Emerging Concepts in Precision Medicine and Cardiovascular Diseases in Racial and Ethnic Minority Populations.

Cardiovascular diseases remain the leading cause of mortality and a major contributor to preventable deaths worldwide. The dominant modifiable risk factors and the social and environmental determinants that increase cardiovascular risk are known, and collectively, are as important in racial and ethnic minority populations as they are in majority populations. Their prevention and treatment remain the foundation for cardiovascular health promotion and disease prevention. Genetic and epigenetic factors are increasingly recognized as important contributors to cardiovascular risk and provide an opportunity for advancing precision cardiovascular medicine. In this review, we explore emerging concepts at the interface of precision medicine and cardiovascular disease in racial and ethnic minority populations. Important among these are the lack of racial and ethnic diversity in genomics studies and biorepositories; the resulting misclassification of benign variants as pathogenic in minorities; and the importance of ensuring ancestry-matched controls in variant interpretation. We address the relevance of epigenetics, pharmacogenomics, genetic testing and counseling, and their social and cultural implications. We also examine the potential impact of precision medicine on racial and ethnic disparities. The National Institutes of Health's All of Us Research Program and the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine Initiative are presented as examples of research programs at the forefront of precision medicine and diversity to explore research implications in minorities. We conclude with an overview of implementation research challenges in precision medicine and the ethical implications in minority populations. Successful implementation of precision medicine in cardiovascular disease in minority populations will benefit from strategies that directly address diversity and inclusion in genomics research and go beyond race and ethnicity to explore ancestry-matched controls, as well as geographic, cultural, social, and environmental determinants of health.

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report.

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

HLBS-PopOmics: an online knowledge base to accelerate dissemination and implementation of research advances in population genomics to reduce the burden of heart, lung, blood, and sleep disorders.

Recent dramatic advances in multiomics research coupled with exponentially increasing volume, complexity, and interdisciplinary nature of publications are making it challenging for scientists to stay up-to-date on the literature. Strategies to address this challenge include the creation of online databases and warehouses to support timely and targeted dissemination of research findings. Although most of the early examples have been in cancer genomics and pharmacogenomics, the approaches used can be adapted to support investigators in heart, lung, blood, and sleep (HLBS) disorders research. In this article, we describe the creation of an HLBS population genomics (HLBS-PopOmics) knowledge base as an online, continuously updated, searchable database to support the dissemination and implementation of studies and resources that are relevant to clinical and public health practice. In addition to targeted searches based on the HLBS disease categories, cross-cutting themes reflecting the ethical, legal, and social implications of genomics research; systematic evidence reviews; and clinical practice guidelines supporting screening, detection, evaluation, and treatment are also emphasized in HLBS-PopOmics. Future updates of the knowledge base will include additional emphasis on transcriptomics, proteomics, metabolomics, and other omics research; explore opportunities for leveraging data sets designed to support scientific discovery; and incorporate advanced machine learning bioinformatics capabilities.

Decline in Cardiovascular Mortality: Possible Causes and Implications.

If the control of infectious diseases was the public health success story of the first half of the 20th century, then the decline in mortality from coronary heart disease and stroke has been the success story of the century's past 4 decades. The early phase of this decline in coronary heart disease and stroke was unexpected and controversial when first reported in the mid-1970s, having followed 60 years of gradual increase as the US population aged. However, in 1978, the participants in a conference convened by the National Heart, Lung, and Blood Institute concluded that a significant recent downtick in coronary heart disease and stroke mortality rates had definitely occurred, at least in the US Since 1978, a sharp decline in mortality rates from coronary heart disease and stroke has become unmistakable throughout the industrialized world, with age-adjusted mortality rates having declined to about one third of their 1960s baseline by 2000. Models have shown that this remarkable decline has been fueled by rapid progress in both prevention and treatment, including precipitous declines in cigarette smoking, improvements in hypertension treatment and control, widespread use of statins to lower circulating cholesterol levels, and the development and timely use of thrombolysis and stents in acute coronary syndrome to limit or prevent infarction. However, despite the huge growth in knowledge and advances in prevention and treatment, there remain many questions about this decline. In fact, there is evidence that the rate of decline may have abated and may even be showing early signs of reversal in some population groups. The National Heart, Lung, and Blood Institute, through a request for information, is soliciting input that could inform a follow-up conference on or near the 40th anniversary of the original landmark conference to further explore these trends in cardiovascular mortality in the context of what has come before and what may lie ahead.

