Cardiovascular diseases – monitoring and control

Cardiovascular diseases – monitoring and control
The 2011 UN High Level Political Declaration saw governments around the world commit to a set of targets and actions to combat CVDs, diabetes, cancer, and chronic respiratory diseases in particular, and their risk factors © iStock

At the ESC annual congress, the WHO’s Jill Farrington provide an overview of the WHO’s role in the control and monitoring of cardiovascular diseases and non-communicable diseases.

Last year, SciTech Europa attended the European Society of Cardiology’s (ESC) annual congress and there listened to Jill Farrington, technical officer at the World Health Organization’s (WHO) Regional Office for Europe, provide an overview of the WHO’s role in the control and monitoring of non-communicable diseases (NCDs) and cardiovascular diseases (CVDs), explaining what different strategies and action plans exist, as well as outlining the results of the WHO’s most up to date monitoring and surveillance with regard to CVD.

“There is a huge focus internationally at the moment on NCDs,” Farrington began. “And that really dates back to 2011, in particular, with the UN High Level Political Declaration.” This saw governments around the world commit to a set of targets and actions to combat cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases in particular, and their risk factors.

“The WHO and other bodies are particularly busy trying to see how countries are doing and whether they have held to their commitments,” Farrington went on. “And there is a particular focus on outcomes, with the main over-arching outcome being on premature mortality and a reduction for the four main diseases.”

There are, she also explained, three frameworks which are monitored by the WHO: the United Nations’ Sustainable Development Goals (SDGs) which call for “a reduction by a third by 2030, the global action plan, with a reduction by 25% by 2025, and, within Europe, the WHO European target of an annual reduction by 2020.” Alongside these, there is also a set of nine global targets which, Farrington told her audience, “are largely prevention-focused.”

The WHO also has a set of progress indicators, which it uses to see “how countries are doing in terms of setting targets, putting broad multi sectoral plans for all the main NCDs in place, and then implementing a set of best buys.”

These ‘best buys’, she explained, are effective and cost effective measures agreed at the World Health Assembly which cover risk factors and the main diseases at both population level and individual treatment level.”

Monitoring instruments

According to Farrington, the WHO is able to monitor the progress that is being made – or the lack thereof – through a range of different instruments. She explained: “Over the last 15 years or so, every three-to-five years we have been doing country capacity surveys; these have the limitation that they are self-assessment surveys by countries, but, more positively, they go to the country’s Ministry of Health and have to be signed off by that ministry as representative of the country.”

The WHO publishes reports from these surveys and, as Farrington explained to her audience in Barcelona, if a country has provided evidence of a cardiac plan, then they have to provide the WHO with a copy of that plan so that it can be uploaded to a dedicated website where it is available for others to view. Finally, from these submissions, the WHO is able to create country-specific profiles.

Surveillance systems

“We also have surveillance systems,” she went on, using the Global Health Observatory as an example, which enables the WHO to “monitor mortality and risk factors, and again we publish capacity information. We have data specifically for Europe that comes directly from the countries themselves, and we also publish risk factor survey information. The tool we use most often is the STEPS survey for NCD risk factors.”

More in-depth studies are also undertaken by the WHO, and Farrington explained that, working alongside the European Stroke Organisation (ESO) and others, the WHO has been reviewing services for acute care and rehabilitation for heart attacks and stroke.

“Where possible,” she continued, “we publish this information. We have also been involved in broader health systems assessments, where we are looking at what are possible barriers to getting good outcomes for NCDs, and again we publish those country reports.”

Strategies and action plans

Farrington then turned her attention to the different strategies and action plans which are in place across the European region. She explained that over the course of the last two-to-three decades, the WHO has gone in different directions: “Starting from a very disease-focussed approach on programmes when it was developing the National Cancer Control Programme… it has then become more broader and taken a focus on common risk factors across diseases.

“What you therefore find is that when we have a global or European action plan for the prevention and control of non-communicable diseases, it is comprehensive; it covers prevention and treatment; and it is really taking a focus on common cross cutting issues.”

Moving on to explore ideas of what a cardiovascular disease programme or plan might look like, she explained: “It is not dissimilar from what would broadly be in a cancer programme or plan, for example, but it has also got an opportunity to include these cross cutting issues, particularly around population level prevention. If we look, for instance, at end of life care, that might be considered a cross cutting issue; improving quality of care and health systems approach is cross cutting issue.

“If we look at what a comprehensive approach to cardiovascular diseases might be in a specific country, it could be a whole range of different policies and plans, rather than one single document.”

The European region and NCD targets

Presenting her audience with what were preliminary results because the analysis was yet to be finalised, Farrington explored the progress being made in the WHO European region towards achieving the global NCD targets.

