The role of GARD in the action plan for the Global Strategy for by gabyion

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									The role of GARD in supporting the WHO Action Plan to Prevent
                    and Control Noncommunicable Diseases




Summary
       In order to prevent and control noncommunicable diseases (NCDs), the 61st World
Health Assembly has endorsed an NCD Action plan (WHA Resolution 61.14) (1). This plan
is intended to support coordinated, comprehensive and integrated implementation of strategies
and evidence-based interventions across individual diseases and risk factors, especially at the
national and regional levels. There are 6 objectives and actions proposed. A Package for
Essential NCDs including chronic respiratory diseases (CRDs) has been developed. It
comprises a core set of interventions to be used at country level.

    The Global Alliance against Chronic Respiratory Diseases (GARD) is a new but rapidly
developing voluntary alliance that is assisting WHO in the task of addressing NCDs. GARD
approach was initiated in 2006 (2, 3). The work of GARD is in line with the 2008-2013
Action Plan for the Global Strategy for the Prevention and Control of NCDs (1). GARD has
been developed in a stepwise approach with short-term, medium-term and long-term
objectives and action-plans. Each step comprises measurable outcomes and deliverables (2).
For example the adoption of an integrated NCD action plan is proposed as part of its medium-
term goals. A syndromic approach in primary health care centers was proposed in the goals of
CRD control provided by the GARD approach.

     The GARD Action Plan 2008-2013 (4) is an instrument of the Action Plan for the Global
Strategy for Prevention and Control of NCDs (1). It was endorsed by the 2008 GARD
General Meeting and sets out the vision, goal, purpose and strategic objectives for GARD
collaborating parties, in order to guide their work between 2008-2013 (4). It is a result-based
management document, and it will be used as an evolving tool, in order to guide the planning,
monitoring and evaluation of the work of the alliance at the global and country levels. GARD
activities have been started in over 40 countries.

Abbreviations
COPD: Chronic Obstructive Pulmonary Disease
CRD: Chronic Respiratory Disease
GARD: Global Alliance against chronic Respiratory Diseases
HCP: Health Care Provider
LMIC: Low and Middle Income Countries
MOH: Ministry of Health
NCD: Noncommunicable disease
PAL: Practical Approach to Lung Health
PALSA: Practical Approach to Lung Health in South Africa
WHA: World Health Assembly




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1- Chronic respiratory diseases; a public health challenge
     Of the 58 million deaths in 2005 in the world, approximately 35 million were estimated
to be the result of noncommunicable diseases (NCDs) (5). They are currently the major cause
of death and burden among adults in almost all countries and the toll is projected to increase
by a further 17% in the next 10 years. Current epidemiologic evidence indicates that there are
4 types of NCDs make the largest burden (cardiovascular diseases, cancer, chronic respiratory
diseases (CRD) and diabetes) and require a concerted and coordinated action. This is a very
serious situation, both for public health and for the societies and economies affected. The
impact and profile of NCDs have been fully appreciated by the 61st WHA (2008) which
endorsed an action plan to support the implementation of the Global Strategy for prevention
and control of NCDs (1).
     Chronic respiratory diseases (CRD) are a group of NCDs affecting the airways and the
other structures of the lungs. Major CRDs include asthma, chronic obstructive pulmonary
disease (COPD), occupational lung diseases, allergic and nonallergic rhinitis, chronic
rhinosinusitis, sleep apnea syndrome and pulmonary hypertension (ICD-10 (6)). Everyone in
the world is exposed to risk factors for CRDs (Table I). A significant number of subjects
suffer from CRDs (Table II). Many patients have major adverse effects on their life and
disability. Over 4 million people died prematurely due to CRDs in 2005 (3). Most of death
and burden occur in low and middle income countries (LMICs).

