東京電力福島第１原発の事故後１年間に摂取した飲食物による内部被ばくで、都内に住む乳幼児の場合、１０万人当たり２〜３人の確率で一生のうちに甲状腺がんになるとの推計を、東京大の研究チームが１２日発表した。

　事故の影響が遠く離れた東京の子どもにまで及ぶことを示す結果。チームの村上道夫（むらかみ・みちお）特任講師は「外部被ばくより影響は小さいが、がんの確率が高いか低いかは、人によって受け止め方が違うだろう」と話している。

　がんの確率はディーゼル車の排ガスの影響より低いが、シックハウス症候群の原因物質のホルムアルデヒドや、ダイオキシン類より高い。

　チームは、厚生労働省が公表した食品や水道水の放射性物質濃度や、一日の食品摂取量データなどを基に、飲食物を通じた都内の住民の内部被ばく量と、それによる生涯の発がんリスクを推計。

　ヨウ素１３１は子どもへの影響が大きく、甲状腺がんになる確率は１０万人当たり乳児で３人、幼児で２人、成人で０・３人。死に至るのは乳児で０・２人、幼児で０・１人となった。セシウム１３４と１３７によってがんになるのは、全年代で１０万人当たり０・３人、死に至るのは０・０８人。

　ヨウ素とセシウムを合わせた１年間の内部被ばく量は、乳児が４８マイクロシーベルト、幼児が４２マイクロシーベルト。だが実際は水道水でなくペットボトルの水を飲むなどしてもっと低かった可能性が高いという。

歯科医師国家試験 　3月19日(月）合格発表

※厚生労働省合格発表会場について

2012年3月19日(月）

14時 医師国家試験 -

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2012年3月26日(月）

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2012年3月28日(水）

14時 臨床工学技士国家試験 -

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2012年3月30日(金）

14時 診療放射線技師国家試験 -

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http://www.mhlw.go.jp/general/sikaku/kaijyou.html

　東京電力は９日、福島第１原発の放射線量が事故当時に比べて低下したことから、屋内で女性従業員の勤務を開始すると経済産業省原子力安全・保安院に報告した。保安院は同日、了承した。

　東電によると、昨年３月の事故直後、免震重要棟１階の線量は毎時４７マイクロシーベルトだったが、同１１月には７・２マイクロシーベルトに低下。女性の線量限度は３カ月で５ミリシーベルト（５千マイクロシーベルト）と男性に比べて低く定められているが、１日８時間、１カ月で２０日働いた場合、３カ月で５ミリシーベルトの上限を守れるとしている。東電は、３カ月で４ミリシーベルトを目安に管理する。

　女性が勤務するのは第１原発の免震重要棟や医務室、休憩室などで、事務作業に当たる。実際に勤務を開始するにはトイレや更衣室などの整備が必要なため、開始時期は決まっていない。対象の３０人程度から同意を得た上で従事させる。

　第１原発で勤務していた女性の被ばくをめぐっては、昨年の事故直後に５０代の女性社員が１７・５５ミリシーベルト被ばく。４０代の社員も上限を超える７・４９ミリシーベルト被ばくしたことから、東電は昨年３月２３日から女性を全員退避させていた。

　見渡す限り、誰一人としていない。自動販売機の明かりだけがこうこうとしていた。東京電力福島第１原発の事故直後の昨年３月中旬。福島県田村市都路地区で、県警双葉署捜査１係長の警部補佐藤孝男（さとう・たかお）さん（５１）は給油のため捜査車両を走らせていた。

　「係長、もういいじゃないですか。死にたくない...」。助手席の部下が思い詰めた顔で訴えた。佐藤さんは一瞬「ほんじゃ、逃げっかな」と思った。「でも、避難できていない人がいる、って。俺らだけ逃げるわけにはいかない」

　同署は第１原発の南約９キロ、富岡町にあったが、地震の発生翌日に約２１キロ離れた川内村の役場に機能移転。当時は地震の影響で携帯電話の電波が届かなかった。佐藤さんは受信できる場所を求め、家族と連絡が取れない同僚らから託された携帯約４０台を車に積んでいた。

　携帯メールの着信音が一斉に鳴る。署に持って戻ると、仲間が携帯をそれぞれ手に取った。「無事だったんだ」。皆、ぼろぼろと涙を流していた。佐藤さんは、備忘録代わりの手帳や大学ノート、後日書き留めた手記を基に最前線の様子を証言した。

　　　×　　　×　　　

　▽死んじゃうのかな

　「パトカーが津波にのみ込まれ浮いているとの情報が寄せられ、現場付近に向かったが、海水とがれきでとても近づける状況ではなかった」。手記には、昨年３月１１日のＪＲ富岡駅周辺の模様が記されていた。

