Policy & Public Health

Policy and Public Health Section Tag

Primary Prevention and the “Polypill”

Samantha Gale, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong

The use of medication in secondary and tertiary prevention is well established, for example, antihypertensives for asymptomatic hypertension to prevent ischaemic heart disease (IHD), and warfarin for ischaemic stroke survivors to prevent further strokes. Similarly, combination medicines containing more than one active ingredient, such as co-amilofruse, co-amoxiclav and co-codamol, which can simplify treatment regimens and improve patient adherence [1] have long been in regular use in both secondary and tertiary prevention.

References: 

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2. Wald NJ, Law MR, A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326:1419. doi:10.1136/bmj.326.7404.1419

3. Mayor S. Polypill will not change prevention of heart disease. BMJ 2004; 329:589.2. doi:10.1136/bmj.329.7466.589-a

4. The Indian Polycap Study. Effects of a polypill (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): a phase II, double-blind, randomised trial. The Lancet 2009; 373(9672):1341-1351 doi:10.1016/S0140-6736(09)60611-5

5. PILL Collaborative Group (2011) An International Randomised Placebo-Controlled Trial of a Four-Component Combination Pill (“Polypill”) in People with Raised Cardiovascular Risk. PLoS ONE 6(5):e19857. doi:10.1371/journal.pone.0019857

6. Wald NJ, Simmonds M, Morris JK. Screening for Future Cardiovascular Disease Using Age Alone Compared with Multiple Risk Factors and Age. PLoS ONE 2011; 6(5): e18742. doi:10.1371/journal.pone.0018742

7. D’Agnostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB. General Cardiovascular Risk Profile for Use in Primary Care. The Framingham Heart Study. Circulation 2008; 117:743-753 doi:10.1161/CIRCULATIONAHA.107.699579

8. National Institute for Health and Clinical Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. 2008. Available online at: http://guidance.nice.org.uk/CG67 (Accessed 31 March 2013)

9. Rose G. Strategy of Preventive Medicine. New York: Oxford University Press 1992

10. Buck D, Frosini F Clustering of unhealthy behaviours over time: Implications for policy and practice. The King’s Fund 2012

11. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th Edition. USA: Oxford University Press 2008

12. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Behav 1988; 15:175-183 doi:10.1177/109019818801500203

13. McCartney M. The press release, relative risks, and the polypill. BMJ 2011;343:d4720. doi:10.1136/bmj.d4720

Story image from Wikimedia Commons

Don't Neglect the Neglected Tropical Diseases

Will Hamilton, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA, UK

Every night and every morn
Some to misery are born,
Every morn and every night
Some are born to sweet delight.
Some are born to sweet delight,
Some are born to endless night.

William Blake, Auguries of Innocence

Introduction

Neglected Tropical Diseases (NTDs) are a group of infectious diseases, mainly caused by parasitic eukaryotes, which disproportionately affect the world’s poorest people (1, 2). At least 1.2 billion people are infected with one or more NTD, mainly living in tropical regions of Africa, South Asia and Latin America (2). The impact of NTDs on global health and development is substantial: they reduce agricultural productivity, impede socioeconomic development, promote societal destabilisation, civil unrest and conflict, have serious adverse effects on childhood education and cognition, and aggravate cycles of poverty. Despite this, many NTDs are easily treated. Efficacious drugs, particularly for helminth infections, are already available that could eliminate much of the global NTD burden at relatively low cost. Large-scale NTD eradication programmes would improve the quality and quantity of life for over a billion people, contributing to socio-political stability and socioeconomic growth. Such efforts must be a major focus for international development and diplomatic relations at the start of the twenty-first century, and will rely on international collaborations between the public and private sectors. This review examines four key areas of global NTD medicine: causal organisms, epidemiology, public health impact and intervention strategies.

