Population-level screening for cardiovascular disease (CVD) risk factors has no effect on lowering CVD morbidity and mortality, concludes a recently published WHO Health Evidence Network (HEN) report. To reduce CVD risks, which are also associated with poorer COVID-19 outcomes, the report proposes some alternative measures for consideration by policy-makers in the WHO European Region.

CVDs are the main cause of death globally, killing an estimated 17 million people each year. Early evidence also points to a heightened susceptibility to, and risk of poor outcomes from, COVID-19 among people with CVDs and associated risk factors such as hypertension. There is an urgent need to effectively address CVDs and reduce the health and economic burden of disease in the European Region.

Cardiovascular screening: what does the evidence say?

Screening the population for risk factors for CVD is one mechanism used by various countries in the Region to identify and address the CVD burden. However, a new WHO/Europe HEN report which synthesized several high-quality randomized controlled trials found that population-level screening for CVD risk factors has no effect on lowering CVD morbidity and mortality at a population level.

Evidence from the Region also showed that while screening for preclinical CVD had some effect on reducing mortality and negative outcomes related to abdominal aortic aneurysm (AAA), the evidence was outdated due to changed population risk factors and improvements in treatment.

According to the HEN report, results from research which is currently in progress are still needed before recommendations can be made about the implementation of screening programmes for other preclinical CVDs, including atrial fibrillation.

How to increase effectiveness of screening: WHO policy considerations

Based on the HEN synthesis findings, the key policy considerations for Member States of the Region are to:

• review systematic population-level screening programmes for CVD risk and CVD risk factors (if such already exist), avoid initiating new analogous programmes and consider alternative methods to achieve the desired outcomes in reducing the CVD burden;
• re-evaluate current systematic population-level programmes for screening for AAA, taking into account the changes in risk factors and improved treatment;
• await the results of current quality trials on the effectiveness of screening for other preclinical CVDs before considering the implementation of such programmes.

While the evidence suggests that population-level screening is not effective, it is crucial that policy-makers do not discount the potential value of case-finding – which involves assessing patients who may be at risk of CVD when they use the health-care system. While systematic screening may be a standalone programme which invites all members of the public to participate, case-finding is integrated with the health-care system and focuses on individuals as they use the system.

Reducing CVDs, remains important for the whole Region and globally. An effective CVD prevention programme incorporates multiple fiscal and policy strategies (including tobacco control, salt reduction and elimination of trans fats) as well as management of CVD risk factors, such as hypertension in primary health care, which can be effectively supported by WHO-recommended tools.

The Health Evidence Network: catalyst to WHO’s mandate to generate evidence

This HEN synthesis report is part of WHO’s initiative to increase the effectiveness of screening, maximize benefits and minimize harm, aimed at understanding the effectiveness of systematic population-level screening programmes for reducing the burden of CVD.

Approximately 20 000 deaths could have been averted in Turkey in 2017 if the country had reached its current goals of reducing tobacco and salt consumption by 30%, and physical inactivity by 10%, according to WHO/Europe experts in an article published in the Lancet. The study calculated possible outcomes of the action plan for noncommunicable diseases (NCDs) adopted in the country for 2017–2025.

Turkey: 89% of deaths related to NCDs

The burden of NCDs is rising globally, and the WHO European Region has the highest rates of associated mortality. In Turkey, NCDs account for 89% of all deaths, with nearly 1 in 5 such deaths occurring before the age of 70.

To address the high social and economic costs of NCDs, compounded by an imminent expansion of Turkey’s elderly population, the government introduced the Multisectoral Action Plan of Turkey for Noncommunicable Diseases 2017–2025.

The plan focuses on tobacco, alcohol, diet and physical inactivity as key risk factors for cardiovascular disease, chronic respiratory disease, cancers and diabetes – the four conditions responsible for 80% of global NCD deaths.

The Lancet article, written by experts from WHO/Europe, calculated the estimated effect of Turkey’s measures aimed at reducing tobacco and salt consumption by 30%, and physical inactivity by 10%.

The analysis examines figures from 2017 and estimates how many fewer deaths would have occurred, had the targets been met. Analysis of available quality statistics shows that there would have been 20 281 fewer deaths in 2017 alone.

“This evidence-based WHO/Europe approach not only assesses potential effects of Turkey’s action plan for NCDs, it can help us to find the most effective measures and lead to more lives saved every year,” said Dr João Breda, Special Advisor to the WHO Regional Director for Europe, who has been leading the research with the WHO European Office for Prevention and Control of Noncommunicable Diseases.

Turkey, in line with other countries of the European Region, strives to reach the Sustainable Development Goal target of reducing NCD mortality by a third, by 2030. WHO/Europe’s European Programme of Work, 2020–2025 – “United Action for Better Health”, highlights the demand for technical guidance on effective NCD interventions in the Region.

Putting priorities in order

The WHO/Europe study placed the most important NCD risks factors for Turkey in order of priority:

• salt intake
• physical inactivity
• tobacco use
• consumption of fruit and vegetables
• alcohol consumption.

