Call to improve health of women, children and adolescents

Societies are failing women, children and adolescents, particularly in the poorest communities around the world, and urgent action is needed to save lives and improve health, say global health experts.

In a special supplement published in September by The BMJ, public health experts from around the globe highlight the critical actions and investments that will have the greatest impact on the health and wellbeing of women, children and adolescents.

The 15 papers in this special supplement outline the current evidence, identify successes as well as critical gaps in progress, and highlight key priorities to end preventable deaths and ensure that women, children and adolescents can thrive and build resilient and prosperous societies.

Dr Marleen Temmerman, Director of WHO Department of Reproductive Health and Research including HRP, and one of the lead authors of the special supplement states, “Clearly business as usual will not work. For women, children and adolescents around the world to survive, thrive and transform our current society to arrive at the future we want, we need radical actions that will result in enormous social, demographic, and economic benefits.”

Although great strides have been made in reducing child and maternal mortality by 53% and over 40% respectively since 1990, the authors explain how many more lives can be saved by improving access to essential health interventions.

Vast inequities within and between countries mean that the poorest, most disadvantaged women, children, and adolescents often miss out on life-saving health services and experience serious violations of their human rights.

Some low- and middle-income countries have:

• Up to three times more pregnancies among teenage girls in rural and indigenous populations than in urban populations

• A difference of up to 80% between the richest and poorest people in the proportion of births attended by skilled health personnel

• A gap of at least 18% in the proportion who seek care for children with pneumonia symptoms, between the poorest and richest people and

• A difference of least 25% in access to antenatal care (of at least four visits) between the most and least educated and between the richest and poorest.

“No woman, child or adolescent should face a greater risk of preventable death just because of where they live,” says Dr Flavia Bustreo, Assistant Director-General of the World Health Organization. “We know what needs to be done. With the existing evidence, we now have the opportunity to end preventable deaths among all women, children, and adolescents, to vastly improve their health, and to bring about the transformative changes needed to fully realise their human rights and build resilient and prosperous societies.”

The papers provide the evidence that has helped inform the development of a new Global Strategy for Women’s, Children’s and Adolescents’ Health, which were launched at the United Nations General Assembly in New York on 26 September 2015.

Scientists create world’s largest catalogue of human genetic variation

An international team of scientists from the 1000 Genomes Project Consortium has created the world’s largest catalogue of genomic differences among humans, providing researchers with powerful clues to help them establish why some people are susceptible to various diseases.

While most differences in peoples’ genomes ñ called variants ñ are harmless, some are beneficial, while others contribute to diseases and conditions, ranging from cognitive disabilities to susceptibilities to cancer, obesity, diabetes, heart disease and other disorders. Understanding how genomic variants contribute to disease may help clinicians develop improved diagnostics and treatments, in addition to new methods of prevention. The National Human Genome Research Institute, part of the US National Institutes of Health, helped fund and direct this international public-private consortium of researchers in the United States, the United Kingdom, China, Germany and Canada.

In two studies published online on 30 September 2015, in Nature, investigators examined the genomes of 2,504 people from 26 populations across Africa, East and South Asia, Europe and the Americas.

In the main Nature study, investigators identified about 88 million sites in the human genome that vary among people, establishing a database available to researchers as a standard reference for how the genomic make-up of people varies in populations and around the world. The catalogue more than doubles the number of known variant sites in the human genome, and can now be used in a wide range of studies of human biology and medicine, providing the basis for a new understanding of how inherited differences in DNA can contribute to disease risk and drug response.

Of the more than 88 million variable sites identified, about 12 million had common variants that were likely shared by many of the populations. The study showed that the greatest genomic diversity is in African populations, consistent with evidence that humans originated in Africa and that migrations from Africa established other populations around the world.

The 26 populations studied included groups such as the Esan in Nigeria; Colombians in Medellin, Colombia; Iberian populations in Spain; Han Chinese in Beijing; and Sri Lankan Tamil in the United Kingdom. All of the individuals studied for the project consented to broad release of their data, and the data can be used by researchers around the world.

“The 1000 Genomes Project was an ambitious, historically signifi - cant effort that has produced a valuable resource about human genomic variation,” said Eric Green, M.D., Ph.D., director of NHGRI.

