World Thrombosis Day – raising awareness of a serious and often overlooked condition

Led by the International Society on Thrombosis and Haemostasis (ISTH), dozens of thrombosis and haemostasis societies, patient advocacy groups, medical/scientific organisations and other interested parties from around the world, including the ISTH’s local affiliate, the Southern African Society of Thrombosis and Haemostasis, have come together with an ambitious agenda.

Their intention is to:
• Increase awareness of the prevalence of and risks associated with thrombosis
• Reduce the number of undiagnosed cases
• Increase the implementation of evidence-based prevention
• Encourage health care systems to implement strategies to ensure ‘best practices’ for prevention, diagnosis and treatment
• Advocate for adequate resources for these efforts and increased support for research to reduce the disease burden from thrombosis
• Ultimately save lives.

ISTH is a not-for-profit organisation and the leading thrombosis- and haemostasis-related scientific medical society in the world. It focuses on advancing the understanding, prevention, diagnosis and treatment of thrombotic and bleeding disorders. Its nearly 4000 members include a worldwide professional network of clinicians, researchers and educators from more than 98 countries who exchange ideas, insights and information to improve public health and patients’ lives.

The date for WTD was chosen because it is the birthday of Rudolf Virchow, a German physician and pathologist who first developed the concept of ‘thrombosis’ and made crucial advances in the understanding of this often misdiagnosed or undiagnosed condition. The mission of WTD is to reduce deaths and disabilities from thromboembolic disease through a greater awareness of its causes, risk factors, signs and symptoms, and through evidence-based prevention and treatment. This mission supports the World Health Assembly's global target of reducing premature deaths caused by non-communicable diseases — of which cardiovascular diseases are an important part — by 25% by 2025, as well as the WHO global action plan for the prevention and control of non-communicable diseases in the 2013-2020 timeframe.

WTD objectives are to:
• Highlight the burden of disease (thrombosis in general) and highlight the need for action, specifically underscoring the unrecognised threat and serious consequences (death and disability) related to venous thromboembolism (VTE), i.e. blood clots in the deep veins of the leg or pelvis (deep vein thrombosis) or in the lungs (pulmonary embolism)
• Increase public awareness of the significance, risks, signs and symptoms of VTE
• Empower individuals to seek medical attention promptly if they have signs or symptoms, and to engage their health care providers in discussions about appropriate diagnosis, prevention and treatment options
• Galvanise organisations in countries across the world to conduct appropriate and aligned campaigns locally
• Begin the process of advocating for ‘systems of care’ to properly prevent, diagnose and treat VTE.

Professor Barry Jacobson, Head of Clinical Haematology, Charlotte Maxeke Johannesburg Hospital, and Director of the Thrombosis and Haemostasis Research Unit, University of the Witwatersrand Health Consortium, says that World Thrombosis Day is an important initiative, as VTE is the number one preventable cause of death worldwide. “It’s particularly significant and relevant in the context of South Africa, with its very high incidence of HIV, as HIV increases the risk of VTE dramatically.”

He explains further that immobility and infection are the chief risk factors for VTE. “Blood clots in the veins cause stasis or lack of blood flow, damaging the lining of the blood vessels and bringing about changes in the consistency of blood. Patients are at risk of thrombosis during long periods of immobility, for example after undergoing surgery. It’s also a risk in the presence of inflammatory conditions like pneumonia or influenza. A deep vein thrombosis in any vein of the leg or pelvis can potentially break away, travel through the heart and into the lung causing a blockage that can be fatal. This phenomenon, known medically as a pulmonary embolism, was responsible for the death last year of well-known radio and TV personality, Vuyo Mbuli.”

Despite VTE’s being the biggest preventable cause of death globally, it remains a relatively unknown entity. “There is much more awareness of the negative health outcomes of breast cancer, prostate cancer, motor vehicle accidents and HIV/AIDS, for example,” continues Professor Jacobson. “While we have no local statistics with regard to VTE in South Africa, we can extrapolate from the UK, which has excellent statistics. In that country the number of people who die annually from a VTE is double the combined death rate of the aforementioned four conditions. World Thrombosis Day is therefore a welcome first step towards making both health care professionals and the public more aware of the burden of VTE,” he concludes.

Q and A

1. What is WTD?
World Thrombosis Day is a global health observance to increase awareness related to the dangers of blood clots and the damage that they cause. The burden of disease worldwide and in South Africa is incalculable. The World Health Assembly has set a target to reduce premature deaths from non-infectious disease, including cardiovascular by 25% by 20251. To meet this goal, it is imperative to reduce the incidence of thrombosis.

2. Why a WTD day?
A global initiative like WTD will unite healthcare professionals, policy makers, patients, academics, public health experts, funders and all stakeholders in the quest to better understand the consequences of thrombosis in all its forms. This campaign will escalate the urgency of this medical condition and establish open narratives at multi-sectoral levels. The impact of VTE is huge. In Europe, half a million people die from VTE each year – that is more than the combined death total from AIDS, breast/prostate cancer and highway motor vehicle accidents. This malady also leads to a high incidence of hospitalizations (in the US alone, more than 500,000 hospital admissions per year)1

Why is it important now?
Current data show that thrombosis is the single cause of the world’s top three cardiovascular killers: heart attack, stroke and venous thrombo-embolism. Today too few people know about VTE and its life-threatening consequences. As a result doctors are not sensitized to diagnose and treat early enough or to prevent embolism hence too many people are dying a preventable death.2

Has there been a rise in the number of people suffering from blood clots (DVT and PE)?
Yes, an increase in incidence has been detected. In South Africa, this is related to the prevalence of HIV and TB. Unfortunately medication taken by those living with HIV and TB increases the risk of DVT and consequential pulmonary embolism (PE) – according to Prof B Jacobson, Department of Haematology, Charlotte Maxeke Academic Hospital as discussed on the 17 September 2014.