Population-level reductions in salt intake and physical inactivity present the greatest opportunity for reducing NCD mortality in Turkey. This could avoid over half of preventable deaths.

“Another important conclusion is the need to promote daily fruit and vegetable consumption. Although fruit and vegetable consumption is not a global NCD target, it is still a crucial factor that can reduce attributable health risks and shouldn’t be neglected while planning national policies,” added Dr Breda.

The WHO/Europe research is helpful for other countries searching for best practices to reduce NCD-related deaths. WHO/Europe’s approach to modelling the impact of different risk factor targets can be used to find the right priorities and convert them into nationally tailored policy targets across the Region.

During a country visit to Georgia on 18–23 December 2020, Dr Hans Henri P. Kluge, WHO Regional Director for Europe, discussed priority areas for health with high-level representatives. The visit was also an opportunity to speak with health care workers on the frontline of the COVID-19 pandemic.

The visit was hosted by the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs of Georgia, and included discussions on strengthening WHO’s presence in the country through leveraging strategic partnerships with the European Union and other partners. COVID-19 was also on the agenda, along with its effect on health systems, which signified the need for a stronger focus on achieving universal health coverage by 2030.

Commenting on the COVID-19 pandemic and its impact on health systems, Dr Kluge said, “Georgia has launched a strong response to COVID-19 but the pandemic has highlighted the need to accelerate progress to ensure that no one is left behind. Robust health systems, primary health care (PHC) and accessible public health services are the best way we can deliver universal health coverage across the country. These strategies will build resilience against future health emergencies and help get essential services to people in need”.

Health on the agenda at high-level meetings

The Government’s commitment to achieving universal health coverage was affirmed at the highest levels in meetings with the President, the Prime Minister, the Ministry of Health and the Chairperson of the Parliament. The Regional Director acknowledged the progress and highlighted the need to take further steps to improve financial protection by reducing out-of-pocket expenses for health care and improving access to high-quality and affordable medicines.

The Regional Director also referred to the launch of the Oslo Medicines Initiative as a milestone on the road to making medicines available and affordable by defining a new vision – informed by solidarity, transparency and sustainability – for collaboration between the public and private sectors to improve access to effective, novel, high-priced medicines in the WHO European Region. Other items high on the agenda included collaboration on addressing cancer, hypertension and mental health. Dr Kluge also congratulated Georgia on its leadership in efforts to eliminate hepatitis C and progress in tobacco control.

WHO stands ready to actively support Georgia in all the priority areas, with the main aim of minimizing disruptions in the sector and ensuring the population’s access to essential medical and public health services and financial protection. This includes implementing a new PHC package of services and a new Law on Medicinal Products for Georgia; improving control of noncommunicable diseases (NCDs) and risk factors, key drivers of mortality in Georgia (93% of mortality is attributable to NCDs).

Meeting health workers

During a visit to a rural PHC centre, Dr Kluge once again expressed his appreciation for health care workers, recognizing the heroic work of Georgia’s frontline health care workers and calling family doctors “the friends of the people”. The Regional Director discussed the impact of COVID-19 on the local population, especially the need to address increased levels of anxiety caused by the pandemic.

Local doctors stressed the need for additional training in managing the mounting mental health needs of their population and the importance of clear and consistent communication in mitigating fear and anxiety.

COVID-19 response

The Regional Director made several site visits to COVID-19 response facilities, including the National Centers for Disease Control and Public Health, 112 hotline headquarters, an “online clinic”, a COVID hotel and a COVID hospital. Dr Kluge recognized Georgia’s innovative approaches to the COVID-19 pandemic, citing the novel use of COVID hotels and online clinics to manage mild and post-discharge COVID-19 cases. He also emphasized the need for a balanced approach and paying attention to the needs of the health workforce.

In response to the COVID-19 pandemic, recent WHO support has been directed towards building capacity in clinical management and lab diagnostics, procurement of lab equipment, test kits, personal protective equipment, development of guidelines and training PHC providers in COVID management and mental health issues related to COVID. Dr Kluge expressed WHO’s commitment to providing technical support for vaccine delivery and development of the national vaccine deployment strategy, and emphasized the importance of establishing safety monitoring systems as well as the regulatory and liability aspects.

European Programme of Work

The country visit was also an opportunity to discuss the European Programme of Work, 2020–2025 – “United Action for Better Health in Europe” (EPW), which sets out a vision of how the WHO Regional Office for Europe can support health authorities in Member States to improve health and well-being.

Linked to the EPW, digital health has both created new opportunities during the pandemic to reach remote citizens and reduced the need for travel to appointments, but it has also exposed the inequity in access to the internet and digital tools as well as gaps in guidelines, health information systems, training and legislation. The Government expressed its commitment to accelerating digital health development in the country through investments in infrastructure and reforming legislation and service delivery.

The EPW reflects WHO/Europe’s determination to leave no one behind and to strengthen the leadership of health authorities in the Region.