Correspondence
NT reports personal fees from Metropolitan Police and Thames Valley Police, has chaired a group that produced the British Psychological Society’s guidance on debriefing. All other authors declare no competing interests.
*David S J Hawker, Jamie Hacker Hughes, Noreen Tehrani, Debbie M Hawker, William Yule [email protected] InterHealth Worldwide, London SE1 6BD, UK (DSJH, DMH); Anglia Ruskin University, Chelmsford, UK (JHH); Noreen Tehrani Associates, Twickenham, UK (NT); and Kings College London, London, UK (WY) 1
2
3
4
5
Smith G, Wessely S. The future of mental health in the UK: an election manifesto. Lancet 2015; 385: 747–49. Mitchell JT, Everly G. Critical incident stress debriefing: an operations manual for the prevention of traumatic stress among emergency services and disaster workers, 2nd edn (revised). Ellicott City: Chevron, 1996. Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2002; 2: CD000560. Hawker DM, Durkin J, Hawker DSJ. To debrief or not to debrief our heroes: that is the question. Clin Psychol Psychother 2011; 18: 453–63. Tuckey MR, Scott JE. Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety Stress Coping 2013; 27: 38–54.
A public health approach to hypertension Sonia Angell and colleagues (Feb 28, p 825)1 describe the part played by the Strategic Fund of the Pan American Health Organization (PAHO) in support of the Global Standardized Hypertension Treatment (GSHT) Project, a joint initiative of the US Centers for Disease Control and Prevention (CDC) and PAHO. This contribution to the GSHT Project is consistent with PAHO’s mandates2 and is part of its body of work in hypertension control,3 a condition that affects 250 million people in the Americas. www.thelancet.com Vol 385 May 9, 2015
Created in 2000, and based on PAHO’s experiences managing the Revolving Fund for vaccines, the PAHO Strategic Fund is an effective mechanism to procure drugs and medical technology at reduced prices to treat people with communicable and non-communicable diseases.4,5 As an example of its relevance in the Americas, between 2004, and 2012, the monetary value of antiretrovirals procured for HIV/AIDS through the PAHO Strategic Fund increased by more than 1500 times.6 Participating countries also receive technical cooperation to strengthen their capacity for planning and management of essential medical supplies. The PAHO Strategic Fund has evolved to better respond to the needs of countries and improve access to quality drugs for non-communicable diseases. As a result of an international bidding process and time-bound agreements, PAHO member states are able to procure antihypertensive drugs recommended by the GSHT Project at a unique price for each country.3 This mechanism also applies to drugs for cancer and diabetes. However, the success of the PAHO Strategic Fund depends on a high level of participation by member states, which allows PAHO to negotiate lower prices, thus increasing availability of drugs and providing benefits to larger numbers of people affected. Guaranteeing long-term daily treatment for a billion people with hypertension worldwide7 is extremely complex. Prioritisation of the availability and affordability of a core set of quality-assured drugs to treat hypertension, one of the pillars of the GSHT Project, is highly strategic. As such, the PAHO Strategic Fund represents a model that ensures access to a set of core drugs at competitive prices. Management and sustaining of such a fund is not without challenges— among them, the powerful competing economic interests of manufacturers. Innovative strategies will need to be adopted for advances towards
universal access to health and universal health coverage to ensure access to drugs for all. We declare no competing interests.
*Pedro Ordunez, Silvana Luciani, Adrian Barojas, James Fitzgerald, Anselm J M Hennis
Sheila Terry/Science Photo Library
as did three RCTs in the systematic review.3 Good RCTs are invaluable, but poor RCTs produce bad evidence. Restating conclusions based on poor evidence makes it harder to gather good evidence and sets back the progress of evidence-based medicine.
[email protected] Pan American Health Organization, Washington, DC 20037, USA 1
2
3
4
5
6
7
Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27. PAHO. Plan of action for the prevention and control of noncommunicable diseases (NCDs) in the Americas 2013–2019. Washington: Pan American Health Organization, 2014. Ordunez P, Martinez R, Niebylski ML, Campbell NR. Hypertension Prevention and Control in Latin America and the Caribbean. J Clin Hypertens (Greenwich) 2015; published online Feb 28. DOI:10.1111/jch.12518. PAHO. PAHO strategic fund. Washington: Pan American Health Organization, 2014. http:// www.paho.org/hq/index.php?option=com_co ntent&view=category&layout=blog&id=1159& Itemid=452 (accessed March 3, 2014). The Lancet Infectious Diseases. Global harmonisation in vaccine price. Lancet Infect Dis 2015; 15: 249. PAHO. Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean 2013. Washington: Pan American Health Organization, 2013. WHO. A global brief on hypertension: silent killer, global public health crisis. Geneva: World Health Organization, 2013.
