Noncommunicable Diseases Global Monitoring Framework: Indicator s and Specifications
Introduction Global monitoring framework Global targets for NCDs Setting national targets Reporting on the global NCD indicators Table of contents Indicators by Categorization Mortality and morbidity: 1. Premature NCD Mortality 2. Cancer incidence Behavioural Risk Factors: 3. Harmful use of alcohol: Adult Per Capita Consumption 4. Harmful use of alcohol: heavy episodic drinking 5. Harmful use of alcohol: alcohol-related morbidity and mortality 6. Physical inactivity in adolescents 7. Physical inactivity in adults 8. Salt intake 9. Tobacco use in adolescents 10. Tobacco use in adults Biological Risk Factors: 11. a) Blood pressure: raised blood pressure 11.b) Blood pressure: mean blood pressure 12. Raised blood glucose/diabetes 13. Overweight and obesity in adolescents 14. Overweight and obesity in adults 15. Saturated fat 16. Low fruit and vegetable consumption 17. a) Total Cholesterol: raised 17.b) Total Cholesterol: mean National Systems Response: 18. Drug therapy and counselling to prevent heart attacks and stroke 19. Essential medicines and technologies for NCD 20. Palliative care 21. Elimination of trans-fats 22. Vaccination for HPV 23. Marketing to children 24. Vaccination for Hepatitis B 25. Cervical cancer screening Frequently asked questions 1 P a g e
Introduction: In May 2013 the 66 th World Health Assembly adopted the comprehensive global monitoring framework (GMF) for the prevention and control of noncommunicable diseases. The Global Monitoring Framework included a set of indicators capable of application across regions and country settings to monitor trends and assess progress made in the implementation of national strategies and plans on noncommunicable diseases. The purpose of this document is to provide detailed guidance to Member States so they can correctly measure each of the 25 indicators and monitor their progress over time. For each indicator, a complete definition is provided, appropriate data sources are identified and a detailed calculation, where applicable, is provided. Global Monitoring Framework: Member States have agreed 25 indicators across three areas which focus on the key outcomes, risk factors and national systems response needed to prevent and control NCDs. (see figure 1). Figure 1. Global Monitoring Framework Framework Element OUTCOMES Premature mortality from noncommunicable disease Additional indicator Target 1. A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases Indicator 1. Unconditional probability of dying between ages of 30 and 70 from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases 2. Cancer incidence, by type of cancer, per 100 000 population BEHAVIOURAL RISK FACTORS Harmful use of alcohol Physical inactivity Salt/sodium intake 2. At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context 3. A 10% relative reduction in prevalence of insufficient physical activity 4. A 30% relative reduction in mean population intake of salt/sodium 3. Total (recorded and unrecorded) alcohol per capita (aged 15+ years old) consumption within a calendar year in litres of pure alcohol, as appropriate, within the national context 4. Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context 5. Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context 6. Prevalence of insufficiently physically active adolescents, defined as less than 60 minutes of moderate to vigorous intensity activity daily 7. Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent) 8. Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years 2 P a g e
Tobacco use 5. A 30% relative reduction in prevalence of current tobacco use 9. Prevalence of current tobacco use among adolescents 10. Age-standardized prevalence of current tobacco use among persons aged 18+ years BIOLOGICAL RISK FACTORS Raised blood pressure 6. A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances 11. Age-standardized prevalence of raised blood pressure among persons aged 18+ years (defined as systolic blood pressure 140 mmhg and/or diastolic blood pressure 90 mmhg) and mean systolic blood pressure Diabetes and obesity 7. Halt the rise in diabetes & obesity 12. Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose concentration 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) 13. Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for schoolaged children and adolescents, overweight one standard deviation body mass index for age and sex, and obese two standard deviations body mass index for age and sex) 14. Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index 25 kg/m² for overweight and body mass index 30 kg/m² for obesity) Additional indicators 15. Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years 16. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day 17. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol 5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration NATIONAL SYSTEMS RESPONSE Drug therapy to prevent heart attacks and strokes Essential noncommunicable disease medicines and basic technologies to treat major noncommunicable diseases Additional indicators 8. At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes 9. An 80% availability of the affordable basic technologies and essential medicines, including generics required to treat major noncommunicable diseases in both public and private facilities 18. Proportion of eligible persons (defined as aged 40 years and older with a 10-year cardiovascular risk 30%, including those with existing cardiovascular disease) receiving drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes 19. Availability and affordability of quality, safe and efficacious essential noncommunicable disease medicines, including generics, and basic technologies in both public and private facilities 20. Access to palliative care assessed by morphine-equivalent 21. Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes 22. Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies 23. Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt 24. Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants 25. Proportion of women between the ages of 30 49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies 3 P a g e