The Importance of Evaluating Health Disparities Research.

Health disparity populations are socially disadvantaged, and the multiple levels of discrimination they often experience mean that their characteristics and attributes differ from those of the mainstream. Programs and policies targeted at reducing health disparities or improving minority health must consider these differences. Despite the importance of evaluating health disparities research to produce high-quality data that can guide decision-making, it is not yet a customary practice. Although health disparities evaluations incorporate the same scientific methods as all evaluations, they have unique components such as population characteristics, sociocultural context, and the lack of health disparity common indicators and metrics that must be considered in every phase of the research. This article describes evaluation strategies grouped into 3 components: formative (needs assessments and process), design and methodology (multilevel designs used in real-world settings), and summative (outcomes, impacts, and cost). Each section will describe the standards for each component, discuss the unique health disparity aspects, and provide strategies from the National Institute on Minority Health and Health Disparities Metrics and Measures Visioning Workshop (April 2016) to advance the evaluation of health disparities research.

Addressing gaps in international blood availability and transfusion safety in low- and middle-income countries: a NHLBI workshop.

In April 2017, a workshop sponsored by the National Heart, Lung, and Blood Institute, Division of Blood Diseases and Resources, and the Center for Translation Research and Implementation Science was held to discuss blood availability and transfusion safety in low- and middle-income countries (LMICs). The purpose of the workshop was to identify research opportunities for implementation science (IS) to improve the availability of safe blood and blood components and transfusion practices in LMICs. IS describes the late stages of the translational research spectrum and studies optimal and sustainable strategies to deliver proven-effective interventions. Regional working groups were formed to focus on opportunities and challenges in East Africa, Central/West Africa, Middle East and North Africa, Latin America and the Caribbean, Southeast Asia, Western Pacific Asia, Eastern Europe, and Central Asia. The need for an "adequate supply of safe blood" emerged as the major overriding theme. Among the regional working groups, common cross-cutting themes were evident. The majority of research questions, priorities, and strategies fell into the categories of blood availability, blood transfusion safety, appropriate use of blood, quality systems, health economics and budgeting, and training and education in IS. The workshop also brought into focus inadequate country-level data that can be used as the basis for IS initiatives. A mixed approach of needs assessment and targeted interventions with sufficient evidence base to move toward sustainment is an appropriate next step for blood availability and transfusion safety research in LMICs.

Hypertension control activities in Latin America and the Caribbean: opportunities for late-stage (T4) translation research.

This work had two objectives: (1) to identify the extent of the problem and gaps pertaining to hypertension control in Latin America and the Caribbean (LAC) and (2) to identify the potential role for late-stage (T4) translation research to tackle the current and future hypertension burden in that region. We explored the extent of the problem and the potential opportunities to use late-stage (T4) translation research to address it. We analyzed calls to action and policies implemented within several LAC countries and also at the regional level. Some LAC countries are currently developing comprehensive plans for controlling noncommunicable diseases. Additionally, the Pan American Health Organization (PAHO) is working on implementing a comprehensive plan of action within the PAHO Strategy for the Prevention and Control of Noncommunicable Diseases. These endeavors underscore the need for and the relevance of implementing effective, evidence-based, affordable interventions for treating and controlling hypertension. In these efforts, late-stage (T4) translation research can help to determine the best strategies for delivery of hypertension control. This late-stage (T4) translation research should involve all relevant stakeholders and partners in order to best enhance and scale up appropriate, affordable, and sustainable public health interventions.