Sonia Angell and colleagues 1 present constructive ideas to address hypertension globally. However, the daunting challenges of implementation of rapid control of hypertension deserve fuller discourse. The fact that “in the USA, barely half of people with hypertension have their blood pressure at target levels”1 speaks volumes. Moreover emulating single-purpose AIDS programming is largely unrealistic. Undertaking of further multibillion dollar initiatives to establish largely parallel health systems is simply not feasible. And despite huge investment, 2·1 million people are still newly diagnosed with HIV every year, and 1·5 million die from it. 2 Although the major implementation challenges for treatment of hypertension share much with HIV—eg, proper identification of 1833
Correspondence
people in need, reliable supply chains, life-long daily drug-taking, and close monitoring—hypertension is far more common. Moreover, other health priorities are clamouring for attention, including not only infectious disease and maternal and child health, but emerging priorities, such as mental health, air quality, injury, cancer, and other cardiovascular disease. Hypertension efforts must be implemented alongside these other priorities, often through weak health systems. Strangely, Angell and colleagues omi t behavioural interventions, which is problematic not only because obesity, tobacco, alcohol, stress, diet, and physical inactivity are important for hypertension, but also because these factors affect cardiovascular disease more directly. After all, management of hypertension is not an end in itself, but is primarily to avert cardiovascular sequelae. Moreover, behavioural interventions are key to demand creation and regimen adherence. One opportunity is engagement of private-sector providers, who provide substantial care in low-income countries and have been successfully enlisted in efforts to tackle contraception3 and malaria.4 Engagement of these providers through training, guidelines, job aids, certification, and providing appropriate drugs could greatly expand efforts to address hypertension. Hypertension deserves to be a key priority, but many challenges exist, and efforts to address it must mesh with those of other pressing global health priorities. I declare no competing interests. The views expressed are those of the author and not necessarily those of USAID.
James D Shelton [email protected] United States Agency for International Development, Washington, DC 20523, USA 1
1834
Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27.
2 3
4
UNAIDS. The GAP report. Geneva: Joint United Nations Programme on HIV/AIDS, 2014. DKT International. Contraceptive social marketing statistics. http://www. dktinternational.org/publications-resources/ contraceptive-social-marketing-statistics/ (accessed March 16, 2015). Ansah EK, Narh-Bana S, Affran-Bonful H, et al. The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial. BMJ 2015; 350: h1019.
the adoption of the single risk factor approach; even Angell and colleagues1 acknowledge that, after more than 50 years of use in the USA, this approach has not led to high coverage levels. An overall-risk approach has the potential to bring great benefits to the USA and the rest of the world and avoids exportation of a failed model.7 We declare no competing interests.