How many patients who get a blood clot, die?
Prof B Jacobson said that approximately one percent of all patients presenting with DVTs will die ( of these DVT cases, 10% will result in pulmonary embolism and of these, 10% will die, hence of the total DVT population 1% mortality is reported).

Can we prevent blood clots?
Yes, blood clots can be prevented by the use of proven effective measures. This is the best way to control the immense burden of disease as well as the resultant catastrophic complications and disability.3

Is there a certain population segment that is most at risk?
The following population groups have an increased risk of DVTs and subsequent PE:
• Hospital admissions
• Surgery especially hip, knee and cancer related
• Not moving for long periods of time e.g. bed rest, long haul flights or other travel without walking for extended periods
• Using oestrogen-based medication such as oral contraception or hormone replacement therapy
• Pregnancy or recently delivery (the leading cause of maternal death)
• An uncontrollable risk factor, namely older age (an 80 year old is five- to- six times more at risk than a 40 year old)
• Family history: if someone in your family had a blood clot, you could be more at risk especially if other trigger situations are included such as bed rest or surgery
• Obesity: There is a two to three times greater risk of DVT among those people who are obese (with a BMI>30)4
• Prof Barry Jacobson also highlights the following groups that have an increased risk of DVTs and PE: Caucasian and Asian population with Factor VLeiden and Prothrombin Mutation. These are genetic factors that predispose individuals to clotting disorders. There are also auto-immune disorders that increase the risk profile of individuals as well as other inherited conditions which increase the risk of thrombosis.

3. What is the goal of the WDT initiative in SA?
WTD 2014 in South Africa must reach the following goals: disease awareness and resultant disease prevention, empowered patients who feel confident to discuss concerns with HCPs and an increased awareness of HCPs. In other words, healthcare consumers must become part of the healthcare partnership and better inform their HCPs relating to their health e.g. a young woman using oral contraceptives who has a family history of DVTs must alert her HCP to this concern and explore other contraceptive methods. The same applies to patients who will undergo surgery; should they have any clotting concerns, discuss prophylaxis with their healthcare team. WTD will also stimulate HCPs to be more aware of the risks of VTE and the need for prevention and early detection and treatment.3

4. What is the burden of disease in South Africa?
Statistics in South Africa are not accurate; however Professor Jacobson from Wits Medical Schoolmaintains that there is always a certain number of DVTs/PE in each and every medical ward. PE is the leading cause of preventable death in hospital.
How does the disease impact the individual?The individual who, either suspects they have an increased risk of VTE or has previously experienced an episode of VTE, will be affected in various ways such as
• They should be alert when any signs or symptoms are being experienced and seek medical attention immediately
• Adherence to any medication to prevent further complications
• Take responsibility for their health and ‘speak up’ e.g. should you require surgery, discuss with healthcare team the risk of VTE and whether or not prophylaxis will be necessary
• Commit to activity, move around as much as possible when traveling
• Maintain a healthy lifestyle e.g. weight control 5
Share statistics such as death and disability from thrombosis-related conditions. See BoD above

5. What actions need to be taken by the public and the “at-risk” patients and the health professionals?
All South Africans should make use of the opportunity to improve their knowledge related to thrombosis and emboli. They must understand that a blood clot can strike anyone, at any time. A blood clot in the leg or lungs can happen to anyone at any age. Some people do not have any warning sign or symptoms. It is thus so important to be aware of ‘trigger’ situations that increase the risk of DVTs and PEs such as surgery, immobility, oral contraception, hormone treatments and the initiation of risk-increasing medication e.g. ART, TB.
Upskill yourself to recognize the telltale warning signs of VTE:
• DVT –pain or tenderness starting in calf, swelling of leg, ankle and foot, redness or noticeable discolouration of leg and warmth
• Pulmonary Embolism (PE) –unexplained shortness of breath, rapid breathing, chest pain (worse with a deep breath), rapid heart rate and lightheadedness or fainting6

6. Five questions to ask your health care provider to reduce your risk of VTE.
• On entering hospital: establish the expected length of stay and whether bed rest is essential (will you be able to move around)
• Establish the probable risk of VTE related to the surgery
• Discuss the need for prophylaxis, in-hospital and after discharge and comply
• At Primary Healthcare facility: should a new medication be initiated, discuss the relative risk of VTE and precautions (e.g. oral contraceptives)
• Share any predisposing family history 5

7. When does WTD take place?
Every year on 13 October. This day was selected to mark the birthday of German physician/pathologist, Rudolf Virchow who first developed the concept of ‘thrombosis’.

8. Who is the lead organisation in SA on WTD?
Southern African Society of Thrombosis and Haemostasis (SASTH), affiliated to the International Society of Thrombosis and Haemostasis and is the official local partner for World Thrombosis Day.

9. Key contact details of South African Society of Thrombosis and Haemostasis.
This initiative is being driven by Professor Barry Jacobson, a haematologist at the Charlotte Maxeke Academic Hospital in Parktown Johannesburg. Email address:. Telephone number: 011 489 8414

References
1. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 53,54
2. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 37
3. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 6
4. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 38
5. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 51
6. How-to Awareness to Action Toolkit [Internet] 2014 September 17. Available from: http://worldthrombosisday.org/campaign-materials/toolkit / page 39

For more information visit http://www.worldthrombosisday.org/