In the previous session, we have seen how population wide and high risk strategy are necessary to address noncommunicable disease. In this session, I will concentrate on the so-called Best Buys in screening and managing non communicable disease in low and middle income countries. And, I would refer to the global plan of action, that I have been referring to in the previous session. And reminding the listeners that there were two Best Buys that are related to noncommunicable disease, which are related to screening and management. One is about drug therapy, including hypertension and diabetes using a totally risk approach including counseling to persons at high risk of cardiovascular disease. And the second one for cardiovascular disease, is giving aspirin to people who have had myocardial infarction. They are also two Best Buys for screening and treating cancer. But this will be addressed in another module. With regards to this so-called Best Buys for noncommunicable disease and especially cardiovascular disease, one of the nine targets mentions that there should be an 80% availability of the affordable basic technology and essential medicines. And medicines include, aspirin, statins, ACE inhibitors, thiazide, Calcium channel blocker, and a few of those. But basically not many, less than 10. And there is also a need for technologies to be ready to absorb people who have been found down to have the noncommunicable disease. And that includes at least blood pressure measurement that is a device to measure blood pressure, weighing scale, machines to measure blood sugar and blood cholesterol. Screening, as this has likely been addressed in other sessions, is best addressed and implemented when the disease is frequent in the population, when there is an inexpensive and safe detection test, and when a treatment exists which is effective. And that is not enough, but whenever we think of screening a condition for high risk strategies, we also have to be sure that there is adequate infrastructure, to take care of the people who have been found out to have the disease. And that there is an adequate training manpower, and that there are adequate finance resources. And as I will show later on, high blood pressure is probably one of the easiest and best target for screening and treatment. Because for that condition, it is frequent, there are tests to measure it, there are cheap treatment, and there are possibilities to have task shifting and having non-doctors take care of this condition. And I will come to this a bit later on. One emphasis in addressing cardiovascular risk is to assess the total risk, and not only the risk factors themselves. And in this slide, you can see that people who are at low risk will develop over time only few effects, and therefore, if you treat persons who have a low risk, you will end up to avoid only a few new cases of heart disease. While, and we can see this in the slide to the right side of the slide, people who are at high risk of developing a disease obviously have a higher chance to get the disease and, therefore, providing them with a treatment will prevent more cases of the disease in that condition. And that's the reason that we generally wish to screen and provide treatment only to persons who have a high total risk of cardiovascular disease. So the treatment is cost effective, and the yield of the treatment is as high as possible. That means you have as many return as possible for the money invested. And this figure probably is common to all of you. This is a chart of cardiovascular risk, total risk, and this has been developed by the World Health Organization in a package for noncommunicable disease in low and middle income countries. And I will not go into details of this. But the point is that, with this kind of risk course, we can assess whether people are at high or low risk. And if they are at high risk, they will be more likely to benefit from a treatment as compared to people who are at low risk. In that slide, I provide an example of a strategy that is based either on a single risk factor approach or on a total risk approach. You can see here in red that if you treat people only based on high blood pressure, you end up to treat a lot of people 44,000, here in this slide for 100,000 people to prevent in that case 127 events and this will cost around $14,000 per year of life saved. While if the strategy is based on total risk then we need to treat only 5,000 and no longer 44,000 and the number of events avoided is almost the same as before, it's 92 instead of 127. And the cost of medication to avoid one event is $5,000. That means three or four times more cost effective. And that's the whole point of using a total-risk approach to cardiovascular disease, is to treat as few people as possible to gain as much benefit as possible. And at the end of the day, to spend as little money as possible to save a maximal number of people. And of course this is a main issue in low income countries because resources are limited. Let me just say that a package of essential noncommunicable disease intervention from primary healthcare in low income countries exists. It has been developed by the World Health Organization. There are several document and the reference is mentioned in the slide so you can have a look. These are documents of 50 or 100 pages all together that provide the frame, the guidelines, the means, the resources that are needed to detect and manage the priority noncommunicable conditions in the context of low and middle income countries. Let me also add that the World Health Organization is currently revising a recommendation on screening cardiovascular disease risk, and this is due this year, or perhaps in 2016. The point is that, systematic screening is likely not the solution, but there is a need for targeted screening. Another point also and that is being shown in many studies now, is that mass screening for diabetes may not be so useful as it is not absolutely clear what to do in terms of screening and management of diabetes especially in terms of early cases of diabetes. And let me finish that section with a word on what is called the polypill. The polypill strategy. And this strategy was thought to give three or four or five different treatment in one single pill to anyone who has a high risk of cardiovascular disease. And that can be only to someone who is aged. This strategy, as was initially presented, would bypass doctors, pharmacists, and the whole health system. The point was, as mentioned by Warden law in the BMG paper that everyone aged 55 plus and that could be another age in other countries, would just take that treatment. And by taking that treatment they would reduce their risk of cardiovascular disease. And everybody would take the same thing. Several treatment to decrease blood pressure, to decrease blood lipids, and perhaps some other medication. This has been debated a lot. But I just mentioned this because I think it's a very interesting and challenging approach to cardiovascular disease. This certainly would need the whole session but I can only encourage you to go and look at papers on the polypills. It's a very interesting challenging, interesting issues. And that would have a lot of relevance to most low and middle income countries but also for high income countries.
