Global Alliance against Chronic Respiratory Diseases

Objectives

GARD aims to: 1) develop a standard way of obtaining relevant data on CRD and risk factors; 2) encourage countries to implement health promotion and CRD prevention policies; and 3) make recommendations of simple and affordable strategies for CRD management.

Health priorities, geographic variability in risk factors and the prevalence of different forms of CRD, along with the diversity of national healthcare service systems and variations in the availability and affordability of treatments all mean that any recommendations should be adapted to ensure appropriateness in the community in which they are applied.

Approach

GARD is dedicated to an integrated approach to CRD, which looks at synergies between chronic diseases and proposes a stepwise and integrated programme of prevention and control of preventable CRD and respiratory allergies, into account taking comorbidities.

GARD also focuses specifically on the needs of developing countries and deprived populations, and fosters country-specific initiatives appropriate to local needs.

Added value

GARD will improve the coordination between the existing governmental and nongovernmental programmes to avoid duplication of efforts and wasting of resources. Increased human and financial resources, as well as technical expertise, will be effectively distributed according to the comparative advantage of each participant organisation towards the GARD vision.

Developing countries

The emphasis on the needs of developing countries is appropriate considering that most CRD occur in these countries, with infectious diseases (including HIV/AIDS) adding to the burden of CRD morbidity. In many developing countries, the focus of healthcare systems is on communicable diseases and injuries. Infrastructure for the diagnosis and management of CRD is either not available or is viewed as low priority on any public-health agenda.

Data on the CRD risk factors, burden and surveillance are scarce or unavailable in most developing countries. Consequently, the true burden of CRD on health services and society is not appreciated; strategies for the prevention and health promotion of CRD are often absent or rudimentary; and exposure to risk factors for CRD, including indoor air pollution, the use of solid biomass fuels and smoking, is high.

In developing countries, surveillance systems and diagnostic services for work-related CRD are often poorly developed, and the true burden of occupational lung disease largely unknown.

Asthma is mostly under-diagnosed and under-treated (in particular in children), causing a high morbidity and a significant mortality. In addition, the exact burden of COPD is unknown but likely to be (very) high, and the treatment emphasis for conditions like asthma and COPD is based upon the treatment of exacerbations instead of chronic care and prevention of exacerbations.

In some countries, additional risk factors such as altitude, parasitosis and sickle cell disease result in unique forms of CRD.

In the majority of developing countries, diagnostic tests like spirometry that are required for the diagnosis and assessment of severity of CRD are not readily available, resulting in incorrect assessment and under-diagnosis of CRD; additionally, essential drugs for the treatment of CRD are not available and/or affordable in a large proportion of developing countries.

Programmes for educating healthcare professionals in the care and management of patients with CRD require strengthening in developing countries, and public awareness of CRD should be increased.

Developed countries

In developed countries, CRD are usually independent from communicable diseases and there are structures for fighting the diseases. A few successful national programmes against CRD exist. However, they are not comprehensive (e.g. asthma or COPD plans), they are fragmented, need to be expanded and integrated within a single action plan and require more coordination. Moreover, CRD are rarely on the public-health agenda. Generally, data on the CRD risk factors, burden and surveillance are fragmented and often incomplete, and awareness of CRD is largely insufficient.

Prevention and health promotion for CRD is also largely insufficient. Although many risk factors predisposing to CRD are preventable, policies and legislations are still inadequate throughout the world. The Framework Convention on Tobacco Control has become an international law but there are still many countries that have yet to ratify it. As a result: 1) asthma is under-diagnosed and not optimally controlled in many patients; 2) COPD is largely under-diagnosed, under-treated and largely induced by smoking; and 3) COPD is not regarded as a systemic disease nor assessed as part of a chronic systemic disease which often includes cardiovascular and metabolic disorders.

Work-related CRD should be better identified, diagnosed and prevented, and it should be recognised that in some countries there may be additional CRD associated with altitude.

With regard to the identification and treatment of patients with CRD, lung function testing is available in specialist practices and, in some countries, in primary care, while drugs are usually available but are not always affordable.

WG-1: Burden, risk factors and surveillance of CRD and respiratory allergies

In all countries, the prevalence and incidence of CRD are under-investigated. There is a need for epidemiological studies with questionnaires and simple spirometry to properly estimate the CRD burden. Existing WHO databases should be integrated with the CRD morbidity rate (and any other risk factor) data. This WG will develop a standardised process to obtain data on CRD risk factors, disease burden, trends, quality and affordability of care and the economic burden, all of which can then be compared between all countries (developed and developing) to define strategies for policy makers.

WG-2: Advocacy for CRD

Although the cost of inaction is clear and unacceptable, CRD and its risk factors receive insufficient attention from the healthcare community, government officials, media, patients and families. There is a need to elevate CRD on the health agenda of key policy makers. All stakeholders should be involved to increase awareness on CRD. The ultimate goal of dissemination is to provide evidence that the burden of CRD can be reduced. Therefore, it is essential to raise awareness of CRD among all stakeholders and to make CRD a public health priority in all countries.

WG-3: Health promotion and prevention of CRD and respiratory allergies

Everyone has the right to live and work in a clean environment. Environmental exposure to an unhealthy environment causes severe and debilitating COPD, asthma, cardiovascular diseases and cancer. Complete elimination of the risk factor is the only way to remove the risk. These messages apply equally to tobacco smoking, indoor and outdoor air pollutants, occupational exposure and allergens. WG-3 will encourage countries to implement policies in order to reduce the burden of tobacco smoke, indoor and outdoor pollution, occupational hazards and other risk factors relevant to CRD.

WG-4: Diagnosis of CRD and respiratory allergies

In all countries CRD are under-diagnosed. There is a need for early CRD diagnosis in order to reduce severe diseases and disability. Low-cost, effective spirometry and allergy tests are needed. GARD will make recommendations for providing simple and affordable diagnostic tools for CRD and respiratory allergies using approaches adapted to different health needs, services, and resources as well as proper training of health professionals in their use.

WG-5: Control of CRD and allergy and drug accessibility

GARD action plans should be tailored to each country's needs, priorities, health services and resources (fig. 3⇓).

In areas with a high burden of communicable diseases and a functioning primary healthcare service, an integrated approach to the prevention, diagnosis and management is recommended. Models like the WHO-Practical Approach to Lung Health (PAL) will be promoted 42. In areas with a high prevalence of HIV infection, models like PAL in South Africa Plus will be promoted 26.

Models of prevention and care for CRD in middle- and high-income countries will use a different model. Disease-specific approaches may be more relevant. They will target asthma, rhinitis, COPD and occupational lung diseases. Approaches will be developed from available management plans and international guidelines according to specific country needs. Of particular interest is the control of occupational CRD and pulmonary hypertension which have not received enough attention worldwide.

The key aspects of GARD action plans will be as follows. 1) To ensure the availability of drugs for patients with CRD in each treatment setting. Most asthmatics live in developing countries and in deprived areas; however, access to essential drugs is limited in these regions. The Asthma Drug Facility recently proposed by the Union 43 will be used by GARD. 2) To assist in knowledge translation strategies for the training of healthcare workers in the management of CRD.

WG-6: Paediatric CRD and respiratory allergies

CRD in children should be considered separately, but, as for adults, GARD should consider low-, middle- and high-income settings and make short-, medium- and long-range goals.