El presente trabajo tuvo dos objetivos: 1) establecer la magnitud del problema y las brechas en cuanto al control de la hipertensión en América Latina y el Caribe, y 2) determinar la posible función de la última fase (T4) de la investigación sobre traslación de los resultados a productos para hacer frente a la carga actual y futura de la hipertensión en la región. Exploramos la magnitud del problema y las oportunidades de usar última fase (T4) de la investigación sobre traslación de los resultados a productos para abordarlo. Analizamos los llamamientos a la acción y las políticas aplicadas en varios países de América Latina y el Caribe, y también en el plano regional. Actualmente, algunos países de América Latina y el Caribe están elaborando planes integrales para controlar las enfermedades no transmisibles. Además, la Organización Panamericana de la Salud (OPS) está trabajando en la ejecución de un plan de acción integral en el marco de su Estrategia para la prevención y el control de las enfermedades no transmisibles. Estos cometidos destacan la necesidad y la relevancia de las intervenciones eficaces, basadas en la evidencia y asequibles para el tratamiento y el control de la hipertensión. En el marco de estos esfuerzos, la última fase (T4) de la investigación sobre traslación de los resultados a productos puede ayudar a determinar las mejores estrategias para las prestaciones relacionadas con el control de la hipertensión. Esta última fase (T4) debe incluir a todos los interesados directos y asociados pertinentes para mejorar y ampliar las intervenciones de salud pública apropiadas, asequibles y sostenibles.

Este estudo teve dois objetivos: (1) identificar o alcance do problema e as lacunas referentes ao controle da hipertensão na América Latina e no Caribe (ALC) e (2) identificar o papel em potencial da pesquisa translacional de fase T4 para combater a carga atual e futura da hipertensão na região. Foi investigado o alcance do problema e as oportunidades em potencial para usar pesquisa translacional de fase T4 para abordar o problema. Foram analisadas convocações à ação e políticas adotadas em vários países da ALC e ao nível regional. Alguns países da ALC estão em fase de elaboração de planos abrangentes para controlar as doenças não transmissíveis. Além disso, a Organização Pan-Americana da Saúde (OPAS) está trabalhando na implementação de um plano de ação integral como parte da Estratégia da OPAS para Prevenção e Controle de Doenças Não Transmissíveis. Esses esforços destacam a necessidade e a importância de implementar intervenções com base científica que sejam eficazes e acessíveis para tratar e controlar a hipertensão. Para tal, a pesquisa translacional de fase T4 pode contribuir para determinar as melhores estratégias para realizar o controle da hipertensão. Este tipo de pesquisa deve envolver todos os interessados diretos e parceiros relevantes a fim de expandir e aprimorar as intervenções de saúde pública que sejam adequadas, acessíveis e sustentáveis.

Perspective: Late-Stage (T4) Translation Research and Implementation Science: The National Heart, Lung, and Blood Institute Strategic Vision.

In August 2016, the National Heart, Lung, and Blood Institute (NHLBI) released its Strategic Vision for charting a course for research over the next decade. This vision was the culmination of an unprecedented process that engaged diverse stakeholders from across the United States and around the globe. The process resulted in four mission-oriented goals and eight strategic objectives that provide an overall framework for advancing research in heart, lung, and blood diseases and sleep disorders. In this perspective, we address opportunities that NHLBI has identified to advance late-stage (T4) translation research, implementation science, health inequities research, global health research, and related research workforce development. Additionally, we highlight the importance of continued active engagement of the clinical and public health research community and the strategic, transdisciplinary, cross-sector partnerships necessary for advancing research priorities to maximize the population-level outcomes and health impact of scientific discoveries.

A Strategic Framework for Utilizing Late-Stage (T4) Translation Research to Address Health Inequities.

Achieving health equity requires that every person has the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances. Inequity experienced by populations of lower socioeconomic status is reflected in differences in health status and mortality rates, as well as in the distribution of disease, disability and illness across these population groups. This article gives an overview of the health inequities literature associated with heart, lung, blood and sleep (HLBS) disorders. We present an ecological framework that provides a theoretical foundation to study late-stage T4 translation research that studies implementation strategies for proven effective interventions to address health inequities.

Cervical Cancer Screening Among Adult Women in China, 2010.