“The latest data and insights add to a growing understanding of the patterns of variation in individuals’ genomes, and provide a foundation for gaining greater insights into the genomics of human disease.” These reports mark the culmination of the 1000 Genomes Project, which found more than 99% of variants in the human genome that occur at a frequency of at least 1% in the populations studied. One of the more immediate uses of 1000 Genomes Project data is for genome-wide association studies, which compare the genomes of people with and without a disease to search for regions of the genome that contain genomic variants associated with that disease. Such studies generally fi nd several genomic regions associated with a disease and many variants in each of those regions. Scientists can now combine GWAS data with the more detailed 1000 Genomes Project data to home in on regions affecting disease more precisely.

Instead of sequencing the genomes of all the people in a study, which remains expensive, researchers can use the 1000 Genomes Project data to fi nd most of the variants in those regions that are associated with the disease.

“When the 1000 Genomes Project was fi rst launched in 2008, there wasn’t much understanding of how rare genomic variants were distributed among populations around the world and their relationship to other variants,” said Adam Auton, Ph.D., the main study senior author and principal investigator who until recently was assistant professor of genetics at the Albert Einstein College of Medicine in New York City.

“The 1000 Genomes Project has laid the foundation for others to answer really interesting questions,” said Dr Auton. “Everyone now wants to know what these variants tell us about human disease.”

New classification system developed for gout

A panel of experts and researchers have developed a new classifi cation system for gout, the most common form of infl ammatory arthritis. This new system standardizes the classifi cation of this condition using a variety of evidence-based criteria.

Led by researchers at Boston University School of Medicine (BUSM) and institutions from around the world, the study is a joint publication appearing in two journals simultaneously, Annals of Rheumatologic Disease and Arthritis & Rheumatology.

Gout is characterized by the deposition of a specifi c type of crystal in joint fl uid and various tissues. Numerous new drugs are being developed and tested in trials for gout, and some agents have been approved by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) in the past few years. These new classifi cation criteria will help standardize how to identify people with gout who should be eligible for enrolment into such trials and other studies.

An international group of investigators with support from the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed the classifi cation criteria through a multi-step process. They conducted a systematic review of the literature regarding advanced imaging for gout, conducted a study in which the gold standard to identify gout was presence of monosodium urate crystals, and used a decision analysis scientifi c approach to generate a comprehensive criteria encompassing multiple domains to guide classifi cation of gout.

“The implications of this new classifi cation are signifi cant as it provides a means for clinical researchers to use validated criteria for enrolment of subjects with gout into studies. This is particularly important for clinical trials which will use these criteria moving forward, and it is anticipated that these will become the standard expected by the FDA and EMA when evaluating gout clinical trials,” explained lead investigator Tuhina Neogi, MD, PhD, associate professor of medicine at BUSM and a rheumatologist at Boston Medical Center.

Johns Hopkins, Mayo experts suggest upgrades to heart disease guidelines

Acknowledging key strengths and “lessons learned”, preventive cardiologists from Johns Hopkins and Mayo Clinic have developed a short list of suggested upgrades to the controversial heart disease prevention guidelines issued jointly in 2013 by the American Heart Association and the American College of Cardiology.

The recommendations, published in the 11 August 2015 issue of Mayo Clinic Proceedings, are designed, the authors say, to improve subsequent guidelines and clarify key points of confusion related to risk prediction and treatment of heart attacks and strokes.

“Given that heart disease and stroke are top killers worldwide, even small improvements in the way we identify and treat those at risk could yield tremendous benefits both in reducing human suffering and healthcare costs,” says lead author Miguel Cainzos- Achirica, M.D., a post-doctoral research fellow in preventive cardiology at the Johns Hopkins University School of Medicine.

Authors of the new report are careful to point out that the guidelines – already scheduled for revision in the next few years – were an important step forward in the quest to improve heart attacks and stroke prevention. Parts of them, however, remain unpopular among frontline clinicians and public health experts alike. And uncertainty or controversy about what constitutes best practice can reduce clinician adherence and dampen patient trust, the authors say. The most contentious aspect of the guidelines is the predictive accuracy of a risk “calculator” that forecasts a person’s likelihood of suffering a heart attack or stroke over a decade.

