The Global Health Intervention Review (GHIR) aims to make global health data accessible to policymakers by distilling evidence from systematic reviews into concise summaries of key intervention effects for various health conditions, including relative risk reductions, strength of evidence, and limitations; phase 1 focused on summarizing intervention efficacy for 10 health conditions like diarrhea, HIV, and malaria; phase 2 will explore effectiveness, burden reduction, and cost-effectiveness to better inform policy and funding decisions.

1. Global Health Intervention ReviewGlobal Health Intervention Review
(GHIR):(GHIR):
Making Global Health DataMaking Global Health Data
Accessible to Policy MakersAccessible to Policy Makers
Mohsen Malekinejad MD, Dr.PHMohsen Malekinejad MD, Dr.PH
Institute for Health Policy StudiesInstitute for Health Policy Studies
University of California, San FranciscoUniversity of California, San Francisco
CUGH, September 21, 2010CUGH, September 21, 2010
University of WashingtonUniversity of Washington

2. BackgroundBackground
 Growing evidence baseGrowing evidence base in global health, muchin global health, much
needed butneeded but dauntingdaunting inin quantity and technicalquantity and technical
complexitycomplexity
 Kaiser Family Foundation project toKaiser Family Foundation project to make keymake key
global health information accessibleglobal health information accessible to policyto policy
makers and health mediamakers and health media
 UCSF asked toUCSF asked to distill existing evidence ondistill existing evidence on
intervention effectsintervention effects for broad set of healthfor broad set of health
conditions and interventionsconditions and interventions

3. Goals – 1Goals – 1
 Translate evidence baseTranslate evidence base for intervention effectsfor intervention effects
into technically sound, concise, accessibleinto technically sound, concise, accessible
quantitative synthesisquantitative synthesis
 Prevention and treatmentPrevention and treatment
 Focus onFocus on data of most potential relevancedata of most potential relevance forfor
policy and funding decisionspolicy and funding decisions
 Complement other summaries with aComplement other summaries with a focus onfocus on
systematic, health-condition level, maximalsystematic, health-condition level, maximal
synthesis of “what works?”synthesis of “what works?”

4. Goals – 2Goals – 2
 Phase 1: summarizing evidence of efficacy for 10Phase 1: summarizing evidence of efficacy for 10
conditionsconditions::
Waterborne diarrheaWaterborne diarrhea
HIVHIV
malariamalaria
TBTB
dengue feverdengue fever
soil-transmitted helminthssoil-transmitted helminths
unintended pregnancyunintended pregnancy
maternal post partum hemorrhagematernal post partum hemorrhage
maternal sepsismaternal sepsis
hypertension (pending)hypertension (pending)

5. MethodsMethods
 Stepwise, transparent progressionStepwise, transparent progression fromfrom
evidence base (mainly systematic reviews)evidence base (mainly systematic reviews)
to key findingsto key findings
 Standardized outcome metricStandardized outcome metric “relative risk“relative risk
reduction” (RRR) =reduction” (RRR) =
By what % does the interventionBy what % does the intervention
reduce negative health outcomes?reduce negative health outcomes?
 Strength of evidenceStrength of evidence – 0 to 6 scale, like– 0 to 6 scale, like
cell phone reception, based on extent andcell phone reception, based on extent and
type of studies, review quality, precision.type of studies, review quality, precision.

6. Search for systematic reviews & pivotal new studies
for prevention & treatment for a health condition.
Select potentially policy-relevant
reviews and comparisons
Extract context, method, and
findings for quantitative efficacy
Rate strength of evidence
(quantity & type of studies, precision)
Present
key findings
Combine evidence by
intervention type
GHIR data
distillation
process
Massive,
Diverse,
Technical
Concise,
Consistent,
AccessibleConsult
with
experts

7. Data DistillationData Distillation
Health Condition
Review
Studies
Intervention-
outcome
Comparisons
Key
Findings
Dengue fever 7 79 6
HIV 36 579 39
malaria 17 337 12
soil-transmitted helminths 5 in progress in progress
TB 18 250 34
waterborne diarrhea 24 373 11
maternal sepsis 20 150 10
maternal PPH* 15 163 11
unintended pregnancy 15 327 15
Nine conditions (total) 157 2321 138
* PPH: post partum hemorrhage