　「当署警察官３名が行方不明となり、２名のご遺体が発見されたものの、１名についてはいまだ発見されていない」

　佐藤さんはこの日、メモを取る余裕がなく、手帳欄に後から「１４：４６　東日本大震災」とだけ書いた。

　機能移転当日の午後、第１原発１号機で水素爆発。「広島とか長崎の原爆を想像して、自分たちも放射能かぶって死んじゃうのかなと。手記に書いてるけど『これで人生終わり』って思った。手帳に『３号機爆発か？』って書いてるけど、１号機とか３号機とか分からなかった」

　双葉署は本部の指示で同１５日、川俣町にある福島署川俣分庁舎に再移転。当時、署員全員に線量計は行き渡らなかった。佐藤さんは浪江町の自宅に帰れず、二本松市の避難所にいた家族と再会できたのもこのころ。無精ひげを生やしたままだったが、娘２人が抱きついてきた。

　▽検視２００体

　手帳やノートには２２日から４月６日の欄にかけて「浪江町請戸（うけど）両竹（もろたけ）　遺体回収」「双葉町両竹（もろたけ）　遺体回収」「富岡町毛萱（けがや）　遺体回収　検視」「双葉病院　４遺体」などと短い言葉が並ぶ。

　双葉病院は、大熊町にある私立の精神科病院。佐藤さんは日付の記憶があいまいながら、院内は暗く冷え込み、首輪をした犬がうろついていたのを覚えている。お年寄り４人の遺体をマイクロバスに運び込み、署で遺族に引き渡したという。

　手帳の４月１４日の欄には「双葉郡内の本格的捜索」。佐藤さんらによる検視は身内や同僚も含め約２００体に上った。その前にも双葉町を捜索。線量計のアラーム音をずっと耳にしながらぬかるみを歩き、津波で柱だけになった民家で女性の遺体を搬送した。２階に見えた男性の遺体は手の施しようがなかった。

　次々と降り掛かる異常な状況に心をむしばまれ、仕事に身が入らなくなった時期もあった。「当時精神的に病んでなかった双葉署員はいなかったと思う」（手記）という過酷さだった。

　４カ月がたち、時間とともに気持ちも落ち着いてきた。佐藤さんはこの時の心境を「唯一得たものは『今を大切に生きる』こと。『過去は過去のもの』として必要以上に振り返らず、前向きに生活していきたい」と手記につづっている。

　弘前大被ばく医療総合研究所（青森県弘前市）の床次真司（とこなみ・しんじ）教授のグループが、福島県の６５人を対象に、東京電力福島第１原発事故で放出された放射性ヨウ素による住民被ばく状況を調査した結果、甲状腺に最大８７ミリシーベルトの被ばくをした人がいることが、９日分かった。

　一方で、２４人が１０ミリシーベルト以下だったことも判明。地域によって放射性ヨウ素の濃度が異なり、避難経路などによって被ばく量に差が出たと考えられるという。

　放射性ヨウ素の半減期は８日で、セシウム１３７の約３０年などと比べて短いため、時間がたつにつれ被ばく状況を把握するのは難しくなる。床次教授は「国が住民の甲状腺を長期的にチェックし、手厚くサポートすることが重要」としており、調査結果を今後、内閣府に提供するという。

　調査は昨年４月１１〜１６日、福島県浜通り地区から福島市に避難した４８人と、原発から３０キロ圏周辺の浪江町津島地区にとどまっていた１７人を対象に、甲状腺内の放射性ヨウ素濃度を調べ、逆算して原発事故翌日の３月１２日時点の放射性ヨウ素の被ばく量を算出。

　その結果、５０人からヨウ素を検出し、１５人は不検出だった。国際原子力機関が甲状腺被ばくを防ぐため安定ヨウ素剤を飲む目安としている５０ミリシーベルトを超えたのは５人。

　このうち数値が最も高かった人は浪江町に残った成人で８７ミリシーベルト。次いで浪江町に２週間滞在後、福島市へ避難した成人が７７ミリシーベルトで、１５歳以下の子どもの最高値は４７ミリシーベルトだった。

　甲状腺被ばくは局所的で、全身被ばくとは異なる。床次教授は「リスクがないとは言い切れないが、チェルノブイリ原発事故などと比べて低い数値だ」としている。

生と死、見つめて　がんと闘う産婦人科医　
新たな命に「全力注ぐ」　「ルポ　ふくしまを生きる」

体育館の床に、白い布をかぶせられた約２０体の遺体が安置されていた。ホースの水で泥を洗い流し、服を脱がせ、所持品を整理した。のどに真っ黒な泥が詰まり、体のあちこちが骨折していた。

