serious valvular damage to the heart and other tissues. Total coverage for primary prevention requiring treatment of every streptococcal sore throat is almost impossible even in affluent societies and in countries with manageable populations. However, intense secondary prophylaxis and primary
prevention, wherever feasible, has proven to be reliable and cost-effective in developing countries.122
In Pakistan, a considerable amount of work has been done in relation to RF and RHD prevention in the last two decades. A review of this is critical since new initiatives must be built on previous efforts.
3.4.1 Background to RF/RHD prevention and control efforts in Pakistan123
As opposed to atherosclerotic CVD, Rheumatic heart diseases have been the focus of cardiovascular public health initiatives in Pakistan over the last two decades. The impetus for this stemmed from the WHO-organized
International Seminar on Cardiovascular Diseases held in Tehran in 1972.
Twenty-one countries from the Eastern Mediterranean Region (EMRO), inclusive of Pakistan, participated in this seminar. Based on its deliberations and earlier assessments, Pakistan was grouped into a cluster of countries, which were asked to prioritize RHD prevention and control within the broader framework of CVD prevention and control. Subsequently, WHO assisted with a range of activities aimed at capacity-building. In 1985, the WHO Global Programme for Prevention of RF/RHD was launched in 16 developing countries; this service-oriented activity needed to be implemented through primary healthcare and national healthcare delivery systems. Partial funding for this was arranged by the Arab Gulf Programme for United Nations Development Organization (AGFUND). As per stipulations of the Programme, the Ministry of Health appointed a National Programme
Manager, who assisted with the development of a Multidisciplinary Advisory Committee and provided local inputs to developing a Plan of Operation.
The immediate objective of the Plan of Operation was to integrate RHD prevention with primary healthcare in a pilot setting. Case finding,
registration, prophylaxis, health education, training and evaluation were part of the approach. The programme was planned in three phases. Focused on community approaches, Phase 1 or the pilot phase was structured to test the feasibility of the RF/RHD programme strategy in a selected area whereas Phase 2 was meant to be implemented in provinces. Islamabad was selected as the pilot site for this purpose; baseline assessments gathered
epidemiological data;v in addition, several training sessions were held for health administrators and clinicians. vi The pilot experience enabled an assessment of operational details and helped define roles of the district and provincial administrative structures, schools and community activists in this loop. In 1994, a larger group meeting brought together provincial directors of health with a view to integrating this strategy with provincial health
v Pilot study in 1985 and prevalence survey in 1986-89.
Primary
prevention,
wherever
feasible, and
secondary
prophylaxis
of RF has
proven to be
reliable and
cost-effective
mandates. Finally, in 1996, the RF/RHD prevention initiative was integrated with the Prime Minister’s Programme for Primary Health Care.vii This provided an unprecedented opportunity to plug in RF/RHD with the work-plans of 50,000 LHWs and would have enabled access at the grassroots level.
Initial efforts in this direction were positive; workshops were arranged at the provincial level and training materials were developed. In tandem, efforts were also made to ensure availability of oral and injectable penicillin at all levels of healthcare. Additionally, RF/RHD Registers were opened at
cardiology departments of 18 medical colleges/teaching hospitals and several trainings were conducted in facility-based settings. However, for a public health strategy to succeed, it must first be modelled in a demonstration area and incorporate an evaluation protocol so that important elements may be refined and lessons learnt applied to a wider setting.
3.4.2 Approaches to prevention and control of RF/RHD In view of the aforementioned considerations, future efforts aimed at
RF/RHD prevention and control must be built upon previous efforts. Primary and secondary prevention can be achieved through four distinct measures that need to be instituted in tandem. Firstly, prevention of RF at the public health level cross-cuts with improving living conditions since RF is known to be a disease of poverty; clearly, this is outside the scope of the present discussion.
However, with a stronger focus on poverty reduction measures, Pakistan is moving closer to achieving this objective. Secondly, health education interventions should incorporate awareness creating elements that promote early recognition of streptococcal sore throat and RF; such interventions should encourage parents to seek healthcare for possible symptoms that their children may have. Thirdly, the reorientation of health services strategy as part of the Action Plan must include guidance for healthcare providers at all levels; in this regard, clinical guidelines on RF/RHD need to be developed.
Recently, the Pakistan Cardiac Society Council on Rheumatic Heart Diseases has initiated efforts to develop locally customized guidelines.124 Such efforts need to be supported. The case for locally applicable guidelines is made even more compelling in Pakistan since this is a high prevalence region for RF;
strict adherence to the Jones Criteria for diagnosis of RF may, therefore, result in under-diagnosis.125
In the fourth place, and in tandem with efforts aimed at professional education, the availability of penicillin should be ensured at all healthcare levels. Results of a recently conducted cross-sectional survey have revealed that penicillin is usually not available at basic healthcare sites.126 Penicillin is a cost-effective drug for secondary prevention of RHD. Follow-up of
treatment can be done by trained paramedical staff. This is, therefore, a feasible intervention even in basic health sites. Every effort should be made to promote its use in appropriate settings.
