- Open Access
WHO MONICA Project: What Have We Learned and Where to Go from Here?
Public Health Reviewsvolume 33, pages373–396 (2011)
The decline in infectious diseases and a rise in chronic diseases, particularly cardiovascular disease (CVD), underlies the health trajectory of the 20th century. While much was known about CVD, particularly myocardial infarction and stroke, population data were problematic. Importantly, the peak and decline of the CVD epidemic in the 1960s and 1970s in some countries was not well recognized, leading to calls for more population-based disease surveillance. The WHO Multinational MONItoring of Trends and Determinants in CArdiovascular Disease (MONICA) Project was the most comprehensive approach to better understanding disease etiology, incidence and trends at the population level. For a period of ten years or more in each center, from the early 1980s to the mid 1990s, MONICA implemented CVD surveillance in 21 countries. It included mortality, morbidity, coronary care, and population-based risk factor surveillance. The study is characterized by well-described methods and high quality data. The findings show large differences between different centers in 21 countries and provide information for disease treatment and prevention. Many MONICA centers continued to actively collect data on populations within their countries. This experience provides a comprehensive approach for CVD patterns in the developed countries and the oncoming epidemic in the developing world.
Havlik RJ, Feinleib M, editors. Proceedings of the Conference on the Decline in Coronary Heart Disease Mortality, October 24–25, 1978. Washington, DC: National Heart, Lung and Blood Institute, 1979, NIH publication No. 79-1610, DHES.
Dawber TR. The Framingham Study: The Epidemiology of Atherosclerotic Disease. Cambridge, MA: Harvard University Press; 1980.
Keys A. Seven Countries: A Multivariate Analysis of Death and Coronary Heart Disease. Cambridge, MA and London, England: Harvard University Press; 1980.
Brown SA, Hutchinson R, Morrisett J, Boerwinkle E, Davis CE, Gotto AM Jr, et al. Plasma-lipid, lipoprotein cholesterol, and apoprotein distributions in selected United States communities: the Atherosclerosis Risk in Communities (ARIC) Study. Arteriosclerosis and Thrombosis. 1993;13:1139–58.
Gillum RF, Hannan PJ, Prineas RJ, Jacobs DRE Jr, Gomez-Marin O, Luepker RV, et al. Coronary heart disease mortality trends in Minnesota, 1960–1980: the Minnesota Heart Survey. Am J Public Health. 1984;74:360–2.
Luepker RV, Murray DM, Jacobs DR, Mittelmark MB, Bracht N, Carlaw R, et al. Community education for CVD prevention: risk factor changes in the Minnesota Heart Health Program. Am J Pub Health. 1994;84:1383–93.
Winkleby MA, Taylor CB, Jatulis D, Fortmann SP. The long-term effects of a cardiovascular disease prevention trial: the Stanford Five-City Project. Am J Pub Health. 1996;86:1773–9.
Carleton RA, Lasater TM, Assaf AR, Feldman HA, McKinlay S. The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk. Am J Pub Health. 1995;85:777–85.
Tunstall-Pedoe H (editor), for the WHO MONICA Project. MONICA Monograph and Multimedia Sourcebook. World Health Organization, Geneva, 2003.
Institute of Medicine. A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. IOM. Washington, DC: The National Academies Press; 2011.
Butler WJ, Ostrander LD Jr, Carman WJ, Lamphiear DE. Mortality from coronary heart disease in the Tecumseh Study: long-term effect of diabetes mellitus, glucose tolerance and other risk factors. Am J Epidemiol. 1985;121:541–7.
Costas R, Garciapalmieri MR, Nazario E, Sorlie PD. Relation of lipids, weight and physical activity to incidence of coronary heart disease: Puerto Rico Heart Study. Am J Cardiol. 1978;42:653–8.
World Health Organization Regional Office for Europe. Myocardial infarction community registers, Copenhagen, 1976 (Public Health in Europe 5).