Global Targets for NCDs: Nine areas have been selected from the 25 indicators in the Global Monitoring Framework to be targets (see figure 2): one mortality target (previously agreed at the WHA in May 2012); six risk factor targets (harmful use of alcohol, physical inactivity, dietary sodium intake, tobacco use, raised blood pressure, and diabetes and obesity), and two national systems targets (drug therapy to prevent heart attacks and strokes, and essential NCD medicines and technologies to treat major NCDs). The targets are both attainable and significant, and when achieved will represent major accomplishments in NCD and risk factors reductions. The global NCD targets are intended to focus global attention on NCDs and would represent a major contribution to NCD prevention and control. Targets have been set for 2025, with a baseline of 2010. Figure 2. Global voluntary targets for NCDs A 25% relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases At least 10% relative reduction in the harmful use of alcohol A 10% relative reduction in prevalence of insufficient physical activity A 30% relative reduction in mean population intake of salt/sodium A 30% relative reduction in prevalence of current tobacco use A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances Halt the rise in diabetes and obesity At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities 4 P a g e
Setting National Targets: Member States are strongly encouraged to consider the development of national targets based on their own national situations, which build on the nine global voluntary targets. Setting targets is a way to draw attention to NCDs and help mobilize resources to address NCD priorities. National targets may need to be adapted from the global targets if a country has already achieved a target or if the global target is too low given the progress already achieved within the country. As a starting point, Member States interested in setting national NCD targets are encouraged to consider the following: Are the targets and indicators included in the GMF all suitable in the national context? Are there additional targets and indicators needed for the country? Are the systems in place to track these 25 global indicators and report on nine global targets? And systems which track any new proposed ones? What is the current level of exposure/mortality/service provision? Are the reductions or coverage proposed for global targets appropriate in the national context or should they be more ambitious? Reporting on the Global NCD Indicators: WHO is mandated to prepare regular updates on the progress towards achieving the nine global NCD targets and the status globally in relation to the 25 indicators included in the Global Monitoring Framework. To enable these reports to be as comprehensive as possible, Member States are strongly encouraged to submit data to WHO on a regular basis to enable analysis of the global status of NCD targets and indicators. For ease of data submission, WHO has prepared a template for reporting against the NCD indicators. This template is available upon request from WHO by contacting: ncdmonitoring@who.int. Where multiple indicators exist for one target (i.e. for alcohol), Member States should endeavor to report against as many indicators as possible. However they should also choose to report against the one most appropriate for their national circumstances. It is important to note that WHO will continue to produce figures for each country that are comparable across all Member States. While these comparable figures will be based on the data submitted by Member States, they will also take into consideration differences across countries in data availability, data type, population structure and other data characteristics that reduce comparability across countries. Thus, the figures produced by WHO may differ from those reported by each individual Member State. 5 P a g e
Premature NCD Mortality Unconditional probability of dying between ages 30 and 70 years from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases Probability of dying between the exact ages 30 and 70 years from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases. Deaths from these four causes will be based on the following ICD codes: I00-I99, C00-C97, E10-E14, and J30-J98. Age-specific death rates for the combined four cause categories (typically in terms of 5- year age groups 30-34,, 65-69). A life table method allows calculation of the risk of death between exact ages 30 and 70 from any of these causes, in the absence of other causes of death. The ICD codes to be included in the calculation are: cardiovascular disease: I00-I99, Cancer: C00-C97, Diabetes: E10-E14, Chronic respiratory: J30-J98. To calculate age-specific mortality rate for each five-year age group and country, for each 5-year age range between 30 and 70: 5 Total deaths from four NCD causes between exact age x and exact age x + 5 Mx = Total population between exact age x and exact age x + 5 Then translate the 5-year death rate to the probability of death in each 5-year age range: 5 qx = 5 M x 5 1 + 5 Mx 2.5 The probability of death from age 30 to age 70, independent of other causes of death can be calculated as: 65 40 q30 = 1 (1 5 q x ) x=30 Other possible data sources Expected frequency of data collection Vital registration systems which record deaths with sufficient completeness to allow estimation of all-cause death rates. Sample registration systems; verbal autopsy. Outcome Sex, other relevant socio-demographic stratifiers where available Annual - incomplete or unusable death registration data Probability 6 P a g e
