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Our Time A Call to Save Preventable Death From Cardiovascular

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David A. Wood and William A. ZoghbiTaubert,Cand. Jur, Diana Vaca McGhie, Johanna Ralston, Ralph L. Sacco, Hans Stam, Kathryn Sidney C. Smith, Jr, Amy Collins, Roberto Ferrari, David R. Holmes, Jr, Susanne Logstrup,and Stroke)Our Time: A Call to Save Preventable Death From Cardiovascular Disease (Heart DiseasePrint ISSN: 0009-7322. Online ISSN: 1524-4539Copyright © 2012 American Heart Association, Inc. All rights reserved.is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/CIR.0b013e318267e99f2012;126:2769-2775; originally published online September 17, 2012;Circulation./content/126/23/2769World Wide Web at:The online version of this article, along with updated information and services, is located on the//subscriptions/is online at: Circulation Information about subscribing to Subscriptions:/reprints Information about reprints can be found online at: Reprints:document. Permissions and Rights Question and Answer this process is available in the click Request Permissions in the middle column of the Web page under Services. Further information about Office. Once the online version of the published article for which permission is being requested is located, can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Circulation in Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions:Our Time:A Call to Save Preventable Death FromCardiovascular Disease(Heart Disease and Stroke)WRITING COMMITTEESidney C.Smith,Jr,MD,FACC,FAHA,FESC,Chair;Amy Collins,MA;Roberto Ferrari,MD,PhD,FESC;David R.Holmes,Jr,MACC,FAHA,FESC;Susanne Logstrup,Cand.Jur.,MBA,FESC;Diana Vaca McGhie,MPA;Johanna Ralston,MA,MSc;Ralph L.Sacco,MS,MD,FAAN,FAHA;Hans Stam,PhD;Kathryn Taubert,PhD,FAHA;David A.Wood,MSc,FRCP,FRCPE,FFPHM,FESC;William A.Zoghbi,MD,FACC,FAHA The writing committee members represent the following participating organizations:World Heart Federation(S.C.S.,A.C.,J.R.,K.T.),American Heart Association(D.V.M.,R.L.S.),American College of Cardiology Foundation(D.R.H.,W.A.Z.),European Heart Network(S.L.,H.S.),and European Society ofCardiology(R.F.,D.A.W.).W orldwide,the aging population,globalization,rapid urbanization,and population growth have fundamen-tally changed disease patterns.Noncommunicable diseases (NCDs),of which cardiovascular disease(CVD)accounts for nearly half,have overtaken communicable diseases as the world’s major disease burden.CVD remains the No.1global cause of death,accounting for17.3million deaths per year,a number that is expected to grow toϾ23.6million by2030. Increasingly,the populations affected are those in low-and middle-income countries,where80%of these deaths occur, usually at younger ages than in higher-income countries,and where the human and financial resources to address them are most limited.1The epidemiological transition occurring is exacerbated by the lack of vital investment in sustainable health policies to address and curtail the risk factors associated with CVD and NCDs.Recognizing the profound mismatch between the need for investment in the prevention and control of CVD at the global and national level and the actual resources allocated, the international CVD community,under the umbrella of the World Heart Federation,joined the NCD community to call for a United Nations(UN)High-level Meeting on Non-communicable Diseases,held in September2011.At this meeting,heads of state signed a Political Declaration that committed governments to the development of4specific measures to address the NCD burden in a specific timeline: (1)Recommendations for a global monitoring framework that included NCD targets to be completed by the end of2012;(2) development of a plan for an effective multisector partnership by the end of2012;(3)national NCD plans by2013;and(4) a comprehensive review to evaluate progress,to take place in 2014.2The World Heart Federation,American Heart Association,American College of Cardiology Foundation,European Heart Network,and European Society of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal,professional,or business interest of a member of the writing panel.Specifically,all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This document was approved by the World Heart Federation,American Heart Association Science Advisory and Coordinating Committee,American College of Cardiology Foundation Board of Trustees,European Heart Network Board,and European Society of Cardiology Board on August10,2012.The American Heart Association requests that this document be cited as follows:Smith SC Jr,Collins A,Ferrari R,Holmes DR Jr,Logstrup S,McGhie DV,Ralston J,Sacco RL,Stam H,Taubert K,Wood DA,Zoghbi WA.Our time:a call to save preventable deaths from cardiovascular disease(heart disease and stroke).Circulation.2012;126:2769–2775.This article has been copublished in Global Heart,Journal of the American College of Cardiology,and European Heart Journal.Copies:This document is available on the World Wide Web sites of the World Heart Federation(),American Heart Association(),American College of Cardiology Foundation(),European Heart Network (),and European Society of Cardiology().A copy of the document is available at / statements by selecting either the“By Topic”link or the“By Publication Date”link.To purchase additional reprints,call843-216-2533or e-mail kelle.ramsay@.Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations.For more on AHA statements and guidelines development,visit /statements and select the“Policies and Development”link.Permissions:Multiple copies,modification,alteration,enhancement,and/or distribution of this document are not permitted without the express permission of the American Heart Association.Instructions for obtaining permission are located at /HEARTORG/General/ Copyright-Permission-Guidelines_UCM_300404_Article.jsp.A link to the“Copyright Permissions Request Form”appears on the right side of the page.