Training of Trainer on

Prevention and Treatment of Major NCDs in the Community

12/1/2019 Monywa 2-4 December 2019

12/1/2019

Global Burden of NCD

12/1/2019

• Non-communicable diseases kill 41 million people each year, equivalent to 71% of all deaths globally.

• Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these "premature" deaths occur in low- and middle-income countries.

• Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million).

• These 4 groups of diseases account for over 80% of all premature NCD deaths.

Source :WHO

Source: WHO Global Health Estimates 2014 (Year: 2012), Deaths by age group

Communicable, maternal, perinatal and nutritional conditions

NCDs Injuries

41 million of the 57 million global deaths in 2016 were due to NCDs

-

5,000,000.00

10,000,000.00

15,000,000.00

20,000,000.00

25,000,000.00

0 to 29 30 to 69 70 and beyond

12/1/2019

Source: WHO Global Health Estimates 2014 (Year: 2012), Deaths by age group

Communicable, maternal, perinatal and nutritional conditions

NCDs Injuries

15 million people died from NCDs in 2016 between ages 30 and 70

-

5,000,000.00

10,000,000.00

15,000,000.00

20,000,000.00

25,000,000.00

0 to 29 30 to 69 70 and beyond

12/1/2019

More than 2 million new cases SEAR Region

Estimated number of Cancer New Case Both Sex , All Age

Data Source : Globocan 2018

12/1/2019

New cancer cases in 2018 in SEAR

Data Source : Globocan 2018

12/1/2019

Myanmar 2018

12/1/2019

Myanmar 2018

12/1/2019

12/1/2019

Myanmar Cancer Number at a glance

12/1/2019

Myanmar and NCD Overview

• Population- 51,486,253 (Census 2014)

• Epidemiological transition taking place in the country the same with Regional and Global trend

• 94% adults live with at least 1 risk factor of NCDs (STEPS 2014)

• 68% deaths due to NCDs (WHO-2017)

12/1/2019

Myanmar is unlikely to meet the target for reducing premature mortality from NCDs unless urgent prioritized actions implemented

• Cardiovascular diseases (heart attack and stroke) are the leading causes of mortality responsible for one out of every four deaths

• Most premature deaths from cardiovascular diseases can be prevented

12/1/2019

Distribution of NCD Patients in Hospital Admission -Myanmar 2014-2016

Source: Hospital Statistics Report (2014-2016) 12/1/2019

Morbidity due to NCDs in Hospital Admitted Patients 2014-2016

Source: Hospital Statistics Report (2014-2016)

12/1/2019

0

1000

2000

3000

4000

5000

6000

7000

8000

Total Stroke Patient Cerebral Infarct Cerebral Hemorrhage

The Stroke Patient admitted to Yangon General Hospital in Year 2016

7333

4968

2365 (67.7%)

(32.3%)

12/1/2019

0

1000

2000

3000

4000

5000

6000

7000

Total Stroke Patient Cerebral Infarct Cerebral Hemorrhage

The Stroke Patient admitted to Yangon General Hospital in Year 2017

4597

1914

6511

(70.6%)

(29.4%)

12/1/2019

Cause of death distribution - Cause Specific Mortality Fraction (CSMF)

All ages in 42 townships (Jan-June 2018)