http://www.who.int/gho/mortality_burden_disease/en/ http://www.who.int/healthinfo/statistics/lt_method.pdf 7 P a g e
Cancer incidence Cancer incidence, by type of cancer Number of new cancers of a specific site/type occurring in the population per year, usually expressed as the number of new cancers per 100,000 population. Numerator Other possible data sources Expected frequency of data collection Number of new cancer cases diagnosed in a specific year At-risk population for that category 100,000 Number of new cancer cases diagnosed in a specific year. This may include multiple primary cancers occurring in one patient. The primary site reported is the site of origin and not the metastatic site. In general, the incidence rate would not include recurrences. At-risk population for the given category of cancer. The population used depends on the rate to be calculated. For cancer sites that occur in only one sex, the sex-specific population (e.g., females for cervical cancer) is used. Population-based cancer registries, which collect and classify information on all new cases of cancer in a defined population Outcome Age, Sex, other relevant socio-demographic stratifiers where available Annual - incomplete records - inadequate coverage of registries Rate http://globocan.iarc.fr/ http://www.iacr.com.fr/canreg5.htm 8 P a g e
Harmful use of alcohol: Adult Per Capita Consumption Total (recorded and unrecorded) alcohol per capita (APC) (15+ years old) consumption within a calendar year in litres of pure alcohol Consumption of pure alcohol (ethanol) in litres per person aged 15+ during one calendar year. Numerator Other possible data sources Expected frequency of data collection Sum of recorded and unrecorded alcohol consumed in a population during a calendar year Midyear resident population aged 15 + for the same calendar year Sum of recorded and unrecorded alcohol consumed in a population during a calendar year, in litres. Midyear resident population aged 15+ for the same calendar year. Administrative reporting systems for recorded APC and survey data for unrecorded APC. The priority of data sources for recorded alcohol per capita consumption should be given to government statistics on sales of alcoholic beverages during a calendar year or data on production, export and import of alcohol in different beverage categories. For countries, where the governmental sales or production data is not available, the preferred data source would be country specific and publicly available data from the private sector, including alcohol producers or country specific data from the Food and Agriculture Organization of the United Nations statistical database (FAOSTAT), which may also include the estimates of unrecorded alcohol consumption. For main categories of alcohol beverages Beer includes malt beers, Wine includes wine made from grapes, Spirits include all distilled beverages, and Other includes one or several other alcoholic beverages, such as fermented beverages made from sorghum, maize, millet, rice, or cider, fruit wine, fortified wine, etc. Data sources for unrecorded alcohol consumption include survey data, FAOSTAT data, other data sources such as customs or police data, and expert opinions. Data sets of FAO and UN Statistical office Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available Annual - incomplete administrative records - bias through self-report, including under-reporting of alcohol consumption - misunderstanding/ -interpretation of questions and/ or size of a standard drink - limited validity of survey instruments Volume http://apps.who.int/gho/data/view.main?showonly=gisah 9 P a g e
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Harmful use of alcohol: heavy episodic drinking Age-standardized prevalence of heavy episodic drinking Heavy episodic drinking among adults is defined as those who report drinking 6 (60 grams) or more standard drinks in a single drinking occasion Number of survey respondents reporting consuming 60 grams or more of pure alcohol on at least one occasion monthly Number of survey respondents x 100% Numerator Other possible data sources Expected frequency of data collection Number of persons reporting consuming 60 grams or more of pure alcohol on at least one occasion monthly All respondents of the survey Population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including under-reporting of alcohol consumption - misunderstanding/ -interpretation of questions and/ or size of a standard drink - limited validity of survey instruments Prevalence http://apps.who.int/gho/data/view.main?showonly=gisah 11 P a g e
Harmful use of alcohol: alcohol-related morbidity and mortality Alcohol-related morbidity and mortality among adolescents and adults (monitored by alcohol use disorders). Adults (15+ years) who suffer from disorders attributable to the consumption of alcohol (according to ICD-10: F10.1 Harmful use of alcohol; F10.2 Alcohol dependence) during a given calendar year. Numerator Other possible data sources Expected frequency of data collection Number of survey respondents (15+ years)with a diagnosis of F10.1 or F10.2 during a calendar year x100% Number of survey respondents aged 15+years Number of adults (15+ years) with a diagnosis of F10. or F10.2 during a calendar year. Using the algorithms specified in the validated instruments, presence or absence of harmful use of alcohol or alcohol dependence can be determined. AUD will be scored if either disease category is present. All respondents of the survey aged 15+ years. Population-based (preferably nationally representative) survey using validated instruments Additional health services reporting systems may provide complementary or confirmatory information regarding to the frequency and severity of alcohol use Disorders. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years -bias through self-report, including under-reporting - misunderstanding/ -interpretation of questions - limited validity of survey instruments Prevalence http://apps.who.int/gho/data/view.main?showonly=gisah 12 P a g e