(Circulation.2012;126:2769-2775.)©2012by the World Heart Federation,American Heart Association,Inc.,American College of Cardiology Foundation,European Heart Network,and European Society of Cardiology.Circulation is available at DOI:10.1161/CIR.0b013e318267e99fCelebrating the2025Global NCDMortality TargetCelebrating the1-year anniversary of the passage of the UN Political Declaration,it is timely that our respective organiza-tions speak with a single voice to advocate for a set of public health interventions that have the potential to mitigate and reverse the rising rates of CVD and NCDs.In May2012,during the World Health Assembly,Ministers of Health took the first critical step by agreeing to adopt a global target to reduce premature NCD mortality25%by2025,a target the global CVD community has been advocating since the UN High-level Meet-ing on Non-communicable Diseases.3We applaud the World Health Assembly for reaching a consensus on this bold goal. The UN Political Declaration on NCDs and the recent resolution to reduce premature NCD deaths by25%are landmark achievements for the health and CVD community. For the first time in history,NCDs have been recognized as a development issue.These targets and indicators have the potential to address longstanding health challenges,including the fragmentation of health funding,gaps in the healthcareinfrastructure,and the lack of local and reliable data,and will address the growing demand for integrated disease manage-ment.As the Millennium Development Goals come to a close in2015,the CVD community is set to ensure that the single largest cause of death—CVD—is addressed.As such,all relevant stakeholders need to be part of the process,putting optimal health at the cornerstone of development.It is our desire to see heart disease and stroke receive the attention they deserve.We recognize that the process is complex and the time is short,but we have an opportunity to ensure that the commitments made in September2011translate into real global,and thus national,action for years to come.Collaboration among appropriate stakeholders will be necessary to address this emerging21st century global health priority and begin to reverse the devastating toll of CVD and NCDs in our communities.Maintaining the Momentum to AddressOther TargetsA first step toward global action has been the passage of the global mortality target,which will provide a shared vision on NCDs for all stakeholders and ensure that all targets are appropriately developed to achieve this overarching goal.As the leading organizations that represent thousands of members in nearly every country,and for the millions of individuals with,or at risk of CVD,we are aligning with the broader NCD community in support of a comprehensive set of additional targets that will ensure this global reduction is achieved.The challenge faced by countries will be to reach agreement concerning the additional targets and indicators to be part of the comprehensive monitoring framework to achieve the overarch-ing global mortality target.In the summer of2010,a World Health Organization(WHO)technical working group developed 10proposed global targets(Appendix A),which remained virtually unchanged until the spring of2012.4At that time, Member States,civil society organizations,and other relevant stakeholders were asked to comment on and make specific recommendations regarding the global monitoring framework for NCDs and the specific targets and indicators that would be used to guide countries and measure progress.The original set of 10targets was reduced before completion of regional consulta-tions and with limited input of Member States(Appendix B).5 Calls to action from the CVD,NCD,and specific risk-factor communities did,however,lead to positive changes within this reduced set of targets and included the insertion of a new target on physical activity.The inclusion of this target in the list of recommendations was a milestone in NCD advocacy efforts, ensuring that each of the major risk factors leading to NCDs was addressed.With the release of the third WHO discussion paper,6 the NCD community’s advocacy efforts are to be noted as the list of recommended targets for adoption includes10strong, evidence-based strategies.Together,the Global Cardiovascular Disease Taskforce calls on the CVD community to endorse and support the top4widely supported exposure targets(Table1)on physical inactivity,hypertension/blood pressure,dietary salt intake,and tobacco as those required to achieve the overarching goal of a25%reduction in premature mortality by2025. Other,originally proposed targets to address NCDs that were dropped in the second WHO discussion paper include evidence-based targets on obesity,trans fat/fat intake,alco-hol,and multidrug therapy to prevent and treat CVD(Table 2).7Although these targets have been included in the most recent discussion paper,they have been identified as having limited support and will need further advocacy to ensure their adoption.7In addition to supporting the NCD community in their call for Member States to agree on this global set of10 voluntary targets,we also explicitly call for Member States to be ambitious and ensure that they address those persons at highest risk now by adopting the additional exposure and health systems targets currently under consideration.To halt and reverse the NCD epidemic,it is paramount that the CVD burden be adequately addressed,which requires that those living with CVD and at highest risk of developing CVD have access to treatment and