8. Web site: Key FindingsWeb site: Key Findings
Diarrhea – PreventionDiarrhea – Prevention

9. Web site: Key FindingsWeb site: Key Findings
Diarrhea – TreatmentDiarrhea – Treatment

10. DISEASE ACQUISITION DISEASE PROGRESSION
Disease process:
Fluid loss
Dehydration
Intestinal wall infection / bleeding
Water source
(risk of microbial
contamination)
Water & food
handling in
household
(risk of microbial
contamination) DiarrheaDiarrhea DEATH
• Protection of source
(eg bore holes)
Waterborne diarrhea
Consumption of
contaminated
water or food
• Oral rehydration
• Micronutrients
• Antimicrobrial for certain pathogens
• Intravenous rehydration
• Decontamination at
point of use (eg
filters, safe vessels)
• Latrines and
sewers
Light blue boxes indicate mechanisms of
disease acquisition and progression.
Orange boxes indicate
interventions
Contamination
of hands
•Behavioral (eg
hand washing)
Hand-mouth
contact

11. Web site: OverviewWeb site: Overview
Diarrhea –1Diarrhea –1

12. Web site: OverviewWeb site: Overview
Diarrhea – 2Diarrhea – 2

13. Interventions forInterventions for diarrheadiarrhea withwith
RRR>20% and SoE+++RRR>20% and SoE+++
 PreventionPrevention
• typhoid vaccine 49%-72%typhoid vaccine 49%-72%
• rotavirus vaccine 63%-85%rotavirus vaccine 63%-85%
• decontamination of water at point of usedecontamination of water at point of use
24%-37%24%-37%
• behavioral intervention 23%-41%behavioral intervention 23%-41%
• multifaceted intervention 26%-57%multifaceted intervention 26%-57%
 TreatmentTreatment
• advance oral rehydration 30%-41%advance oral rehydration 30%-41%
• oral zinc 29%-45%oral zinc 29%-45%
• anti-protozoan 61%-87%anti-protozoan 61%-87%

14. Interventions forInterventions for malariamalaria withwith
RRR>20% and SoE+++RRR>20% and SoE+++
 PreventionPrevention
• bed nets 17%-23%*bed nets 17%-23%*
• chemoprophylaxis (IPT) for childrenchemoprophylaxis (IPT) for children
24%-57%24%-57%
 TreatmentTreatment
• Artemisinin-based combination regimenArtemisinin-based combination regimen
38%-88%, and 25%-49%*38%-88%, and 25%-49%*

15. Interventions forInterventions for HIVHIV withwith
RRR>20% and SoE +++RRR>20% and SoE +++
 PreventionPrevention
• adult male circumcision 50%-54%adult male circumcision 50%-54%
• Zidovudine for infected mothers to baby 54%-Zidovudine for infected mothers to baby 54%-
69%*69%*
 TreatmentTreatment
• ART + CD4 count + clinical monitoring 26%*ART + CD4 count + clinical monitoring 26%*
• Early initiation of ART 74%*Early initiation of ART 74%*
• Cotrimoxazole 23%-37%*Cotrimoxazole 23%-37%*
• Fluconazole for oropharyngeal candidiasis 39%-Fluconazole for oropharyngeal candidiasis 39%-
84%84%

16. Phase 1 limitationsPhase 1 limitations
 EfficacyEfficacy (risk reduction in ideal setting)(risk reduction in ideal setting)
essential but insufficient … need real worldessential but insufficient … need real world
effects, impact, and resource allocation.effects, impact, and resource allocation.
 Orientation aroundOrientation around intervention-outcomeintervention-outcome
pairs within health conditionspairs within health conditions usual &usual &
hence necessary, but poorly matched tohence necessary, but poorly matched to
some policy issues (e.g., MDGs) andsome policy issues (e.g., MDGs) and
opportunities (e.g., system building).opportunities (e.g., system building).

17. Next Step:Phase 2 – Objectives:Next Step:Phase 2 – Objectives:
 Effectiveness:Effectiveness: How well does theHow well does the
intervention evidence base reflect real-intervention evidence base reflect real-
world, large scale implementation?world, large scale implementation?
 Burden reduction:Burden reduction: How much wouldHow much would
intervention scale-up reduce burden ofintervention scale-up reduce burden of
disease? Measured in DALYsdisease? Measured in DALYs
 Cost-effectiveness:Cost-effectiveness: How does a set ofHow does a set of
interventions translate to cost per DALYinterventions translate to cost per DALY
averted?averted?

18. Investigators (phase1):
Jim G Kahn MD, MPH (PI)
Mohsen Malekinejad MD, DrPH
Brian Harris M.A.
Institute for Health policy Studies,
University of California, San Francisco
Elliot Marseille DrPH, MPP
Health International Strategies
Jeniffer Kates MPH
Kaiser Family Foundation