The guidelines state that in those with high cholesterol but no overt heart disease, preventive statins should be considered — typically as a lifelong therapy — among those whose 10-year risk for suffering a heart attack or stroke is 7.5% or higher. But because the risk-scoring algorithm can overestimate likelihood of heart attack or stroke in many, experts have voiced concerns over the hazard of overtreatment.

Recent studies have shown that, indeed, most clinical calculators, including the one endorsed in the 2013 guidelines, tend to overrate risk. Overreliance on such algorithms can lead to unnecessary treatment with statins. To ensure greater precision, the researchers say, new formulas should estimate risk based on outcomes from modern rather than historical populations. Current calculators base their risk estimates on people from the 1970s and 1980s who had a worse risk profile than modern-day patients.

New formulas, the authors say, should be recalibrated regularly to reflect the latest data. “Electronic medical records put at our fingertips a wealth of new information, so recalibrating risk calculators periodically is not the pipe dream that it was 10 years ago,” says senior author Seth Martin, M.D., M.H.S., an assistant professor of medicine at the Johns Hopkins University School of Medicine.

The Johns Hopkins-Mayo group also suggests further “diversifying” risk scores. While current risk-scoring systems account for well-established differences in risk between white and black patients, they are “insensitive” when it comes to patients of other races and ethnicities. Researchers says recent evidence shows starkly different disease patterns among people of Latin American, South Asian or East Asian origin. “Subtle and not-so-subtle racial and ethnic differences in heart disease should be reflected in how we measure risk and tailor treatment,” Martin says.

Additionally, they say, closer attention must be paid to patients with borderline risk scores.

“For those at low or high risk for an event, treatment choices are rather straightforward,” Martin says. “But in those with borderline scores, that decision can become a knotty clinical dilemma.”

To help solve such dilemmas, the authors say the next set of guidelines can offer a list of tests that clarify a patient’s risk and move the needle on treatment choice. For example, coronary calcium scans that visualize calcified deposits inside the heart’s arteries could be an excellent tie-breaker, they say, because of mounting evidence showing them to be potent predictors of risk.

New guidelines could also clarify the role of non-statin alternatives to lowering cholesterol. While a healthy lifestyle is both the foundation and a first step to minimizing a patient’s overall risk, clinicians are often uncertain if and how soon after a lifestyle modification statins should follow. The next set of guidelines ought to provide greater clarity on what constitutes “successful” lifestyle change, how soon after implementing it patients should be re-evaluated, and when and if drug treatment should be considered. Additionally, the authors say, more clarity is needed on the value of several non-statin cholesterol-lowering drugs.

Another much-needed fix, the authors say, is synchronizing treatment goals for reducing cholesterol.

Current US guidelines urge clinicians to gauge treatment success by calculating the percentage drop in a patient’s cholesterol levels. But European and Canadian guidelines call on physicians to aim for a fixed cholesterol number instead. The “percentage” approach is not only discordant with international guidelines, Martin says, but requires confusing and messy arithmetic that often discourages clinicians from using it. Moreover, the authors write, the “percentage” approach has fuelled the misconception that cholesterol levels no longer matter. They do, the authors say. Harmonizing the “percentage drop” and “target number” approach to measuring therapeutic success would go a long way to improving clarity in clinical decisions.

Insomnia ranks 2nd after cold as most common health complaint internationally

Half of people internationally say they have had a cough or cold in the last 12 months and over a quarter report suffering from insomnia or problems sleeping. These are findings from a recent GfK online survey that asked over 27,000 people in 22 countries which health conditions from a given list they had experienced in the past 12 months.

The possible conditions asked about included items such as skin conditions, allergies, vomiting or diarrhoea, diabetes or pre-diabetes and high cholesterol or blood pressure. But, internationally, the top five most common conditions that people say they have experienced in the past 12 months are a cold (which was bundled with a cough, sore throat, upper respiratory infection, flu or influenza and was reported by 51%), problems sleeping (27%), muscle or joint pain due to injury or over exertion (25%), weight problems (21%) and migraines or severe headaches (21%).

Looking at the breakdown between men and women, there are some clear gender differences. For almost all the conditions listed, women have higher percentages saying they have experienced these in the last 12 months than men.

