2nd Meeting PASCAR Task Force on Hypertension London, UK, August 30, 2015 Update on PASCAR HT Roadmap & EBM review & purpose of the meeting Anastase Dzudie Chair: PASCAR HT Task Force Hypertension in Africa From 80 millions HT in 2000 to … 150 million in 2025 Unless we actact!! PASCAR recommendations of priority interventions to ministries of health for prevention of heart disease, diabetes and stroke in the African region: The 10 “Best buys” (Bongani Mayosi, Heart, 2013) Outcome of the Nairobi meeting Outcome of the Nairobi meeting The burden of raised BP in Africa is huge Need for a clear policy program & guidelines, several limitations: Need for outcome data Need to search for existing drug evidence (Clinical trials) Anticipated lack of evidence Outcome of the Nairobi meeting THE CREOLE TRIAL PROJECT TITLE : Compa rison of Thr ee Combination Therapies in Lowering Blood Pressure in Black Africans (The CREOLE study). RESEARCH TEAM: PI: Dike Ojji (Co-chair, PASCAR Task Force on Hypertension). Co-PI: Neil Poulter Investigators Cameroon (1): Anastase Dzudie (Douala); Kenya (2):Elijah Ogola (Nairobi), and Ayub Barasa (Eldoret); Mozambique (1): Albertino Damasceno (Maputo); Nigeria (3): Egenti Nonye and Manmak Mamven (Abuja), Okechukwu Ogah (Ibadan), and Mahmoud Sani (Kano);South Africa (2): Biddy Buchanan Lee and Ikechi Okpechi (Cape Town), Gboyega Ogunbanjo and Phindile Mntla (Ga Rankuwa); Uganda (1): Charles Mondo (Kampala) Outcome of the Nairobi meeting Health Decision Model to address BP control Patient Characteristics Policy Provider Characteristics Perceived Cognition Communication Medication Risks Style Regimen Coping & Literacy Treatment Stress Intensity of Guidelines Therapy Adherence Comorbidities Side Effects Medical Environment : Depression health systems etc.. Mental Health Social Environment TREATMENT ADHERENCE Bosworth HB, Olsen MK, Oddone EZ. (2006). Am Heart J 149:795-803.l Bosworth HB & Oddone EZ. (2002). BLOOD PRESSURE CONTROL J Nat Med Ass. 94; 236-248 Creation of a Warehouse Existing randomized control clinical trials (RCTs) Clinical practice guidelines Pan African Society of Cardiology & Centre for the Development of Best Practices in Health – CDBPS With the technical support of: African Community of Guidelines International Network – G-I-N Africa Existing Clinical Trials (CTs) for Hypertension in Africa Pan-African Society of Cardiology Definition used for RCTs for Hypertension for Africa (NIH 2015) Pre-planned studies of the safety, efficacy, or optimum dosage schedule (if appropriate) of one or more diagnostic, therapeutic, or prophylactic drugs, devices, or techniques selected according to predetermined criteria of eligibility and observed for predefined evidence of favourable and unfavourable effects’. Research questions – What are the RCTs conducted for hypertension in Africa? – Which countries have been actively involved? – In which years were the RCTs conducted? Methods • Systematic search using MeSH terms • Database searched: PubMed, Cochrane Library, ISH, WHO ICT, PACTR • Language: English, French, Spanish & Portuguese. • No assessment of quality CT Progress 1971 to Present No of Studies 35 30 25 20 15 10 5 0 1970 - 1979 1980 - 1989 1990 - 1999 2000 - 2009 2010 - 2015 With courtesy of CDBPS Preliminary results • 84 studies, from 69 authors, in 18 countries • published in 47 journals (9 African Journals). • Studies ranged from between 1971 to 2015. • NIH 2015: 32 CTs with only 22 drug trial and less than 10 were RCTs • Old, small sample and single center studies except NOOAH (183 patients) With courtesy of CDBPS Conclusions on CT search • Very little knowledge on treatment of hypertension has been generated from Africa through randomised controlled trials. • Except NOAAH, most are small sample size and single center study. • Compared to what we need to develop evidence based guidelines , there is still a long way to go. Clinical Practice Guidelines (CPGs) for Hypertension in Africa Pan-African Society of Cardiology Step 1: PASCAR Internal Survey Is the ministry of health of your country running a hypertension focus national program to tackle hypertension? 