Sonia Angell and colleagues are to be congratulated on drawing attention to the challenges posed by hypertension in the context of the global burden of non-communicable diseases. 1 However, we take issue with the focus on hypertension defined at an arbitrary cutoff level.2 Modern approaches to the management of cardiovascular disease risk focus on overall levels of risk, based on assessment of the presence (or absence) of several risk factors, rather than tackling each risk factor in isolation.3 This multifactor approach is promoted by WHO in its Package of Essential Non-communicable (PEN) disease interventions for primary health care in low-resource settings.4 A key element of PEN is the stratification of target populations by overall level of risk of cardiovascular disease, ideally assessed with simple, non-invasive measurements (eg, age, sex, smoking, or blood pressure levels).5 On the basis of this stratification, countries can then use the available financial and human resources to provide disease management to people at the highest risk of cardiovascular disease using generic drugs. As experience is gained and more resources become available, people at more modest levels of risk can be treated. The agreed global treatment target for 2025 is to treat 50% of people who have at least a 30% risk of a cardiovascular disease event during the 10 years after risk assessment.6 The overall-risk-based approach for management of cardiovascular disease risk is intuitively appealing, but needs more assessment in real-world settings. At this stage, however, this approach offers many advantages over
*Ruth Bonita, Robert Beaglehole [email protected] University of Auckland, Devonport, Auckland 0624, New Zealand 1
2
3
4
5
6
7
Angell SY, De Cock DM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27. Martin SA, Boucher M, Wright JM, Saini V. Mild hypertension in people at low risk. BMJ 2014; 349: g5432. Jackson R, Lawes CMM, Bennett DA, Milne RJ, Rodgers A. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual’s absolute cardiovascular risk. Lancet 2005; 365: 434–41. WHO. Package of essential non-communicable (PEN) disease interventions for primary health care in low resource settings. Geneva; World Health Organization, 2010. Port S, Demer L, Jennrich R, Garfinkel A. Systolic blood pressure and mortality. Lancet 2000; 355: 175–80. WHO. Global action plan for the prevention and control for non-communicable diseases 2013–2020. Geneva: World Health Organization, 2013. Ebrahim S, Davey Smith G. Exporting failure? Coronary heart disease and stroke in developing countries. Int J Epidemiol 2001; 30: 201–05.
Department of Error Elmariah S, Mauri L, Doros G, et al. Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis. Lancet 2015; 385: 792–98—In this Article, the hazard ratio for the ARCTIC-Interruption study in figure 2 and appendix figure 3 should have been 0·76 (95% CI 0·28–2·04). This correction changes the overall meta-analytic hazard ratio for all-cause mortality without the DAPT trial included to 1·02 (95% CI 0·94–1·14) and with the DAPT trial included to 1·04 (95% CI 0·96–1·18) and changes the overall meta-analytic hazard ratio for all-cause mortality within the sensitivity analysis for patients with coronary artery disease without the DAPT trial included to 1·00 (95% CI 0·87–1·16) and with the DAPT trial included to 1·04 (95% CI 0·91–1·22). These correction have been made to the online version as of May 7, 2015.
www.thelancet.com Vol 385 May 9, 2015
NT reports personal fees from Metropolitan Police and Thames Valley Police, has chaired a group that produced the British Psychological Society’s guidance on debriefing. All other authors declare no competing interests.
*David S J Hawker, Jamie Hacker Hughes, Noreen Tehrani, Debbie M Hawker, William Yule [email protected] InterHealth Worldwide, London SE1 6BD, UK (DSJH, DMH); Anglia Ruskin University, Chelmsford, UK (JHH); Noreen Tehrani Associates, Twickenham, UK (NT); and Kings College London, London, UK (WY) 1
2
3
4
5
Smith G, Wessely S. The future of mental health in the UK: an election manifesto. Lancet 2015; 385: 747–49. Mitchell JT, Everly G. Critical incident stress debriefing: an operations manual for the prevention of traumatic stress among emergency services and disaster workers, 2nd edn (revised). Ellicott City: Chevron, 1996. Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2002; 2: CD000560. Hawker DM, Durkin J, Hawker DSJ. To debrief or not to debrief our heroes: that is the question. Clin Psychol Psychother 2011; 18: 453–63. Tuckey MR, Scott JE. Group critical incident stress debriefing with emergency services personnel: a randomized controlled trial. Anxiety Stress Coping 2013; 27: 38–54.
