NCDs: Next pandemic in the making?
NCDs are the leading cause of death and disability around the world. The United Nations’ Sustainable Development Goal 3.4 focuses on reducing mortality from NCDs by a third by 2030. The pandemic slowed down the process of achieving this goal. Considering the scale and speed at which they are rising, it’s time to re-consider some of the interventions that are important to prevent them.
NCDs threaten progress towards the 2030 Agenda for Sustainable Development, which includes a target of reducing the probability of death from any of the four main NCDs between ages 30 and 70 years by one-third by 2030.
Dr Gautam Wankhede, Director-Medical Affairs, Mylab Discovery Solutions emphasises that the burden of NCDs exceeds the burden of communicable diseases. He said, “NCDs are the leading cause of morbidity and premature mortality around the world, which were primarily due to cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. India is in the midst of an epidemiological transition as the burden of NCDs exceeds the burden of communicable diseases. The pandemic has significantly worsened outcomes for many NCDs.”
Current status: Where do we stand?
As per WHO recent data, “NCDs kill 41 million people each year, equivalent to 74 per cent of all deaths globally. Also, cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.3 million), chronic respiratory diseases (4.1 million), and diabetes (2.0 million including kidney disease deaths caused by diabetes).”
Dr Grace E. Terrell, Chief Product Officer, IKS Health said, “The pandemic unleashed many unanticipated tragedies with magnitudes of unprecedented scale and impact. While the world gradually comes out of the pandemic phase, the last couple of years or so have led to dilution and diversion of attention required towards reducing NCDs which continue to plague society at large with an immensity of higher proportion compared to the pandemic.”
“About a hundred years ago the most common causes of death were communicable diseases and our health care systems worldwide were designed and developed to treat these acute diseases. With the advent of antibiotics and vaccines, lifespans have increased and chronic diseases have become an increasingly significant proportion of the disease burden. Currently, 73 per cent of global deaths are the result of chronic diseases and 60 per cent of the global disease burden. Prior to the pandemic, cardiovascular diseases, cancer, diabetes and chronic respiratory diseases made up most of the causes of premature death worldwide. With the impact of the pandemic subsiding, it is time to refocus our efforts on these non-communicable diseases. The pre-pandemic data from 2019 shows that the top three countries’ total incidence of diabetes (China, India, US) is 224.4 million but without any intervention, it will be 318.2 million people by 2045. Additionally, worldwide non-communicable diseases collectively will cost $47 trillion by 2030. The United Nations’ goal of reducing premature mortality from non-communicable diseases by one-third by 2030 is now running behind due to the pandemic. It is essential to apply focused efforts on the main causes (poor diet, inadequate physical exercise, tobacco use and excessive alcohol use) through designing models of care that are person-centered and preventative, with early diagnostics and cost-effective, accessible therapies”, she added.
Access to high-quality diagnostics to manage the burden of NCDs
Unlike communicable diseases where diagnostic tools have played an important role in addressing the disease, the diagnostic landscape of NCDs still needs more attention. The diagnosis of NCDs at an early stage can help avert a potential fatality.
Dr Preeti Kabra, Chief of Lab, Neuberg Diagnostics shares some numbers. She said, “In the survey conducted by ASSOCHAM titled “Non-Communicable Diseases in India” more than 40 per cent of the respondents suffering from CVD and hypertension accepted that they were not aware of having their respective diseases for more than 3 years. The report highlighted that for the heart ailment over 70 per cent of respondents stated that they were diagnosed after 1 year of suffering. The survey further showed that over 52 per cent of CVD/heart disease patients seek medical advice only in the case of an emergency.”
Although, there are substantial advances in the diagnostics ecosystem of the NCDs, innovating on the ways that can make early diagnosis more possible still needs attention.
Vikram Thaploo, CEO, Apollo Telehealth also believes, “The development of diagnostic tools allows for the rapid detection of NCDs biomarkers with high sensitivity to help detect diseases at their early stages, which subsequently contributes to the easier treatment and fast cures.”
While innovating new diagnostic solutions is an important factor, accessibility and availability of these solutions is also crucial factor.
Stressing on the same, Dr Yogesh Gupta, MD Medicine, Consultant Physician & Geriatrician, Sterling Hospitals stresses, “Despite substantial advances, it is still not possible to prevent or completely cure NCDs. For years, people with diabetes may go undiagnosed, and with the current state of cancer diagnostics, patients may not find out they have the disease until it is in its latter stages. We need to have high-quality, integrated, and people-centered primary health services for all and an appropriate well-trained, equipped health workforce which will be beneficial to increase access to early and advanced diagnostics. It has been discovered that NCD diagnostic and monitoring technologies are either not available inside health systems or are too expensive for individuals to obtain for self-monitoring.”
Dr Vikram, MS-General Surgery, Aarvy Healthcare Super speciality hospital said, “It is often too late when these diseases are diagnosed by the physician, during which they set in often leading to devastating consequences for the patients. It would not be an exaggeration to state that if COVID is termed as a pandemic, NCDs in patients running parallelly with COVID caused a syndemic. The loss of immunity due to COVID in relatively healthy individuals made them vulnerable to a plethora of dormant diseases. COVID not only lowered immunity but also aggravated the severity of NCDs. Therefore, it is pivotal that the diagnosis of NCDs is done at an early stage, to ensure holistic treatment and avoidance of chronic recurrence. The clinical handling of NCDs requires a 360-degree approach in terms of their diagnostics.”