福島県南相馬市の産婦人科医、高橋亨平（たかはし・きょうへい）さん（７３）は東日本大震災の発生２日後、市内の県立高校で津波犠牲者の検視に協力した。自分の病院でお産した女性とみられる遺体もあった。

「突然恐ろしい目に遭って。本当に無念だったろうな...」。４１年間で取り上げた赤ちゃんは約１万５千人。自らの経験を、生まれてくる命に全力で注ぐと決心した。

福島第１原発から約２４キロ離れた南相馬市の原町中央産婦人科医院。昨年３月１１日、診察中に激しく揺れた。沿岸部には大津波。老若男女、症状を問わず、患者を受け入れた。原発事故で周りの病院はほとんど避難したが、看護師４人と残り、院長として地域の医療を支え続けた。

５月下旬、お尻に鈍い痛みを感じた。「痔（じ）かな」と思ったが、精密検査の結果は「進行した直腸がん。肝臓と肺にも転移していて、何も治療しなければ余命半年」。突然の宣告に戸惑った。

診察室を離れなかった。抗がん剤治療を受け、体調が整えば手術に挑む道を選んだ。４０年来の"コンビ"看護師長の山田米美（やまだ・よねみ）さん（７３）は「抗がん剤で体の抵抗力が落ちてしまうのに、もし病気がうつったら...」と心配したが、高橋さんは「やっぱり現場にいたいんだ」と思いを貫いた。

２週間に１度、福島市の県立医大病院で、右胸に開けた穴から抗がん剤を４時間かけて点滴する。自宅に戻ってからも、４６時間は簡易ポンプを持ち歩き、同様に抗がん剤を体に染み込ませる。目まいや貧血の副作用が出るときもあるが、治療を受けた翌日もポンプを胸ポケットに入れ、診察を休まない。

山田さんは、高橋さんが怒って大きな声を出したのを一度も見たことがない。「もともとお産に不安は付き物だけど、先生はあの穏やかな笑顔で、妊婦に信頼されてきた」。がんを患っても、それは変わらない。原発事故でいったん避難したが、高橋さんを頼って通院を再開した妊婦もいた。

南相馬市では、放射線への不安から多くの妊婦や子どもが避難したまま。高橋さんは「１年、１年半と子どもが避難先になじんでしまうと、家族としてはなかなか戻れないよね」と心配する。

「俺はいつか訪れる日のために、一日一日、ベストを尽くすっていうことかな」。高橋さんの病院で１年間に生まれる赤ちゃんは、ここ数年９０人以上。状況は厳しかったが昨年は３０人、今年も１１人が産声を上げた。

寝るとき以外は白衣を着て、妊婦が産気づくのを待つ。「未来の子どもに将来を託すしかないんだよ。子どもの存在自体が、希望で、夢で、復興そのものなんだよ。絶対に」

Ｄｒ．中川のがんの時代を暮らす：／３０　リスクを見る目を養う

　東日本大震災と東京電力福島第１原発の事故から１年を迎えましたが、「放射線パニック」は収まる気配がありません。放射線被ばくによる健康被害は「今のところゼロ」です。一方、震災による死者・行方不明者は約２万人、建築物の全壊・半壊は３７万戸以上、ピーク時の避難者は４０万人以上に達し、震災による被害額は１６兆〜２５兆円と見積もられています。震災による被害と放射線による健康影響は、比較にならないと考えています。

　津波などの災害は現実の「損害」です。放射線被ばくは「ただちに健康に影響がない＝将来がんが増えるかもしれない」という潜在的な「リスク」です。

　「リスク」は、現実に発生した災害などと違い、今は起きていないものの、将来、起きる可能性のある損害を指します。また、私たちの判断や選択に左右され、起きたり起きなかったりする「不確実性」を持つ点が特徴です。

　巨大津波は、人間の判断とは無関係に起きますから、リスクではありません。しかし、地震と津波による「全電源喪失」が起こる可能性がある立地で原発を稼働するのはリスクになります。

　天災とリスクの違いは、震災そのものと原発事故に対する日本人の態度にも顕著に表れました。津波の被害に対しては、どんなに深い悲しみに沈んでも、復興に向けた「絆」が発揮されました。ところが、原発事故については、がれきの受け入れも進まず、風評被害も収まりません。背景には、リスクに対する「漠然とした不安」があると感じます。

