55 65 75 age (years) YLD YLL 50 Years of Life with Disability Years of Life Lost

  15. COPD - DALYs / 1000 year 2000

  16. COPD - Deaths / 1000 year 2000 <6.2 6.2-9.7 . 9.7-15.7 15.7-18.1 18.1-19.9 19.9-22.1 22.1-35.5 35.5-38.1 >38.1 no data

  17. Burden of COPD by Region WHO region SES stratum % Deaths % DALYs AFRO 1.1 0.3 D 1.1 0.3 E AMRO 5.2 3.7 A 3.3 1.7 B 1.8 1.1 D EMRO 2.1 1.4 B 2.3 0.9 D EURO 3.6 3.4 A 2.4 1.8 B 2.0 1.7 C SEARO 4.6 2.3 B source: World Health Report 2003 4.5 1.9 D WPRO 1.9 2.5 A 12.6 4.0 B Total 4.8 1.9

  18. ASTHMA

  19. Trends of Asthma Prevalence in Europe 20 England Asthma epidemic has already broken all the frontiers on a global scale This process is part of Westernization and is typical of the "epidemiological transition" England 15 Finland France 10 % Norway Scotland 5 Sweden Wales 0 1955 1965 1975 1985 1995 Trends of asthma prevalence outside Europe 20 Australia Canada - Hong Kong Israel 15 Japan New Zealand New Zealand % 10 Papua New Guinea Singapore Tahiti 5 Taiwan United States United States Vietnam 0 1955 1965 1975 1985 1995 Matricardi et al. AAAI 2001

  20. ASTHMA ISAAC most High-income countries most Low-Middle income countries

  21. in 2020 most cases of “inner-city asthma” will affect poor children in megalopolises of developing countries westernization + urbanization + poverty = inner-city asthma

  22. The enormous human suffering caused by chronic respiratory diseases (CRD) has been recognised by the 53rd World Health Assembly (May 2000) which requested the Director General "to coordinate, in collaboration with the international community, global partnershipsand alliances " for prevention and control of non-communicable diseases, including CRD (resolution WHA 53.17).

  23. OUTLINE 1. WHO and its mandate 2. CRD, a public health priority for the WHA 3. GARD: an ambitious idea 4. GARD: programs against CRD 5. Present status of GARD

  24. GLOBAL PARTNERSHIPS hosted by WHO WHO role ? coordination link with countries monitoring quality

  25. current status = lack of coordination, competition

  26. WHO calls for a global and coordinated effort to fight chronic respiratory diseases GARD

  27. GARD Target: to Develop and Implement a National Plan against CRD

  28. OUTLINE 1. WHO and its mandate 2. CRD, a public health priority for the WHA 3. GARD: an ambitious idea 4. GARD: programs against CRD 5. Present status of GARD

  29. WHO/ARIA Including adaptation to developing countries: EBM low drug cost affordable for most patients WHO essential list of drugs. 2001 WHO/NHLBI One of the first examples of worldwide used disease-specific guidelines and the 1st one on Asthma Project coordinators 1995 edition Nikolai Khaltaev (WHO) Claude Lenfant (NHLBI) 1995 Source : WHO/PMM

  30. WHO/NHLBI 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. 2001

  31. 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 epidemiologica transition. Targets Improve diagnostic strategies, reduce inappropriate care, foster cost reduction strategies, savings in antibiotic usage, increase appropriate CS usage Tested in 12 different countries 2003 Source : WHO/STB BUT poor economic conditions require an integrated approach at primary health care level

  32. Practical Approach to Lung health PAL A primary health care strategy for a holistic approach and an integrated management of the patient with respiratory symptoms in countries with epidemiological transition. started in Morocco, Chile, South Africa, Nepal improve detection, reduce inappropriate care, foster cost reduction strategies, savings in antibiotic usage now in >15 countries

  33. The Practical Approach to Lung health (PAL) 1. derived from Stop-TB and IMCI. 2.Clinical practice guidelines for respiratory symptoms integrating WHO guidelines for TB control, asthma and COPD management. 3. Targeted and adapted for “Multi-purpose health workers” in low and middle income countries. 4. Studies in progress in several countries (e.g. Chile, Morocco, Peru). Evidence based assessments carried out with the Cochrane Collaboration.

  34. WHO/MNC/CRA/03.2 STEP SuRF Prevention of Allergy and Allergic Asthma Based on the WHO/WAO Meeting on the Prevention of Allergy and Allergic Asthma Geneva,8-9 January 2002 FCTC

  35. OUTLINE 1. WHO and its mandate 2. CRD, a public health priority for the WHA 3. GARD: an ambitious idea 4. GARD: programs against CRD 5. Present status of GARD

  36. GARD historical background Before Sep. 2002: brainstorming meetings (Geneva, Montpellier) on the WHO Global Strategy against CRD Sept. 2002 1st proposal of "WARD" within the WHO CRA Unit Oct.-Dec. 2002 1st draft GARD bylaws 1st informal mtg with 2 NGO's Jan. 2003 1st proposal to LEG March-June 2003 CRA Unit mtg with Robert Beaglehole March 2004 CRA Unit mtg with Serge Resnikoff May 2004 Brainstorming mtg on GARD with 15 NGO's June 2004 TOR approved by LEG & ADG Aug 2004 Mtg in Glasgow with founders Sep 2004 20 NGOs join GARD – donors' agreements Nov 2004 Informal meeting 21 Dec 2004 WHO mtg with all partners + p. to be 18-19 Jan 2005 TODAY mtg of WGs in Geneva 10-11 May 2005 Nov 2005 launch in China 1st An Mtg May 2006

  37. GARD - categories of members (according to the current bylaws) World NGO (eg.: WAO) Reg NGO (eg.: EAACI) 2 1 Natl NGO (eg.: TTS) Gov Org (e.g.: NHLBI, KTL) 3 9 Foundations (e.g.: ECARF) 4 WHO-CC (eg.: Dokkyo Un.) 8 5 Intl. groups of Experts (eg.: GINA, ARIA) 7 Intl. Research Networks (e.g.: GA2LEN) 6 Patients Associations (eg: EFA)

  38. STRUCTURE Executive Board Incl. the Chairman Executive Committee General Assembly

  39. Potential structure of a future GARD EC and EB Executive Board Operative area Working groups 6 5 4 3 2 1 GARD EXECUTIVE COMMITTEE Vice-Chairman B Working groups Chairman C Head CRA Unit (WHO) D 6 5 4 3 2 1 Delegates of categories of members Assembly area

  40. Working Groups WG-1 Epidemiology and Surveillance WG-2 Respiratory Health Promotion and Disease Prevention WG-3 Diagnosis WG-4 Control and Drug Accessibility WG-5 Paediatric CRD and Allergy WG-6 Awareness

  41. WORKING GROUP • A chairman, a vice-ch., WHO professional & members • Autonomy and budget • Using WHO programs when applicable • Acting on country focused activities • Measurable outcomes • Annual Report • Subject to external evaluation (EC, WHO) • (One staff professional seconded to WHO)

  42. GARD: current & candidate members

  43. The Global Alliance against CRD GARD: rationale and objectives of a novel WHO initiative Nikolai Khaltaev, MD Chronic Respiratory Diseases TeamWorld Health OrganizationGeneva, Switzerland 8th Annual Congress of the Turkish Thoracic Society April, 2005 photo: US EPA

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