Uemura K, Pisa Z. Trends in cardiovascular disease mortality in industrialized countries since 1950. World Health Stat Q 1988;41:156–78.
Higgins M, Luepker RV, editors. Trends and determinants of coronary heart disease mortality: international comparisons. Int J Epidemiol. 1989;18:S1–235.
Madans JH, Cox CS, Kleinman JC, Makuc D, Feldman JJ, Finucane FF, et al. 10 years after NHANES-1: mortality experience at initial follow-up, 1982–84. Pub Health Reports. 1986;101:474–81.
Winkleby, MA, Feldman, HA, Murray, DM. Joint analysis of three U.S. community intervention trials for reduction of cardiovascular disease risk. J Clin Epidemiol. 1997;50:645–58.
WHO MONICA Project. MONICA Manual. (1998–1999). 31 March 1999. Available from URL: http://www.ktl.f/publications/monica/manual/index. htm (Accessed 2 August, 2011).
Prineas RJ, Crow RS, Blackburn HW. The Minnesota Code Manual of Electrocardiographic Findings: Standards and Procedures for Measurement and Classification. J. Wright, 1982.
WHO MONICA Project. MONICA Quality assessment reports. MONICA Web Publications 2–18. 12 August, 2010. Available from URL: http://www.ktl.f/publications/monica/index.html (Accessed 2 August, 2011).
Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, Arveiler D, Rajakangas AM, Pajak A, for the WHO MONICA Project. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994;90:583–612.
Asplund K, Tuomilehto J, Stegmayr B, Wester PO, Tunstall-Pedoe H, for the WHO MONICA Project. Diagnostic criteria and quality control of the registration of stroke events in the WHO MONICA project. Acta Med Scan Suppl 1988;728:26–39.
Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas AM, Schroll M, for the WHO MONICA Project. Stroke incidence, case fatality, and mortality in the WHO MONICA Project. Stroke. 1995;26:361–7.
Tunstall-Pedoe H. Descriptions and definitions of myocardial infarction–personal reminiscences and a challenge. Int J Epidemiol. 2011;40:147–9.
Mähönen M, Cepaitis Z, Kuulasmaa K, for the WHO MONICA Project. Quality assessment of acute coronary care data in the WHO MONICA Project. February 1999. Available from URL: http://www.ktl.f/publications/monica/accqa/accqa.htm, URN:NBN:f-fe19991081 (Accessed 2 August, 2011).
DeGaudemaris R, Folsom AR, Prineas RJ, Luepker RV. The random-zero versus the standard mercury sphygmomanometer: a systematic blood pressure difference. Am J Epidemiol. 1985;121:282–90.
Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, Tolonen H, Ruokokoski E, Amouyel P. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA Project populations. Lancet 1999;353:1547–57.
Kuulasmaa K, Tunstall-Pedoe H, Dobson A, Fortmann S, Sans S, Tolonen H, Evans A, Ferrario M, Tuomilehto J. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. Lancet 2000;355:675–87.
Tunstall-Pedoe H, Vanuzzo D, Hobbs M, Mahonen M, Capaitis Z, Kuulasmaa K, Keil U. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000;355:688–700.
The WHO MONICA Website. 19 September, 2009. URL: http://www.ktl.f/monica/ (Accessed 2 August, 2011).
Chambless LE, Dobson AJ, Patterson CC, Raines B. On the use of a logistic risk score in predicting risk of coronary heart disease. Stat Med. 1990;9:385–96.
Kulathinal SB, Kuulasmaa K, Gasbarra D. Estimation of an errors-in-variables regression model when the variances of the measurement errors vary between the observations. Stat Med. 2002;21:1089–101.
Kuulasmaa K, Dobson A, for the WHO MONICA Project. Statistical issues related to following populations rather than individuals over time. Bulletin of the International Statistical Institute: Proceedings of the 51st Session; 1997 Aug 18-26; Istanbul, Turkey. Voorburg: International Statistical Institute; 1997. Book 1; 295-8. Also available from URL: http://www.ktl.f/publications/monica/isi97/isi97.htm (Accessed 15 December 2011).