care.The2011report by the WHO, Scaling Up Action Against Noncommunicable Diseases:How Much Will It Cost?,details a core set of low-cost strategies, identified as“Best Buys”that all countries can implement to prevent and treat NCDs.This list includes population-based Table1.Suggested Global Targets to Address NCDs With Wide Support(See Appendix C)Proposed TargetBestBuyRecommendationto MemberStates1Physical inactivity:10%Relative reduction in prevalenceof insufficient physical activityߛAdopt2Raised blood pressure:25%Relative reduction in prevalenceof raised blood pressureߛAdopt3Salt/sodium intake:30%Relative reduction in meanpopulation intake of salt,with aim ofachieving recommended level ofϽ5g/d(2000mg of sodium)ߛAdopt4Tobacco:30%Relative reduction in prevalenceof current tobacco smokingߛAdopt NCDs indicate noncommunicable diseases.2770Circulation December4,2012measures to address risk factors and specific individual-based interventions,including a multidrug therapy regimen of aspirin, a statin,and blood pressure–lowering agents to prevent heart disease and stroke and to treat those with,or at highest risk of, heart disease and stroke.8As Member States determine how best to achieve this global target,the global CVD community looks to this package of the WHO’s“Best Buys”as a critical way forward.CVD and the WHO Best BuysWith CVD as the largest single contributor to global mortality, accounting for nearly half of the36million NCD deaths,and with a global cost of nearly US$863billion,achieving the global target to reduce premature NCD deaths by25%requires that CVD and its risk factors be adequately addressed.9The Global Cardiovascular Taskforce supports the set of recommendations identified by the WHO as“Best Buys,”feasible and cost-effective interventions that can be undertaken regardless of the income level of a country.This core set of interventions are recommended at2levels—population-wide measures to reduce exposure to risk factors and interventions targeting individuals who already have NCDs or are at high risk of developing them—and are implemented through a systematic layered ap-proach.Regarding population-wide risk factor measures,the WHO has identified“Best Buys”in the areas of tobacco use, harmful use of alcohol,salt intake,physical activity,and replace-ment of trans fat with polyunsaturated fat.Interventions target-ing individuals include evidence-based,cost-effective medical therapies alongside counseling,as well as aspirin therapy for acute myocardial infarction.10On the occasion of the UN High-level Meeting in September 2011,the WHO introduced a tool for low-,middle-,and high-income countries to guide and estimate the feasibility of the implemention of this core set of NCD interventions.8The cost of the interventions isϽUS$11.4billion per year in low-and middle-income settings.Yearly,per person,this translates toϽUS$1a day (US$0.43–US$0.90)across low-income countries andϽUS$3a day(US$0.54–US$2.93)across middle-income countries.11 Several of the10targets being supported by the NCD community have been identified within this core set of“Best Buy”interventions and are at risk of failing to be adopted as global targets,including the evidence-based drug therapy regimen to address those at highest risk for developing CVD. Studies have indicated that nearly17.9million deaths could be averted over a10-year period with the implementation of multidrug therapy.11The cost would amount to just over US$1a day annually.Beyond the lives saved and the life-years extended,reducing the mortality rate for ischemic heart disease and stroke by10%would also reduce economic losses in low-and middle-income countries by an estimated US$25billion per year.12Drug therapy,singly or in combi-nation with multiple drugs,is documented to be a concrete investment and should be a target to be accomplished.As Member States look to finalize targets in the coming months,doubt regarding country-level compliance in the imple-mentation of NCD interventions,as a result of underdeveloped monitoring and surveillance systems,must not overshadow the real,cost-effective,and feasible solutions offered by the WHO “Best Buys.”Collection of data,for all targets,remains a critical issue that can,and should,be addressed through the Global Monitoring Framework.It is recognized that target levels may vary slightly in different regions of the world.As such,when considering national NCD action plans,all targets will require adequate and well-developed indicators that encourage the improvement of data at the country level and provide an impetus to countries that have the tools to collect and monitor data.Moreover,improved health-care delivery and an expanded health workforce with coordination of local and national approaches are paramount in building com-prehensive health systems to achieve this end.Global Cardiovascular Taskforce Summary Position:Prevention,Risk Factors,and TreatmentMember States have taken the first step and set a bold overar-ching goal of reducing mortality from NCDs by25%by2025. We now have the opportunity to make meaningful changes in our countries by adopting evidence-based targets and imple-menting tactics that will guide health policy,chronic disease plans and,ultimately,resources for national public health inter-ventions.Many of these are feasible and cost-effective.Reduc-ing NCDs are central to a country’s economic growth.As such, we respectfully request Member States to consider our recom-mendations and adopt the evidence-based targets to address CVD and NCDs and avert millions of deaths by2025.Table2.Proposed Targets and Indicators to Address NCDs With Some Support(See Appendix C)Proposed Target BestBuyRecommendationto MemberStates5Saturated fat intake:15%Relative reduction in mean proportion of total energy