INTRODUCTION: Cervical cancer is one of the most commonly diagnosed cancers among women in China. The World Health Organization (WHO) recommends routine screening for cervical cancer, and the WHO Global Monitoring Framework suggests that every nation monitors cervical cancer screening. However, little information is available on cervical cancer screening behavior among women in China. METHODS: We used data from the 2010 China Chronic Disease and Risk Factor Surveillance System that included 51,989 women aged 18 years and older. We report the proportion of women who reported ever having had a Papanicolaou (Pap) test, stratified by sociodemographic characteristics and geographic region. Multivariable logistic regression modeling was performed to adjust for potential confounders. RESULTS: Overall, 21% of 51,989 women reported having ever had a Pap test. The highest proportion was reported among women aged 30-39 years (30.1%, 95% confidence interval, 26.8%-33.4%). In all geographic regions, women in rural areas were consistently less likely than women in urban areas to report having had a Pap test. Among women who reported ever having a Pap test, 82% reported having the most recent test in the past 3 years. Factors associated with reporting ever having a test were being aged 30-49 years, higher education, being married, and having urban health insurance. CONCLUSION: Our results indicate that screening programs need to be strengthened along with a more intense focus on specific demographic groups. National cervical cancer screening guidelines and comprehensive implementation strategies are needed to make screening services available and accessible to all women. IMPLICATIONS FOR PRACTICE: This study is the largest nationwide and population-based assessment of self-reported history of Pap test for cervical cancer screening in China. This article describes cervical cancer screening behavior among women and examines key demographic and geographic factors. Only one fifth of Chinese women reported having ever had a Pap test for cervical cancer screening. The results highlight the urgent need to develop national cervical cancer screening guidelines and strategies that make screening services widely available, accessible, and acceptable to all women, especially to those who reside in rural areas and those with no health insurance.

Breast cancer screening among adult women in China, 2010.

INTRODUCTION: Breast cancer is the most frequently diagnosed type of cancer among women in China. However, China does not have a national screening program or national screening guidelines. Little information on participation in breast cancer screening among Chinese women is available. METHODS: We used data from the 2010 China Chronic Disease and Risk Factor Surveillance System that included 53,513 women aged 18 years or older. Women were asked about breast cancer screening participation (any type of screening method), and we examined screening participation rates. We adjusted estimates and performed multivariable logistic regression to adjust for potential confounders. RESULTS: Overall, 21.7% (95% confidence interval [CI], 19.2%-24.2%) of respondents reported previous breast cancer screening. The participation rates were highest among women aged 30 to 39 years (30.7%; 95% CI, 26.9%-34.4%) and lowest among women 70 years or older (6.3%; 95% CI, 5.1%-7.6%). Compared with women living in the western region, women in the eastern region were 1.5 times more likely to be screened (adjusted odds ratio [OR], 1.5; 95% CI, 1.2-2.0). Compared with women without insurance, women with urban insurance were more likely to be screened (prevalence ratio = 2.6; 95% CI, 2.3-3.0) and be screened within the last 2 years (OR = 1.3; 95% CI, 1.0-1.7; P = .04). CONCLUSION: Breast cancer screening participation rates among Chinese women were low and varied greatly by age, region, and insurance status. Comprehensive and prioritized strategies are needed to improve breast cancer screening participation among older women, those without medical insurance, and those living in the west.

The Economic impact of Non-communicable Diseases on households in India.

BACKGROUND: In India, Non Communicable Diseases (NCDs) and injuries account for an estimated 62% of the total age-standardized burden of forgone Disability Adjusted Life Years (DALYs). Public and private financing of clinical services to reduce the NCD burden is a major challenge. METHODS: We used National Sample Survey Organization (NSSO) survey data from 1995-96 and 2004 covering nearly 200 thousand households to assess healthcare utilization patterns and out of pocket health spending by disease category. For this purpose, self-reported diseases and conditions were categorized into NCDs and non-NCDs. Survey data were used to assess how households financed their overall health expenditures and related this pattern to specific health conditions. We measured catastrophic spending on NCD-related hospitalization, defined as occurring when health expenditures exceeded 40% of a household's ability to pay, that is, household consumption spending less combined survival consumption expenditure; and impoverishment when per capita expenditure within the household decreased to below the poverty line once health spending was netted out. RESULTS: The share of NCDs in out of pocket health expenses incurred by households increased over time, from 31.6 percent in 1995-96 to 47.3 percent in 2004. In both years, own savings and income were the most important source of financing for many health conditions, typically between 40-60 percent of all spending, whereas 30-35 percent was from borrowing. The odds of catastrophic hospitalization expenditures for cancer was nearly 170% greater and for CVD and injuries 22 percent greater than the odds due to communicable diseases. Impoverishment patterns were similar. CONCLUSIONS: Out of pocket expenses for treating NCDs rose sharply over the period from 1995-96 to 2004. When NCDs are present, the financial risks to which Indians households are exposed are significant.

Physical activity levels and differences in the prevalence of diabetes between the United States and Canada.