This section has reviewed current epidemiological data on cardiovascular diseases and the existing on ground programmes relating to their prevention, control and health promotion outlining their strengths and weaknesses. Based on this information, a strategy has been devised to guide future efforts aimed
vii Currently known as the National Programme for Family Planning and Primary Health Care.
at CVD prevention, control and health promotion in Pakistan. The Action Agenda items as part of this strategy have been listed below. However, as part of the Integrated Framework for Action, CVD has been grouped alongside other NCDs in an integrated model which combines a range of interventions and actions across other NCD domains.
? Integrate surveillance of cardiovascular risk factors with a population-based NCD surveillance system; develop and validate tools of assessment for the Pakistani population. Integrate public health programme monitoring and evaluation with NCD surveillance.†
? Promote physical activity and a healthy diet as a cultural norm as part of the NCD behavioural change communication strategy. Create awareness about the risks of CVD and its mitigates, prevention of RF and RHD and screening approaches.†
? Promote strategies for mitigation of cardiovascular risks through population-level approaches.†
? Revisit health policy on diet and nutrition to expand its current focus on under-nutrition.†
? Develop a nutrition and physical activity policy seeking guidance from the WHO Global Strategy on Diet and Physical Activity.†
? Develop policies and strategies to limit the production of, and access to, ghee as a medium for cooking.
? Develop agricultural and fiscal policies that increase the demand for, and make healthy food more accessible.
? Create an enabling physical and social environment for physical activity.†
? Generate support from religious leaders to endorse the need for participation of women in physical activity. †
? Enforce effective legislation to stipulate standards for urban planning.
? Utilize available open spaces for physical activity where feasible and appropriate.
? Integrate concerted primary and secondary prevention programmes into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive CME programme for all categories of healthcare providers.
? Promote screening for raised blood pressure at the population level. Promote high-risk screening for dyslipidaemia and diabetes in high-risk groups only.
? Focus attention on improving the quality of prevention programmes within primary and basic health sites.
? Ensure availability of aspirin, beta blockers, thiazides, ACE inhibitors, statins and penicillin at all levels of healthcare.
? Conduct clinical end-point trials in the native Pakistani setting to define cost-effective therapeutic strategies for primary and secondary prevention of CVDs.
? Build capacity of health systems in support of CVD prevention and control.†
? Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum to CVD prevention and control as part of a comprehensive NCD prevention effort.
† Priority Action Areas
Priorities within other Action Areas will be determined subsequently 3.5 Cardiovascular Diseases - Action Agenda
4
Diabetes
4.1 Context
Diabetes is a growing global health concern. The worldwide prevalence of diabetes in the adult population over 20 years of age, reported at 4% in 1995 with an estimated 135 million people affected, is expected to rise to 300 million by the year 2025; 75% of these people will hail from the developing countries.127
Pakistanis are an ethnic group having an inherent predilection to develop diabetes; 128 increase in life expectancy and major changes in diet and lifestyles that are a part of urbanization and social development further contribute to the existing trend.129 Undiagnosed, untreated and poorly controlled diabetes is known to exhort a considerable toll on individuals, communities and the healthcare system. It significantly adds to the burden of preventable diseases and leads to economic losses that stem from high cost of care and lost productivity. On the other hand, scientific evidence highlights the potential to prevent diabetes and its complications through cost-effective measures at the population and high-risk levels of intervention. 130,131
4.2 Data on diabetes in Pakistan
South Asian expatriates living in the western world – particularly in the United Kingdom and USA – are known to have higher prevalence of diabetes and the metabolic syndrome compared with native and other resident
populations.132 In a recently conducted survey in the UK, the age
standardized (35-79 years) prevalence of diabetes in a Pakistani population was reported at 33% compared with 20% in Europeans and 22% in the Afro-Caribbean population.128 High prevalence of diabetes in expatriate Pakistanis cannot entirely be attributed to migration as surveys conducted on the native settings have yielded similar results.
Conducted in the mid-90s, the National Diabetes Survey of Pakistan was a phased nationwide prevalence study of diabetes; this survey documented prevalence of diabetes and Impaired Glucose Tolerance (IGT) in four provinces (NWFP, Balochistan and Sindh) utilizing similar study protocols and standardized WHO definitions for the diagnosis of IGT and diabetes.
Even though overall glucose intolerance (diabetes and IGT combined) was present in 22-25% of the subjects examined, some differences were observed across provinces. In the urban areas, overall prevalence of diabetes ranged from 10.8 % in Balochistan to 16.5% in Sindh, whereas in the rural areas, prevalence ranged from 13.9% in Sindh, 7.5% in Balochistan to 6.39% in