intake from saturated fatty acids(SFA),with aim of achieving a recommended level of Ͻ10%of total energy intake ߛAdopt withmodification6Obesity:Halt the rise in obesity prevalenceAdopt7Alcohol:10%Relative reduction in overall alcohol consumption(especially hazardous,excessive,and harmful drinking)ߛAdopt withmodification8Raised cholesterol:20%Relative reduction in prevalenceof raised total cholesterolAdopt9Drug therapy to prevent heart attacksand strokes:50%Of eligible people receive drugtherapy to prevent heart attacks andstrokes,and counselingߛAdopt10Essential NCD medicines and basictechnologies to treat major NCDs:80%Availability of basic technologiesand generic essential medicinesrequired to treat major NCDs in bothpublic and private facilitiesAdoptNCDs indicate noncommunicable diseases.Smith et al A Call to Save Preventable Deaths From CVD2771Appendix A.Original Set of TargetsOutcome Targets Indicator SourcePremature mortality from NCDs25%Relative reduction in overall mortality from CVD,cancer,diabetes,or chronic respiratory disease Unconditional probability of dying between ages30and70y from CVD,cancer,diabetes,orchronic respiratory diseaseCivil registration system,with medical certification ofcause of death,or survey with verbal autopsyDiabetes10%Relative reduction in the prevalence of diabetes mellitus(elevated blood glucose levelՆ7.0mmol/L[26mg/dL] or on treatment for diabetes)Age-standardized prevalence of diabetes mellitusamong persons ageՆ25y(defined as fastingplasma glucoseՆ7.0mmol/L[126mg/dL]or ontreatment for diabetes)National survey(with measurement)Exposure TargetsTobacco smoking40%Relative reduction in prevalence of current tobacco smoking Age-standardized prevalence of current tobaccosmoking among persons ageՆ15yNational surveyAlcohol10%Relative reduction in alcohol per capita consumption among persons ageՆ15y Per capita consumption of pure liters of alcoholamong persons ageՆ15yOfficial statistics and reporting systems for production,import,export,and sale or taxation data and nationalsurveyDietary salt intakeMean adult population intake of salt Ͻ5g/d(2000mg of sodium)Age-standardized mean population intake of saltper day in gramsNational survey(with measurement)Blood pressure/hypertension25%Relative reduction in the prevalenceof elevated blood pressure(defined assystolic blood pressureՆ140mm Hgand/or diastolic blood pressureՆ90mm Hg)National survey(with measurement)ObesityNo increase in obesity prevalence Age-standardized prevalence of obesity(definedas BMIՆ30kg/m2)in persons ageՆ25yNational survey(with measurement)Prevention of heart attack and stroke 80%Coverage of multidrug therapy (including glycemic control)for people ageՆ30y with a10-y risk of heart attack or strokeՆ30%,or existing CVD Percentage of people ageՆ30y with a10-yrisk of heart attack or strokeՆ30%,or existingCVD who are currently on multidrug therapy(including glycemic control)National survey(with measurement)Cervical cancer screening80%Of women between ages30and49y screened for cervical cancer at least once Prevalence of women between ages30and49y screened for cervical cancer at least onceNational survey;health facility dataElimination of industrially produced trans fatty acids(PHVO)from the food supply Adoption of national policies that eliminatePHVOs in the food supplyPolicy reviewNCDs indicate noncommunicable diseases;CVD,cardiovascular disease;BMI,body mass index;and PHVO,partially hydrogenated vegetable oil.Appendix B.Reduced List of TargetsOutcome Targets Indicator Data Source(s)Mortality from NCDs25%Relative reduction in overall mortality from CVD, cancer,diabetes,or chronic respiratory disease Unconditional probability of dying between ages30and70y from CVD,cancer,diabetes,or chronicrespiratory diseaseCivil registration system,with medical certification ofcause of death,or survey with verbal autopsyBlood pressure/hypertension25%Relative reduction in the prevalence of elevated blood pressure(defined as systolic blood pressureՆ140mm Hg and/or diastolic blood pressureՆ90mm Hg)25%relative reduction in the prevalence of elevatedblood pressure(defined as systolic blood pressureՆ140mm Hg and/or diastolic blood pressureՆ90mm Hg)National survey(with measurement)Tobacco smoking40%Relative reduction in prevalence of current tobacco smoking Age-standardized prevalence of current tobaccosmoking among persons ageՆ15yNational surveyDietary salt intakeMean adult population intake of saltϽ5g/d (2000mg of sodium)Age-standardized mean population intake of salt perday in gramsNational survey(with measurement)Physical inactivity10%Relative reduction in prevalence of insufficient physical activity in adults agedՆ18y Age-standardized prevalence of obesity(defined asBMIՆ30kg/m2)in persons ageՆ25yNational surveyNCDs indicate noncommunicable diseases;CVD,cardiovascular disease;and BMI,body mass index. 2772Circulation December4,2012Appendix C.Current Set of TargetsOutcome Targets Indicator Data Source(s)Premature mortality from NCDs25%Relative reduction in overall mortality from CVD,cancer,diabetes,or chronic respiratory disease Unconditional probability of dying between ages30–70y from CVD,cancer,diabetes,or chronicrespiratory diseaseCivil registration system,with medical certification ofcause of death,or survey with verbal autopsyExposure TargetsAlcohol10%Relative reduction in overall alcohol consumption(including hazardous and harmful drinking)Total(recorded and unrecorded)alcohol percapita(Ն15y)consumption within a calendaryear in liters of pure alcoholOfficial statistics and reporting systems for production,import,export,and sales or taxation dataFat intake15%Relative reduction in mean proportion of total energy intake from saturated fatty acids (SFA),with aim of achieving recommended level ofϽ10%of total energy