Tolonen H, Dobson A, Kulathinal S, for the WHO MONICA Project. Effect on trend estimates of the difference between survey respondents and non-respondents: results from 27 populations in the WHO MONICA Project. Eur J Epidemiol. 2005;20:887–98.
Wolf HK, Kuulasmaa K, Tolonen H, Sans S, Molarius A, Eastwood BJ, for the WHO MONICA Project. Effect of sampling frames on response rates in the WHO MONICA risk factor surveys. Eur J Epidemiol. 2005;20:293–9.
Tolonen H, Ferrario M, Kuulasmaa K, For the WHO MONICA Project. Standardization of total cholesterol measurement in population surveys-pre-analytic sources of variation and their effect on the prevalence of hypercholesterolaemia. Eur J Cardiovasc Prev Rehabil. 2005;12:257–67.
Barnett A, Sans S, Salomaa V, Kuulasmaa K, Dobson A, For the WHO MONICA Project. The effect of temperature on systolic blood pressure. Blood Press Monit. 2007;12:195–203.
Salomaa V, Dobson A, Miettinen H, Rajakangas A-M, Kuulasmaa K, For the WHO MONICA Project. Mild myocardial infarction–a classification problem in epidemiologic studies. J Clin Epidemiol. 1997;50:3–13.
Hense HW, Koivisto A-M, Kuulasmaa K, Zaborskis A, Kupsc W, Tuomilehto J, For the WHO MONICA Project. Assessment of blood pressure measurement quality in the baseline surveys of the WHO MONICA Project. J Hum Hypertens. 1995; 9:935–46.
Tolonen H, Dobson A, Kulathinal S, For the WHO MONICA Project. Assessing the quality of risk factor survey data: lessons from the WHO MONICA Project. Eur J Cardiovasc Prev Rehabil. 2006;13:104–14.
Waterhouse J, Muir CS, Correa P, Powell I, eds. Cancer incidence in five continents. Lyon, IARC, 1976. Vol 3, p.456.
Tunstall-Pedoe H. Is acute coronary heart disease different in different countries in the two sexes: lessons from the MONICA Project. Cardiovasc Risk Factors. 1996;6:254–61.
Evans A, Salomaa V, Kulathinal S, Asplund K, Cambien F, Ferrario M, Percia M, Peltonen L, Shields D, Tunstall-Pedoe H, Kuulasmaa K, For the MORGAM Project. MORGAM (an international pooling of cardiovascular cohorts). Int J Epidemiol 2005; 34: 21–7.
Tunstall-Pedoe H, Connaghan J, Woodward M, Tolonen H, Kuulasmaa K, For the WHO MONICA Project. Pattern of declining blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s to mid-1990s, and the role of medication. BMJ. 2006;332:629–35.
Asplund K, Bonita R, Kuulasmaa K, Rajakangas A-M, Feigin V, Schädlich H, et al., For the WHO MONICA Project. Multinational comparisons of stroke epidemiology–evaluation of case-ascertainment in the WHO MONICA stroke study. Stroke. 1995;26:355–60.
Sarti C, Stegmayr B, Tolonen H, Mähönen M, Tuomilehto J, Asplund J, For the WHO MONICA Project. Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project. Stroke. 2003;34:1833–41.
Yarnell J, McCrum E, Rumley A, Patterson C, Salomaa V, Lowe G, et al., On behalf of the MONICA Optional Haemostasis Study Investigators. Association of European population levels of thrombotic and infammatory factors with risk of coronary heart disease: the MONICA Optional Haemostasis Study. Eur Heart J. 2005;26:332–42.
Nuttens MC, Romon M, Ruidavets JB, Arveiler D, Ducimetiere P, Lecerf JM, et al. Relationship between smoking and diet: the MONICA-France project. J Internal Med. 1992;231:349–56.