Physical inactivity in adolescents Prevalence of insufficiently physically active adolescents Percentage of adolescents participating in less than 60 minutes of moderate to vigorous intensity physical activity daily. Adolescents are defined as 10 19 year olds or according to country definition. Number of adolescent respondents for whom the number of days per week with < 60 minutes of moderate to vigorous intensity activity is < 7 days Number of adolescent survey respondents x 100% Numerator Number of respondents for whom the number of days per week with <60 minutes of moderate to vigorous intensity activity is <7 days Other possible data sources Expected frequency of data collection All adolescent respondents of the survey School-based or population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including over-reporting of activity - misunderstanding/ -interpretation of questions and/ or intensity of physical activity - limited validity of survey instruments Prevalence http://who.int/chp/gshs/en/ http://www.who.int/dietphysicalactivity/publications/9789241599979/en/index.html 13 P a g e
Physical inactivity in adults Age-standardized prevalence of insufficiently physically active persons aged 18+ years Percentage of adults aged 18+ years not meeting any of the following criteria: 150 minutes of moderate-intensity physical activity per week 75 minutes of vigorous-intensity physical activity per week an equivalent combination of moderate- and vigorous-intensity physical activity accumulating at least 600 MET-minutes* per week Minutes of physical activity can be accumulated over the course of a week but must be of a duration of at least 10 minutes. *MET refers to metabolic equivalent. It is the ratio of a person's working metabolic rate relative to the resting metabolic rate. One MET is defined as the energy cost of sitting quietly, and is equivalent to a caloric consumption of 1 kcal/kg/hour. Physical activities are frequently classified by their intensity, using the MET as a reference. Numerator Number of respondents aged 18 + years not meeting the aforementioned criteria for physical activity Number of survey respondents aged 18 + years Number of respondents where all 3 of the following criteria are true: (1) Weekly minutes* of vigorous activity < 75 mins. (2) Weekly minutes* of moderate activity < 150 mins. (3) Weekly MET-minutes** < 600. x 100% Other possible data sources Expected frequency of data collection * Weekly minutes is calculated by multiplying the number of days on which vigorous/moderate is done by the number of minutes of vigorous/moderate activity per day. ** Weekly MET-minutes is calculated by multiplying the weekly minutes of vigorous activity by 8 and the number of weekly minutes of moderate activity by 4 and then adding these two results together. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including over-reporting of activity - misunderstanding/ -interpretation of questions and/ or intensity of physical activity - limited validity of survey instruments 14 P a g e
Prevalence http://www.who.int/chp/steps/gpaq/en/ http://www.who.int/chp/steps/en/index.html http://www.who.int/dietphysicalactivity/publications/9789241599979/en/index.html 15 P a g e
Salt intake Age-standardized mean population intake of salt (sodium chloride) per day in grams in persons aged 18+ years Mean population intake of salt in grams Numerator Other possible data sources Expected frequency of data collection Sum of sodium excretion in urine samples from all respondents aged 18 + years Number of survey respondents aged 18 + years Sum of sodium excretion in urine samples from all respondents aged 18+years. The goldstandard for estimating salt intake is through 24-hour urine collection, however other methods such as spot urines and food frequency surveys may be more feasible to administer at the population level. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error Mean http://www.who.int/chp/steps/en/index.html http://whqlibdoc.who.int/publications/2011/9789241501699_eng.pdf 16 P a g e
Tobacco use in adolescents Prevalence of current tobacco use among adolescents Percentage of adolescents who currently use any tobacco product (smoked or smokeless). Smoked tobacco products includes the consumption of cigarettes, bidis, cigars, cheroots, pipes, shisha (water pipes), fine-cut smoking articles (roll-your-own), krekets, and any other form of smoked tobacco. "Smokeless tobacco" includes moist snuff, plug, creamy snuff, dissolvables, dry snuff, gul, loose leaf, red tooth powder, snus, chimo, gutkha, khaini, gudakhu, zarda, quiwam, dohra, tuibur, nasway, naas/naswar, shammah, betel quid, toombak, pan (betel quid), iq mik, mishri, tapkeer, tombol and any other tobacco product that is sniffed, held in the mouth, or chewed. Numerator Adolescents are defined as 10 19 year olds or according to country definition. Number of adolescent respondents who are current tobacco users (daily or less than daily) x 100% Number of adolescent survey respondents Number of current adolescent tobacco users. Current users includes both daily and non-daily users of smoked or smokeless tobacco. All adolescent respondents of the survey. School-based or population-based (preferably nationally representative) survey Other possible data sources Expected frequency of data collection Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including under-reporting of tobacco use - misunderstanding/ -interpretation of questions - limited validity of survey instruments Prevalence http://www.who.int/tobacco/surveillance/gyts/en/ http://who.int/chp/gshs/en/ 17 P a g e
