Neonatal mortality in countries of the Americas, 2000-2020: trends, inequalities, and target-setting

Objective

To analyze temporal trends and inequalities in neonatal mortality between 2000 and 2020, and to set neonatal mortality targets for 2025 and 2030 in the Americas.

Methods

A descriptive ecological study was conducted using 33 countries of the Americas as units of analysis. Both the percentage change and average annual percentage change in neonatal mortality rates were estimated. Measurements of absolute and relative inequality based on adjusted regression models were used to assess cross-country social inequalities in neonatal mortality. Targets to reduce neonatal mortality and cross-country inequalities were set for 2025 and 2030.

Results

The estimated regional neonatal mortality rate was 12.0 per 1 000 live births in 2000-2004 and 7.4 per 1 000 live births in 2020, representing a percentage change of -38.3% and an average annual percentage change of -2.7%. National average annual percentage changes in neonatal mortality rates between 2000-2004 and 2020 ranged from -5.5 to 1.9 and were mostly negative. The estimated excess neonatal mortality in the 20% most socially disadvantaged countries, compared with the 20% least socially disadvantaged countries, was 17.1 and 9.8 deaths per 1 000 live births in 2000-2004 and 2020, respectively. Based on an extrapolation of recent trends, the regional neonatal mortality rate is projected to reach 7.0 and 6.6 neonatal deaths per 1 000 live births by 2025 and 2030, respectively.

Conclusions

National and regional health authorities need to strengthen their efforts to reduce persistent social inequalities in neonatal mortality both within and between countries.

Greater agreement is required to harness the potential of health intelligence: a critical interpretive synthesis

OBJECTIVES

To synthesize existing knowledge on the features of, and approaches to, health intelligence, including definitions, key concepts, frameworks, methods and tools, types of evidence used, and research gaps.

STUDY DESIGN AND SETTING

We applied a critical interpretive synthesis methodology, combining systematic searching, purposive sampling, and inductive analysis to explore the topic. We conducted electronic and supplementary searches to identify records (papers, books, websites) based on their potential relevance to health intelligence. The key themes identified in the literature were combined under each of the compass subquestions and circulated among the research team for discussion and interpretation.

RESULTS

Of the 290 records screened, 40 were included in the synthesis. There is no clear definition of health intelligence in the literature. Some records describe it in similar terms as public health surveillance. Some focus on the use of artificial intelligence, while others refer to health intelligence in a military or security sense. And some authors have suggested a broader definition of health intelligence that explicitly includes the concepts of synthesis of research evidence for informed decision making.

CONCLUSION

Rather than developing a new or all-encompassing definition, we suggest incorporating the concept and scope of health intelligence within the evidence ecosystem.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys

BACKGROUND

Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time.

METHODS

We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality.

RESULTS

Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits.

CONCLUSIONS

Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo

BACKGROUND

The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed.

METHODS

Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps -absolute (AIG), and relative (RIG)- were scenario outcomes.

RESULTS

At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030.

CONCLUSION

The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

Inequalities in Violent Death across Income Levels among Young Males and Females in Countries of the Americas

BACKGROUND

Violent deaths (i.e., those due to road traffic injury, homicide, and suicide) are among the most important causes of premature and preventable mortality in young people. This study aimed at exploring inequalities in violent death across income levels between males and females aged 10 to 24 years from the Americas in 2015, the SDG baseline year.

METHODS

In a cross-sectional ecological study design, eleven standard summary measures of health inequality were calculated separately for males and females and for each cause of violent death, using age-adjusted mortality rates and average income per capita for 17 countries, which accounted for 87.9% of the target population.

RESULTS

Premature mortality due to road traffic injury and homicide showed a pro-poor inequality pattern, whereas premature mortality due to suicide showed a pro-rich inequality pattern. These inequalities were statistically significant (p < 0.001), particularly concentrated among young males, and dominated by homicide. The ample array of summary measures of health inequality tended to generate convergent results.