A public health approach to hypertension Sonia Angell and colleagues (Feb 28, p 825)1 describe the part played by the Strategic Fund of the Pan American Health Organization (PAHO) in support of the Global Standardized Hypertension Treatment (GSHT) Project, a joint initiative of the US Centers for Disease Control and Prevention (CDC) and PAHO. This contribution to the GSHT Project is consistent with PAHO’s mandates2 and is part of its body of work in hypertension control,3 a condition that affects 250 million people in the Americas. www.thelancet.com Vol 385 May 9, 2015
Created in 2000, and based on PAHO’s experiences managing the Revolving Fund for vaccines, the PAHO Strategic Fund is an effective mechanism to procure drugs and medical technology at reduced prices to treat people with communicable and non-communicable diseases.4,5 As an example of its relevance in the Americas, between 2004, and 2012, the monetary value of antiretrovirals procured for HIV/AIDS through the PAHO Strategic Fund increased by more than 1500 times.6 Participating countries also receive technical cooperation to strengthen their capacity for planning and management of essential medical supplies. The PAHO Strategic Fund has evolved to better respond to the needs of countries and improve access to quality drugs for non-communicable diseases. As a result of an international bidding process and time-bound agreements, PAHO member states are able to procure antihypertensive drugs recommended by the GSHT Project at a unique price for each country.3 This mechanism also applies to drugs for cancer and diabetes. However, the success of the PAHO Strategic Fund depends on a high level of participation by member states, which allows PAHO to negotiate lower prices, thus increasing availability of drugs and providing benefits to larger numbers of people affected. Guaranteeing long-term daily treatment for a billion people with hypertension worldwide7 is extremely complex. Prioritisation of the availability and affordability of a core set of quality-assured drugs to treat hypertension, one of the pillars of the GSHT Project, is highly strategic. As such, the PAHO Strategic Fund represents a model that ensures access to a set of core drugs at competitive prices. Management and sustaining of such a fund is not without challenges— among them, the powerful competing economic interests of manufacturers. Innovative strategies will need to be adopted for advances towards
universal access to health and universal health coverage to ensure access to drugs for all. We declare no competing interests.
*Pedro Ordunez, Silvana Luciani, Adrian Barojas, James Fitzgerald, Anselm J M Hennis
Sheila Terry/Science Photo Library
as did three RCTs in the systematic review.3 Good RCTs are invaluable, but poor RCTs produce bad evidence. Restating conclusions based on poor evidence makes it harder to gather good evidence and sets back the progress of evidence-based medicine.
[email protected] Pan American Health Organization, Washington, DC 20037, USA 1
2
3
4
5
6
7
Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27. PAHO. Plan of action for the prevention and control of noncommunicable diseases (NCDs) in the Americas 2013–2019. Washington: Pan American Health Organization, 2014. Ordunez P, Martinez R, Niebylski ML, Campbell NR. Hypertension Prevention and Control in Latin America and the Caribbean. J Clin Hypertens (Greenwich) 2015; published online Feb 28. DOI:10.1111/jch.12518. PAHO. PAHO strategic fund. Washington: Pan American Health Organization, 2014. http:// www.paho.org/hq/index.php?option=com_co ntent&view=category&layout=blog&id=1159& Itemid=452 (accessed March 3, 2014). The Lancet Infectious Diseases. Global harmonisation in vaccine price. Lancet Infect Dis 2015; 15: 249. PAHO. Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean 2013. Washington: Pan American Health Organization, 2013. WHO. A global brief on hypertension: silent killer, global public health crisis. Geneva: World Health Organization, 2013.
Sonia Angell and colleagues 1 present constructive ideas to address hypertension globally. However, the daunting challenges of implementation of rapid control of hypertension deserve fuller discourse. The fact that “in the USA, barely half of people with hypertension have their blood pressure at target levels”1 speaks volumes. Moreover emulating single-purpose AIDS programming is largely unrealistic. Undertaking of further multibillion dollar initiatives to establish largely parallel health systems is simply not feasible. And despite huge investment, 2·1 million people are still newly diagnosed with HIV every year, and 1·5 million die from it. 2 Although the major implementation challenges for treatment of hypertension share much with HIV—eg, proper identification of 1833
Correspondence
people in need, reliable supply chains, life-long daily drug-taking, and close monitoring—hypertension is far more common. Moreover, other health priorities are clamouring for attention, including not only infectious disease and maternal and child health, but emerging priorities, such as mental health, air quality, injury, cancer, and other cardiovascular disease. Hypertension efforts must be implemented alongside these other priorities, often through weak health systems. Strangely, Angell and colleagues omi t behavioural interventions, which is problematic not only because obesity, tobacco, alcohol, stress, diet, and physical inactivity are important for hypertension, but also because these factors affect cardiovascular disease more directly. After all, management of hypertension is not an end in itself, but is primarily to avert cardiovascular sequelae. Moreover, behavioural interventions are key to demand creation and regimen adherence. One opportunity is engagement of private-sector providers, who provide substantial care in low-income countries and have been successfully enlisted in efforts to tackle contraception3 and malaria.4 Engagement of these providers through training, guidelines, job aids, certification, and providing appropriate drugs could greatly expand efforts to address hypertension. Hypertension deserves to be a key priority, but many challenges exist, and efforts to address it must mesh with those of other pressing global health priorities. I declare no competing interests. The views expressed are those of the author and not necessarily those of USAID.