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Indicator name Tobacco use in adults Age-standardized prevalence of current tobacco use among persons aged 18+ years Age-standardized prevalence of current tobacco use among persons aged 18+ years Smoked tobacco products includes the consumption of cigarettes, bidis, cigars, cheroots, pipes, shisha (water pipes), fine-cut smoking articles (roll-your-own), krekets, and any other form of smoked tobacco. "Smokeless tobacco" includes moist snuff, plug, creamy snuff, dissolvables, dry snuff, gul, loose leaf, red tooth powder, snus, chimo, gutkha, khaini, gudakhu, zarda, quiwam, dohra, tuibur, nasway, naas/naswar, shammah, betel quid, toombak, pan (betel quid), iq mik, mishri, tapkeer, tombol and any other tobacco product that is sniffed, held in the mouth, or chewed. Number of respondents aged 18 + years currently using any tobacco product (smoked or smokeless) Number of survey respondents aged 18 + years x 100% Numerator Other possible data sources Expected frequency of data collection Number of current tobacco users aged 18+ years. Current users includes both daily and non-daily users or smoked or smokeless tobacco. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including under-reporting of tobacco use - misunderstanding/ -interpretation of questions - limited validity of survey instruments - representativeness of the sample Prevalence http://www.who.int/tobacco/surveillance/survey/gats/en/ http://www.who.int/chp/steps/en/index.html 19 P a g e
Raised blood pressure Age-standardized prevalence of raised blood pressure among persons aged 18+ years Systolic blood pressure 140 and/or diastolic blood pressure 90 among persons aged 18+ years. Number of respondents aged 18 + years with systolic blood pressure 140mmHg or diastolic blood pressure 90mmHg Number of survey respondents aged 18 + years x 100% Numerator Other possible data sources Expected frequency of data collection Number of respondents with systolic blood pressure 140mmHg or diastolic blood pressure 90mmHg. Ideally three blood pressure measurements should be taken and the average systolic and diastolic readings of the second and third measures should be used in this calculation. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey in which blood pressure was measured, not self-reported. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error - representativeness of the sample Prevalence http://www.who.int/chp/steps/en/ 20 P a g e
Mean blood pressure Age-standardized mean systolic blood pressure in persons aged 18+ years Mean systolic blood pressure in persons aged 18+ years Numerator Other possible data sources Expected frequency of data collection Sum of systolic blood pressure from all respondents aged 18 + years Number of survey respondents aged 18 + years Sum of systolic blood pressure from all participants aged 18+ years. Ideally three blood pressure measurements should be taken and the average systolic reading of the second and third measures should be used in this calculation. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey in which blood pressure was measured, not self-reported. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error - representativeness of the sample Mean http://www.who.int/chp/steps/en/ 21 P a g e
Raised blood glucose/diabetes Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years or on medication for raised blood glucose Fasting plasma glucose value 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose among adults aged 18+ years. Number of respondents aged 18 + years with fasting plasma glucose value 7.0 mmol/l(126 mg/dl)or on medication for raised blood glucose x 100% Number of survey respondents aged 18 + years Numerator Other possible data sources Expected frequency of data collection Number of respondents aged 18+ years with fasting plasma glucose value 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose. Fasting blood glucose must be measured, not self-reported, and measurements must be taken after the person has fasted for at least eight hours. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey. There are two main blood chemistry screening methods- dry and wet chemistry. Dry chemistry uses capillary blood taken from a finger and used in a rapid diagnostic test. Wet chemistry uses a venous blood sample with a laboratory based test. Either method is acceptable. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error - lack of fasting status - limited validity of measurement instruments - representativeness of the sample Prevalence http://www.who.int/chp/steps/en/ 22 P a g e
Overweight and obesity in adolescents Prevalence of overweight and obesity in adolescents According to the WHO growth reference for school-aged children and adolescents, overweight one standard deviation body mass index for age and sex, and obese two standard deviations body mass index for age and sex. Adolescents are defined as 10 19 year olds or according to country definition. Number of adolescent respondents who are overweight Number of adolescent survey respondents x 100% Number of adolescent respondents who are obese Number of adolescent survey respondents x 100% Numerator Other possible data sources Expected frequency of data collection Number of adolescent respondents who are overweight. Number of adolescent respondents who are obese. Body mass index (BMI) is calculated by dividing weight in kilograms by height in meters squared. Overweight is 1SD BMI for age and sex (equivalent to BMI 25kg/m² at 19 years). Obese is 2SD BMI for age and sex (equivalent to BMI 30kg/m² at 19 years). All adolescent respondents of the survey. School-based or population-based (preferably nationally representative) survey in which height and weight were measured. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error - representativeness of the sample Prevalence http://who.int/chp/gshs/en/ 23 P a g e
