Transcript Asthma
The Union – (Way) Beyond TB
North America Regional Conference San Antonio, 23-25 February 2012 Dr Nils E. Billo, MD, MPH
Outline
• Little history of The Union • Beyond TB
– tobacco control and mpower – pneumonia in children – asthma – operational research – management education
• Summary
Origins of The Union
• • • • Paris 1867 : first international TB meeting Berlin 1902 : first permanent office Paris 1920 : International Union Against Tuberculosis officially established Paris 1986: Board decision to expand beyond TB:
adding Lung Disease to name
What is The Union?
An Institute
• 14 Offices worldwide • 5 Scientific Departments
Tuberculosis Tobacco Control HIV A Federation
• 79 Constituent Members • 22 Organisational Members • 2738 Individual Members • over 30,000 contacts
Research Lung Health & NCDs
The Union’s vision and mission today Mission
The Union brings innovation, expertise, solutions and support to address health challenges in low and middle- income populations
Vision
Health solutions for the poor
Activities of The Union
• Founded in 1920 • Up to 1986: focus on TB: mainly Conferences, publications, courses and technical assistance in TB • Between 1978 and 1990: Development of the TB DOTS strategy, mainly in Africa • 1990s: adding asthma, child lung health, tobacco control using TB model • 2000-2012 adding HIV and expanding in TB and tobacco control, adding operational research and management education to portfolio
The Union then and today
• 1992: Staff of 12 people Small Federation Secretariat: 1 Executive Director, 1 Scientific Director, admin staff for membership services and Editorial office for Journal, 1 accountant
Budget 2 million USD
• From 1992 onwards: gradually growing Secretariat in Paris with enlarged focus on Technical Assistance, Education and Research: Institute function added • 2011: about 250 staff and consultants in 14 offices:
Budget 50 million USD
The Tobacco Epidemic
Tobacco is the leading behavioural risk factor causing a substantially large number of potentially preventable deaths worldwide. The five million deaths translate to an incredible statistic: one death every six seconds. Unless strong actions are taken to halt the tobacco epidemic, 1,000,000,000 people are projected to die this century - we cannot let this happen. I urge all countries to implement fully the WHO Framework Convention on Tobacco Control.
Dr Ala Alwan, Assistant Director General , WHO, November 2011
Proportion of TB burden attributable to some major risk factors in high TB burden countries
HIV infection Relative risk for active TB disease
20.6/26.7*
Weighted prevalence (adults 22 HBCs)
0.8%
PAF
P P
RR RR
1 1
Population Attributable Fraction (adults) 16% Malnutrition
3.2** 16.7%
27% Diabetes
3.1
5.4%
10% Alcohol use (>40g / d) Active smoking
2.9
2.0
8.1% 26%
13% 21% Indoor Air Pollution
1.4
71.2%
22%
Sources:
Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.
Deaths attributable to tobacco (in %)
WHO Global Report: Mortality attributable to tobacco, 2012
Exposure to second-hand smoke causes death and disease
Source: Office of the U.S. Surgeon General. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General, 2006
Bloomberg Initiative To Reduce Tobacco Use • Grants Programme • Capacity Building • Programme Impact 2011 • Progress of The Union’s Tobacco Control work 2011
WHO MPOWER Package
m
onitor tobacco use and prevention policies protect people from tobacco smoke (Smoke-free)
o
ffer help to quit tobacco use
w
arn about the dangers of tobacco enforce bans on tobacco advertising, promotion and sponsorship (TAPS)
r
aise taxes on tobacco
Grants programme
Capacity building
Technical and management courses since 2007 (to 31 May 2011)
Number of trainings 109 Number of participants Number of countries covered 2305 36
Progress 2011 9
trainings held since January 2011 including
5
in March – May 2011 Total IMDP trainings in 2011 –
6
Total technical trainings in 2011
- 3
Progress in Tobacco Control
Indicator 2011 Achieved 2011
Increased Smokefree initiatives in 7 priority countries and 1 country noted for its regional influence.