CONCLUSIONS

Significant inequalities in violent death among young people seems to be in place across countries of the Americas, and they seem to be socially determined by both income and gender. These findings shed light on the epidemiology of violent death in young people and can inform priorities for regional public health action. However, further investigation is needed to confirm inequality patterns and to explore underlying mechanisms, age- and sex-specific vulnerabilities, and gender-based drivers of such inequalities.

La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud

La iniciativa Todas las Mujeres Todos los Niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en el 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente 2016-2030 en América Latina y el Caribe (ALC), lo que incluye su adaptación a necesidades específicas de la Región, para poner fin a las muertes evitables, garantizar la salud y el bienestar, y ampliar los entornos propicios para la salud y el bienestar de mujeres, niños y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC apoyan colectivamente a los países de ALC en la medición y el monitoreo de las desigualdades sociales en la salud, la promoción de la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar las brechas actuales asegura que nadie se quede atrás. Los miembros de la iniciativa EWEC-LAC incluyen al UNFPA, la OPS, ONU-Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores, y ha comenzado a colaborar con los países para utilizarlos a fin de reducir las brechas en la equidad. Estos incluyen un marco de medición de las desigualdades sociales en la salud, herramientas de promoción de datos, como un tablero de datos para visualizar tendencias en las desigualdades sociales en la salud, una metodología para establecer metas en la disminución de las desigualdades, y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en la salud. EWEC-LAC ha trabajado en la Región para enfatizar la importancia de reconocer estas desigualdades a los niveles sociales y políticos, y ha abogado por su disminución. La atención para cerrar las brechas de equidad en la salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Los sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries

BACKGROUND

Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries.

METHODS

Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group.

FINDINGS

Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries.

INTERPRETATION

Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants.

FUNDING

Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health

The Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) initiative was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women’s, Children’s and Adolescents’ Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC’s three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

The slowdown in the reduction rate of premature mortality from cardiovascular diseases puts the Americas at risk of achieving SDG 3.4: A population trend analysis of 37 countries from 1990 to 2017

Cardiovascular diseases (CVD) are leading causes of mortality and morbidity in the Americas, resulting in substantial negative economic and social impacts. This study describes the trends and inequalities of CVD burden in the Americas to guide programmatic interventions and health system responses. We examined the CVD burden trends by age, sex, and countries between 1990 and 2017 and quantified social inequalities in CVD burden across countries. In 2017, CVD accounted for 2 million deaths in the Americas, 29% of total deaths. Age-standardized DALY rates caused by CVD declined by -1.9% (95% uncertainty interval, -2.0 to -1.7) annually from 1990 to 2017. This trend varied with a striking decreasing trend over the interval 1994-2003 (annual percent change (APC) -2.4% [-2.5 to 2.2]) and 2003-2007 (APC -2.8% [-3.4 to -2.2]). This was followed by a slowdown in the rate of decline over 2007-2013 (APC -1.83% [-2.1 to -1.6]) and a stagnation during the most recent period 2013-2017 (APC -0.1% [-0.5 to 0.3]). The social inequality in CVD burden along the socio-demographic gradient across countries decreased 2.75-fold. The CVD burden and related social inequality have both substantially decreased in the Americas since 1990, driven by the reduction in premature mortality. This trend occurred in parallel with the improvement in the socioeconomic development and health care of the region. The deceleration and stagnation in the rate of improvement of CVD burden and persistent social inequality pose major challenges to reduce the CVD burden and the achievement of the United Nations' Sustainable Development Goals Target 3.4.

Spatial dynamics and the basic reproduction number of the 1991-1997 Cholera epidemic in Peru