Overweight and obesity in adults Age-standardized prevalence of overweight and obesity in persons aged 18+ years Body mass index 25 kg/m² for overweight and body mass index 30 kg/m² for obesity in adults aged 18+ years. Number of survey respondents aged 18 + years who are overweight Number of survey respondents aged 18 + years x 100% Number of survey respondents aged 18 + years who are obese Number of survey respondents aged 18 + years x 100% Numerator Other possible data sources Expected frequency of data collection Number of respondents aged 18+ years who are overweight. Number of respondents aged 18+ years who are obese. Body mass index (BMI) is calculated by dividing weight in kilograms by height in meters squared. Overweight is defined as having a BMI 25 kg/m² and obesity is defined as having a BMI 30 kg/m². All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey in which height and weight were measured. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error - representativeness of the sample Prevalence http://www.who.int/chp/steps/en/ 24 P a g e
Saturated fat Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years Mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years estimation/calculatio n X100%Numerator Preferred data sources Other possible data sources Expected frequency of data collection Sum of proportion of SFA of total energy intake from all participants aged 18 + years Number of survey respondents aged 18 + years Sum of proportion of SFA of total energy intake from all participants aged 18+years. For each participant, divide the saturated fatty acid intake by the total energy intake to get the proportion of total energy from SFA. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey FAO National Food Balance Sheets Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report, including under-reporting of consumption - misunderstanding/ -interpretation of questions - limited validity of survey instruments Prevalence x100% 25 P a g e
Unit of measure Low fruit and vegetable consumption Age-standardized prevalence of persons aged 18+ years consuming less than five total servings (400 grams) of fruit and vegetables per day Percentage of population aged 18+ years who eat less than five servings of fruit and/or vegetables on average per day A serving of fruit and vegetables is equivalent to 80 grams measurement Self-report Number of respondents aged 18 + years eating less than 5 servings of fruit and/or vegetables per day Number of survey respondents aged 18 + years x 100% Numerator Number of respondents aged 18+ years eating less than 5 servings of fruit and/or vegetables per day. The average number of servings of fruit and/or vegetables is calculated for each participant as follows: 1) Calculate the average number of vegetable servings per week: total number of vegetable servings per day multiplied by number of days per week vegetables are eaten divided by 7. 2) Calculate the average number of fruit servings per week: total number of fruit servings per day multiplied by number of days per week fruit are eaten divided by 7. 3) Sum the average number of vegetable and fruit servings per week. If this total is less than 5, then the participant is counted in the numerator of the equation as eating less than 5 servings of fruit and/or vegetables per day. A serving of fruit or vegetables is equivalent to 80 grams. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey Other possible data sources Expected frequency of data collection Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - bias through self-report Prevalence http://who.int/chp/steps/en/ 26 P a g e
Raised total cholesterol Age-standardized prevalence of raised total cholesterol among persons aged 18+ years Total cholesterol 5.0 mmol/l (190 mg/dl). Number of respondents aged 18 + years with total cholesterol value 5.0 mmol/l (190 mg/dl) Number of survey respondents aged 18 + years x 100% Numerator Number of respondents aged 18+ years with total cholesterol value 5.0 mmol/l (190 mg/dl). Other possible data sources Expected frequency of data collection All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey in which cholesterol was measured, not self-reported. There are two main blood chemistry screening methodsdry and wet chemistry. Dry chemistry uses capillary blood taken from a finger and used in a rapid diagnostic test. Wet chemistry uses a venous blood sample with a laboratory based test. Either method is acceptable. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error due to insufficient blood sample - limited validity of measurement instruments representativeness of the sample Prevalence http://www.who.int/chp/steps/en/ 27 P a g e
Mean total cholesterol Age-standardized mean total cholesterol among persons aged 18+ years Mean total cholesterol. Numerator Other possible data sources Expected frequency of data collection Sum of total cholesterol from all respondents aged 18 + years Number of survey respondents aged 18 + years Sum of total cholesterol (in mmol/l or mg/dl) from all participants aged 18+ years. All respondents of the survey aged 18+ years. Population-based (preferably nationally representative) survey in which cholesterol was measured, not self-reported. There are two main blood chemistry screening methodsdry and wet chemistry. Dry chemistry uses capillary blood taken from a finger and used in a rapid diagnostic test. Wet chemistry uses a venous blood sample with a laboratory based test. Either method is acceptable. Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years - measurement error due to insufficient blood sample - limited validity of measurement instruments - representativeness of the sample Mean http://www.who.int/chp/steps/en/ 28 P a g e