“From the perspective of healthcare providers, it should be their endeavor to tap into logistics and modern-day technology enabling support for ease of specimen collection, real-time connectivity to provide required test data to clinicians and users and provision of sensitive and specific diagnostic technology to avoid false positive and negative results”, he added.
Venkatraman V, Commercial Director, Hologic South Asia throws light on cervical cancer surveillance and currently available technologies. He said, “It is important to ward off the disease through regular screening along with the HPV vaccination (most cervical cancer is caused by HPV). Awareness and prevention are the two most effective weapons against this disease. As health is a state concern in India, a joint strategy between the state and central government is necessary to boost cervical cancer screening penetration. Today, there are various non-invasive and convenient screening tests available in the market like Visual Inspection with Acetic Acid (VIA), Pap smear, Liquid-based cytology (LBC), HPV testing, etc., each has benefits and limitations. The VIA has a lot of false positives, the Pap test misses many cases. Globally, Liquid-based cytology (LBC)-an improved liquid-based collection method was created, which increases the chance of detection. The Liquid-based cytology (LBC) test consists of rapid fixation, an exact monolayer depiction of the complete material, and diminished obscuring components. This test has enhanced the detection of aberrant cervical cells since its implementation. Liquid-based cytology (LBC) solution is the most widely used test globally, as it has the advantage of allowing a single specimen to be used for HPV testing, sexually transmitted disease screening, and cytology. This alternative not only allows providers to reduce manpower and supply costs but can also reduce the frequency of repeat appointments for add-on testing and thus, making it more convenient for both patients and doctors. LBC filtration technology has shown enhanced identification of adenocarcinomas, as well as the capacity to undertake out-of-vial testing, such as co-testing for HPV or sexually transmitted infections, without the need for an additional specimen.”
Disease surveillance and technology
Tracking the disease trends and systematically evaluating the interventions are some of the necessary factors for effective NCD surveillance.
Dr Kabre explains that We have seen in the recent COVID-19 pandemic that people with co-morbidities had higher mortality compared to those who did not. This makes prevention and control of NCDs all the more important.
She added, “India has a National Program for Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS). MPW (Multi Purpose Workers) play a major role in population screening, identification of cases for referral, Follow-ups and treatments, recognition of complications and prevention and health promotion. ANM/MPW need to closely work with ASHA in their areas and this can really make a difference in managing these NCDs at the grassroot level. Proper awareness, training and guidance to these people can help India combat NCDs at a larger level. Proper monitoring, evaluation and surveillance of this program as well as proper analysis of data at all levels is the need of the hour. Just like we had a national level data collection during COVID, we need to have such use of digitisation at all levels for managing national level programs.”
Dr Wankhede opines, “Monitoring of epidemiological trends for modifiable risk factors including tobacco use, harmful alcohol use, physical inactivity and eating unhealthy diets is crucial to accurately estimate disease burden, and also for policy/program implementation and evaluation. it will also provide a huge boost to the economic development of the country. Big data and data analytics, other cutting-edge technologies could be used to collect NCD surveillance data. Including behavioral, environmental and community data into the surveillance of NCDs could lead to opportunities for interventions aimed at improving population health.”
Due to the complex nature of NCDs, having a multiple surveillance approach in place is also required.
Vikas Gupta, Co-Founder and Chief Product Officer, MyDiagnostics stresses that the advancements in technology have enabled researchers to investigate the root cause of these diseases, rather than just focusing on treating them. He said, “In the past, doctors and scientists have been able to identify diseases by studying the signs and symptoms of a patient. However, the advancements in technology have enabled researchers to investigate the root cause of these diseases, rather than just focusing on treating them. This has led to a new era of diagnosis where doctors can pinpoint what is causing health issues by analysing data from various sources such as blood samples and stool samples etc.”
Highlightening the importance of disease surveillance and technology, Dr Nitendra Sesodia, Senior Director-Medical Communications & Corporate Sales at Thieme Group said, “There is a dire need to improve surveillance, monitoring and reporting tools and methodologies. Disease-specific surveillance and monitoring tools would have to be employed. Given the innate role of baseline data, mobile phones and internet technologies can be used for data collection.”
Infrastructure to deal with NCDs
The pandemic has highlighted the gaps in India’s healthcare system that needs to be filled and has prompted calls for reform. The same reforms and learnings can also be used in enhancing the current healthcare infrastructure for NCDs.
Dr Wankhede says, “Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India. The need of the hour is to develop strong healthcare systems. Primary care is the best avenue for delivering NCD care in the most comprehensive way. Public health facilities should be strengthened for providing services of screening.”
Dr Yogesh also says, “The healthcare system has improved dramatically, thus facilities must be sanitary, safe, and cost-effective. Improvements have been made to the infrastructure, but more can be done. There are now a greater number of hospitals with specialisation in services and technology that allow hospitals to treat non-communicable conditions like cancer. The pandemic has highlighted the many ways in which India’s healthcare system falls short and has prompted calls for reform.”