　戦後の日本は、「安全・安心」な社会を目指してきました。一方、放射線被ばくといったリスクでは、「安全」と「安心」が必ずしも両立しません。低線量被ばくの安全性は確立していませんが、少なくとも大きなリスクではありません。しかし、安心のため、わずかの被ばくを恐れて避難すれば、逆に安全が損なわれることもあります。日常生活を改悪すれば、放射線被ばくよりずっと巨大な発がんリスクを背負い込むこともあるからです。

　目の前のリスクに振り回されると、かえって損害を受けることがあります。リスクを見る「目」を養うことが何より大切です。（中川恵一・東京大付属病院准教授、緩和ケア診療部長）

　東京電力福島第一原子力発電所事故で拡散したとみられるプルトニウム２４１を、放射線医学総合研究所などが福島県内で初めて検出した。

　文部科学省による昨年９月の調査結果では、同位体のプルトニウム２３８、２３９、２４０を検出していたが、２４１は調査対象外だった。英国の科学電子雑誌に８日、発表した。

　研究チームは浪江町、飯舘村のほか、広野と楢葉の両町にまたがるＪヴィレッジの３か所から採取した土壌や落ち葉から、２４１（１キロ・グラムあたり４・５２〜３４・８ベクレル）を検出した。２４１は国内ではほとんど検出されないため、原発事故で拡散したと結論づけた。

　最大濃度の落ち葉が採取された場所の今後５０年間の被曝(ひばく)線量は０・４４ミリ・シーベルトと試算され、健康影響はほとんどないと研究チームはみている。ただ、２４１が崩壊して生じる放射性物質のアメリシウムは植物へ移行しやすいという研究もあり、「継続調査が必要だ」としている。文科省は２４１を調査から外した理由について、「検査に時間がかかるため、同じベータ核種のストロンチウムを優先した」と説明している。

　昨年１年間の全国の自殺者は前年より１０３９人減り３万６５１人だったことが９日、警察庁の統計で分かった。月別では５月の自殺者が多く、統計を分析した内閣府は東日本大震災による経済的な影響が作用した可能性があると推定している。

　１９９８年に３万人を超えてから最も少ない記録。１４年連続で３万人を超え、女性は前年より２８９人増えて全体の３１・６％となった。

　内閣府自殺対策推進室によると、自殺者数は例年、企業が決算期を迎える３月にピークを迎える傾向にあるが、昨年は３月まで低めに推移し、５月に前年比２１・２％増の３３７５人と急増した。

　内閣府は被災地や各地の自治体関係者らから聞き取り調査し、経済動向も分析。４、５月は企業倒産件数の増加や輸出の落ち込みなどが見られた上、同時期に「３０代」「経済・生活問題が動機」などの層が大幅に増加したことが分かった。担当者は背景事情の一つとして「震災を契機に経済リスクが広がり、特定の層に影響した可能性がある」との見方を示している。

　年齢別では、６０代が５５４７人と最も多く、５０代、４０代の順。３０〜６０代は前年より減少したが、２０歳未満と２０代は増加した。

　原因・動機別では、健康問題の１万４６２１人が最多で、経済・生活問題、家庭問題と続いている。

※自殺統計

　警察は変死者の捜査で自殺と認定すれば、生前の生活実態や自殺手段、推定できる三つ以内の原因・動機を記録する「自殺統計原票」を作成する。これを基に警察庁は動機などを分類した年間データと月ごとの自殺者数を公表。内閣府は提供されたデータを分析し、地方自治体に地域別の傾向を伝えて対策を促している。

文献：Ortegón M et al.Cost effectiveness of strategies to combat cardiovascular disease, diabetes, and tobacco use in sub-Saharan Africa and South East Asia: mathematical modelling study.BMJ 2012;344:e607.

　心血管疾患、糖尿病、喫煙に対する123の対策を対象に、サブサハラ・アフリカおよび東南アジア地域での費用対効果を数学的モデリングで検討。「たばこ規制枠組条約」（障害調整生存年当たり費用サブサハラで＜950国際ドル、東南アジアで＜200国際ドル）、心血管疾患予防の併用薬物療法、糖尿病性網膜症検診などの費用対効果が高かった。

Cost effectiveness of strategies to combat cardiovascular disease, diabetes, and tobacco use in sub-Saharan Africa and South East Asia: mathematical modelling study

BMJ2012;344doi: 10.1136/bmj.e607(Published 2 March 2012)
Cite this as:BMJ2012;344:e607

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1.Mónica Ortegón, researcher1,
2.Stephen Lim, associate professor of global health2,
3.Dan Chisholm, health economist3,
4.Shanthi Mendis, coordinator4

Author Affiliations

1.1School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
2.2Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
3.3Department of Health Systems Financing, World Health Organization, Geneva, Switzerland
4.4Department of Chronic Diseases and Health Promotion, World Health Organization, Geneva
Correspondence to: M Ortegón Carrera 24 # 63C-69 Bogotá, Colombia monica.ortegon@urosario.edu.co

・Accepted 26 October 2011

Abstract

Objective To determine the relative costs and health effects of interventions to combat cardiovascular disease, diabetes, and tobacco related disease in order to guide the allocation of resources in developing countries.