intake Age-standardized mean proportion of total energyintake from saturated fatty acids(SFA)in adultsagedՆ18yNational surveyObesityHalt the rise in obesity prevalence Age-standardized prevalence of obesity amongadults agedՆ18yNational survey(with measurement)Physical inactivity10%Relative reduction in prevalence of insufficient physical activity Age-standardized prevalence of insufficientphysical activity in adults agedՆ18yNational surveyRaised blood pressure25%Relative reduction in prevalence of raised blood pressure Age-standardized prevalence of raised bloodpressure among adults agedՆ18yNational survey(with measurement)Raised cholesterol20%Relative reduction in prevalence of raised total cholesterol Age-standardized prevalence of raised totalcholesterol among adults agedՆ18yNational survey(with measurement)Salt/sodium intake30%Relative reduction in mean population intake of salt,with aim of achieving recommended level ofϽ5g/d(2000mg of sodium)Age-standardized mean adult(agedՆ18y)population intake of salt per dayNational survey(with measurement)Tobacco30%Relative reduction in prevalence of current tobacco smoking Age-standardized prevalence of current tobaccosmoking among persons agedՆ15yNational surveyHealth Systems Response TargetsDrug therapy to prevent heart attacks and strokes 50%Of eligible people receive drug therapy to prevent heart attacks and strokes,and counseling Drug therapy to prevent heart attacks andstrokes(including glycemic control),andcounseling for people agedՆ40y with a10-year cardiovascular riskՆ30%(includesthose with existing cardiovascular disease)National surveyEssential NCD medicines and basic technologies to treat major NCDs80%Availability of basic technologies and generic essential medicines required to treat major NCDs in both public and private facilities Availability of basic technologies and genericessential medicines required to treat major NCDsin public and private sector facilities,includingprimary care facilitiesFacility dataNCDs indicate noncommunicable diseases;CVD,cardiovascular disease.Smith et al A Call to Save Preventable Deaths From CVD2773DisclosuresReferences1.World Health Organization,World Heart Federation,World Stroke Orga-nization.Global atlas on cardiovascular disease prevention and control: policies,strategies,and interventions.Published2011.Available at:http:// www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/.Accessed August7,2012.2.United Nations General Assembly.Resolution adopted by the GeneralAssembly:66/2:Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases.Adopted September19,2011;published January24,2012.Available at:http://www.who.int/nmh/events/un_ ncd_summit2011/political_declaration_en.pdf.Accessed June 26,2012.3.World Health Organization.65th World Health Assembly documentA65/54:Second report of Committee A.Published May25,2012.Available at:http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_54-en.pdf.Accessed August7,2012.4.World Health Organization.WHO discussion paper:a comprehensiveglobal monitoring framework and voluntary global targets for the prevention and control of NCDs.Updated December21,2011.Available at:http://www.who.int/nmh/events/2011/consultation_dec_ 2011/WHO_Discussion_Paper_FINAL.pdf.Accessed August7, 2012.5.World Health Organization.WHO discussion paper:summary offeedback from member states on the first discussion paper on the proposed global monitoring framework and indicators and targets for the prevention and control of noncommunicable diseases.Published March22,2012.Available at:http://www.who.int/nmh/events/2012/ targets_feedback_summary_22032012.pdf.Accessed August7, 2012.6.World Health Organization.Revised[third]WHO discussion paper on thedevelopment of a comprehensive global monitoring framework,including indicators,and a set of voluntary global targets for the prevention and control of NCDs.Published July2012.Available at:http://www.who.int/Writing Group DisclosuresWriting GroupMember Employment ResearchGrantOtherResearchSupportSpeakers’Bureau/HonorariaExpertWitnessOwnershipInterestConsultant/AdvisoryBoard OtherSidney C.Smith,Jr University of North Carolina None None None None None None None Amy Collins World Heart Federation None None None None None None NoneRoberto Ferrari University of Ferrara BoehringerIngelheim†;Novartis†;Roche†;Servier†None BoehringerIngelheim*;Roche*;Servier†None None Servier†NoneDavid R.Holmes,Jr Mayo Clinic None None None None None None NoneSusanne Logstrup European Heart Network None None None None None None None Diana Vaca McGhie American HeartAssociationNone None None None None None None Johanna Ralston World Heart Federation None None None None None None NoneRalph L.Sacco University of Miami MillerSchool of MedicineNone None None None None None None Hans Stam Dutch Heart Foundation None None None None None None None Kathryn Taubert World Heart Federation None None None None None None NoneDavid A.Wood Imperial College London AstraZeneca†;Bristol-MyersSquibb†;Emea Sari†;MSD†;GlaxoSmithKline†;Novartis†;PfizerPharmaceuticals†;Roche†None AstraZeneca*;Kowa*;MSD*None MyAction Ltd.†MerckSharp&Dohme*NoneWilliam Zoghbi TMH Physician Organization None None None None None None None This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire,which all members of the writing group are required to complete and submit.A relationship is considered to be“significant”if(1)the person receives$10000or more during any12-month period,or5%or more of the person’s gross income;or(2)the person owns5%or more of the voting stock or share of the entity,or owns$10000or more of the fair market value of the entity.A relationship is considered to be“modest”if it is less than“significant”under the preceding definition.*Modest.†Significant.2774Circulation December4,2012。