FCTC compliant legislation focusing on MOPWER interventions achieved in 2 priority countries and 2 countries of regional influence. China* Indonesia Russia* Egypt Pakistan India* Bangladesh* Russia Nepal Indonesia* Lebanon Incorporating TC into the broader health agenda in 3 priority countries.
Russia Philippines* Indonesia* One recognised civil society organisation and/or government subsidiary takes on tobacco control in 6 countries as its main area of work.
Bangladesh India Egypt Pakistan Philippines Lebanon
*
Partially achieved
Reducing childhood pneumonia-related mortality
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
Child Lung Health Programme (CLHP) MALAWI Making a Difference in Child Survival
Specific objectives
• To standardise case management for severe and very severe pneumonia in district hospital paediatric inpatient ward • To reduce mortality due to respiratory disease especially severe/very severe pneumonia in children under 5 years of age • To rationalise the use of drugs for ARI in children under 5 years of age.
• To provide uninterrupted supply of essential drugs and oxygen at District Hospital
Enrolment into CLHP by year 2000 - 2005 n = 48,365
14000 12000 10000 8000 6000 4000 2000 0 5 districts 2000 Total 10 districts 2001 Total 16 districts Total 23 districts Total 24 districts 24 districts 2002 2003 2004 2005
Trend in Outcomes 1 October 2000 to 30 September 2005 % 90 80 70 60 50 40 30 20 10 0 Treatment completed 1 3 2000 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 2001 2002 2003 2004 2005
Months after program introduction
Achievements of the CLHP Malawi
• Total number of children admitted between October 2000-December 2005 48,365 • Baseline pneumonia CFR • Pneumonia CFR December 2005 • Reduction over the baseline • Total number lives saved 2000-2005 18.6
8.4
54.8% 4,357
Summary
• Implementation of standard case management to district hospitals is feasible and successful • Key elements for success are supply of drugs, accountability and supportive visits • The cost is competitive, facilitating sustainability CLHP Malawi incorporated into the Essential Health Package • Adoption of Child Lung Health into National Planning sector wide approach (SWAPS)
Why Asthma?
• • • • • • Asthma is the most common chronic disease among children.
Asthma affects millions of adults. 235 million people worldwide suffer from asthma.
Asthma is a non-communicable disease (NCD).
Effective medicines are available.
Unfortunately, for many people with asthma – particularly the poor – these medicines are too costly or not available at all.
Asthma in Children
Asthma in Adults
Essential Medicines: Pricing, Availability and Affordability
A Practical Solution: Asthma Drug Facility (ADF)
• Provides affordable access to quality-assured, essential asthma medicines for low and middle-income countries • Promotes a quality improvement package for the diagnosis, treatment and management of asthma
In countries, the cost for one year of medicines for a patient with severe asthma can be less than 40 USD when medicines are purchased through ADF
ADF Clients Countries that have already received their orders
• Pilot Projects in Benin (NTP), El Salvador (NTP), Sudan (Epi-Lab) • Kenya (KAPTLD) • Burundi (NTP) 7 orders for a total of €99,826
Current orders
• Vietnam (CHDI) • Guinea Conakry (NTP) • Burkina Faso (NTP)
Reduction in annual costs for a patient with severe asthma when medicines purchased through ADF (in euros, based on 2009/2010 ADF prices)
ADF Product Prices for 2011
Additional costs: transport, insurance, preshipment inspection and 10% fees for ADF services
Product Primary Supplier (Country) Price per unit FCA (USD)
Beclometasone 100µg/puff 200 doses, HFA inhaler* Salbutamol 100 µg/puff 200 doses, HFA inhaler* Budesonide 200µg/puff 200 doses, HFA inhaler* Fluticasone 125µg/puff 120 doses, HFA inhaler Beximco (Bangladesh) GSK Export (UK) Cipla/Medispray (India) Cipla/Goa (India) 1.28
1.08
2.60
2.50
*On the 17
th WHO Essential Medicines List March 2011
Challenges at country level
• Lack of political will, other priorities • Guidelines not available or not implemented • Corticosteroids often not on the national Essential Medicines List (EML) • Non-essential medicines pushed by pharmaceutical companies and specialists • Lack of trained health workers • Lack of funds to purchase essential medicines • Restrictions in national procurement system about using the ADF mechanism
The Economic Burden of Asthma
Treating asthma entails vastly more than the cost of medicines. It amounts to billions of dollars in both direct and indirect costs.