Design Cost effectiveness analysis of 123 single or combined prevention and treatment strategies for cardiovascular disease, diabetes, and smoking by means of a lifetime population model.

Setting Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE) and countries in South East Asia with high adult and high child mortality (SearD).

Data sources Demographic and epidemiological data were taken from the WHO databases of mortality and global burden of disease. Estimates of intervention coverage, effectiveness, and resource needs were drawn from clinical trials, observational studies, and treatment guidelines. Unit costs were taken from the WHO-CHOICE (Choosing Interventions that are Cost-Effective) price database.

Main outcome measures Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.

Results Most of the interventions studied were considered highly cost effective, meaning they generate one healthy year of life at a cost of <$Int2000 (which is the gross domestic product per capita of the two regions considered here). Interventions that offer particularly good monetary value, and which could be considered for prioritised implementation or scale up, include demand reduction strategies of the Framework Convention for Tobacco Control (<$Int950 and <$Int200 per DALY averted in AfrE and SearD respectively); combination drug therapy for people with a >25% chance of experiencing a cardiovascular event over the next decade, either alone or together with specific multidrug regimens for the secondary prevention of post-acute ischaemic heart disease and stroke (<$Int150 and <$Int230 per DALY averted in AfrE and SearD respectively); and retinopathy screening and glycaemic control for patients with diabetes (<$Int2100 and <$Int950 per DALY averted in AfrE and SearD respectively).

Conclusion This comparative economic assessment has identified a set of population-wide and individual strategies for prevention and control of cardiovascular disease that are inexpensive and cost effective in low resource settings.

Introduction

There is growing concern about the escalating burden of non-communicable diseases and injuries throughout the world, from both epidemiological and economic perspectives. Lives lost to diseases such as cancer, cardiovascular disease, and diabetes—together with the often longstanding disability associated with them—have an economic impact on households and communities, both through the uptake of health services and goods that diverts expenditure away from other possible uses and through loss of income or labour productivity.1 2 Despite these adverse consequences on health and economic welfare, non-communicable diseases and injuries have been neglected in international health and development initiatives. The recent high level meeting on non-communicable diseases at a special session of the United Nations General Assembly and the subsequent political declaration3 provides a political mandate and an unprecedented opportunity to develop an international policy framework for the prevention and control of non-communicable diseases. A key action in support of this strategy is the evidence on the interventions that work best at the lowest cost in the prevention and control of non-communicable disease and injuries, in developing regions with a high disease burden.

In this series of articles we examine the relative cost effectiveness of a comprehensive set of interventions and strategies for combating major non-communicable diseases and injury in economically developing regions of the world: this paper covers cardiovascular disease and some of its key risk factors (including raised blood pressure, raised blood cholesterol, and tobacco use), and the others assess respiratory disease (asthma and chronic obstructive pulmonary disease), cancer (of the breast, cervix, and colon or rectum), neuropsychiatric disorders (schizophrenia, bipolar affective disorder, depression, harmful alcohol use, and epilepsy), sense organ diseases (including cataract, trachoma, refractive error, and hearing loss), and road traffic injury.4 5 6 7 8 Although this list leaves some gaps in the diseases covered—musculoskeletal diseases and blood disorders, for example—these analyses provide the largest available database of comparable cost effectiveness estimates, which a final paper uses to identify key priorities for the prevention and control of non-communicable diseases and injuries.9 We also provide a companion paper that shows the use of these methods at the country level (Mexico), as opposed to the level of epidemiologically defined World Health Organization sub-regions.10

Cardiovascular disease is the single largest cause of mortality worldwide, accounting for 17 million deaths, equivalent to 29% of all deaths annually. We cover primary prevention efforts at both the population level (such as tobacco control measures, reduced dietary salt intake) and at the individual level (such as control of hypertension or blood cholesterol with drugs and combination drug therapy for individuals at high risk of a cardiovascular event) as well as secondary and tertiary prevention or management of ischaemic heart disease and stroke. We also include the management (but not prevention) of another major cardiovascular risk factor, namely diabetes and its associated complications (which account for more than another million deaths worldwide each year). Intervention cost effectiveness results for two further cardiovascular risk factors—unhealthy diet and physical inactivity—have recently been reported elsewhere for a set of (mainly middle income) countries,11 but are not integrated into our analysis because of differences in the modelling environment adopted.