Table I: Risk factors for chronic respiratory diseases

Risk factors                                        Number of subjects exposed             References

Outdoor air pollution (living in urban areas)       > 3 billions                           (7)
Solid biomass fuel combustion                       2 billions                             (8)
Tobacco smoke                                       > 1 billion                            (9)
Occupational inhalants                              500 millions                           (10)
Inhaled allergens                                   Everyone in the world




Table II: Estimates of prevalence for chronic respiratory diseases

CRD                            Year of estimation            Prevalence         References

Asthma                                   2007                    300 millions   (3)
COPD                                     2007                    210 millions   (3)
Allergic rhinitis*                       2007                    400 millions   (3)
Non-allergic rhinitis*                   2008                    400 millions   (11, 12)
Sleep apnea syndrome                     2007                >100 millions      (3)
Other CRD                                2007                    >50 millions   (3)

*: estimates of rhinitis do not include patients with asthma and rhinitis




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2- The 2008-2013 Action Plan for the Global Strategy for the
  Prevention and Control of Noncommunicable diseases
    In order to prevent and control NCDs, the world’s biggest killers, and to address key
challenges to global development in the 21st Century, the 61st WHA has endorsed an NCD
Action plan (WHA Resolution 61.14) (1).
    This Action Plan has the following purposes:

   Mapping the emerging epidemics of NCDs and analyzing their social, economic,
    behavioural and political determinants as the basis for providing guidance on the policy,
    programmatic, legislative and financial measures, that are needed to support and monitor
    the prevention and control of NCDs.
   Reducing the level of exposure of individuals and populations to the common modifiable
    risk factors for NCDs – namely, tobacco use, unhealthy diet and physical inactivity, and
    the harmful use of alcohol – and their determinants, while at the same time strengthening
    the capacity of individuals and populations to make healthier choices and follow lifestyle
    patterns that foster good health
   Strengthening health care for people with NCDs by developing evidence-based norms,
    standards and guidelines for cost-effective interventions and by reorienting health systems
    to respond to the need for effective management of diseases of a chronic nature.
     The plan is based on current scientific knowledge, available evidence and a review of
international experience. It comprises a set of actions which will tackle the growing health
burden imposed by NCDs.
     This plan is intended to support coordinated, comprehensive and integrated
implementation of strategies and evidence-based interventions across individual diseases and
risk factors, especially at the national and regional levels.
    There are 6 objectives and actions proposed:
   Objective 1: To raise the priority accorded to NCDs in development work at global and
    national levels, and to integrate prevention and control of such diseases into policies
    across all government departments.
   Objective 2: To establish and strengthen national policies for the prevention and control of
    NCDs.
   Objective 3: To promote interventions to reduce the main shared modifiable risk factors
    for NCDs (tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol).
   Objective 4: To promote research for the prevention and control of NCDs.
   Objective 5: To promote partnerships for the prevention and control of NCDs.
   Objective 6: To monitor NCDs and their determinants to evaluate progress at national,
    regional and global levels.

3- Core set of interventions for noncommunicable diseases
    3-1- Rationale
    A mixture of cost-effective, population-wide and individual interventions are available
for prevention and control of major NCDs. Individual interventions address the needs of



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people at high risk of developing NCDs and those with established disease. If effectively
applied in combination with population wide interventions, they can reduce morbidity and
premature mortality and are cost-effective in developed (13) and developing countries (14).
     Many major NCDs can be prevented and/or controlled. Direct and indirect costs of
treating complications are enormous and can be reduced. However, despite the existing
knowledge the vast majority of people in the world are not covered by adequate prevention
against NCDs and do not receive appropriate management, in particular in primary care of
resource constrained settings.
     People with NCDs or at risk of developing NCDs require long-term care that is proactive,
patient-centered, community based and sustainable. Such care can be delivered through health
systems based on primary care (15).
     However, since this involves consideration of over 50 NCD conditions, it represents a
considerable challenge, particularly for health care workers in LMICs. Particular challenging
is deciding on priorities and integrating the many separate disease-specific interventions to
avoid fragmentation and duplication of efforts. Such integration involves a health systems
approach, preferably at country level. There are currently a few examples of successful
programs that address several NCDs, in some cases combined with the management of
infectious diseases (16, 17). Lessons learned from these initial efforts confirm that such
methods may be extended in many LMICs to address priority needs in NCD prevention and
management.