James D Shelton [email protected] United States Agency for International Development, Washington, DC 20523, USA 1
1834
Angell SY, De Cock KM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27.
2 3
4
UNAIDS. The GAP report. Geneva: Joint United Nations Programme on HIV/AIDS, 2014. DKT International. Contraceptive social marketing statistics. http://www. dktinternational.org/publications-resources/ contraceptive-social-marketing-statistics/ (accessed March 16, 2015). Ansah EK, Narh-Bana S, Affran-Bonful H, et al. The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial. BMJ 2015; 350: h1019.
the adoption of the single risk factor approach; even Angell and colleagues1 acknowledge that, after more than 50 years of use in the USA, this approach has not led to high coverage levels. An overall-risk approach has the potential to bring great benefits to the USA and the rest of the world and avoids exportation of a failed model.7 We declare no competing interests.
Sonia Angell and colleagues are to be congratulated on drawing attention to the challenges posed by hypertension in the context of the global burden of non-communicable diseases. 1 However, we take issue with the focus on hypertension defined at an arbitrary cutoff level.2 Modern approaches to the management of cardiovascular disease risk focus on overall levels of risk, based on assessment of the presence (or absence) of several risk factors, rather than tackling each risk factor in isolation.3 This multifactor approach is promoted by WHO in its Package of Essential Non-communicable (PEN) disease interventions for primary health care in low-resource settings.4 A key element of PEN is the stratification of target populations by overall level of risk of cardiovascular disease, ideally assessed with simple, non-invasive measurements (eg, age, sex, smoking, or blood pressure levels).5 On the basis of this stratification, countries can then use the available financial and human resources to provide disease management to people at the highest risk of cardiovascular disease using generic drugs. As experience is gained and more resources become available, people at more modest levels of risk can be treated. The agreed global treatment target for 2025 is to treat 50% of people who have at least a 30% risk of a cardiovascular disease event during the 10 years after risk assessment.6 The overall-risk-based approach for management of cardiovascular disease risk is intuitively appealing, but needs more assessment in real-world settings. At this stage, however, this approach offers many advantages over
*Ruth Bonita, Robert Beaglehole [email protected] University of Auckland, Devonport, Auckland 0624, New Zealand 1
2
3
4
5
6
7
Angell SY, De Cock DM, Frieden TR. A public health approach to global management of hypertension. Lancet 2015; 385: 825–27. Martin SA, Boucher M, Wright JM, Saini V. Mild hypertension in people at low risk. BMJ 2014; 349: g5432. Jackson R, Lawes CMM, Bennett DA, Milne RJ, Rodgers A. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual’s absolute cardiovascular risk. Lancet 2005; 365: 434–41. WHO. Package of essential non-communicable (PEN) disease interventions for primary health care in low resource settings. Geneva; World Health Organization, 2010. Port S, Demer L, Jennrich R, Garfinkel A. Systolic blood pressure and mortality. Lancet 2000; 355: 175–80. WHO. Global action plan for the prevention and control for non-communicable diseases 2013–2020. Geneva: World Health Organization, 2013. Ebrahim S, Davey Smith G. Exporting failure? Coronary heart disease and stroke in developing countries. Int J Epidemiol 2001; 30: 201–05.
Department of Error Elmariah S, Mauri L, Doros G, et al. Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis. Lancet 2015; 385: 792–98—In this Article, the hazard ratio for the ARCTIC-Interruption study in figure 2 and appendix figure 3 should have been 0·76 (95% CI 0·28–2·04). This correction changes the overall meta-analytic hazard ratio for all-cause mortality without the DAPT trial included to 1·02 (95% CI 0·94–1·14) and with the DAPT trial included to 1·04 (95% CI 0·96–1·18) and changes the overall meta-analytic hazard ratio for all-cause mortality within the sensitivity analysis for patients with coronary artery disease without the DAPT trial included to 1·00 (95% CI 0·87–1·16) and with the DAPT trial included to 1·04 (95% CI 0·91–1·22). These correction have been made to the online version as of May 7, 2015.
www.thelancet.com Vol 385 May 9, 2015