Methods

This analysis follows the standardised methodology on cost effectiveness analysis set forth by the WHO-CHOICE project12 13 14 and builds on previous analyses of public health interventions to lower systolic blood pressure and cholesterol15 and of tobacco use.16 We provide an overview of the methods and data used to carry out and update these earlier analyses and a more detailed description of modelling assumptions and data sources adopted for previously unpublished analyses (management of cardiovascular disease and diabetes).

In common with other papers in this and a previous WHO-CHOICE series,17 cost effectiveness modelling was carried out for two WHO reporting sub-regions, one in Africa (countries with high child and very high adult mortality, henceforth denoted “AfrE”) and the other in South East Asia (countries with high child and adult mortality, henceforth denoted “SearD”). Information on the countries pertaining to these two WHO epidemiological sub regions can be found in appendix 1 on bmj.com. Results for other WHO reporting regions can be viewed at the WHO-CHOICE website (www.who.int/choice); the models used have been designed for subsequent contextualisation by individual member states.

Interventions

A range of strategies for prevention and control were considered; where it was clinically meaningful to do so, we also assessed combination strategies. Table 1⇓ lists all single interventions included in this analysis. Interventions were selected according to the strength of evidence supporting their effectiveness as well as recommendations from published guidelines (see appendices 2–4 on bmj.com). Effectiveness of interventions was sought using the best available evidence reported in international literature. Source data for intervention effectiveness included meta-analyses, systematic reviews, clinical trials, and observational studies (appendices 2–4).

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Table 1

 List of single interventions considered in cost effectiveness analysis of strategies to combat cardiovascular disease, diabetes, and tobacco related disease in WHO sub-Saharan African sub-region AfrE and South East Asian sub-region SearD

Tobacco control strategies—Prevention of cardiovascular disease—as well as lung cancer and chronic obstructive pulmonary disease—via enhanced tobacco control efforts included key strategies of the WHO Framework Convention for Tobacco Control to reduce demand (current and increased taxation, legislated restrictions on smoking in public places, comprehensive bans on advertising of tobacco products, information dissemination through health warning labels, counter advertising, and various consumer information packages). Personal health interventions include nicotine replacement therapy and physician advice. Appendix 2 on bmj.com documents the efficacy, non-compliance, and target coverage levels of these measures.

Cardiovascular disease interventions—Primary prevention strategies cover both population-wide and individual level interventions aimed at reducing the risk of coronary heart disease and cerebrovascular disease through the voluntary or regulated reduction in dietary salt intake, control of blood pressure and cholesterol with drugs, and combination drug therapy for people at an absolute (as opposed to relative) risk of experiencing a cardiovascular disease event over the next 10 years >25%.15 The multidrug regimen consisted of four generic drugs—a β blocker, a diuretic, a statin, and aspirin (because of the risk of gastrointestinal bleeding in a group of patients, debate continues about the overall risk:benefit ratio of aspirin in primary prevention of cardiovascular disease). Management strategies focus on acute care of myocardial infarction and stroke in the inpatient setting, covering both surgical and drug interventions. Secondary and tertiary prevention interventions concern the long term treatment of patients with a previous myocardial infarction or stroke with the aim of reducing the risk of a subsequent event and the occurrence of more severe stages of the disease. Interventions for the management of symptomatic left ventricular systolic dysfunction in patients with a previous myocardial infarction are also included since this condition is common in patients with a previous myocardial infarction. Heart failure interventions are intended for patients in stage C of the disease according to the American College of Cardiology and American Heart Association classification of chronic heart failure progression.18 Appendix 3 on bmj.com provides a list of the cardiovascular disease intervention strategies assessed, together with estimates of their effect on reducing the risk, incidence or fatality of disease. All interventions were assessed at a treatment coverage level of 80%.

Diabetes interventions—For managing type 1 and type 2 diabetes, we focused on diabetes cases and the sequelae covered by the Global Burden of Disease study (blindness due to retinopathy, neuropathy, and diabetic foot and amputation).19 Key interventions assessed were standard and intensive approaches to glycaemic control, screening for retinopathy and subsequent treatment as needed, and screening for neuropathy plus associated preventive foot care (appendix 4 on bmj.com provides a more detailed description of these interventions and how they were modelled). A uniform 80% treatment coverage was also used in order to facilitate comparison with cardiovascular disease results.