    3-2- Prioritized interventions: The WHO Package for Essential NCDs
         interventions
    The WHO NCD initiative has adopted this approach in its recently developed Package
for Essential NCDs. This comprises a minimum set of interventions to be used at country
level and is accompanied by a variety of tools including a manual of operations (in
preparation). The development of core set of interventions is in line with the Action Plan for
the Global Strategy for Prevention and Control of Noncommunicable Diseases (1). The
package is designed to provide guidance for integrating prevention and control of the 4
essential NCDs at the primary care level. This package should be considered as a minimum
care standard for low resource settings. It is expected that these essential interventions will
reduce death and burden caused by NCDs.
     For example, among the CRDs, asthma and COPD are included, and the recommendation
is that recommended that peak flow meters, pulse oximetry, generic oral and inhaled
corticosteroids, salbutamol, ipratropium, and adrenaline be among the equipment and
essential medicines to be available in every primary health care center.
    The core set of interventions provides charts to help health care workers to better manage
symptoms of essential NCDs including dyspnea and cough. However, flexibility is
encouraged in order to adapt these charts to the local needs and situations.

4- GARD
       4-1 GARD Action Plan
     The Global Alliance against Chronic Respiratory Diseases (GARD) is a new but rapidly
developing voluntary alliance that is assisting WHO in the task of addressing NCDs. It is an
alliance of national and international organizations, medical and scientific societies,



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institutions, and agencies working with the common goal of reducing the global burden of
chronic respiratory diseases (4). The WHO provides technical leadership and secretariat
support.

     The GARD Action Plan 2008-2013 (4) is an instrument of the Action Plan for the Global
Strategy for Prevention and Control of Noncommunicable Diseases (1).

     The GARD Action Plan was endorsed by 2008 GARD General Meeting and sets out the
vision, goal, purpose and strategic objectives for GARD collaborating parties, in order to
guide their work between 2008-2013 (4). It is a result-based management document, and it
will be used as an evolving tool, in order to guide the planning, monitoring and evaluation of
the work of the alliance at the global and country level.

     The vision of GARD is a world where all people breathe freely. Its goal is to reduce the
global burden of chronic respiratory diseases, and its purpose is to initiate a comprehensive
approach to fight CRDs. GARD pursues the following four strategic objectives. The first two
relate to the functions of the alliance, in terms of advocating and raising awareness, providing
a network for discussion, enhancing partnerships at global, regional and country levels and
resource mobilization for chronic respiratory diseases. The other two are related to the support
that GARD provides to WHO technical work.

GARD core strategic objectives:

   ADVOCACY. To raise the recognition of the importance of chronic respiratory diseases
    at global and country levels, and to advocate the integration of prevention and control of
    such diseases into policies across all government departments.
   PARTNERSHIP. To promote partnering for the prevention and control of chronic
    respiratory diseases.

GARD strategic objectives to support WHO technical work:

   NATIONAL PLANS ON PREVENTION AND CONTROL. To support WHO in
    assisting countries to establish and strengthen national policies and plans for the
    prevention and control of CRDs using WHO endorsed approaches and methods.
   SURVEILLANCE. To support WHO in monitoring CRDs and their determinants and
    evaluate progress at country, regional and global levels.

     GARD provides a network through which collaborating parties can combine their
strengths, thereby achieving results that no one partner could obtain alone. GARD improves
coordination between existing governmental and nongovernmental programs which avoids
duplication of efforts and wasting of resources.

