Noncommunicable disease prevention and control in Mongolia: a policy analysis

BACKGROUND: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. METHODS: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified. RESULTS: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008-2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards. CONCLUSIONS: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease, physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice.

Moving towards a more integrated approach to chronic disease prevention in Australian general practice

There is increasing evidence that prevention of chronic disease is possible and that primary care can contribute to this. This paper aims to explore the development of policies and programs to improve chronic disease prevention via behavioural risk factor management in Australian general practice and the impact of these between 2001 and the present. This involved a review of policy initiatives and developments in Australian general practice, drawing on published research over this period. Behavioural risk factor management has not been comprehensively implemented in the way in which it was originally envisaged under the SNAP (Smoking, Nutrition, Alcohol and Physical Activity) framework, with initiatives and programs emerging over time in a much less planned way, including Lifescripts and more recently the 45 - 49 year health check. There has been a gradual development in capacity, especially in relation to workforce, education and training, educational materials, financial and decision support with divisions of general practice emerging to play a key facilitation role. Despite this, important gaps remain especially in relation to the use of team approaches within and outside the practice including access to referral services and programs.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Noncommunicable disease prevention and control in Mongolia: a policy analysis

Background: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008– 2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs.

Methods: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified.

Results: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008– 2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008– 2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards.

Conclusions: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease,physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice.

Effective coordination and management of emerging infectious diseases in wildlife populations

A transdisciplinary, One Health approach is proposed for the coordination of wildlife health diagnostics, research, and policy development. In some countries, considerable effort has been made to establish specific activities including surveillance and integration of wildlife health within diagnostic and research laboratories. We suggest that some of these activities can be improved and many countries still require national structures to deal with wildlife disease investigation and management. We also suggest that scientists in this field should actively engage with national and international organizations and conferences to influence the development of policy, diagnostics, research, and management of emerging wildlife diseases.

Approaches to population health care : the emerging context!

This paper provides a review of recent developments in population-based approaches to community health and explores the origins of the population health concept and its implications for the operation of health service management. There is a growing perception among health professionals that the key to improving health outcomes will be the implementation of integrated and preventive population-based resource management rather than investment in systems that respond to crises and health problems at the acute end of the service provision spectrum only. That is, we will need increasingly to skew our community health and welfare investments towards preventive care, education, lifestyle change, self-management and environmental improvement if we are to reduce the rate of growth in the incidence of chronic disease and mitigate the impact of these diseases upon the acute health care system. While resources will still need to be devoted to the treatment and management of physical trauma, infectious diseases, inherited illness and chronic conditions, it is suggested we could reduce the rate at which demand for these services is increasing at present by managing our environment and communities better, and through the implementation of more effective early intervention programs across particular population groups. Such approaches are known generally as population health management, as opposed to individual or illness - based health management' or even public health - and suggest that health systems might productively focus in the future on population level causation and not just upon disease-specific problems or illness management after the fact. Population health approaches attempt to broaden our understanding of causation and manage health through an emphasis on the health of whole populations and by building healthy communities rather than seeing "health care" as predominantly about illness management or responses to health crises. The concept also presupposes the existence of cleaner and healthier environments, clean water and food, and the existence of vibrant social contexts in which individuals are able to work for the overall good of communities and, ultimately, of each other.

High adult mortality in disease-challenged frog populations increases vulnerability to drought

Pathogen emergence can drive major changes in host population demography, with implications for population dynamics and sensitivity to environmental fluctuations. The amphibian disease chytridiomycosis, caused by infection with the fungal pathogen Batrachochytrium dendrobatidis (Bd), is implicated in the severe decline of over 200 amphibian species. In species that have declined but not become extinct, Bd persists and can cause substantial ongoing mortality. High rates of mortality associated with Bd may drive major changes in host demography, but this process is poorly understood. Here, we compared population age structure of Bd-infected populations, Bd-free populations, and museum specimens collected prior to Bd emergence for the endangered Australian frog, Litoria verreauxii alpina (alpine tree frog). We then used population simulations to investigate how pathogen-associated demographic shifts affect the ability of populations to persist in stochastic environments. We found that Bd-infected populations have a severely truncated age structure associated with very high rates of annual adult mortality. Near-complete annual adult turnover in Bd-infected populations means that individuals breed once, compared with Bd-free populations where adults may breed across multiple years. Our simulations showed that truncated age structure erodes the capacity of populations to withstand periodic recruitment failure; a common challenge for species reproducing in uncertain environments. We document previously undescribed demographic shifts associated with a globally emerging pathogen and demonstrate how these shifts alter host ecology. Truncation of age structure associated with Bd effectively reduces host niche width, and can help explain the contraction of L. v. alpina to perennial waterbodies where the risk of drought-induced recruitment failure is low. Reduced capacity to tolerate other sources of mortality may explain variation in decline severity among other chytridiomycosis-challenged species and highlights the potential to mitigate disease impacts through minimising other sources of mortality.

Reservoir-host amplification of disease impact in an endangered amphibian

Emerging wildlife pathogens are an increasing threat to biodiversity. One of the most serious wildlife diseases is chytridiomycosis, caused by the fungal pathogen, Batrachochytrium dendrobatidis (Bd), which has been documented in over 500 amphibian species. Amphibians vary greatly in their susceptibility to Bd, with some species tolerating infection, while others experience rapid mortality. Reservoir hosts - species that carry infection while maintaining high abundance, but are rarely killed by disease - can increase extinction risk in highly susceptible, sympatric species. However, whether reservoir hosts amplify Bd in declining amphibian species has not been examined. We combine a laboratory study with field surveys, disease sampling, and statistical modeling to investigate the role of reservoir hosts in chytridiomycosis dynamics and species decline in an amphibian community in south-eastern Australia. We show that the non-declining common eastern froglet (Crinia signifera) is a reservoir host for Bd, with laboratory animals carrying intense infection burdens over 12 weeks and the majority of wild sampled individuals carrying intense infections. We find that the presence of C. signifera is strongly associated with Bd prevalence in the sympatric, IUCN red-listed northern corroboree frog (Pseudophryne pengilleyi). Consistent with disease amplification by a reservoir host, we find that P. pengilleyi has declined from areas with high C. signifera abundance. Our results suggest that when reservoir hosts are present, population declines can continue long after the initial emergence of Bd, highlighting an urgent need to assess extinction risk in remnant populations of other declined amphibian species. Reintroductions and in situ management strategies must focus on identifying reservoir hosts and minimizing exposure of threatened species.

What are the implications of changing treatment delivery models for patients with inflammatory bowel disease : a discussion paper

An integrated model of care has been used effectively to manage chronic diseases; however, there is limited, yet encouraging evidence on its introduction in the management of inflammatory bowel disease (IBD), a chronic gastrointestinal condition. Here, the rationale for and implications of introducing an integrated model of care for patients with IBD are discussed, with a particular focus on psychology input, patient-centred care, efficiency as perceived by patients and doctors, financial implications and the possible means of model introduction. This is a discussion paper on the integrated model of care for IBD against a background of what has been learned from an integrated model of care established in other chronic conditions. Although limited, the emerging data on an integrated model of care in IBD are encouraging with respect to patient outcomes and savings in healthcare costs. In other conditions, the model has been well received by both patients and practitioners, although the loss of autonomy by doctors is listed among its drawbacks. The cost-effectiveness data are now sufficiently convincing to recommend the model's acceptance in principle. The model should be promoted at the policy level rather than by individual practitioners to facilitate equal access for patients with IBD on a larger scale than currently.