After being cholera free for over 100 years, Peru experienced an unprecedented epidemic of Vibrio cholerae O1 that began in 1991 and generated multiple waves of disease over several years. We developed a mechanistic transmission model that accounts for seasonal variation in temperature to estimate spatial variability in the basic reproduction number ([Formula: see text]), the initial concentration of vibrios in the environment, and cholera reporting rates. From 1991-1997, cholera spread following a multi-wave pattern, with weekly incidence concentrated during warm seasons. The epidemic first hit the coastal departments of Peru and subsequently spread through the highlands and jungle regions. The correlation between model predictions and observations was high (range in R2: 58% to 97%). Department-level population size and elevation explained significant variation in spatial-temporal transmission patterns. The overall R0 across departments was estimated at 2.1 (95% CI: 0.8,7.3), high enough for sustained transmission. Geographic-region level [Formula: see text] varied substantially from 2.4 (95% CI: 1.1, 7.3) for the coastal region, 1.9 (0.7, 6.4) for the jungle region, and 1.5 (0.9, 2.2) for the highlands region. At the department level, mean [Formula: see text] ranged from 0.8 to 6.9. Department-level [Formula: see text] were correlated with overall observed attack rates (Spearman ρ = 0.59, P = 0.002), elevation (ρ = -0.4, P = 0.04), and longitude (ρ = -0.6, P = 0.004). We find that both [Formula: see text] and the initial concentration of vibrios were higher in coastal departments than other departments. Reporting rates were low, consistent with a substantial fraction of asymptomatic or mild cases associated with the El Tor cholera biotype. Our results suggest that cholera vibrios, autochthonous to plankton in the natural aquatic environment, may have triggered outbreaks in multiple coastal locations along the Pacific coast of Peru. Our methodology could be useful to investigate multi-wave epidemics of cholera and could be extended to conduct near real-time forecasts and investigate the impact of vaccination strategies.

Social inequalities and prevalence of depressive symptoms: a cross-sectional study of women in a Mexican border city, 2014

Objective.

To assess the association between intersectional disadvantage and clinically significant depressive symptoms (CSDS), describing the magnitude of social inequalities in the prevalence of symptoms among adult women in Tijuana, Mexico.

Methods.

This was a cross-sectional study. CSDS were assessed using the Centers for Epidemiological Studies Depression Scale among a probability sample of 2 345 women from 18 – 65 years of age in 2014. CSDS prevalence was calculated according to categories of three social stratifiers: socioeconomic status (SES), educational attainment, and fertility (number of children). Social inequality was measured with the slope index of inequality (SII) and the concentration index (CIx). Intersectionality among stratifiers was explored descriptively and with multivariable regression analysis.

Results.

CSDS prevalence was 17.7% (95%CI: 15.1% – 21.0%). The SII and CIx showed inequity in all social stratifiers. The absolute difference in CSDS prevalence between the lowest and highest ends of the SES gradient was 21.9% (95%CI: 21.5% – 22.4%). Among the most disadvantaged women, i.e., those at the intersection of lowest SES, lowest educational attainment, and highest fertility, the CSDS prevalence was 39.5% (95% CI: 26.0% – 52.9%).

Conclusions.

Disadvantage along multiple axes was associated with CSDS. Efforts to improve the mental health of women should include equity-oriented policies that address its social determinants.

Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990-2017: a population-based study

BACKGROUND

The World Health Assembly 2018 approved a resolution on rheumatic heart disease to strengthen programmes in countries where this condition remains a substantial public health problem. We aimed to describe the regional burden, trends, and inequalities of rheumatic heart disease in the Americas.

METHODS

In this secondary analysis of the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2017, we extracted data for deaths, prevalence of cases, disability-adjusted life-years (DALYs), years lived with disability, and years of life lost (YLL) as measures of rheumatic heart disease burden using the GBD Results Tool. We analysed 1990-2017 trends in rheumatic heart disease mortality and prevalence, quantified cross-country inequalities in rheumatic heart disease mortality, and classified countries according to rheumatic heart disease mortality in 2017 and 1990-2017.