21%

10

%

9%

6%

6%

3%

3%

2%

2%

2%

1%

1%

1%

1%

1%

1%

1%

1%

1%

1%

1%

1%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

5%

10%

15%

20%

25%

Stro

keCh

roni

c Re

spira

tory

Isch

emic

Hea

rt D

iseas

eCi

rrho

sisDi

abet

esO

ther

Non

-com

mun

icab

le D

iseas

esPn

eum

onia TB

Chro

nic

Rena

l Fai

lure

Leuk

emia

/Lym

phom

asAI

DSEs

opha

geal

Can

cer

Falls

Lung

Can

cer

Road

Tra

ffic

Pros

tate

Can

cer

Cerv

ical

Can

cer

Brea

st C

ance

rSt

omac

h Ca

ncer

Diar

rhea

/Dys

ente

ryDr

owni

ngO

ther

Infe

ctio

us D

iseas

esO

ther

Can

cers

Oth

er In

jurie

sCh

ildho

od C

ardi

ovas

cula

r Dise

ases

Mat

erna

lFi

res

Neo

nata

l Men

ingi

tis/S

epsis

Bite

of V

enom

ous A

nim

alSu

icid

ePo

isoni

ngs

Colo

rect

al C

ance

rM

alar

iaHo

mic

ide

Cong

enita

l mal

form

atio

nDi

gest

ive

Dise

ases

Oth

er C

ardi

ovas

cula

r Dise

ases

Birt

h as

phyx

iaCh

ildho

od C

ance

rPr

eter

m D

eliv

ery

Men

ingi

tisN

eona

tal P

neum

onia

Oth

er D

efin

ed C

ause

s of C

hild

Dea

ths

Ence

phal

itis

Mea

sles

Hem

orrh

agic

feve

r

Source : Myanmar Verbal autopsy in 42 townships, Jan to June 2018 12/1/2019

12/1/2019

What are NCDs Risk Factors?

Underlying Determinants Globalization Urbanization

Population Ageing Social

Determinants

Behavioral Risk

Factors: Unhealthy diet

Tobacco smoking Harmful use of

alcohol Physical Inactivity

Physiological / Metabolic Risk

Factors Raised Blood Pressure Raised Blood Glucose

Raised Blood Cholesterol

Overweight/Obesity Abnormal lung function

Diseases Cardiovascular

diseases Cancers Diabetes

Chronic Obstructive Respiratory Diseases

Premature death

Source: Adapted from Preventing Chronic Disease: a Vital Investment. Geneva, World Health Organization, 2005.

12/1/2019

Current tobacco use among adult men (in %)

62

16

2

26

31

1

26

30

4

27

44

70

67

45

27

47

29

19

35

11

80

71

67

58

48

47

46

42

36

34

0 10 20 30 40 50 60 70 80 90

Myanmar

Timor-Leste

Indonesia

Bangladesh

Nepal

Thailand

Sri Lanka

India

Maldives

Bhutan

Total

Smoking

Smokeless

Source :WHO STEP survey 2014 12/1/2019

Current tobacco use among adult women (in %)

24

27

28

5

13

11

5

5

2

1

8

10

2

10

2

3

3

3

3

29

29

29

14

14

14

8

5

5

4

0 5 10 15 20 25 30 35

Myanmar

Timor-Leste

Bangladesh

Nepal

India

Bhutan

Thailand

Sri Lanka

Indonesia

Maldives

Total

Smoking

Smokeless

12/1/2019

Current tobacco use among youth (boys, in %)

6.7

9.2

15.2

19

21.8

24.6

26.3

36.2

39

65.5

3.2

4

10.4

11.2

20.7

11.4

21.1

35.3

26.3

61.4

4.2

5.9

9.2

11.1

4.1

19.7

11

3

25

7.7

0 10 20 30 40 50 60 70

Sri Lanka

Bangladesh

Maldives

India

Thailand

Nepal

Myanmar

Indonesia

Bhutan

Timor-Leste

Smokeless

Smoking

Total

Source GYTS 2016

12/1/2019

Current tobacco use among youth (girls, in %)

0.7

2.8

3.7

4.3

6.7

8.1

8.3

16.4

23.2

23.9

0.2

1.1

2.4

3.4

5

7.1

3.7

6.5

8.6

15.4

0.5

2

1.5

1.1

2.9

1.3

6

12.9

18.9

9.3

0 5 10 15 20 25 30

Sri Lanka

Bangladesh

Myanmar

Indonesia

Maldives

Thailand

India

Nepal

Bhutan

Timor-Leste

Smokeless

Smoking

Total

Source GYTS 2016

12/1/2019

Findings of STEP survey, 2014 Description Male Female Both sexes

Percentage of current smoker 43.8 % 8.4% 26.1%

Percentage of current smokeless tobacco user

62.2 % 24.1% 43.2 %

Percentage of with raised fasting blood glucose or raised 2-h blood or currently on medications for raised blood glucose

9.1% 11.8% 10.5 %

Percentage of overweight in adult (BMI >25 kg/m2 )

14.1% 30.8% 22.4 %

Percentage of adult Obesity (BMI >30kg/m2 )

2.6% 8.4% 5.5 %

Percentage of adults with raised blood pressure (SBP ≥140 and/or DBP ≥90 mmHg)