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河北省衡水市重点2024届高三第二次联考英语试卷含解析

河北省衡水市重点2024届高三第二次联考英语试卷含解析

河北省衡水市重点2024届高三第二次联考英语试卷注意事项：1．答卷前，考生务必将自己的姓名、准考证号填写在答题卡上。

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回答非选择题时，将答案写在答题卡上，写在本试卷上无效。

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第一部分（共20小题，每小题1.5分，满分30分）1．Lucy_ _writing her essay by 10:00 this morning. After that, she listened to music for a while.A．will finish B．finishesC．has finished D．had finished2．It is not like her to be so impolite; she you when you greeted her.A．might not have heard B．should not have heard C．mustn’t hear D．shouldn’t hear3．The manager is trying to find a man to recommend how the job .A．is done B．be done C．should done D．to do4．He has written two articles for the journal，one to be published in this issue，the other to___________ in the next. A．turn out B．come outC．bring out. D．leave out5．Country people don't pretend to have these ridiculous manners which are necessary _____ we call polite society．A．what B．in whatC．which D．in which6．This restaurant has an inviting, homelike atmosphere ______ many others are short of.A．where B．whenC．that D．what7．A firm from New Zealand has revealed a set of robotic legs which they claim will soon allow ________wheelchair-bound people to walk again.A．extremely B．previously C．actually D．eventually8．Air pollution, together with littering, ____ many problems in our large industrial cities today.A．causes B．cause C．caused D．causing9．In Sydney, there’s only ________ average of 23 days a year when ________ sun doesn’t shine.A．the, the B．an, / C．an, the D．the, /10．--Hello, Kate. How is your weekend at home?--Awful! Y ou know it is the first time I ____ alone at home, bored to death.A．has left B．had left C．had been left D．have been left11．The International Monetary Fund has received both criticism and for its efforts to promote financial stability, prevent crises, facilitate trade, and reduce poverty.A．worship B．creditC．argument D．privilege12．(2013·福建) _____________ basic first-aid techniques will help you respond quickly to emergencies.A．Known B．Having knownC．Knowing D．Being known13．We have decided to fulfill the task in time, difficulties we may meet with.A．no matter how B．however C．whatever D．whichever14．Among the young people, there is a growing tendency _____ money more highly than quality of life. A．regarding B．to regarding C．to regard D．regarded15．The police recognized the criminal from his typical facial ________.— a scar on the forehead.A．expression B．featureC．outline D．gesture16．—The T--shirt I received is not the same as is shown online.—________？But I promise you we’ll look into it right away.A．Who says B．How comeC．What for D．Why worry17．As a child, I was _________to keep quiet when my parents were discussing something, while parents nowadays often ask for their children’s opinions.A．demanded B．hoped C．forbidden D．required18．Many people may be surprised by the number of chemicals that they are ________ to through everyday household products.A．devoted B．addicted C．exposed D．applied19．The earthquake in Japan, measuring 9.0 on the Richter Scale, was so violent _______ cause a series of explosions of the nuclear reactors in several power stations.A．to B．that C．as to D．as that20．Please call my secretary to arrange a meeting this afternoon，or____________ it is convenient to you. A．wherever B．howeverC．whichever D．whenever第二部分阅读理解（满分40分）阅读下列短文，从每题所给的A、B、C、D四个选项中，选出最佳选项。

2023北京通州高二(上)期中英语(教师版)

2023北京通州高二(上)期中英语(教师版)

2023北京通州高二（上）期中英语第一部分：知识运用(共两节，30分)第一节完形填空(共10小题;每小题1. 5分, 共15分)阅读下面短文, 掌握其大意, 从每题所给的 A、B、C、D 四个选项中, 选出最佳选项, 并在答题卡上将该项涂黑。

Just a few months earlier I would never have ___1___ myself acting in a play in front of two hundred people. But when I got up on stage and face one of my greatest fears, I found a new person inside me, a much more ___2___, outgoing person who had been hidden, just waiting for the opportunity to come. If not for my teacher, Mrs. Sather, I might never have found that ___3___.One day, Mrs. Sather ___4___ that our class was going to perform a play. “I need someone to play the lead part of Dorothy, “she said. ”Anybody want to try?“A few ___5___ hands shot up—mine, of course, was not one of them.After class Mrs. Sather came to me. “Dallas, I think you would be the person for Dorothy.You’re great at ___6___ things, so you won’t worry about lines, ”she said.Mrs. Sather stared into my eyes as if seeing my inner self locked away inside. “I’d love you to give this a ___7___ for me. But if you really don’t want to, I won’t make you. It’s your ___8___. ”Mrs. Sather wanted me in this role. She ___9___ me. I realized it was time to ____10____ my shy cloak (披风).In the end, when the audience stood and applauded, I knew I had really done it!1. A. praised B. agreed C. pictured D. remembered2. A. energetic B. courageous C. generous D. sincere3. A. story B. method C. solution D. opportunity4. A. realized B. repeated C. found D. announced5. A. firm B. excited C. powerful D. friendly6. A. analyzing B. observing C. memorizing D. predicting7. A. plan B. try C. guess D. promise8. A. choice B. destination C. suggestion D. interest9. A. reminded B. challenged C. trusted D. shocked10. A. throw off B. keep off C. knock off D. call off第二节语法填空(共10小题;每小题1. 5分, 共15分)A阅读下列短文，根据短文内容填空。

湖南省岳阳市2023-2024学年高三下学期二模英语试卷

湖南省岳阳市2023-2024学年高三下学期二模英语试卷

岳阳市2024届高三教学质量监测（二）英语试卷时量：120分钟；满分：150分。

注意事项：1. 本试卷分为四部分，共12页。

2. 答题前，考生务必将自己的姓名，准考证号与校名填写在答题卡的相应位置。

3. 全部答案在答题卡上完成，答在本试卷上无效。

第一部分听力（共两节，满分30分）第一节（共5小题；每小题1.5分，满分7.5分）听下面5段对话。

每段对话后有一个小题，从题中所给的A、B、C三个选项中选出最佳选项，并标在试卷的相应位置。

听完每段对话后，你都有10秒钟的时间来回答有关小题和阅读下一小题。

每段对话仅读一遍。

1. What does the man want to do?A. Admire the scenery.B. Have a rest.C. Continue walking.2. What’s the probable relationship between the speakers?A. Professor and student.B. Interviewer and interviewee.C. Doctor and patient.3. What is the woman’s attitude to the man’s words?A. Negative.B. Unclear.C. Favorable.4. What do we learn about the woman?A. She cooled herself down by a fan.B. She wants to buy an air conditioner.C. She is more sensitive to hot weather than the man.5. Which drink is probably unavailable in the party?A. White wine.B. Beer.C. Orange juice.第二节（共15小题；每小题1.5分，满分22.5分）听下面5段对话或独白。

