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.

Action to address the household economic burden of non-communicable diseases.

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

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.

A Global Perspective on Using Implementation Research to Address Hypertension-Associated Target Organ Damage.

Hypertension, a major risk factor for cardiovascular disease, imposes a significant public health burden and challenge to address it worldwide. Scaling up delivery of proven, effective interventions for hypertension could significantly advance the goal of reducing the global burden. Although significant progress has been made in many countries, some lament that large-scale initiatives focused on reducing blood pressure in global populations have not effectively addressed this challenge. Late-stage implementation research plays a critical role in determining effective and sustainable scale-up of these initiatives. In this article, we briefly discuss some of the global initiatives that have been funded by the National Heart, Lung, and Blood Institute of the US National Institutes of Health. Intervention delivery strategies in low resource settings must have demonstrated effectiveness and consideration for the social, cultural and physical context (eg, access, affordability, and availability of medications) in which a program is being delivered in order to be sustainable nationally and globally. Hence, the use of implementation research is central to determining sustainable delivery of evidence-based and tailored interventions focused on hypertension control. The sustained control of hypertension in global populations holds tremendous potential for reducing morbidity, premature mortality, and the adverse economic impact of cardiovascular disease in all regions.

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.

The household-level economic burden of heart disease in India.

OBJECTIVES: To estimate healthcare use and financial burden associated with heart disease among Indian households. METHODS: Data from the 2004 round household survey of the National Sample Survey in India were used to assess the implications of heart disease for out-of-pocket health spending, spending on items other than health care, employment and healthcare financing patterns, by matching households with a member self-reporting heart disease (cardiovascular disease (CVD)-affected households) to (control) households with similar socio-economic and demographic characteristics. Propensity score matching methods were used. RESULTS: Compared with control households, CVD-affected households had more outpatient visits and inpatient stays, spent an extra INT$ (International Dollars) 232 (P < 0.01) per member on inpatient care annually, had lower non-medical spending (by INT$5 (P < 0.01) per member for a 15-day reference period), had a share of out-of-pocket health spending in total household expenditure that was 16.5% higher (P < 0.01) and relied more on borrowing and asset sales to finance inpatient care (32.7% vs. 12.8%, P < 0.01). Members of CVD-affected households had lower employment rates than members of control households (43.6% vs. 46.4%, P < 0.01), and elderly members experienced larger declines in employment than younger adults. CVD-affected households with lower socio-economic status were at heightened financial risk. CONCLUSION: Non-communicable conditions such as CVD can impose a serious economic burden on Indian households.

Association of children's eating behaviors with parental education, and teachers' health awareness, attitudes and behaviors: a national school-based survey in China.

BACKGROUND: In China, childhood obesity is a growing health issue. Eating behaviors among children can be influenced by both the family and school environment. We examine the association between these environments and eating habits among children. METHODS: A total of 11 270 fourth to sixth grade school children, 11 270 of their fathers or mothers, and 1348 teachers from 48 schools were sampled using a multistage cluster random sampling method. Questionnaires collected information on eating behaviors among children, non-communicable chronic disease (NCD)-related health knowledge and behaviors among teachers, and education levels among parents. Mixed effect logistic regression models were used to describe the key associations between eating behaviors among children and teacher and parental characteristics. RESULTS: Health awareness, positive health attitudes, never-smoking and regular-exercise among teachers was positively associated with healthy eating behaviors among their students (having breakfast, vegetables and dairy products every day; P < 0.05), and negatively associated with the unhealthy behaviors (daily intake of fried foods and desserts and sugary beverages; P < 0.05). More than one parent having a high school level or above was positively related to healthy eating behaviors among their children (P < 0.05), but its associations with high-calorie eating habits were negative in urban and positive in rural areas (P < 0.05). CONCLUSIONS: School-based interventions which target health-related awareness, attitude and behaviors among school teachers may help improve school-aged children's eating behaviors. Parental education levels may help guide efforts to target children at higher risk of unhealthy eating habits.

Hypertension prevalence, awareness, treatment, and control and sodium intake in Shandong Province, China: baseline results from Shandong-Ministry of Health Action on Salt Reduction and Hypertension (SMASH), 2011.