       4-2- GARD comprehensive approach
      GARD approach was initiated in 2006 and published in "Global surveillance,
prevention and control of CRDs. A comprehensive approach" (2, 3). It includeds the
following:
   Burden, Risk Factors and Surveillance of CRDs and Respiratory Allergies: Development
    of a standardized process to obtain data on CRD risk factors, disease burden, trends,
    quality and affordability of care as well as the economic burden imposed on families and


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    countries alike. Standardized data will support the creation of comparable estimates
    across countries, and will help policy makers to prioritize actions and assess the impact of
    their interventions.
   Advocacy for CRDs and Respiratory Allergies: Increasing awareness about CRD and
    strengthening commitment for action across a wide range of stakeholders to make CRD a
    public health priority in all countries.
   Health Promotion and Prevention of CRDs and Respiratory Allergies: Encouraging the
    implementation of policies to reduce the burden of tobacco smoke, indoor and outdoor
    pollution, occupational hazards and other risk factors relevant to CRDs.
   Diagnosis of CRDs and Respiratory Allergies: In all countries, CRDs are under-
    diagnosed. GARD will promote simple, available and affordable diagnostic tools for
    CRDs and respiratory allergies using approaches adapted to different health needs,
    services, and resources as well as proper training of health professionals in their use. In
    primary health care centers, measurement of peak flow should be proposed worldwide.
   Control of CRDs and Allergy, and Drug Accessibility (Figure 1):


Figure 1: Goals of chronic respiratory disease control, according to the income-level of
          the country




from (2, 3)


     In areas with a high burden of communicable diseases and a functioning PHC service,
      models like the WHO-PAL (Practical Approach to Lung Health) is promoted (16,
      18).
     In areas with a high prevalence of HIV infection, models like PALSA Plus (PAL in
      South Africa) is promoted (17).


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     Models of prevention and care for CRDs in middle and high-income countries can
      use a different model. They will target asthma, rhinitis, COPD, occupational lung
      diseases and other CRDs. Approaches will be developed from available management
      plans and international guidelines according to specific country needs.
     A particular interest is the control of pulmonary hypertension (PH) (19) which has not
      deserved enough attention worldwide.
     The key aspects of GARD work for the control of CRD are:
      o To ensure the availability of drugs for patients with CRDs in each treatment
          setting (20).
      o To assist in knowledge translation strategies for the training of health care
          workers in the management of CRDs.
   Pediatric CRDs and Respiratory allergies: CRDs in childhood and adolescence represent
    a serious and increasing public health problem. In LMICs, CRD underdiagnosis in pre-
    school children is an important issue particularly. It is of great concern that children
    (even in primary school) tend to smoke earlier than before and that adolescents tend to
    smoke more than before, and particularly in LMICs (9). Due to the features of pediatric
    CRDs and allergies a separate program is needed.

5- GARD in the 2008-2013 noncommunicable disease Action Plan
  and core set of interventions
    GARD has been developed in a stepwise approach with short-term (Step 1), medium-
term (Step 2) and long-term (Step 3) objectives and action-plans. Each step comprises
measurable outcomes and deliverables (2). For example the adoption of an integrated NCD
action plan is proposed as part of its medium-term goals (Figure 2). The work of GARD is
therefore in line with the 2008-2013 Action Plan for the Global Strategy for the Prevention
and Control of NCDs (1). GARD collaborating parties continue to offer their support to
WHO to achieve the agreed objectives according to clear indicators and milestones.

Figure 2: GARD developing steps




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from (2)


    Moreover, GARD is in line with the Cores set of interventions based on the 2008 World
Health Report (15). A syndromic approach in primary health care centers was proposed in the
goals of CRD control provided by the GARD approach (figure 1). This approach should
optimally be integrated with core set of interventions to accomplish the objectives of the
2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs (1).

6- GARD activities in countries
        Health priorities, geographic variability in risk factors and CRD, the diversity of
national health care service systems and variations in the availability and affordability of
treatments all require that any recommendation should be adapted locally to ensure their
appropriateness in the community in which they are applied. GARD activities have been
started in over 40 countries (Figure 3).
Figure 3: GARD activities in countries