Both genders report a cold or cough as being the most common complaint (53% of women and 49% of men), but, for women, the next most common complaint is insomnia (32%), while, for men, it is a tiebreaker between muscle or joint pain due to over-exertion or injury, and insomnia (both standing at 24%). There is also a difference in what items make it into the top five for each gender. For women, migraine or severe headache is their third most common complaint, but does not feature in men’s top five list (reported by 27% of women and 15% of men). And for men, heartburn or acid reflux is their fourth most common complaint, but does not feature in the women’s top five list - even though more women than men report having experienced it over the last year (19% of men and 21% of women).

WHO warns societal changes needed to manage ageing population

With advances in medicine helping more people to live longer lives, the number of people over the age of 60 is expected to double by 2050 and will require radical societal change, according to a new report released by the WHO for the International Day of Older Persons (1 October).

“Today, most people, even in the poorest countries, are living longer lives,” says Dr Margaret Chan, Director-General of WHO. “But this is not enough. We need to ensure these extra years are healthy, meaningful and dignified. Achieving this will not just be good for older people, it will be good for society as a whole.” Contrary to widespread assumptions, the “World report on ageing and health 2015” finds that there is very little evidence that the added years of life are being experienced in better health than was the case for previous generations at the same age. “Unfortunately, 70 does not yet appear to be the new 60,” says Dr John Beard, Director of the Department of Ageing and Life Course at WHO. “But it could be. And it should be”. While some older people may indeed be experiencing both longer and healthier lives, these people are likely to have come from more advantaged segments of society.

“People from disadvantaged backgrounds, those in poorer countries, those with the fewest opportunities and the fewest resources to call on in older age, are also likely to have the poorest health and the greatest need,” says Dr Beard.

The Report stresses that governments must ensure policies that enable older people to continue participating in society and that avoid reinforcing the inequities that often underpin poor health in older age. The Report rejects the stereotype of older people as frail and dependent and says the many contributions that older people make are often overlooked, while the demands that population ageing will place on society are frequently overemphasised or exaggerated.

The Report emphasises that while some older people will require care and support, older populations in general are very diverse and make multiple contributions to families, communities and society more broadly. It cites research that suggests these contributions far outweigh any investments that might be needed to provide the health services, long- term care and social security that older populations require. And it says policy needs to shift from an emphasis on controlling costs, to a greater focus on enabling older people to do the things that matter to them.

This will be particularly important for women, who comprise the majority of older people and who provide much of the family care for those who can no longer care for themselves. “As we look to the future, we need to appreciate the importance of ageing in the lives of women, particularly in poorer countries,” says Dr Flavia Bustreo, WHO Assistant Director-General for Family, Women’s and Children’s Health. “And we need to think much more about how we can ensure the health of women right across the life course”.

But one factor will play a key role in whether the opportunity for ageing societies to reinvent themselves can be realised - the health of these older people.

The Report highlights 3 key areas for action which will require a fundamental shift in the way society thinks about ageing and older people. These actions can give the older people of today and tomorrow the ability to invent new ways of living.

The first is to make the places we live in much more friendly to older people. Good examples can be found in WHO’s Global Network of Age-friendly Cities and Communities that currently comprises over 280 members in 33 countries. These range from a project improving the security of older people in the slums of New Delhi to “Men’s Sheds” in Australia and Ireland that tackle social isolation and loneliness.

Realigning health systems to the needs of older people will also be crucial. This will require a shift from systems that are designed around curing acute disease, to systems that can provide ongoing care for the chronic conditions that are more prevalent in older age. Initiatives that have already proved successful can be expanded and introduced in other countries. Examples include the establishment of teams composed of different specialists such as physiotherapists, psychologists, nutritionists, occupational therapists, doctors and nurses in Brazil, and the sharing of computerized clinical charts among care institutions in Canada.

Governments also need to develop longterm care systems that can reduce inappropriate use of acute health services and ensure people live their last years with dignity. Families will need support to provide care, freeing up women, who are often the main caregivers for older family members, to play broader roles in society. Even simple strategies like internet-based support for family caregivers in the Netherlands or support to older peoples’ associations that provide peer support in Viet Nam hold great promise.

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