24.7% 28% 26.4 %

Percentage of Adult with high blood cholesterol level

30.9% 42.5% 36.7 %

Percent age of current drinker 38.1% 1.5% 19.8 %

12/1/2019

12/1/2019

The WHO Global NCD Action Plan 2013-2020 – six objectives

Commits governments to develop national responses: Target 3.4: By 2030, reduce by one third

premature mortality from NCDs Target 3.5: Strengthen responses to

reduce the harmful use of alcohol Target 3.8: Achieve universal health

coverage Target 3.a: Strengthen the

implementation of the WHO Framework Convention on Tobacco Control

Target 3.b: Support research and development of vaccines and medicines for NCDs that primarily affect developing countries

Target 3.b: Provide access to affordable essential medicines and vaccines for NCDs

Historic crossroads: NCDs included in the 2030 Agenda for Sustainable Development

12/1/2019

SDG targets for 2030 are aligned with the NCD targets for 2025 12/1/2019

12/1/2019

DOPH –NCD Unit

DM CVD

Cancer CRD

Snake Bite

Mental Health

Epilepsy

RTA Deafness

Rehab

12/1/2019

Are NCDs Preventable and How?

• Most Premature Deaths and Suffering from NCD are preventable

• NCD Best Buys

12/1/2019

NCD Prevention and Control

Prevention • To focus on reducing the risk

factors associated with Major NCDs – Promote Physical Activities – Tobacco Control – Alcohol Control – Unhealthy Diet

• Health Promotion • Low-cost solutions exist for

governments and other stakeholders

Control • PEN approach for major

NCD • Preventive Cardiology for

early detection and treatment

• It is also secondary Prevention to reduce complication

12/1/2019

Population-wide

interventions Multi-sectoral

Individualised interventions Health Sector

"Best buy" Interventions Risk factor / disease

- Raise taxes on tobacco - Protect people from tobacco smoke - Warn about the dangers of tobacco - Enforce bans on tobacco advertising

Tobacco use

- Raise taxes on alcohol - Restrict access to retailed alcohol - Enforce bans on alcohol advertising

Harmful use of alcohol

- Reduce salt intake in food - Replace trans fat with polyunsaturated fat - Promote public awareness about diet and physical

activity

Unhealthy diet and physical inactivity

- Provide counselling and multi-drug therapy for people with medium-high risk of developing heart attacks and strokes

- Treat heart attacks with aspirin

Cardiovascular disease and diabetes

- Hepatitis B immunization beginning at birth to prevent liver cancer

- Screening and treatment of pre-cancerous lesions to prevent cervical cancer

Cancer

NCD

Bes

t Buy

s

12/1/2019

DOPH - NCD Screening and Treatment

• Secondary Prevention of Major NCD at PHC Level • Based on WHO PEN approach • Service include Screening and Treatment of DM and

HT , Screening of Oral , Breast and Cervical Cancers • 10 yr CVD risk assessment is conducted • Covered 232 townships (from 2017 May up to date ) • In April 2019 - Ministry of Health and Sports initiate