五年级生命至上安全第一英语作文

五年级生命至上安全第一英语作文

五年级生命至上安全第一英语作文全文共3篇示例，供读者参考篇1Life First, Safety ForemostHave you ever stopped to think about how important safety is? As a 5th grader, I've learned that safety should always come first, no matter what you're doing. Keeping ourselves and others safe is something we have to prioritize every single day. Otherwise, we could get seriously hurt or even worse!At school, there are lots of safety rules we have to follow. We can't run in the hallways because we could slip and fall or crash into someone. We have to walk in single file lines and keep our hands to ourselves. During recess, there are certain areas of the playground that are off limits because they aren't safe to play on. We aren't allowed to go past the fence or into the parking lot either. The playground equipment has rules too - only one person on the slide at a time and no climbing up the wrong way. By following these rules, we avoid unnecessary injuries.Safety is also super important when we go on field trips. We have to wear our safety vests or bright colored shirts so ourteachers can easily keep track of all of us. We get assigned a partner to stay with at all times. We practice lining up and following our teachers' instructions exactly. That way, no one will get separated from the group or lost. The bus rules are strict too - we must remain seated, use indoor voices, and keep the aisle clear. The bus driver needs to be able to focus without distractions so we all arrive safely.At home, there are different types of safety concerns. Things like cleaning products, medications, and sharp objects need to be kept up and away from younger kids. My parents taught me kitchen safety from an early age - how to properly use knives for cutting food, turning pot handles inward on the stove, and being careful around the hot oven. We also have rules about supervising younger siblings, letting parents know if we need to go outside to play, and discussing internet safety. My parents installed secure locks, cover electrical outlets, and keep emergency numbers posted. Household safety is so important to avoid fires, poisoning, and other preventable accidents.Even though I'm still a kid, I've learned that safety needs to be a top priority whether I'm at school, home, or out in public places. Paying attention to my surroundings, following all rules, and being aware of potential hazards can help prevent injuries orworse. Not taking shortcuts and doing things the safe way, even if it's harder or takes longer, is always worth it. A few extra minutes of being cautious could literally save your life!I've seen what can happen when people don't take safety seriously enough. Last year, there was an accident at a baseball field near my house. Some older kids were goofing around and ignoring the "No Climbing" signs on the backstop fencing. One of them fell off and broke his arm in two places. It was really scary seeing him get loaded into the ambulance, crying in pain. His parents must have felt awful knowing it could have been prevented if he had just followed the rules. Whenever I think about taking a risk or doing something unsafe, I picture that scene and it helps me make the smarter choice.There are all kinds of ways to prioritize safety in our daily lives. Wearing a helmet while bike riding, skateboarding, or rollerblading can prevent serious head injuries. Looking both ways before crossing the street and only going when it's clear is crucial. Using crosswalks, sidewalks, and pedestrian signals properly also keeps us safe when walking around the neighborhood. At the pool, lake, or beach, following all posted rules and instructions from lifeguards is so important to avoid drowning accidents. At home, it's safest not to answer the doorfor strangers or let people inside when our parents aren't home. We should never get into a car or go anywhere with someone we don't know, even if they seem nice. These are just some of the countless safety tips I've learned so far.As I get older and gain more independence, the importance of safety will only increase. When I'm able to stay home alone, there will be new responsibilities like knowing what to do in case of emergencies and following all house rules set by my parents. One day I may get my driver's license, and driving safely will be my top priority to prevent accidents. I'll need to follow all traffic laws, avoid distractions, never drive under the influence, and make sure my car is properly maintained. I know my parents worry about my safety, and for good reason! The teenage years can be a dangerous time filled with pressures and temptations like alcohol, drugs, reckless behavior, peer pressure and more. Surrounding myself with positive friends who make smart choices will be so important.Looking even further ahead, safety will continue to be crucial no matter what career I pursue. If I work in an office, I'll need to prioritize computer ergonomics, fire safety protocols, secure data handling and more. If I have an active job in construction, healthcare, manufacturing or another hands-on field, there willlikely be extensive safety training, procedures and protective gear required. Putting safety first benefits me, my coworkers, and the company as a whole by preventing workplace injuries and downtime. One small shortcut or lapse in following protocol could lead to devastating consequences.No matter where life takes me, keeping myself and those around me safe needs to be my top priority each and every day. I never want to experience the consequences of neglecting safety rules and common sense precautions. An "it won't happen to me" attitude is just naive and reckless. Injuries, accidents, and tragedies can happen to anyone at anytime if they let their guard down. Even something as simple as not looking both ways before crossing the street could lead to catastrophe. Why risk losing your life or facing terrible pain all because you didn't take a few extra seconds to be safe?While safety might sometimes seem annoying or inconvenient in the moment, I know it's for my own protection and wellbeing. Following rules, being aware of hazards, and not taking unnecessary risks is a small price to pay for peace of mind and keeping myself out of harm's way. I hope sharing what I've learned so far about the importance of safety will inspire others to make it their top priority too. Our lives are so precious, andsafety should always come first before anything else. If we all do our part, we can avoid preventable accidents and keep each other safe no matter what we're doing. Life first, safety foremost!