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A Vaccine against Tuberculosis Infections

Sara Steeves, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Introduction

Tuberculosis (TB) results from infection by the bacterium, Mycobacterium tuberculosis. According to the WHO in 2009 around 1.7 million people are thought to have died from TB, with the majority of these deaths occurring in Africa (1). TB is a particular problem in this area due to the high incidence of HIV infection, which acts to suppress the immune system, allowing M. tuberculosis to overcome the body’s defences. In 2008 the number of new cases of TB was still rising each year in regions of Africa, the Eastern Mediterranean and South East Asia (1). With TB being responsible for such a large number of deaths the demand for an effective vaccine against it is great. This article aims to investigate the implications that a novel vaccine against TB might have for reducing the number of deaths caused by M. tuberculosis.

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An eradicating vaccine for Plasmodium falciparum: Possibility or Pipe-dream?

Balazs Fazekas, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

“Every 45 seconds, a child dies of Malaria in Africa”
World Health Organisation - 2010

Balazs Fazekas discusses the challenges facing the development of a malaria vaccine, and the progress so far.

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Eradicating God's Fiery Serpents

Will Hamilton, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Will Hamilton discusses the features of Guinea Worm Disease, and the progress which is being made in its eradication.

References: 

1. God’s Fiery Serpents. The Skeptic’s Annotated Bible, Numbers 21:4-9. http://www.skepticsannotatedbible.com/topics/guinea_worms.html (accessed 22/2/11)

2. Guinea Worm Facts, Carter Center website: http://www.cartercenter.org/health/guinea_worm/mini_site/facts.html (accessed 22/2/11)

3. World moves closer to eradicating ancient worm disease. Tiffany Domingo, WHO Media Centre, 27th March 2007. http://www.who.int/mediacentre/news/notes/2007/np15/en/index.html (accessed 22/2/11)

4. Center for Disease Control (CDC) Dracunculiasis fact page:
http://www.dpd.cdc.gov/dpdx/HTML/Dracunculiasis.htm (accessed 22/2/11)

5. Inspired by Charles Darwin’s famous line, “What a book a devil’s chaplain might write on the clumsy, wasteful, blundering low and horridly cruel works of nature!” From a letter to Hooker in 1856.

6. Guinea Worm Countdown: The Road to Eradication, The Carter Center http://www.cartercenter.org/health/guinea_worm/mini_site/current.html (accessed 22/2/11)

7. Barry, M. 2007. The tail end of guinea worm - global eradication without a drug or a vaccine. N. Engl. J. Med. 356(25); 2561-4. DOI: 10.1056/NEJMp078089

8. South Sudan Gets New Government. Jonah Fisher, BBC News 23rd October 2005. http://news.bbc.co.uk/1/hi/world/africa/4370100.stm (accessed 22/2/11)

9. Guinea Worm Cases Hit All-Time Low: Carter Center, WHO, Gates Foundation, and U.K. Government Commit $55 Million Toward Ultimate Eradication Goal. Emily Staub, The Carter Center. December 5th 2008. http://www.cartercenter.org/news/pr/gates_120508.html (accessed 22/2/11)

The future of HIV depends on our ability to change the risk calculus for individuals and communities in hyper-endemic countries

David Harrison, MBChB, MSc(Med), MPP

David Harrison, Chief Executive Officer of the DG Murray Trust, discusses the differences between sexual behaviours in hyper-endemic countries and the rest of the world in relation to HIV transmission

Table 1

Country Estimated HIV prevalence (total) HIV prevalence 15-49 years (%) Estimated number of people living with HIV
Botswana 15.1% 23.9 300,000
Lesotho 9.9% 23.2 200,000
Mozambique 6.9% 12.5 1,500,000
Namibia 9.5% 15.3 200,000
South Africa 11.7% 18.1 5,700,000
Swaziland 16.3% 26.1 190,000
Zambia 8.7% 15.2 1,100,000
Zimbabwe 10.3% 15.3 1,300,000
Total 10.2% 10,490,000
References: 

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2. Kagaayi J, Gray R, Ssetaba A, Nabukenya D, Makumbi F, Kiwanuka N et al. Individual self-perception of HIV risk is associated with HIV acquisition. Poster presented at Conference of the International AIDS Society, July 2009; Cape Town.