to go a big way on preventive cardiology

12/1/2019

Community Health Clinics Cum Diabetes , Hypertension Screening , Diagnosis

and Treatment Clinics

20 Townships

CHC

12/1/2019

PEN Approach Vs CHC Approach Preparation /

implementation PEN CHC

Training Conducted Not able to Conduct

IEC Material Provided Not Provided

Supplies & Equipment Provided From PEN Supplies

Interventions • Screening and Treatment of DM, HT

• CVD Risk assessment • Cancer Screening • Chronic Respiratory Disease

Treatment • Health Promotion

• Screening and Treatment of DM, HT

• CVD Risk assessment • Elderly Care • Health Promotion

Focal Unit NCD Basic Health

Implementation Site RHC and SRHC RHC

Township Covered Trained 232 Townships All Township

12/1/2019

Training and Implementing of Diabetes and Hypertension Clinics in PEN Approach

(2017 May – 2019 February) 18

7 7 9

10

10

7

11

9

10

17

45

11

20 21

12

8

232

27

21

14

19

3

14

98

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

enta

ge

State/Region 12/1/2019

Total Screened Patient by State/Region ( 2017 May -2018 Dec ) from 149 Townships

6954

1673

2 6126

5

7150

1

7342

0

5722

7

9828

0

6407

9

7109

8

3471

1

1210

23

1535

8

6916

48

0

100000

200000

300000

400000

500000

600000

700000

Num

ber o

f Scr

eene

d pe

ople

State/Region

12/1/2019

Diabetes among screened patients ( 2017 May -2018 Dec ) from 149 Townships

Diabetes, 104245, 15%

Non Diabetes, 587403, 85%

12/1/2019

Hypertension among screened patients ( 2017 May -2018 Dec ) from 149 Townships

Hypertension, 231398, 33%

Without Hypertension, 460250, 67%

12/1/2019

CVD Risk among screened patients ( 2017 May -2018 Dec ) from 149 Townships

CVD Risk (<10%), 752991, 78%

115950, 12%

61343, 6%

33824, 4%

CVD Risk (>=10%), 211117, 22%

CVD Risk (<10%)

CVD Risk 10 - <20%

CVD Risk 20 - <30%

CVD Risk >=30%

12/1/2019

Assessment of Cardio Vascular Risk in NCD Clinic

12/1/2019

Weakness of NCD Clinics

Coverage • Not planned Target

Population • Most Clinic are Facility

Based • Community outreach are

still weak in most Townships • Lack of support for

Outreach Services • Awareness about NCD

Clinics is low

Quality of Care • High Lost to follow up • Team-based approach is a

challenge • Weak coordination among

Hospital Doctors and BHS • Some staff need training • Screening of Cancer is weak

12/1/2019

Weakness of NCD Clinics -contd

Supplies • Replenishment of medicines

is not possible • Weak supply Chain • All items of NCD medicines

are not procured • Not product segmentation

(Central & Regional Supplies)

M and E • Clinical mentoring and

supportive supervision is weak

• Health outcome monitoring system

• Community outreach are still weak in most Townships

• Limited support for M&E at all level

12/1/2019

Providers’ reasons for not readiness at NCD Clinics (n=47)

Reasons given by BHS (multiple responses)

No. of providers by type of facility Total

No. (%) MCH n = 6

RHC n = 21

Sub RHC n = 20

Facility had not enough medicines for NCDs 6 19 15 40 (85.1%)

Facility had not enough equipment 6 11 8 25 (53.2%)

Facility had not full staff 2 3 4 9 (19.2%)

Health staff were already overload 0 2 1 3 (6.4%)

Facility had no trained staff for NCDs 0 0 1 1 (2.1%)

Other 0 5 7 12 (25.5%)

Study on Preparedness and responsiveness of NCD service delivery: PEN clinics, Myanmar( 2019 April –May ) 12/1/2019

Reported NCD medicines used at PEN clinics by type of facility (n = 131)

Type of medicines Type of facility

MCH RHC Sub RHC Special clinic

Total No. (%)

Amlodipine 5 mg 13 52 57 3 125 (95.4%)

Atenolol50 mg 4 8 10 1 23 (17.6%)

Enalapril5 mg 0 8 5 0 13 (9.9%)

Metformin 500 mg 13 49 47 2 111 (84.7%)

Gliclazide80 mg 10 31 30 2 73 (55.7%)

Aspirin 75 mg 2 8 12 1 23 (17.6%)

Atorvastatin10 mg 2 3 4 0 9 (6.9%)

Study on Preparedness and responsiveness of NCD service delivery: PEN clinics, Myanmar( 2019 April –May )

12/1/2019

Providers’ reasons for not readiness at NCD Clinics (n=47)

Types of refilling (Multiple responses)

Essential medicines Equipment

No. % No. %

Received from higher level 64 48.9 64 48.9

Bought by using different funding sources 27 20.6 18 13.7

Bought by staff with own expense 28 21.4 25 19.1

Bought by patients 4 3.1 2 1.5

Shared among facilities 0 1 0.8

Don’t know 0 1 0.8

Study on Preparedness and responsiveness of NCD service delivery: PEN clinics, Myanmar( 2019 April –May ) 12/1/2019

NCD Clinic in Preventive Cardiology Approach

12/1/2019

1st Preventive Cardiology meeting, Mingalarthiri Hotel, Nay Pyi Taw(15-5-2019)

12/1/2019

12/1/2019