篇2Life First, Safety ForemostLiving safely is the most important thing we can do. If we aren't safe, we could get really hurt or even die. That's why at school, at home, and everywhere else, we need to make safety our number one priority. Life is precious and we have to protect it at all costs.At school, there are lots of safety rules we have to follow. We can't run in the hallways because we could trip and fall or crash into someone. We have to walk in a line and keep our hands to ourselves. During a fire drill, we have to leave the building quickly but calmly. We line up outside and wait for the teachers to check if everyone got out okay.If there's an emergency like a shooter or a tornado, we do special safety drills. For a shooter drill, we hide quietly in a locked room away from windows. For a tornado drill, we go into the hallway, sit down, and cover our heads to protect us from gettinghit by debris. We practice these drills so we'll know just what to do to stay safe if a real emergency ever happens.On the playground, we have lots of safety rules too. We can't play roughly or push people off the equipment. We have to go down the slides sitting down, not headfirst. We wear helmets for sports like baseball and bikes. The playground monitors make sure everyone follows the rules so no one gets hurt.At home, we also need to think about safety all the time. We shouldn't run with sharp objects or play with matches and lighters. We have to be really careful around stoves and ovens so we don't get burned. My mom always makes sure to unplug heating appliances when we're done using them.When we're in the car, we have to wear our seatbelts at all times. My dad is a very safe driver and never speeds or runs red lights. He doesn't text or talk on the phone while driving either because that's really dangerous. We're not allowed to stick any body parts out the window or make too much noise to distract the driver.If we're walking near the street, we have to pay close attention and look both ways before crossing. We don't chase balls or toys that roll into the road. We have to wait for a crossing guard or walk signal to make sure it's safe to cross. My momalways holds my little sister's hand tightly when we're crossing so she doesn't run out into traffic.Staying safe around animals is important too. We can't tease or chase animals because they might bite or scratch us if they feel threatened. We're not supposed to approach stray dogs or cats since we don't know if they're sick or dangerous. If a dog is on a leash with its owner, we always ask for permission before petting it.We also need to be really cautious around bodies of water. We're never allowed to swim without a lifeguard or trusted adult watching us. We can't run near pools or waterways since it's easy to slip and fall in. Even if the water looks shallow, it could actually be a lot deeper than we think with strong currents that could pull us under.It's important to know some basic first aid too, just in case someone does get hurt. We should know how to clean and bandage minor cuts and scrapes. We need to know how to do CPR and get help right away if someone is seriously injured, not breathing, or unconscious. Keeping a first aid kit stocked with bandages, antiseptic, etc. is a good idea for dealing with basic injuries.We have to follow all these safety guidelines no matter what. Even if we really want to do something fun, we can't take risks that could endangerour safety or our lives. Sometimes it's tempting to break the rules, like if we want to swim without a lifeguard or roughhouse on the playground. But we absolutely cannot give into those urges because it's just not worth risking our wellbeing over.Every year, tons of kids get injured or even killed from not following basic safety precautions. They ignore the rules about swimming safely, playing carefully, or being cautious around roads and vehicles. Then they get in tragic accidents that could have been completely prevented if they had just listened and put safety first.Dying from something stupid like playing carelessly would be such a waste of a precious life. I don't ever want to throw my life away over a moment of recklessness. I want to live a long, full life doing amazing things to make the world better. So no matter how tempting it might be to break the rules sometimes, I'm going to keep safety as my highest priority, just like I've been taught.Life is a miraculous gift that we're incredibly lucky to have. With all the wars, diseases, natural disasters, and other threatsout there, we can't take our safety for granted even for a second. We have to treat our lives with the utmost care and protection at all times. That's why I'll never get tired of hearing "Life First, Safety Foremost" - because those words could save my life or someone else's life one day. Safety first, safety always - that's my core belief that I'll never compromise on. My life is just too precious.篇3Life First, Safety ForemostWe hear it all the time from our teachers and parents - "Safety first!" They are always reminding us to be careful, follow the rules, and put our safety ahead of everything else. At first, I used to think they were just being overprotective and worrying too much. But after watching some serious safety videos in class and learning about all the potential dangers around us, I realize now just how important it is to make safety the top priority.One of the biggest safety risks we face every day is traffic safety when walking, riding bikes, or riding in vehicles. The roads can be very dangerous places if we don't follow proper procedures. As pedestrians, we have to be extra alert when crossing streets, only go when the walk signal instructs, andavoid distractions like phones. Drivers often don't see smaller pedestrians, so we need to make eye contact and wait for them to see us before crossing, even if we have the right of way.For those who ride bikes, wearing a helmet is absolutely essential to prevent serious head injuries if you fall or get hit. And cyclists need to obey all the same traffic laws and signals that drivers do, riding in the same direction as traffic and signaling turns. Of course, drivers themselves have an incredible responsibility to operate their vehicles safely and avoid distractions like texting. One moment of negligence could lead to a devastating accident.Traffic isn't the only area where we need to prioritize safety though. When participating in sports and physical activities, using proper protective gear like helmets, pads, and mouth guards can prevent injuries. And it's crucial to stretch properly, warm up, and know your limits to avoid pulling muscles or overexerting yourself. I've seen kids get seriously hurt because they weren't being cautious.The same concept of prioritizing our personal safety applies to so many areas of life. When handling kitchen utensils or tools, we need to learn the proper techniques to avoid getting cut or pinched. Around fires and heating elements, we have to be。