Policy interventions
At the policy level, strategies and programs to combat NCDs are already in place.
Dr Sushrut Pownikar, Head-Quality Assurance Department & Deputy Director, Oncquest Laboratories said, “During the pandemic, India witnessed severe morbidity and high mortality associated with the prior affliction of the NCDs, making it a public health emergency. According to experts, there is an immediate need for a concerted global effort with policy instruments to promote health, detect and control risk factors early and effectively treat diseases in a cost-effective manner to significantly prevent untimely deaths. With increased financial allocations and initiatives to strengthen the health system, the government should make addressing the NCDs a priority, with an enhanced focus on primary healthcare.”
He also shares, “The unprecedented pandemic has created havoc across the globe for over two years, with thousands of people getting infected by the novel virus and many having lost their lives. Governments and the healthcare system in almost all countries aggressively focused on combating the pandemic and normalizing the healthcare crisis. In this disturbing scenario, it should be remembered that the concurrent threat of people being vulnerable to non-communicable diseases still exists and complicates and already troublesome situation. During the pandemic, while the world witnessed millions of people getting affected by COVID-19, a communicable disease, the vulnerability of people to non-communicable diseases (NCDs) also escalated parallelly. The pandemic has also managed to significantly disrupt NCD services, the impact of which has been severe for people already living with that disease.”
“Now, as the turmoil caused by the pandemic has significantly normalised, a renewed focus on prioritising non-communicable diseases and their solutions has become the need of the hour. Though the focus still remains on recovering from the pandemic, the government and healthcare system should also find ways to curb the impact of the NCDs during this period. Multiple factors have impacted the risks and outcomes of non-communicable diseases, and there is an imperative need for an integrated approach from all associated players to tackle the severity of the ailments overshadowed during the pandemic”, he added.
Srinivasa Vivek, Co-Founder, Resolute throws light on the initiatives by the government to control NCDs. He said, “To prevent and control NCDs, NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke) was launched in 2010 with the sole vision of focusing on strengthening the existing infrastructure. NPCDCS looks over human resource development, health promotion, early diagnosis, management, and referral to an appropriate level of the healthcare facility for the treatment of non-communicable diseases. Under this initiative, NCD cells are being established at the district, state, and national levels for program management and to provide facilities for early diagnosis, treatment, and follow-up for common NCDs. There is additionally a provision to provide free diagnostic facilities and drugs for patients attending such clinics. Also, Cardiac Care Units (CCUs) are being established for providing emergency care along with daycare centers for cancer care.”
Sharing his views on the accessibility and availability of policies at the public level, Dr Yogesh said, “Many strategies have been developed to improve the treatment of non-communicable illnesses since everyone should have equal access to excellent health; any disparity should not be accepted. To promote pharmaceutical accessibility, affordability, and acceptance for those in need, policies should bridge the gap between resources and influence. Policies should be inclusive of everyone and accessible to everyone. More resources should be directed into the health sector in general, and chronic diseases in particular, by the federal and state governments.”
Emphasising on the policies and need of the hour specifically for cervical cancer in India, Sumit Bagaria, Managing Director and CEO, Hemogenomics said, “The approach of organising outreach clinics and camps was followed over decades where women voluntarily approach the camp for screening when provided with awareness regarding cervical cancer. It was useful for women who actively participated in the screening programs. It did not, however, translate into active community participation. The apprehension to undergo travel and internal examination during testing led to poor acceptance and participation. The initial screening approach, using VIA and sometimes the Pap test, also led to multiple dropouts at various steps. There is a need to advocate policy support for early screening and its impact. It is imperative to ensure a higher number of women are screened, which will result in the overall reduction of the socio-economic burden owing to the treatment of cervical cancer at a late stage. In the current pandemic era, HPV-assisted self-sampling can be an ideal method for screening, and if co-testing is combined with liquid-based cytology, it can provide the highest sensitivity and increase the chances of detection. Professional organizations like FOGSI, Asia-Oceania Research Organization in Genital Infection and Neoplasia (AOGIN-India), Indian Society of Colposcopy and Cervical Pathology (ISCCP) and Association of Gynaecologic Oncologists of India (AGOI) have contributed to cervical cancer prevention strategies by developing screening guidelines, conducting screening outreach camps and conducting awareness talks across the country, using innovative strategies like the Lifeline Express to reach remote areas and collaborating with corporate and paramedical organisations.”
“In 2020, all member states endorsed the global strategy towards the Elimination of Cervical Cancer at the World Health Assembly – the first elimination strategy for cancer in WHO’s history. India, a signatory, has to have a national program while active participation of the states should be incentivised. Strengthening of cancer registries and improvement of linkages between different healthcare levels with the incorporation of task-shifting, adding digital technology and supporting programs that promote women’s welfare and health will also provide synergy to cancer control programs”, he added.
Way forward
In the aftermath of the pandemic, renewed focus to prevent, detect, control and treat NCDs is the need of the hour. We don’t want another pandemic!