OBJECTIVE: To examine the American-Canadian difference in physical activity and its association with diabetes prevalence. METHODS: We used cross-sectional data from nationally representative samples of adults (8688 persons aged > or =18 years) participating in the 2004 Joint Canada/U.S. Survey of Health. Using data on up to 22 activities in the past 3 months, we defined 3 physical activity groups (in metabolic equivalents-hours/day) as low (<1.5), moderate (1.5-2.9), and high (> or =3.0). We employed logistic regression models in our analyses. RESULTS: Self-reported diabetes prevalence was 7.6% in the U.S. and 5.4% in Canada. The prevalence of low physical activity was considerably higher in the U.S. (70.9%) than in Canada (52.3%), while levels of moderate and high physical activity were higher in Canada (24.6% and 23.1%, respectively) than in the U.S. (14.3% and 14.8%, respectively). Using nationality (Canada as reference) to predict diabetes status, the adjusted odds ratio was 1.48 (95%CI, 1.22-1.79), and became 1.38 (95%CI, 1.15-1.66) when additionally adjusting for physical activity level. We estimate that 20.8% of the U.S.-Canada difference in diabetes prevalence is associated with physical activity. CONCLUSIONS: The difference in the prevalence of diabetes between U.S. and Canadian adults may be partially explained by differences in physical activity between the two countries.

Precision Health Analytics With Predictive Analytics and Implementation Research: JACC State-of-the-Art Review.

Emerging data science techniques of predictive analytics expand the quality and quantity of complex data relevant to human health and provide opportunities for understanding and control of conditions such as heart, lung, blood, and sleep disorders. To realize these opportunities, the information sources, the data science tools that use the information, and the application of resulting analytics to health and health care issues will require implementation research methods to define benefits, harms, reach, and sustainability; and to understand related resource utilization implications to inform policymakers. This JACC State-of-the-Art Review is based on a workshop convened by the National Heart, Lung, and Blood Institute to explore predictive analytics in the context of implementation science. It highlights precision medicine and precision public health as complementary and compelling applications of predictive analytics, and addresses future research and training endeavors that might further foster the application of predictive analytics in clinical medicine and public health.

Economic Dimensions of Health Inequities: The Role of Implementation Research.

Health inequities are well-documented, but their economic dimensions have received less attention. In this report, we describe four economic dimensions of health inequities in the United States. First, we describe an economic conceptual framework that connects poverty and health inequities at both individual and population levels and conveys the concept of reverse causality, where poverty worsens health inequities and health inequities worsen poverty. This framework can help us understand the key elements of health inequity and its drivers. Second, we describe economic measurements used for quantifying the economic burden of health inequalities and summarize the empirical findings from studies. Third, we review the evidence on the return-on-investment of economic interventions that are aimed at reducing health inequities. Finally, we highlight the importance of cross disciplinary perspectives from economics and implementation research in effectively delivering interventions that can mitigate health inequities.

Stakeholder Engagement in Late-Stage Translation Research and Implementation Science: Perspectives From the National Heart, Lung, and Blood Institute.

Stakeholder engagement is crucial for turning discovery into health. Although it is a highly effective approach for research in general, it is an essential component in late-stage translation research and implementation science in which the central objective is to accelerate the sustained uptake and integration of proven-effective interventions into routine clinical and public health practice. Where the stakeholder is an entire community, the term community engagement has often been used and has traditionally been defined as "the process of working collaboratively with groups of people who are affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being." More recently, this definition has been expanded to specifically incorporate pre-study needs assessment, shared decision making about study themes and specific aims, data collection and analysis, interpretation and dissemination of research findings, and plans for scale-up and spread of research findings. In this article, the authors explore the scientific foundations of stakeholder engagement in biomedical research and public health practice. They highlight the strategic vision goals and objectives of the National Heart, Lung, and Blood Institute and the commitment to advance dissemination and implementation research and community-engaged participatory research. The authors conclude with comments on the stakeholder engagement efforts in the National Heart, Lung, and Blood Institute-funded TREIN/Hy-TREC consortium's work published in this issue of Global Heart and their perspectives on the challenges and opportunities as we chart the future together.

The National Heart, Lung, and Blood Institute Strategic Vision Implementation for Health Equity Research.