Drug therapy and counseling to prevent heart attacks and stroke Proportion of eligible persons receiving drug therapy and counseling (including glycaemic control) to prevent heart attacks and strokes Percentage of eligible persons (defined as aged 40 years and older with a 10-year cardiovascular disease (CVD) risk* 30%, including those with existing CVD) receiving drug therapy** and counseling*** (including glycaemic control) to prevent heart attacks and strokes. *A 10-year CVD risk of 30% is defined according to Age, Sex, other relevant sociodemographic stratifiers where available, blood pressure, smoking status (current smokers OR those who quit smoking less than 1 year before the assessment), total cholesterol, and diabetes (previously diagnosed OR a fasting plasma glucose concentration >7.0 mmol/l (126 mg/dl). **Drug therapy is defined as taking medication for raised blood glucose/diabetes, raised total cholesterol, or raised blood pressure, or taking aspirin or statins to prevent or treat heart disease. Numerator Other possible data sources Expected frequency of data collection ***Counseling is defined as receiving advice from a doctor or other health worker to quit using tobacco or not start, reduce salt in diet, eat at least five servings of fruit and/or vegetables per day, reduce fat in diet, start or do more physical activity, maintain a healthy body weight or lose weight. Number of eligible survey respondents who are receiving drug therapy and counseling x 100% Number of eligible survey participants Number of eligible survey participants who are receiving drug therapy and counseling. See for definition of eligible people. Receiving drug therapy and counseling is calculated by self-report from respondents reporting they are taking medication for raised blood glucose/diabetes, raised total cholesterol, or raised blood pressure, or taking aspirin or statins to prevent or treat heart disease; and receiving advice from a doctor or other health worker to quit using tobacco or not start, reduce salt in diet, eat at least five servings of fruit and/or vegetables per day, reduce fat in diet, start or do more physical activity, maintain a healthy body weight or lose weight. Total number of eligible survey participants. Eligible people are those people aged 40 and older who either currently self-report that they have existing CVD or who have a 10 year cardiovascular risk of 30 per cent or higher calculated by using the WHO/ISH Risk prediction charts for 14 WHO epidemiological sub-regions which provide the approximate estimates of cardiovascular disease (CVD) risk in people who do not have established coronary heart disease, stroke or other atherosclerotic disease, based on responses to the following: Age, gender, smoking status, SBP, TC and absence or presence of diabetes. Population-based (preferably nationally representative) survey Risk factor exposure Age, Sex, other relevant socio-demographic stratifiers where available At least every 5 years 29 P a g e
- bias through self-report - misunderstanding/ -interpretation of questions - limited validity of survey instruments - measurement error due to insufficient blood sample - limited validity of measurement instruments Prevalence http://www.who.int/chp/steps/en/ http://www.who.int/cardiovascular_diseases/publications/chart_predictions/en/ 30 P a g e
Essential medicines and technologies for NCD Availability and affordability of quality, safe and efficacious essential noncommunicable disease medicines, including generics, and basic technologies in both public and private facilities Percentage of public and private primary health care facilities who have all of the following available: Medicines - at least aspirin, a statin, an angiotensin converting enzyme inhibitor, thiazide diuretic, a long acting calcium channel blocker, a beta-blocker, metformin, insulin, a bronchodilator and a steroid inhalant. Technologies - at least a blood pressure measurement device, a weighing scale, blood sugar and blood cholesterol measurement devices with strips and urine strips for albumin assay. Number of facilities that have all essential medicines and basic technologies from the minimum list available x 100% Number of surveyed facilities Numerator Other possible data sources Expected frequency of data collection Number of facilities that have available during assessment the minimum list of essential medicines and basic technologies. The minimum list is: Medicines - at least aspirin, a statin, an angiotensin converting enzyme inhibitor, thiazide diuretic, a long acting calcium channel blocker, a beta-blocker, metformin, insulin, a bronchodilator and a steroid inhalant. Technologies - at least a blood pressure measurement device, a weighing scale, height measuring equipment, blood sugar and blood cholesterol measurement devices with strips and urine strips for albumin assay. Number of surveyed facilities. Nationally-representative health facility assessment National systems response Public, Private At least every 5 years Prevalence http://www.who.int/healthinfo/systems/sara_introduction/en/ 31 P a g e
