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  • In September a high level meeting of the UN called

    2019-06-12

    In September 2011, a high-level meeting of the UN called for a concerted global response to the growing challenge of non-communicable diseases (NCDs). Subsequently, in 2013, the World Health Assembly adopted a WHO-generated action plan and set a target of 25 × 25: a 25% reduction in premature mortality from four major NCDs (deaths in the age group of 30–70 years) by 2025, when compared with a baseline of 2010. The mortality target was linked to six targets for control of major risk factors and two targets for improving coverage with, and access to, essential drugs. Can the world achieve this aspirational mortality target in the face of advancing NCD epidemics in low-income and middle-income countries? Affirmation came from a modelling study by Kontis and colleagues who estimated that achieving the six risk-factor-related targets would take us close to the mortality target, and it could be fully accomplished by adopting an aggressive approach to tobacco control (to achieve 50% reduction in prevalence of global tobacco consumption, moving beyond the 30% target set by WHO). An extension of that study by Kontis and colleagues, published in , profiles the likely changes in premature NCD-related mortality, modelling both the anticipated secular trends and the potential added effect of six risk factor reduction strategies in each of the six regional groupings of WHO member countries. The study finds that, without any new intervention, proportional rates of premature mortality from NCDs would show a secular decline in all regions other than Africa, which would experience a rise. However, the cumulative effect of this decline would fall well short of the global 25 × 25 target. Effective actions for achieving the six risk-factor-related targets can move all regions, except Africa, close to the target of 25% reduction in premature mortality, according to Kontis and colleagues. Europe, with low levels of premature mortality and a 20·3% projected secular decline, will surpass the target, whereas four other regions will fall slightly short. With more aggressive tobacco control, they too can breach the 25% mark. Africa remains the exception because the rise of NCDs will affect a relatively young procollagen c proteinase and the presently low level of tobacco consumption will restrict the effect of tobacco control. The need for Africa to focus on other NCD risk factors, especially those of infectious aetiology, was emphasised in an earlier call for a revised target. The wide range of premature mortality across regions can be explained by differing stages of epidemiological transition. Europe has high life expectancy and the burden of NCD deaths mostly occurs at older ages. Africa is in the earlier stages of epidemiological transition, with the burdens of NCD mortality mostly distributed at younger ages. Other regions are midway through health transition and have high burdens of premature mortality despite declining secular trends. Even within regions, countries vary widely in their positions across the transition pathway.
    The new modelling work by Tran Dang Nguyen and colleagues in , which focuses on optimum distribution strategies of artemisinin combination therapies (ACTs) for treatment of malaria, comes at a crucial juncture in the public health battle to contain drug resistance. At a time that many countries are heeding calls to develop aggressive national plans to eliminate malaria and are reporting encouraging news of declining morbidity and mortality, worrisome evidence in the Greater Mekong subregion of southeast Asia confirms that resistance to artemisinin and to non-artemisinin partner drugs used in ACTs remains a threat. Safeguarding the effectiveness of ACTs should remain a paramount concern of the malaria community, and choosing optimum strategies for distribution of the various ACT options available to countries is a key component of this challenge. Availability of several ACTs has fuelled years of debate and modelling efforts to understand how this range of options can best be used to safeguard this class of treatments. Boni and colleagues first suggested the superior performance of concomitant use of multiple first-line therapies (MFT) over sequential application of single first-line therapies with an evolutionary–epidemiological modelling framework. By use of hybrid modelling approaches, Smith and colleagues also showed that, compared with sequential use of single first-line antimalarial drugs, MFT strategies were more effective in reducing drug pressure and delaying emergence and spread of resistance. However, with a population genetics model, Antao and Hastings suggested that the advantage of MFT over sequential application was not as clearly advantageous as other models had shown, owing to linkage disequilibrium that could yield multidrug resistance earlier than sequential application. These discrepant outputs led the WHO Drug Resistance and Containment Technical Expert Group in 2013 to declare that evidence for the benefits of MFT was inconclusive but that the concept was crucially important and warranted further modelling.