The National Heart, Lung, and Blood Institute (NHLBI) provides global leadership for a research, training, and education program to promote the prevention and treatment of heart, lung, and blood diseases and enhance the health of all individuals so that they can live longer and more fulfilling lives. Inherent in this mission is the commitment to advance health equity research as an avenue for enhancing the health of all individuals. Additionally, the four goals and eight research objectives of the NHLBI Strategic Vision directly support the commitment to health equity. In this article, we present selected examples of the NHLBI Strategic Vision implementation approaches for advancing health equity research in our mission areas of heart, lung, and blood diseases. Examples of diseases for which the burden of health inequities and our strategic vision implementation approaches are discussed include hypertension, heart failure, vascular dementia, asthma, and sickle cell disease. Examples are provided of new avenues of Institute-solicited research to stimulate and address compelling scientific questions and critical challenges to advance health equity. We also highlight the emerging fields of implementation science and predictive analytics as important opportunities to accelerate the translation of discovery science into health impact for all and to advance health equity.

Evidence-based approach for disaster preparedness authorities to inform the contents of repositories for prescription medications for chronic disease management and control.

INTRODUCTION: Chronic diseases are major causes of death and disability and often require multiple prescribed medications for treatment and control. Public health emergencies (e.g., disasters due to natural hazards) that disrupt the availability or supply of these medications may exacerbate chronic disease or even cause death. PROBLEM: A repository of chronic disease pharmaceuticals and medical supplies organized for rapid response in the event of a public health emergency is desirable. However, there is no science base for determining the contents of such a repository. This study provides the first step in an evidence-based approach to inform the planning, periodic review, and revision of repositories of chronic disease medications. METHODS: Data from the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to examine the prescription medication needs of persons presenting to US hospital emergency departments for chronic disease exacerbations. It was assumed that the typical distribution of cases for an emergency department will reflect the patient population treated in the days after a public health emergency. The estimated numbers of prescribed drugs for chronic conditions that represent the five leading causes of death, the five leading primary diagnoses for physician office visits, and the five leading causes of disease burden assessed by disability-adjusted life years are presented. RESULTS: The 2004 NHAMCS collected data on 36,589 patient visits that were provided by 376 emergency departments. Overall, the five drug classes mentioned most frequently for emergency department visits during 2004 were narcotic analgesics (30.7 million), non-steroidal anti-inflammatory drugs (25.2 million), non-narcotic analgesics (15.2 million), sedatives and hypnotics (10.4 million), and cephalosporins (8.2 million). The drug classes mentioned most frequently for chronic conditions were: (1) for heart disease, antianginal agents/vasodilators (715,000); (2) for cancer, narcotic analgesics (53,000); (3) for stroke, non-narcotic analgesics (138,000); (4) for chronic obstructive pulmonary disease, anti-asthmatics/bronchodilators (3.2 million); and (5) for diabetes, hypoglycemic agents (261,000). Ten medication categories were common across four or more chronic conditions. CONCLUSIONS: Persons with chronic diseases have an urgent need for ongoing care and medical support after public health emergencies. These findings provide one evidence-based approach for informing public health preparedness in terms of planning for and review of the prescription medication needs of clinically vulnerable populations with prevalent chronic disease.

Noncommunicable Diseases in Low- and Middle-Income Countries: A Strategic Approach to Develop a Global Implementation Research Workforce.

Globally, most of the burden from noncommunicable disease is now evident in low- and middle-income countries (LMICs). At the same time, many effective noncommunicable disease interventions are now available and recommended for implementation and scale-up across LMIC health systems-yet are not being widely implemented. Understanding optimal and sustainable implementation strategies for these interventions within the LMIC context will need locally led and conducted implementation research- a research capacity which currently is lacking. The National Institutes of Health institutes, centers, and offices work with the Fogarty International Center to support biomedical research and research training across the globe. The National Heart, Lung, and Blood Institutes' Center for Translation Research and Implementation Science has a strategic focus on implementation research in global health. The Center for Translation Research and Implementation Science is considering strategies for developing research capacity and skill sets to conduct this priority research along with National Institutes of Health institutes and centers and other key global institutions that highly value implementation research. Short-term and medium-term strategies will be needed along with building on current efforts and investments and considering new efforts to address gaps. Developing and sustaining this research workforce will present many challenges and require much effort, but the returns could be transformative in advancing the prevention, treatment, and control of noncommunicable diseases within LMICs.