FINDINGS

GBD 2017 estimated that 3 604 800 cases of rheumatic heart disease occurred overall in the Americas in 2017, with 22 437 deaths. We showed that in 2017 rheumatic heart disease mortality in the Americas was 51% (95% UI 44-59) lower (1·8 deaths per 100 000 population [95% uncertainty interval 1·7-1·9] vs 3·7 deaths per 100 000 population [3·4-3·9]) and prevalence was 30% (29-33) lower (346·4 cases per 100 000 [334·1-359·2] vs 500·6 cases per 100 000 [482·9-519·7]) than the corresponding global estimates. DALYs were half of those globally (55·7 per 100 000 [49·8-63·5] vs 118·7 per 100 000 [108·5 to 130·7]), with a 70% contribution from YLL (39·1 out of 55·7 per 100 000). A significant reduction in rheumatic heart disease mortality occurred, from a regional average of 88·4 YLL per 100 000 (95% uncertainty interval 88·2-88·6) in 1990 to 38·2 (38·1-38·4) in 2017, and a significant reduction in income-related inequality, from an excess of 191·7 YLL per 100 000 (68·6-314·8) between the poorest and richest countries in 1990 to 66·8 YLL per 100 000 (6·4-127·2) in 2017. Of the 37 countries studied, eight (22%) had both the highest level of premature rheumatic heart disease mortality in 2017 and the smallest reduction in this mortality between 1990 and 2017.

INTERPRETATION

The Americas have greatly reduced premature mortality due to rheumatic heart disease since 1990. These health gains were paired with a substantial reduction in the magnitude of income-related inequalities across countries, which is consistent with overall socioeconomic and health improvements observed in the Region. Countries with less favourable rheumatic heart disease situations should be targeted for strengthening of their national programmes.

FUNDING

None.

The Pan American Health Organization-adapted Hanlon method for prioritization of health programs

Objectives.

To document the underlying science of how the Pan American Health Organization (PAHO) adapted the Hanlon method, which prioritizes disease control programs, to its wider range of program areas and used it to implement the PAHO Strategic Plan 2014 – 2019.

Methods.

In 2014, PAHO established a Strategic Plan Advisory Group (SPAG) with representatives from 12 Member States to work closely with the PAHO Technical Team to adapt the Hanlon method to disease and non-disease control programs. Three meetings were held in 2015 – 2016 during which SPAG reviewed existing priority-setting methods, assessed the original Hanlon method and subsequent revisions, and developed the adapted method. This project was initiated by Member States, facilitated by PAHO, and conducted jointly in transparent and horizontal technical cooperation.

Results.

From the original Hanlon equation, the PAHO-adapted method maintains components A (size of problem), B (seriousness of problem), and C (effectiveness of intervention), drops component D (PEARL – Propriety, Economics, Acceptability, Resources, and Legality), and adds component E (inequity) and F (institutional positioning). The PEARL score was dropped because it serves a purpose for pre-screening process, but not in the priority-setting process for PAHO.

Conclusions.

The PAHO-adapted Hanlon method provides a refined approach for prioritizing public health programs that include disease and non-disease control areas. The method may be useful for the World Health Organization and country governments with similar needs.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries

BACKGROUND

Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions.

METHODS

We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression.

FINDINGS

Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries.

INTERPRETATION

The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes.

FUNDING

The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Malaria in the Americas: trends from 1959 to 2011

Malaria has declined in recent years in countries of the American continents. In 2011, 12 of 21 endemic countries had already met their 2015 Millennium Development Goal. However, this declining trend has not been adequately evaluated. An analysis of the number of cases per 100,000 people (annual parasite index [API]) and the percentage of positive blood slides (slide positivity rate [SPR]) during the period of 1959-2011 in 21 endemic countries was done using the joinpoint regression methodology. During 1960-1979, API and SPR increased significantly and peaked in the 1980s. Since the 1990s, there have been significant declining trends in both API and SPR. Additionally, both Plasmodium vivax and P. falciparum species-specific incidence have declined. With the exception of two countries, such a collectively declining malaria trend was not observed in previous decades. This presents a unique opportunity for the Americas to seriously consider malaria elimination as a final goal.

Prevalence of visual impairment in El Salvador: inequalities in educational level and occupational status

OBJECTIVE

To examine the prevalence of blindness, visual impairment, and related eye diseases and conditions among adults in El Salvador, and to explore socioeconomic inequalities in their prevalence by education level and occupational status, stratified by sex.