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References

1.    2008-2013 Action plan for the global strategy for the prevention and control of non
      communicable diseases. Prevent and control cardiovascular diseases, cancers, chronic respiratory
      diseases, diabetes. http://wwwwhoint/nmh/Actionplan-PC-NCD-2008pdf. 2008.
2.    Bousquet J, Dahl R, Khaltaev N. Global Alliance against Chronic Respiratory Diseases. Eur
      Respir J. 2007 Feb;29(2):233-9.
3.    Bousquet J, Khaltaev N. Global surveillance, prevention and control of Chronic Respiratory
      Diseases. A comprehensive approach. Global Alliance against Chronic Respiratory Diseases.
      World Health Organization. ISBN 978 92 4 156346 8. 2007:148 pages.
4.    Action Plan of the Global Alliance against Chronic Respiratory Diseases 2008-2013.
      http://wwwwhoint/gard/publications/GARD_actionplan_FINALpdf. 2008.
5.    Preventing chronic diseases: a vital investment: WHO global report. World Health Organization
      October 5, 2005 htpp://wwwwhoint/chp/chronic_disease_report/en/. 2005.
6.    International Statistical Classification of Diseases and Related Health Problems , 10th Revision
      Version for 2003 (http://www3.who.int/icd/vol1htm2003/fr-icd.htm). 2003.
7.    United Nation Population Fund (UNFPA). State of the world population 2007. wwwunfpaorg.
      2007.
8.    Torres-Duque C, Maldonado D, Perez-Padilla R, Ezzati M, Viegi G. Biomass Fuels and
      Respiratory Diseases: A Review of the Evidence. Proc Am Thorac Soc. 2008 Jul;5(5):577-90.
9.    Esson K, Leeder S. The Millennium Development Goals and Tobacco Control. An opportunity
      for global partnership. Geneva, Switzerland: World Health Organization, www.who.int/tobacco;
      2003.
10.   Balmes J, Becklake M, Blanc P, Henneberger P, Kreiss K, Mapp C, et al. American Thoracic
      Society Statement: Occupational contribution to the burden of airway disease. Am J Respir Crit
      Care Med. 2003 Mar 1;167(5):787-97.
11.   Bousquet PJ, Leynaert B, Neukirch F, Sunyer J, Janson CM, Anto J, et al. Geographical
      distribution of atopic rhinitis in the European Community Respiratory Health Survey I. Allergy.
      2008 Oct;63(10):1301-9.
12.   Weinmayr G, Forastiere F, Weiland SK, Rzehak P, Abramidze T, Annesi-Maesano I, et al.
      International variation in prevalence of rhinitis and its relationship with sensitisation to perennial
      and seasonal allergens. Eur Respir J. 2008 Nov;32(5):1250-61.
13.   Haahtela T, Tuomisto LE, Pietinalho A, Klaukka T, Erhola M, Kaila M, et al. A 10 year asthma
      programme in Finland: major change for the better. Thorax. 2006 Aug;61(8):663-70.
14.   Franco R, Santos AC, do Nascimento HF, Souza-Machado C, Ponte E, Souza-Machado A, et al.
      Cost-effectiveness analysis of a state funded programme for control of severe asthma. BMC
      Public Health. 2007;7:82.
15.   The World Health Report 2008 - Primary Health Care: Now More Than Ever.
      http://wwwwhoint/whr/2008/en/indexhtml. 2008.
16.   Murray JF, Pio A, Ottmani S. PAL: a new and practical approach to lung health. Int J Tuberc
      Lung Dis. 2006 Nov;10(11):1188-91.
17.   English RG, Bateman ED, Zwarenstein MF, Fairall LR, Bheekie A, Bachmann MO, et al.
      Development of a South African integrated syndromic respiratory disease guideline for primary
      care. Prim Care Respir J. 2008 Sep;17(3):156-63.
18.   Camacho M, Nogales M, Manjon R, Del Granado M, Pio A, Ottmani S. Results of PAL
      feasibility test in primary health care facilities in four regions of Bolivia. Int J Tuberc Lung Dis.
      2007 Nov;11(11):1246-52.
19.   Humbert M, Khaltaev N, Bousquet J, Souza R. Pulmonary hypertension: from an orphan disease
      to a public health problem. Chest. 2007 Aug;132(2):365-7.
20.   Ait-Khaled N, Enarson DA, Bissell K, Billo NE. Access to inhaled corticosteroids is key to
      improving quality of care for asthma in developing countries. Allergy. 2007 Mar;62(3):230-6.




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