983 emails sent via our internal system Very much 146 answers from 40 countries (27 African) Much 3.5% 4.9% Active 30.1% Neutral 16.1% Not so much active 11.9% 7.7% Very dormant 25.9% No, the ministry of health of my country is NOT running a hypertension focus national program to tackle hypertension. With courtesy of George Nel Step 2: Research questions with the CDBPS – Which countries have developed or adapted guidelines for hypertension within the African region? – Which countries have made these CPGs available either on the MOH website, medical associations or as documents to clinicians and patients? – Which countries are using adopted but not adapted guidelines? – Which countries have their CPGs still in the works? – Which countries do not have CPGs for hypertension? Methods Search in May and July 2015 Web search of guidelines and related articles: Google, Google scholar and PubMed. Hand search: MOH, WHO & association websites. Emails authors and request for CPGs Languages: English-French-Spanish-Portuguese. Only considered existence if we received a copy Not considered: CPGs could not be delivered to us or if delivered CPGs were for European/South American countries. Results CPGs Percentage Countries Existing CPGs for Burundi, Egypt, Ethiopia, Ghana, Kenya, Lesotho, 16 (24.20%) Malawi, Mauritius, Nigeria, Rwanda, South Africa, Hypertension Sudan, Uganda, United Republic of Tanzania, Zambia Algeria, Gabon, Democratic Republic of Congo, Comoros WHO ISH 12.90% Islands, Seycheles. Adoption without Adaptation 3.20% Angola, Equitorial Guinea, Mozambique CPGs in the Works 4.80% Sierra Leone, Tunisia, Cameroon Benin, Botswana, Canary Islands, Cape Verde, Central African Republic, Chad, Côte d'Ivoire, Djibouti, Eritrea, Non-Existent or Unclear (No Gambia, Guinea, Guinea-Bissau, Liberia, Libya, Mali, evidence for existence or 56.50% Mauritania, Morocco, Niger, Republic of the Congo, Réunion, São Tomé and Príncipe, Senegal, Somalia, non-existence) Swaziland, Togo, Western Sahara, Zimbabwe, Burkina Faso, Madagascar, South Sudan. Limitation: No assessment of quality of CPGs Anticipated Conclusions from the Warehouse 1. Lack or dormant hypertension policy in 75% of countries in Africa 2. 22.4% of countries in Africa having clinical practice guidelines for hypertension. Next step? • Support African MOH, medical associations medical staff and all stakeholders with the development of high quality policy programs to tackle raised BP. Urgent need for a clear policy with an Implementation and monitoring strategy National cardiac societies, African Ministries hypertension & other professional societies countries of health In this direction, your expert opinion on Month Main Activities Description Feb 2014 Build Task force Appointment of chair Recruitment of task force Members May 2014 Consolidate the taskforce Planning the meeting 1rst taskforce meeting Oct 2014 1st meeting Review of previous relevant hypertension programs and guidelines and plan the Africa roadmap Nov 2014 Publication of the 1 st meeting proceedings with conclusions from the task force April 2015 Warehouse - WHF Internal survey – Identification of a Ware house developer – Work with WHF on roadmap Aug 2015 2nd meeting Feedback from members and how to customize the WHF roadmap for Africa Sept 2015 Draft Afro roadmap Draft of roadmap by PASCAR & WHF experts Oct 2015 3rd meeting Discuss the Africa roadmap with National cardiac and hypertension societies 13 to 14 Task force review and agree on the final version of draft roadmap by emails 14 to 15 Validation Submission of roadmap for external peer review 15 to 16 Task force collect and summarize external peer review comments 16 4th GDG meeting Task force review external peer review comments and update if needed 16 to 17 Task force review and agree on the final version of evidence report and recommendations by emails 18 Review and approval + publication by PASCAR steering committee Purpose of the meeting Update on the development of our roadmap & review the development of a Warehouse for African guidelines and RCTs on HTN. Achieve a better understanding of the WHF Roadmap for BP. Discuss how WHF Roadmap for BP can be customized for Africa. Plan the next steps in the development of the Africa BP roadmap. Conclusion & Acknowledgements Together Each African country will achieve More. PASCAR Exco (Prof Mayosi et al) CDBPS (Patrick Okwen et al) Thx to George, Dike & Bongani) Task force members (3).