METHODS

Based upon the Rapid Assessment of Avoidable Blindness (RAAB) methodology, this nationwide sample comprised 3 800 participants (3 399 examined) ≥ 50 years old from 76 randomly selected clusters of 50 persons each. The prevalence of blindness, visual impairment and related eye diseases and conditions, including uncorrected refractive error (URE), was calculated for categories of education level and occupational status. Multiple logistic regression models were fitted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) and stratified by sex.

RESULTS

Age-adjusted prevalence was 2.4% (95% CI: 2.2-2.6) for blindness (men: 2.8% (95% CI: 2.5-3.1); women: 2.2% (95% CI: 1.9-2.5)) and 11.8% (95% CI: 11.6-12.0) for moderate visual impairment (men: 10.8% (95% CI: 10.5-11.1); women: 12.6% (95% CI: 12.4-12.8)). The proportion of visual impairment due to cataract was 43.8% in men and 33.5% in women. Inverse gradients of socioeconomic inequalities were observed in the prevalence of visual impairment. For example, the age-adjusted OR (AOR) was 3.4 (95% CI: 2.0-6.4) for visual impairment and 4.3 (95% CI: 2.1-10.4) for related URE in illiterate women compared to those with secondary education, and 1.9 (95% CI: 1.1-3.1) in cataract in unemployed men.

CONCLUSIONS

Blindness and visual impairment prevalence is high in the El Salvador adult population. The main associated conditions are cataract and URE, two treatable conditions. As socioeconomic and gender inequalities in ocular health may herald discrimination and important barriers to accessing affordable, good-quality, and timely health care services, prioritization of public eye health care and disability policies should be put in place, particularly among women, the unemployed, and uneducated people.

[Core competencies in public health: a regional framework for the Americas]

The response is described to the 2010 call from the Pan American Health Organization to develop a Regional Framework on Core Competencies in Public Health, with a view to supporting the efforts of the countries in the Americas to build public health systems capacity as a strategy for optimal performance of the Essential Public Health Functions. The methodological process for the response was divided into four phases. In the first, a team of experts was convened who defined the methodology to be used during a workshop at the National Institute of Public Health of Mexico in 2010. The second phase involved formation of the working groups, using two criteria: experience and multidisciplinary membership, which resulted in a regional team with 225 members from 12 countries. This team prepared an initial proposal with 88 competencies. In the third phase, the competencies were cross-validated and their number reduced to 64. During the fourth phase, which included two workshops, in March 2011 (Medellín, Colombia) and June 2011 (Lima, Peru), discussions centered on analyzing the association between the results and the methodology.

Outbreak of acute renal failure in Panama in 2006: a case-control study

OBJECTIVE

In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak.

METHODS

Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls.

FINDINGS

Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup.

CONCLUSION

The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.

[Preparedness planning for an influenza pandemic: regional efforts]

Failure to establish a contingency plan prior to a public health emergency can have catastrophic consequences. The threat of a new influenza pandemic has prompted countries to draft national strategic preparedness plans to prevent, mitigate, and recover from a potential influenza pandemic. This paper examines these preparations in Latin America and the Caribbean and describes potential scenarios of pandemic impact on the burden of mortality and on health services in the Region. In particular, the paper reports on the progress made by Member States in developing national influenza pandemic preparedness plans and implementation mechanisms at both the national and local levels. These achievements were facilitated through a series of planning workshops and self-assessment exercises conducted by PAHO for intersectoral country teams and guided by the WHO global influenza preparedness plan. Although significant progress has been made in plan completeness, intercountry preparedness planning and local level implementation remain key challenges. Multisectoral partnerships are clearly paramount to securing the commitment and resources needed to reach and sustain effective pandemic preparedness in the Americas.

[Methods for measuring inequalities in health]

Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

[Geographic information systems as a tool for monitoring health inequalities]

OBJECTIVE

To show how geographic information systems (GISs) can be used as technological tools to support health policy and public health actions.

METHODS

We assessed the relationship between infant mortality and a number of socio-economic and geographic determinants. In explaining how GISs are applied, we stressed their ability to integrate data, which makes it possible to perform epidemiologic evaluations in a simpler, faster, automated way that simultaneously analyzes multiple variables with different levels of aggregation. In this study, GISs were applied in analyzing infant mortality data with three levels of aggregation in countries of the Americas from 1995 to 2000.