3. Shisana, O, Rehle, T, Simbayi, L et al. Third South African national HIV, behaviour and health survey 2008: Outcome Indicators for assessing mid-term progress on the NSP 2007-2011. Report 1: A turning tide among teenagers? Cape Town: HSRC Press. 2009

4. Young South Africans, Broadcast Media and HIV Awareness: Results of a national survey. Kaiser Family Foundation and South African Broadcast Corporation. Johannesburg. March 2007

5. World Health Report 2002: Reducing risks, promoting health life. Geneva. World Health Organisation. 2002

6. Wellings K, Collumbien M, Skymaker E, Singh S, Hodges Z, Patel D, Bajos N. Sexual behaviour in context: a global perspective. The Lancet. 2006. 368: 1706 – 1720. Doi:10.1016/S0140-6736(06)69479-8

7. Gupta G, Parkhurst J, Ogden J, Aggleton P, Mahal A (2008). Structural approaches to HIV prevention. Lancet, 372 (9640):764 – 775. Doi:10.1016/S0140-6736(08)60887-9

8. Blas E, Gilson L, Kelly M, Labonté R, Lapitan J et al. Addressing social determinants of health inequities: what can the state and civil society do? The Lancet. 2008; 372:1684-89. Doi:10.1016/S0140-6736(08)61693-1

9. Boerma J, Weir S. Integrating demographic and epidemiological approaches to research on HIV/AIDS: The proximate-determinants framework. Journal of Infectious Diseases 2005; 191(Suppl 1): S61-67. Doi:10.1086/425282

10. Piot P, Russell S, Larson H. Good politics, bad politics: The experience of AIDS. American Journal of Public Health.2007b; 97 (11): 1934-1936. Doi: 10.2105/AJPH.2007.121418

11. Grebe, E (Centre for Social Science Research, AIDs and Society Research Unit). Networks of influence: A theoretical review and proposed approach to AIDS treatment activism. Cape Town. aids2031 Leadership Working Group. 2008. CSSR working paper 3.

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13. Halperin D, Epstein H. Concurrent sexual partnerships help to explain Africa’s high prevalence: Implications for prevention. Lancet. 2004; 364(9428):4-6. 16606-3 Doi: 10.1016/S0140-6736(04)16606-3

14. Lurie M, Rosenthal S. Concurrent partnerships as a driver of the HIV epidemic in sub-Saharan Africa? The evidence is limited. AIDS Behaviour (EPub ahead of print). 2009 Doi: 10.1007/s10461-009-9583-5

15. Halperin D, Epstein H. Letter of response to Wellings et al. Lancet. 2007; 369:557.

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17. Hendriksen E, Pettifor A, Sung-Jae Lee, Coates T, Rees H. Predictors of condom use among young adults in South Africa: the Reproductive Health and HIV Research Unit National Youth Survey. American Journal of Public Health. 2007; 97(7): 1241-1248. Doi: 10.2105/AJPH.2006.086009

18. Kenyon C, Badri M. The role of concurrent sexual relationships in the spread of sexually transmitted infections in young South Africans. Southern African Journal of HIV Medicine. 2009; 33: 29-34

19. Jacobson C, Amoateng A, Heaton T. Inter-Racial Marriages in South Africa. Journal of Comparative Family Studies. 2004; 35: 443-458

20. Zungu-Dirwayi N, Shisana S, Udjo E, Mosala T, Seager J. An audit of HIV/AIDS policies in Botswana, Lesotho, Mozambique, Swaziland and Zimbabwe. Research Report. Pretoria: Human Sciences Research Council. 2005

21. Pettifor A, Rees H, Kleinschmidt I, Steffenson A, MacPhail C, Hlongwa-Madikizela L, Vermaak, Padian N. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviours from a nationally representative household survey. AIDS. 2005, 19:1525-1534

22. Pisani E, Garnett G, Brown T, Stover J, Grassly N, Hankins C, Walker N, Ghys D. Back to basics in HIV prevention: Focus on exposure. British Medical Journal. 2003; 326:1384-1387. Doi:10.1136/bmj.326.7403.1384

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25. Slovic P, Weber E. Perception of risk posed by extreme events. Paper prepared for: Conference on Risk Management Strategies in an Uncertain World, April 12-13, 2002; New York, USA.