The large majority of interventions analysed are drug based. Current availability of drugs to treat chronic diseases ranges from 36% to 55% in low and middle income countries in the public and private sector, respectively.20 In Bangladesh, Malawi, and Nepal—specific countries in the regions studied—the availability of chronic disease drugs ranges from 5% to 37.5%.21 Cardiac units to perform angioplasty are available in hospitals in the following countries in AfrE: Kenya, Tanzania, Mozambique, South Africa, and Ivory Coast.22 Taking India as a country example for SearD, there are 220 hospitals capable of performing percutaneous angioplasty, located in the main cities.23

We have not been able to include all possible interventions in this analysis because of lack of information on either the impact of the treatment or the underlying epidemiological data required for determining treatment effectiveness. Renal disease and cardiovascular disease, for example, were not specified as sequelae for diabetes in the Global Burden of Disease study of 2004, so we have not assessed key interventions relating to them (including the prevention of diabetes through reduction of risk of cardiovascular disease, management of cardiovascular complications among diabetic patients, and treatment of diabetic nephropathy with angiotensin converting enzyme (ACE) inhibitors). Other excluded interventions that may have a positive health impact include those for preventing rheumatic heart disease or angina pectoris and treatment of refractory end stage heart failure, early diastolic and systolic dysfunction, and concomitant diseases such as arrhythmia and cardiac valve disorders. The treatment of complications of acute events (hypotension, pulmonary congestion, cardiogenic shock, etc) and diagnostic or prognostic interventions performed during management of an acute event were beyond the scope of this analysis.

Modelling approach

WHO-CHOICE employs an epidemiological, population based approach to the assessment of health outcomes (see general appendix on bmj.com). Along with background birth, population, and mortality rates, observed rates of disease incidence, prevalence, and mortality—drawn from the Global Burden of Disease database19 and shown in table 2⇓—are entered into a state transition model in order to establish the total number of years of healthy life experienced over the (100 year) lifetime of a defined population.24 The model is successively run in order to calculate the additional number of healthy years lived by the population—equivalent to the number of disability adjusted life years (DALYs) averted—after the implementation of a single or combined health intervention, compared with a baseline or null scenario of no interventions for the disease in question. This null scenario was determined by back calculating incidence and case fatality rates using intervention effect sizes and current coverage rates (that is, epidemiological rates are adjusted upwards to reflect the absence of any effective intervention). Interventions are taken to be implemented for a period of 10 years, after which epidemiological rates go back to their counterfactual level of no intervention. Consistent with the WHO Global Burden of Disease study, DALYs are discounted (at 3% per year) and age weighted.

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Table 2

 Main epidemiological parameters used in analysis of cardiovascular disease, diabetes, and tobacco related disease rates in WHO sub-Saharan African sub-region AfrE and South East Asian sub-region SearD*

The specific benefits of tobacco control measures on population health were estimated through the impact of reduced smoking on the tobacco attributable incidence of cardiovascular disease, respiratory disease, and mortality from various forms of cancer. We modelled the increase in taxation that would reduce smoking prevalence by 10% on the basis of data on tobacco taxation from previous WHO and World Bank studies.25 The effect of price changes on consumption was estimated from information about price elasticities of demand for tobacco products (the percentage change in consumption resulting from a 1% increase in price). For a 10% rise in price due to tobacco taxes, consumption generally falls by 8–10% in low and middle income countries.26 27 We calculated that the prevalence elasticity (the percentage change in smoking prevalence resulting from a 1% increase in price) was half the total price elasticity of demand, because at least half of the estimated effect on the demand for tobacco products results from a reduction in smoking prevalence.28 Given that current smoking prevalence is a poor proxy for the accumulated health risks of tobacco use, we used the smoking impact ratio as a marker for cumulative smoking risk.29 The smoking impact ratio captures the accumulated hazards of smoking by converting the smokers in the population analysed into equivalents of smokers in a reference population, where hazards for other diseases have been measured. The reference population used in our case was the CPS II cohort.30 We used relative risks in estimating tobacco attributable morbidity and mortality. Intervention effectiveness was assessed through changes in smoking impact ratio and relative risks of mortality and morbidity from tobacco related diseases per unit of smoking impact ratio (see table 3⇓ for relative risk values used in the analysis).

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Table 3

 Relative risks for disease (per unit increase in risk factor) used in analysis of cardiovascular disease, diabetes, and tobacco related disease rates in WHO sub-Saharan African sub-region AfrE and South East Asian sub-region SearD*

For the primary prevention of cardiovascular disease, health effects were modelled by stochastically simulating populations specific for age and sex with the observed baseline values of ischaemic heart disease and stroke incidence and the observed distribution of risk factors (systolic blood pressure, serum cholesterol, body mass index, and prevalence of long term smokers15) (see table 2⇑). Incidence risk is apportioned between individuals using estimates of the relative risk of modelled risk factors on cardiovascular events (table 3⇑). Population level incidence of ischaemic heart disease and stroke is recalculated after applying the impact of the intervention on the individual risk factor values for those receiving the intervention.

