Advancing Surveillance of Chronic and Non-Communicable Disease—A Path Forward

Objective

To characterize current and future approaches to surveillance of chronic and non-communicable diseases and establish the agenda for both methodological and condition-specific progress.

Introduction

Major global stakeholder groups including the United Nations, World Health Organization and Institute of Medicine seek to raise awareness of the threat to global health and security of chronic and non-communicable diseases. These conditions comprise 50–85% of the global annual morbidity burden and constitute a major drain on national economies. To move from awareness of this problem to action and amelioration of issues, we need effective means for monitoring and intervening with populations using approaches that span primary, secondary and tertiary prevention.

Methods

This session will begin with a discussion of key concepts and terms and their implications for defining target problems, populations and surveillance strategies. We will also begin by reviewing the epidemiologic and economic arguments for advancing surveillance in this area. The discussion will center on a critical assessment of issues related to surveillance of chronic and non-communicable diseases: how do approaches differ from established and evolving approaches to surveillance of infectious disease? Are there opportunities for synergy with current surveillance efforts and assets? Where are new methods needed? How might surveillance approaches be advanced in different regions (e.g., developing and industrialized settings)? Might new approaches predicated on “citizen science” and engaged patient and public health cohorts provide platforms for advancing surveillance of chronic and non-communicable diseases and what is required to ensure their success?

Results

Points of discussion:

1. Participants are encouraged to come prepared to share their experiences engaging patient and public health cohorts in this area, including sharing experiences engaging cohorts using online social networks, participatory research and surveys.
2. Brainstorm ideas for development of a workshop in non-communicable disease surveillance.

Sample questions:

1. What are the issues related to surveillance in the context of resource rich and poor contexts?
2. What are the special needs for establishing cost-effective and sustainable methods for longitudinal tracking?
3. How can technological advances and engaged patient and public health cohorts be used in the advancement of surveillance? What are methods to maximize engagement in both the developed and developing world?

Conclusions

Non-communicable diseases are a major and growing morbidity and mortality burden globally. This round table discussion will focus on the importance of non-communicable disease surveillance, attempt to elicit participant’s experiences in the surveillance of these conditions, and outline special needs for establishing cost-effective and sustainable methods for longitudinal tracking of non-communicable diseases.     

Chronic Kidney Disease Staging in Nursing Home and Community Older Adults: Does the Choice of Cockcroft-Gault,Modification of Diet in Renal Disease Study,or the Chronic Kidney Disease Epidemiology Collaboration Initiative Equations Matter?

ObjectiveTo compare the chronic kidney disease (CKD) stages derived from GFR estimates using 3 different formulae in a sample of older adults from the community and long term care settings.ParticipantsData from 1535 older, hospitalized patients (2000–2008) were collected; individuals were hospitalized for acute illness unrelated to renal function.MeasurementsPatient demographics, pertinent medical history, and routine laboratory test results were collected. Estimate of glomerular filtration rate and creatinine clearance values were determined by the Cockcroft-Gault, Modification of Diet in Renal Disease Study, and Chronic Kidney Disease Epidemiology Collaboration equations.ResultsThe Cockcroft-Gault equation generated significantly lower mean estimate of glomerular filtration rate values than either Modification of Diet in Renal Disease Study or Chronic Kidney Disease Epidemiology Collaboration equations in the total sample (P < .0005) and in a subset of patients diagnosed as renal insufficiency (P < .00005). Using the 3 formulae produced a significant disconnect in CKD staging resulting in the potential for different recommendations for monitoring and management across formulae (National Kidney Foundation Guidelines) (P < .0005). When stratified by age, the 3 equations produce nearly identical glomerular filtration rate estimates in patients younger than 70 years (P = .989) but significantly different glomerular filtration rate estimates in patients from 70 to 104 years (P < .0005).ConclusionsThe Cockcroft-Gault equation systematically provides lower (more severe) estimates of renal function than the Modification of Diet in Renal Disease Study and Chronic Kidney Disease Epidemiology Collaboration equation in patients older than 70 years. However, significant differences in CKD staging derived from estimate of glomerular filtration rate or creatinine clearance were not observed in adults from 59 to 69 years of age. These findings do not validate one formula over the others, but demonstrate that disparities exist; it may be prudent to use the same formula over time in a given patient to monitor changes in renal function.     