Danet S, Richard F, Montaye M, Beauchant S, Lemaire B, Graux C, et al. Unhealthy effects of atmospheric temperature and pressure on the occurrence of myocardial infarction and coronary deaths: A 10-year survey: the Lille-World Health Organization MONICA Project (Monitoring Trends and Determinants in Cardiovascular Disease). Circulation. 1999;100:e1–e7.
Nilsson M, Trehn G, Asplund K. Use of complementary and alternative medicine remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA Project. J Internal Med. 2001;250:225–33.
Isaksson RM, Jansson JH, Lundblad D, Näslund U, Zingmark K, Eliasson M. Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006: an analysis of 8630 patients in the Northern Sweden MONICA Study. BMC Cardiovasc Disorders. 2011;11:1.
Lundblad D, Holmgren L, Jansson JH, Näslund U, Eliasson M. Gender differences in trends of acute myocardial infarction events: the Northern Sweden MONICA Study 1985–2004. BMC Cardiovasc Diseases. 2008;8:17.
Briffa T, Hickling S, Knuiman M, Hobbs M, Hung J, Sanflippo FM, et al. Long term survival after evidence based treatment of acute myocardial infarction and revascularization: follow-up of population based Perth MONICA cohort, 1984–2005. BMJ. 2009;338:b36.
Sans S, Puigdefábregas A, Paluzie G, Monterde D, Balaguer-Vintró I. Increasing trends of acute myocardial infarction in Spain: the MONICA-Catalonia Study. Eur Heart J. 2005;26:505–15.
Kuch B, Wende R, Barac M, von Scheidt W, Kling B, Greschik C, et al. Prognosis and outcomes of elderly (75-84 years) patients with acute myocardial infarction 1–2 years after the event–AMI-elderly study of the MONICA/KORA Myocardial Infarction Registry. Int J Cardiology. 2011;149:205–10.
Pigeyre M, Dauchet L, Simon C, Bongard V, Bingham A, Arveiler D, et al. Effects of occupational and educational changes on obesity trends in France: the results of the MONICA-France survey 1986–2006. Prev Med. 2011;52:305–9.
Eriksson M, Holmgren L, Janlert U, Jansson JH, Lundblad D, Stegmayr B, et al. Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–2009. J Internal Med. 2010;269:219–31.
Imhof A, Woodward M, Doering A, Helbecque N, Loewel H, Amouyel P, et al. Overall alcohol intake, beer, wine, and systemic markers of inflammation in western Europe: results from three MONICA samples (Augsburg, Glasgow, Lille). Eur Heart J. 2004;25:2092–100.
Hense HW, Schulte H, Löwel H, Assmann G, Keil U. Framingham risk function overestimates risk of coronary heart disease in men and women from Germany–results from the MONICA Augsburg and the PROCAM cohorts. Eur Heart J. 2003;24:937–45.
Beck JA, Meisinger C, Heier M, Kuch B, Hörmann A, Greschik C, et al. Effect of blood glucose concentrations on admission in non-diabetic versus diabetic patients with first acute myocardial infarction on short- and long-term mortality (from the MONICA/KORA Augsburg Myocardial Infarction Registry). Am J Cardiol. 2009;104:1607–12.
McDonagh TA, Woodward M, Morrison CE, McMurray JJV, Tunstall-Pedoe H, Lowe GDO, et al. Helicobacter pylori infection and coronary heart disease in the North Glasgow MONICA population. Eur Heart J. 1997;18:1257–60.
Euro Heart Survey. Available from URL: http://www.escardio.org/guidelinessurveys/ehs/Pages/welcome.aspx (Accessed 26 September, 2011).
Feasibility of a European Health Examination Survey. Available from URL: http://www.ktl.f/fehes/index.html (Accessed 26 September, 2011).
Levy RI, Causes of the decrease in cardiovascular mortality. Am J Cardiol. 1984;54:7C–13C.