For acute myocardial infarction and stroke, health effects were modelled through their impact on case fatality in hospital and after discharge up to 28 days after the event (out of hospital case fatality rates were assumed to remain unchanged). Secondary and tertiary prevention interventions were modelled through their impact on post-28 day case fatality rates for each condition and the rate of complications attributable to ischaemic heart disease (angina, congestive heart failure). The interaction in risk between ischaemic heart disease and stroke was modelled using estimates of relative risk of stroke for those with previous ischaemic heart disease and vice versa from published epidemiological studies (see appendix 3 on bmj.com).

Finally, for managing diabetes and its complications, intervention health effects were expressed in terms of composite disability weights that reflect varying distributions of different health states (diabetes without complications, neuropathy, lower extremity amputation, background retinopathy, proliferative diabetic retinopathy plus macular oedema, and blindness due to retinopathy). These six disease states reflect the progression of diabetes along the long term consequences of eye and foot disease. To derive a composite disability weight for each intervention, we simulated the evolution of a closed population cohort of people aged >15 years over 100 years via a health state model (MiniMod, see appendix 4 on bmj.com for further details).

Intervention costs

We pursued an ingredients approach to costing, meaning that information on the quantities of all services and goods required for the delivery of an intervention as well as data on their unit costs were sought. The total cost of an intervention is the product of these quantities and their respective unit costs. Particular attention was given to maintaining consistency of the information on resource use with that described in the articles selected as source of effectiveness for the interventions. Costs were calculated for a 10 year period of implementation (subsequently discounted annually by 3%) and expressed in international dollars for 2005. An international dollar is a hypothetical currency that is used as a means of comparing costs taking into account differences in purchasing power. One international dollar ($Int1) buys the same quantity of healthcare resources in Kenya or India as it does in the United States. As reference, $Int1 is worth US$0.44 and US$0.32 in sub-Saharan Africa and South East Asia regions, respectively. We considered both patient and programme costs. Patient costs included drugs, laboratory tests, and inpatient and outpatient visits. A detailed description of resource quantities used at the patient level is given for each diabetes intervention in appendix 4 and for each cardiovascular disease intervention in appendix 5 on bmj.com. Programme costs included all resources required for the implementation and maintenance of interventions, such as administration and planning, media and communications, law enforcement activities, training, evaluation, and monitoring. Population-wide measures for reducing salt intake or tobacco use involve costs exclusively at the programme level and are documented elsewhere.25 Costing of these interventions was performed using WHO-CHOICE programme costing templates and world regional pricing databases (www.who.int/choice).

Handling of cost effectiveness data and uncertainty

Dividing the total implementation costs of each intervention by its effects generates a simple cost effectiveness ratio, relative to a comparator situation of no intervention. In addition to average cost effectiveness ratios, incremental cost effectiveness ratios are reported for the successive set of interventions that would be selected at expanding levels of resource availability, starting with the intervention with the lowest cost per DALY averted, then moving to the next most cost effective combination intervention out of the remaining available set of interventions. An intervention that is more costly or less effective than other more efficient interventions is denoted as dominated.

All interventions are imbued with a certain degree of uncertainty. To handle this aspect of reporting for such a wide range of interventions, we first placed intervention results on a logarithmic scale, with a view to ascertaining order of magnitude differences in cost effectiveness (such as $Int10–100 versus $Int100–1000 per DALY averted). Secondly, we categorised results according to a defined set of cost effectiveness thresholds: WHO-CHOICE denotes an intervention as “cost effective” if it produces a healthy year of life for less than three times the gross domestic product (GDP) per capita, and as “very cost effective” if it produces a healthy year of life for less than the GDP per capita. Finally, for the subset of intervention strategies that were not dominated by others and therefore fall on the cost effectiveness frontier, we undertook a probabilistic uncertainty analysis using the MCLeague software program.32 We also assessed the impact of removing age weights or discounting on baseline results via one way sensitivity analysis.

Results

A total of 123 single and combined intervention strategies were assessed (36 for tobacco control, 77 for cardiovascular disease, and 10 for diabetes). The annual cost, effect, and cost effectiveness for all interventions are provided in appendix 6 on bmj.com, and are shown graphically in figures 1⇓ and 2⇓. Costs ($Int) and effects (DALYs averted) have been calculated for a standardised population of one million people to allow for easier comparison between different geographical regions