“Generally,” she said, “we are not doing so well.” She went on to first focus on the targets which the region is more likely to be achieved by the target deadlines of 2025 or 2030. “Premature mortality and hypertension appear to be on course to be achieved,” she explained. “But risk factors like tobacco, alcohol, obesity look set to miss achieving those targets. For the other risk factors, we have a mixed picture, and it is hard to assess how we are doing.”

Looking at premature mortality for NCDs, which includes, and indeed is largely driven by, cardiovascular disease mortality, Farrington said that the target looks likely to be achieved – although there remains a pronounced difference between the mortality rates of men and women, with this appearing to “get wider the further across Europe we go.”

“In terms of clinical prevention services,” she continued, “the prevalence of [high] blood pressure is seeing a decline, and we are expecting that to continue and for us to therefore reach the target; we have also seen some improvements since the last survey in terms of the provision of cardio metabolic risk assessment and management in countries, but some things such as guideline provision and implementation hasn’t changed.”

Something Farrington found “particularly disappointing” was progress being made to tackle the challenges posed by tobacco, alcohol and obesity, with “things that we know are effective like increasing taxation…just not changing or not reaching the level to be effective.”

Plans for cardiovascular diseases

When it comes to the development and implementation of CVD plans, Farrington said that of the 53 countries who responded, 31 of them said they have a national policy strategy or action plan for cardiovascular diseases, and, moreover, that this was not too different from the responses the WHO had received in its 2015 survey, suggesting that progress had stalled a little.

She continued: “The new EU members, the old EU members, and the commonwealth of independent states are broadly similar in the proportion that have these in place. But if we look at the titles of those cardiovascular plans, only 18 of the 31 specifically mention cardiovascular disease; the others are much broader NCD strategies, or public health strategies. Given that picture, we would therefore say that a third of countries in the European region have got a CVD-specific plan, and that just over half to two thirds have got something in place that covers the main elements.”

She also explained that almost all of these plans are operational: while one was still under development and the state of another remained unknown, the rest were said to be being implemented and, what is more, over half of these had become operational in the last six years, while the older ones, the WHO had been assured, remained valid.

The data from this survey also demonstrated that operational guidelines are in place in around three quarters of the countries and being implemented in more than 50% of facilities.

“In terms of cardiovascular disease risk assessments and management” Farrington added, “this is said to be in place in more than two-thirds of countries which have said that it is offered in more than half of the facilities in their country.”

Content analysis

Concluding her speech at the ESC event, Farrington made reference to a 2009 EuroHealth project which provided an overview of 16 strategies, as well as a content analysis, which is, according to Farrington, something the WHO has been unable to do thus far.

“I suggest that between the information we have got and the information that the ESC and others have got, that is an opportunity there for the future.”

From Farrington’s presentation, it is quite easy to agree with her argument that the WHO has “reasonably good monitoring systems in place” across Europe and while these may indeed have their own limitation, as Farrington herself recognised at the end of her address, multiple sources exist which can be pulled together.

There is also, as Farrington concluded, significant scope for further exploration as well as for “accelerating achievement in non-communicable disease and cardiovascular disease prevention and control and in terms of the question of how many countries in Europe have got a CVD specific plan in place.”

Noise and cardiovascular diseases

According to the World Health Organization, cardiovascular diseases are responsible for 31% of all global deaths, taking the lives of 17.7 million people every year.

Triggering these diseases – which manifest primarily as heart attacks and strokes – are tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol. These in turn show up in people as raised blood pressure, elevated blood glucose and overweight and obesity, risks detrimental to good heart health.

Alongside this, exposure to high levels of noise, which the WHO refers to as an ‘underestimated threat’, has also been linked to a number of short- and long-term health problems, including cardiovascular effects.

When SciTech Europa spoke with the World Health Organization’s Rokho Kim back in 2012, he explained that ‘beyond the level of 55 decibels Lnight [the A-weighted annual average sound level used to assess sleep disturbance over an eight hour night time period] there is epidemiological evidence documenting the risk of cardiovascular diseases. Therefore, the WHO has recommended 55dB Lnight as an interim target for noise control for both short- and mid-term governmental goals, and 40 Db as ultimate guidelines value for protecting public health from environmental noise.”

Indeed, the linkage of CVD to noise pollution is not a new one, with a body of literature now available from diverse sources pointing to fact that long term exposure to noise can increase the risk of heart disease both biologically – for example by raising blood pressure – and psychologically, from disturbed sleep and increased release of stress hormones.

This article will appear in SciTech Europa Quarterly issue 27, which will be published in June, 2018.

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