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WHO MONICA Project: What Have We Learned and Where to Go from Here?

Abstract

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.

References

  1. 1.

    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.

    Google Scholar 

  2. 2.

    Dawber TR. The Framingham Study: The Epidemiology of Atherosclerotic Disease. Cambridge, MA: Harvard University Press; 1980.

    Google Scholar 

  3. 3.

    Keys A. Seven Countries: A Multivariate Analysis of Death and Coronary Heart Disease. Cambridge, MA and London, England: Harvard University Press; 1980.

    Google Scholar 

  4. 4.

    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.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    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.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    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.

    CAS  Article  Google Scholar 

  7. 7.

    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.

    CAS  Article  Google Scholar 

  8. 8.

    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.

    CAS  Article  Google Scholar 

  9. 9.

    Tunstall-Pedoe H (editor), for the WHO MONICA Project. MONICA Monograph and Multimedia Sourcebook. World Health Organization, Geneva, 2003.

    Google Scholar 

  10. 10.

    Institute of Medicine. A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. IOM. Washington, DC: The National Academies Press; 2011.

    Google Scholar 

  11. 11.

    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.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    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.

    Article  PubMed  Google Scholar 

  13. 13.

    World Health Organization Regional Office for Europe. Myocardial infarction community registers, Copenhagen, 1976 (Public Health in Europe 5).

    Google Scholar 

  14. 14.

    Uemura K, Pisa Z. Trends in cardiovascular disease mortality in industrialized countries since 1950. World Health Stat Q 1988;41:156–78.

    Google Scholar 

  15. 15.

    Higgins M, Luepker RV, editors. Trends and determinants of coronary heart disease mortality: international comparisons. Int J Epidemiol. 1989;18:S1–235.

  16. 16.

    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.

    CAS  Google Scholar 

  17. 17.

    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.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    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).

  19. 19.

    Prineas RJ, Crow RS, Blackburn HW. The Minnesota Code Manual of Electrocardiographic Findings: Standards and Procedures for Measurement and Classification. J. Wright, 1982.

    Google Scholar 

  20. 20.

    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).

  21. 21.

    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.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    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.

    CAS  Google Scholar 

  23. 23.

    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.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Tunstall-Pedoe H. Descriptions and definitions of myocardial infarction–personal reminiscences and a challenge. Int J Epidemiol. 2011;40:147–9.

    Article  PubMed  Google Scholar 

  25. 25.

    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).

    Google Scholar 

  26. 26.

    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.

    CAS  Article  Google Scholar 

  27. 27.

    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.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    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.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    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.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    The WHO MONICA Website. 19 September, 2009. URL: http://www.ktl.f/monica/ (Accessed 2 August, 2011).

  31. 31.

    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.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    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.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    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).

    Google Scholar 

  34. 34.

    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.

    Article  PubMed  Google Scholar 

  35. 35.

    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.

    Article  PubMed  Google Scholar 

  36. 36.

    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.

    PubMed  Google Scholar 

  37. 37.

    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.

    Article  PubMed  Google Scholar 

  38. 38.

    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.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    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.

    CAS  PubMed  Google Scholar 

  40. 40.

    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.

    PubMed  Google Scholar 

  41. 41.

    Waterhouse J, Muir CS, Correa P, Powell I, eds. Cancer incidence in five continents. Lyon, IARC, 1976. Vol 3, p.456.

    Google Scholar 

  42. 42.

    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.

    Google Scholar 

  43. 43.

    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.

    Article  PubMed  Google Scholar 

  44. 44.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    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.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    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.

    Article  PubMed  Google Scholar 

  47. 47.

    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.

    Article  PubMed  Google Scholar 

  48. 48.

    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.

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    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.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    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.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    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.

    Article  Google Scholar 

  52. 52.

    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.

    Article  Google Scholar 

  53. 53.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    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.

    Article  PubMed  Google Scholar 

  55. 55.

    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.

    Article  Google Scholar 

  56. 56.

    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.

    Article  PubMed  Google Scholar 

  57. 57.

    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.

    Article  PubMed  Google Scholar 

  58. 58.

    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.

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    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.

    Article  PubMed  Google Scholar 

  60. 60.

    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.

    CAS  Article  PubMed  Google Scholar 

  61. 61.

    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.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Euro Heart Survey. Available from URL: http://www.escardio.org/guidelinessurveys/ehs/Pages/welcome.aspx (Accessed 26 September, 2011).

  63. 63.

    Feasibility of a European Health Examination Survey. Available from URL: http://www.ktl.f/fehes/index.html (Accessed 26 September, 2011).

  64. 64.

    Levy RI, Causes of the decrease in cardiovascular mortality. Am J Cardiol. 1984;54:7C–13C.

    CAS  Article  PubMed  Google Scholar 

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Correspondence to Russell V. Luepker MD, MS.

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Luepker, R.V. WHO MONICA Project: What Have We Learned and Where to Go from Here?. Public Health Rev 33, 373–396 (2011). https://doi.org/10.1007/BF03391642

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Keywords

  • Cardiovascular diseases
  • coronary care
  • coronary risk factors
  • disease surveillance
  • epidemiologic methods
  • international studies