Palliative care Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer Consumption of morphine-equivalent strong opioid analgesics (excluding methadone) per death from cancer. Morphine- equivalent is a method of standardizing and combining volumes of opioids with differing potencies and is used as a measure of opioid consumption, which is used as the indicator for access to pain and palliation. Population-level consumption of morphine-equivalent strong opioid analgesics Total number of cancer deaths over the same time period Numerator Other possible data sources Expected frequency of data collection Population-level consumption of morphine-equivalent strong opioid analgesics for a given time period. Levels of consumption of opioid medicines in kilograms or grams (for Fentanyl) are calculated by the INCB on the basis of statistics on manufacture and trade provided by Governments. Consumed quantities include those distributed by wholesalers or manufacturers to retailers (mainly pharmacies and hospitals) plus quantities imported directly by retailers. In countries where the retailers obtain their supply from abroad, quantities declared as imported are considered to be destined for consumption. Therefore the average reported consumption for the previous three-year period in many cases provides a more accurate estimate of actual consumption since volumes procured in one year may be consumed in the following year. Morphine-equivalent volumes are calculated as: (1*morphine)+(83.3*fentanyl)+(5*hydromorphone)+(1.33*oxycodone)+ (0.25*pethidine) Number of cancers deaths occurring in the population over the same time period. Consumption of opioids from International Narcotics Control Board annual reports for narcotics consumption. Cancer deaths from vital registration systems which record deaths with sufficient completeness to allow estimation of all-cause death rates. Opioid consumption data from national competent authorities National systems response None Annual - incomplete administrative records - incomplete or unusable death registration data Ratio http://www.incb.org/documents/publications/annualreports/ar2010/supplement- AR10_availability_English.pdf 32 P a g e
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Elimination of trans-fats Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes Adoption of a policy to limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply. Other possible data sources Expected frequency of data collection Country can respond "yes" to the question Is your country implementing any national policies that limit saturated fatty acids and virtually eliminate industrially produced transfats (i.e. partially hydrogenated vegetable oils) in the food supply? WHO NCD Country Capacity Survey National systems response None Every 2 years - bias through self-report - misunderstanding/ -interpretation of questions - limited validity of survey instruments Prevalence http://www.who.int/chp/ncd_capacity/en/ 34 P a g e
Indicator Indicator name name Vaccination for Human Papillomavirus (HPV) Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies Availability of HPV vaccines as part of a national immunization schedule Country can indicate that they have added HPV vaccine to their national immunization programme, as reflected in their responses to the WHO-UNICEF Joint Reporting Form. WHO-UNICEF Joint Reporting Form (JRF) Other possible data sources Expected frequency of data collection National systems response None Annual - bias through self-report - misunderstanding/ -interpretation of questions Percentage http://www.who.int/nuvi/hpv/decision_implementation/en/index.html http://www.who.int/immunization_monitoring/routine/joint_reporting/en/index.html 35 P a g e
Marketing to children Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt Existence of a policy to reduce the impact on children of marketing of foods and nonalcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt Country can respond "yes" to the question Is your country implementing any policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt? Other possible data sources Expected frequency of data collection WHO NCD Country Capacity Survey National systems response None Every 2 years - bias through self-report - misunderstanding/ -interpretation of questions - limited validity of survey instruments Prevalence http://www.who.int/chp/ncd_capacity/en/ http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/ 36 P a g e
Vaccination for Hepatitis B Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants Percentage of one-year-olds who have received three doses of hepatitis B vaccine in a given year. Unit of measure measurement Doses of Hep-B vaccine (HepB3) administered to infants Service/facility reporting system /administrative data: Reports of vaccinations performed by service providers (e.g. district health centres, vaccination teams, physicians) are used for estimates based on service/facility records. The estimate of immunization coverage is derived by dividing the total number of vaccinations given by the number of children in the target population, often based on census projections. Household surveys: Survey items correspond to children s history in coverage surveys. The principle types of surveys are the Expanded Programme on Immunization (EPI) 30-cluster survey, the UNICEF Multiple Indicator Cluster Survey (MICS), and the Demographic and Health Survey (DHS). The indicator is estimated as the percentage of children ages 12 23 months who received three doses of hepatitis B vaccine either any time before the survey. Service/facility reporting system /administrative data: Total number of hepatitis B vaccinations given to children Number of children in target population x 100% Household survey data: Number of children aged 12 23 months participating in the survey who received three doses of hepatitis B vaccine any time before the survey Number of children aged 12 23 months who participated in the survey x100% Numerator Service/facility reporting system /administrative data: Total number of hepatitis B vaccinations given to children taken from reports of vaccinations performed by service providers (e.g. district health centres, vaccination teams, physicians). Household survey data: Total number of children aged 12-23 months who received three doses of hepatitis B vaccine any time before the survey. Service/facility reporting system /administrative data: Number of children in target population covered by service/facility reporting system/administrative data. Household survey data: Total number of children aged 12-23 months participating in the survey. Annual WUENIC reports (which are derived from the administrative coverage and the household survey data) 37 P a g e