www.theunion.org
http://isaac.auckland.ac.nz
The Global Asthma Report 2011 www.globalasthmareport.org
Operational Research at The Union
Centre for Operational Research Activities
Support Bold and Innovative Strategies MALAWI
HIV testing of all pregnant women and ART offered to all those HIV positive regardless of CD4 count
In 3 months from April – June 2011: 509,645 persons were HIV tested 18,442 new HIV-positive patients started on ART 7524 (88%) of 8525 HIV-positive pregnant women started on ART
The DOTS Model for monitoring Non-Communicable Diseases
Operational Research Fellows
• 6 Union-based OR Fellows: Malawi; Zimbabwe; South Africa; India; Vietnam; Brazil • 4 MOU-supported OR Fellows: South Africa (2) and Kenya (2) •
Outputs from April 2009 - December 2011 (33 months) 55 research projects undertaken 39 completed and submitted to journals 30 papers in press or published
Operational Research Courses
Purpose:
To teach the practical skills for conducting and publishing operational research
Approach:
• Product –oriented [ a submitted research paper ] • Participants go through whole research process • Milestones must be achieved to stay in course • Trained participants become facilitators
Three module – course starting this week in Nepal for Asian candidates
• Module 1a:
research questions, protocol development and ethics (5 days) – February
• Module 1b:
Data management and data analysis (5 days) – February/March
• Module 2:
Paper writing, peer review and policy implications (5 days) – October
Does the Model work?
• 7 courses – either underway or completed since 2009 - 86 participants enrolled • 3 courses completed: – 34 participants enrolled – 31 completed milestones /awarded certificate – 35 papers submitted to journals – 27 papers (>70%) in press or published
70 60 50 40 30 20 10 0
Published Papers as a result of training / support from COR
Published Papers 2009 2010 2011
“If you do not write about it, it did not happen” Virginia Woolf
RESEARCH TO POLICY
•
One Expert Meeting 2009
•
Two papers in IJTLD
•
Two papers in TMIH
•
One paper in TRSTMH
•
One paper in BMC Medicine
POLICY TO PRACTICE Bi-Directional Screening of TB and Diabetes Mellitus China and India
World Diabetes Foundation Support •National Stakeholders Meeting •Training for implementers •Implementation •Review activities and data •National Stakeholders Meeting
•
Strengthening Health Systems
The Union’s International Management Development Programme (IMDP) was created to aid countries with the difficult task of operating a national health programme by training health managers in management education. • Its mission is to develop a community of leaders and innovators in public health who improve the quality of services provided to the public through well-managed national health programmes.
•
Training Leaders in Public Health
Participants who attend IMDP courses have the opportunity to become multi-talented managers capable of dealing with complex situations in public health that require multiple skills and competencies. • IMDP participants generate greater value for health organisations by being more capable of handling a variety of challenges that health programmes face.
Summary
• Main activities in TB and tobacco control • Models ready to be scaled up in child lung health and asthma • Operational research critical to investigate new areas of intervention • Publish successes a must • Management training and Human Resource Development critical
Health Solutions for the Poor Technical Assistance – Education – Research
Union Values
• • • •
Quality
We deliver our services and products to the highest possible standards.
Accountability
We are responsible stewards of resources and deliver on our commitments.
Independence
We maintain the freedom to pursue innovation and are guided by the best evidence to improve the health of the poor.
Solidarity
We stand together as one Union to overcome the greatest challenges to improve health among the communities we serve.