Prevalence of Peripheral Arterial Disease – Results of the Heinz Nixdorf Recall Study

Background: This report presents population-based estimates of the prevalence of peripheral arterial disease (PAD), chronic critical limb ischemia (CLI), and Moenckeberg’s medial calcinosis (MC) in Germany. Patients and methods: From the year 2000 to 2003, a total of 4,814 subjects aged 45–75 years were included in the study. In 30 of the subjects (0.6%), determination of the ankle brachial index (ABI) was not possible, leaving 4,735 subjects (99.4%) in the data set. PAD was considered present in all subjects with an ABI < 0.9 in one leg, and/or a history of prior treatment for PAD. CLI was considered present if the highest ankle artery pressure measured < 70 mmHg. Prevalence of MC was calculated for ABI cut-off values of 1.3 and 1.5. Findings: The overall prevalence of PAD according to the ABI criteria was 6.4% among men and 5.1% among women. After accounting for history of PAD, the prevalence increased to 8.2% among men and 5.5% among women. Taking the ABI criteria and medical history into account, males had a higher prevalence of PAD, with large increases in males aged 65–69 and 70–75 years. Chronic CLI was rare in the investigated population, and was found in only five older subjects (0.1%). With the criterion of ABI > 1.3, about 13.3% of males and 6.9% of females had MC. In contrast to PAD, the prevalence of MC did not increase with age. With the criterion of ABI > 1.5, MC was present in only 1.1% and 0.5% of men and women, respectively, but only 30 (0.6%) subjects had incompressible ankle arteries with a cuff pressure > 260 mmHg. Conclusion: Prevalences of PAD based only on ABI generally underestimate the true prevalence of PAD in population-based studies. CLI predominantly affects older subjects. In addition, cut-off values for MC must be newly determined.     

Genetic Transmission of Disease: A Legal Harm?

This paper considers whether existing law could potentially be used to criminalize the transmission of genetic disease. The paper argues that even if an offence could be made out, the criminal law should not be involved in this context for many reasons, including the need to protect reproductive liberty and pregnant women’s rights. The paper also examines whether there might be scope for civil claims between reproductive partners for a ‘failure to warn’ of potential genetic harm and argues there are strong policy grounds for resisting such claims. If such a duty were to exist, there might, in the future, be scope for a child to bring a claim under the Congenital Disabilities (Civil Liability Act) 1976. Such a claim could be for the failure by the child’s father to warn her mother, which in turn led to the loss of opportunity to have treatment in utero which could have prevented the disability. It is suggested that the same arguments which supported granting maternal immunity under the Act would also support paternal immunity and that, therefore the issue of the lack of paternal immunity under the Act should be revisited.     

Genetic Aspects of Scurvy and the European Famine of 1845–1848

The view of scurvy being exclusively a nutritional disorder needs to be updated. Genetic polymorphisms of HFE and haptoglobin (Hp) may explain the geographic variability of mortality caused by the European famine of the mid-19th century. In this period, potatoes had fallen victim to the potato blight and Ireland was more severely hit than continental Europe. Hereditary hemochromatosis is a genetic disorder with mutations in the HFE gene, characterized by iron overload (with a reduced vitamin C stability) and with a predominance of affected men. The Irish have the world’s highest frequency of the C282Y mutation and the particular iron metabolism of the Irish helps to understand the size of the catastrophe and the observed overrepresentation of male skeletons showing scurvy. Hp is a plasma α₂-glycoprotein characterized by 3 common phenotypes (Hp 1-1, Hp 2-1 and Hp 2-2). When the antioxidant capacity of Hp is insufficient, its role is taken over by hemopexin and vitamin C. The relative number of scurvy victims corresponds with the Hp 2-2 frequency, which is associated with iron conservation and has an impact on vitamin C stability. As iron is more abundant in males, males are overrepresented in the group of skeletons showing scurvy signs.