INTRODUCTION: In China, population-based blood pressure levels and prevalence of hypertension are increasing. Meanwhile, sodium intake, a major risk factor for hypertension, is high. In 2011, to develop intervention priorities for a salt reduction and hypertension control project in Shandong Province (population 96 million), a cross-sectional survey was conducted to collect information on sodium intake and hypertension prevalence, awareness, treatment, and control. METHODS: Complex, multistage sampling methods were used to select a provincial-representative adult sample. Blood pressure was measured and a survey conducted among all participants; condiments were weighed in the household, a 24-hour dietary recall was conducted, and urine was collected. Hypertension was determined by blood pressure measured on a single occasion and self-reported use of antihypertension medications. RESULTS: Overall, 23.4% (95% confidence interval [CI], 20.9%-26.0%) of adults in Shandong were estimated to have hypertension. Among those classified as having hypertension, approximately one-third (34.5%) reported having hypertension, approximately one-fourth (27.5%) reported taking medications, and one-seventh (14.9%) had their blood pressure controlled (<140/<90 mm Hg). Estimated total average daily dietary sodium intake was 5,745 mg (95% CI, 5,428 mg-6,063 mg). Most dietary sodium (80.8%) came from salt and high-salt condiments added during cooking: a sodium intake of 4,640 mg (95% CI, 4,360 mg-4,920 mg). The average daily urinary sodium excretion was 5,398 mg (95% CI, 5,112 mg-5,683 mg). CONCLUSION: Hypertension and excessive sodium intake in adults are major public health problems in Shandong Province, China.

A large-scale cluster randomized trial to determine the effects of community-based dietary sodium reduction--the China Rural Health Initiative Sodium Reduction Study.

BACKGROUND: Cardiovascular diseases are the leading cause of death and disability in China. High blood pressure caused by excess intake of dietary sodium is widespread and an effective sodium reduction program has potential to improve cardiovascular health. DESIGN: This study is a large-scale, cluster-randomized, trial done in five Northern Chinese provinces. Two counties have been selected from each province and 12 townships in each county making a total of 120 clusters. Within each township one village has been selected for participation with 1:1 randomization stratified by county. The sodium reduction intervention comprises community health education and a food supply strategy based upon providing access to salt substitute. Subsidization of the price of salt substitute was done in 30 intervention villages selected at random. Control villages continued usual practices. The primary outcome for the study is dietary sodium intake level estimated from assays of 24-hour urine. TRIAL STATUS: The trial recruited and randomized 120 townships in April 2011. The sodium reduction program was commenced in the 60 intervention villages between May and June of that year with outcome surveys scheduled for October to December 2012. Baseline data collection shows that randomisation achieved good balance across groups. DISCUSSION: The establishment of the China Rural Health Initiative has enabled the launch of this large-scale trial designed to identify a novel, scalable strategy for reduction of dietary sodium and control of blood pressure. If proved effective, the intervention could plausibly be implemented at low cost in large parts of China and other countries worldwide.

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.

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

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.

The economic effect of noncommunicable diseases on households and nations: a review of existing evidence.

In developing countries, the noncommunicable disease (NCD) and risk factor burdens are shifting toward the poor. Treating chronic diseases can be expensive. In developing countries where generally much health care costs are borne by patients themselves, for those who live in poverty or recently escaped severe poverty, when faced with large, lifelong out-of-pocket expenses, impoverishment persists or can reoccur. These patterns have implications for national economic growth and poverty-reduction efforts. NCDs can change spending patterns dramatically and result in significantly reducing non-medical-related spending on food and education. In India, about 40% of household expenditures for treating NCDs are financed by households with distress patterns (borrowing and sales of assets). NCD short- and long-term disability can lead to a decrease in working-age population participation in the labor force and reduce productivity and, in turn, reduce per capita gross domestic product growth. To fully capitalize on the demographic dividend (i.e., aging of the population resulting in less dependent children, not yet more dependent elderly, and greater national productivity), healthy aging is necessary, which, in turn, requires effectively tackling NCDs. Last, from an equity standpoint, the economic effect of NCDs, evident at the household level and at the country level, will disproportionately affect the poor and vulnerable populations in the developing world.