26. Weber E, Milliman R. Perceived Risk Attitudes: Relating Risk Perception to Risky Choice. Management Science, 1997; 43: 123-144. Doi: 10.1287/mnsc.43.2.123

27. Loewenstein G, Hsee C, Weber E, Welch N. Risk as feelings. Psychological Bulletin, 2001; 127(2): 267-286. Doi: 10.1037/0033-2909.127.2.267

28. LeClerc-Madlala S. Intergenerational/ age-disparate sex and young women’s vulnerability in Southern Africa. Presentation prepared for: UNAIDS Technical Meeting on young women in HIV hyper-endemic countries of southern Africa, at ICASA 2008. 18-19 June 2008; Muldersdrift, South Africa

29. Oster E. HIV and sexual behaviour: Why not Africa? University of Chicago and National Bureau of Economic Research Working paper. February 2009

30. Becker G. A Theory of Marriage. In: Schultz T (ed.). Economics of the family: Marriage, Children and Human Capital. Chicago: University of Chicago Press. 1974. p. 299-344.

31. Graham C, Hoover M (University of Maryland). Optimism and poverty in Africa: Adaption or a means to survival? South Africa. Afrobarometer Working Papers. November 2007 Working Paper no. 76

32. Lowenstein G, Prelec D. Anomalies in Intertemporal Choice: Evidence and an Interpretation, The Quarterly Journal of Economics. 1992; vol. 107(2), 573-597.

33. Douglas, M, and Wildavsky A. Risk and Culture: an Essay on the Selection of Technical and Environmental Dangers. Berkeley and Los Angeles: University of California Press. 1983

34. Bajos N, Marquet J. Research on HIV Sexual Risk: Social relations-based approach in a cross-cultural perspective. Social Science and Medicine. 2000; 50(11):1533-1546. Doi:10.1016/S0277-9536(99)00463-3

35. Pettifor A, Measham D, Rees H, Padian N. Sexual Power and HIV risk, South Africa. Emerging Infectious Diseases. 2004; 10: 1996 - 2004

36. Persson A, Sjöstedt M. Government structures and behaviour change in the Politics of HIV/AIDS. The Quality of Government Institute, Department of Political Sciences, Göteborg University. 2008. QoG Working Paper Series 2008:10

37. Krishna A. Active Social Capital: Tracing the Roots of Development and Democracy. Columbia University Press. New York. 2002.

38. Seedat M, van Niekerk A, Jewkes R, Suffla S, Ratele K. Violence and injuries in South Africa: Prioritizing an agenda for prevention. The Lancet. 2009 374: 1011- 1022. Doi:10.1016/S0140-6736(09)60948-X 

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The White Paper Reforms – The end of the NHS?

Steve Baker, Imperial College School of Medicine, South Kensington Campus, London, SW7 2AZ

The coalition government’s white paper 'Equity and Excellence: Liberating the NHS' [1] is the first step along the road in their vision to majorly reform the NHS; harked by many as the biggest overhaul in NHS structure since its conception in 1948. Its strongest critics say that it is flawed, under tested and will lead to the destruction of the NHS [2]. But are their concerns unfounded?

References: 

1. Department of Health. Equity and Excellence: Liberating the NHS [Internet]. 2010. [cited 2011 Feb 13]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/...

2. Department of Health. Liberating the NHS: legislative framework and next steps [Internet]. 2010. [cited 2011 Feb 13]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/...

3. NHS choices. About the NHS – Authorities and trusts [Internet]. [cited 2011 Feb 13]. Available from: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/authoritiesandtrusts.aspx [Accessed 10th November 2010]

4. Department of Health. Healthy lives, healthy people: Our strategy for public health in England [Internet]. 2010. [cited 2011 Feb 13]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/...

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