RESULTS

Infant mortality in the Region of the Americas was estimated at an overall average of 24.4 deaths per 1,000 live births. However, the inequalities that were found indicate that the probability of an infant death is almost 20 times greater in the less developed countries of the Region than in more developed ones. Mapping infant mortality throughout the Region of the Americas allowed us to identify the countries that need to focus more attention on health policy and health programs, but not to determine what specific actions are of the highest priority. An analysis of smaller geopolitical units (states and municipalities) revealed important differences within countries. This shows that, as is true of data for the entire Region of the Americas, using national-level average figures for indicators can obscure the differences that exist within countries. When we examined the relationship between female illiteracy and malnutrition as determinants of infant mortality in Brazil and Ecuador, we identified social and epidemiologic strata where risk factors had different distribution patterns and that thus require health interventions that match their individual social and epidemiologic profiles.

CONCLUSIONS

With this type of epidemiologic study using GISs at the local level of health services, it is easy to see how a health event and its risk factors behave at a specific period in time. It is also possible to identify patterns in the spatial distribution of risk factors and in these factors' potential impact on health. Using GISs in an appropriate way will make it easier to deliver more effective, equitable public health services.

[Indices based on entropy for measuring social inequalities in health]

As described in the scientific literature, indices used to measure social inequalities in health have positive features, but they also have shortcomings, depending on how they are applied. The objective of this article is to put forward and to demonstrate, in both theoretical and practical terms, the advantages of measurements of inequality based on the notion of entropy, which is well known in physics and in information theory. The article defines and presents the main properties of indices based on the notions of entropy and redundancy. The application of the indices is illustrated with two fictitious data sets and also with real data derived from basic health indicators for the Americas, from the Pan American Health Organization. Indices based on the notion of entropy have properties that include: a) not varying with scale changes, b) being symmetrical, c) incorporating a socioeconomic dimension, and d) being easy to interpret thanks to the condition of equivalence between entropy and a system with two categories.

Trends in infant mortality inequalities in the Americas: 1955-1995

STUDY OBJECTIVE

s: To describe overall and income related trends in infant mortality inequalities in the Region of the Americas from 1955 to 1995.

DESIGN

Infant mortality rates (IMRs) were computed and their trends assessed by ordinary least squares. Overall trends in IMR inequalities among countries were analysed by comparing 10 year period IMRs, Gini coefficients, and Lorenz curves. Income related trends in IMR inequalities were assessed using 10 year period IMR ratios between the highest and the lowest quintiles of the per capita gross national product (GNP) distributions (adjusted for purchasing power).

SETTING

Aggregated country data were used for all countries with over 200 thousand inhabitants (33 geopolitical units). The 10 year period midpoint IMR estimates used for the 1955-1995 time series were those published by the United Nations in 1997.

MAIN RESULTS

IMRs decreased from 90.34 to 31.31 per 1000 live births between 1955 and 1995 at an average of 15.3 every 10 years. In contrast, Lorenz curves and Gini coefficients were similar for the five 10 year periods. After grouping by adjusted GNP distribution, a similar decreasing trend of IMR was observed in all groups. The rate ratio between the group at the lowest quintile and that at the highest quintile ranged from 4 to 5. The analysis of variance for repeated observations showed that there is a significant reduction in the IMR (F=130.18; p<0.01), that trends did not differ significantly among groups (F=1.16; p=0.32), and that they were approximately linear (F=155.83; p<0.01).

CONCLUSIONS

Despite a sizable reduction in the infant mortality, whether or not income related, levels of IMR inequality among countries have remained almost constant between 1955 and 1995 in the Region of the Americas. Further analysis and focused interventions are needed to tackle the challenges of reducing these persistent mortality inequalities.

Epidemic cholera in the Amazon: the role of produce in disease risk and prevention

Epidemic cholera struck Peru in January 1991 and spread within a month to the Amazon headwaters. A case-control study was done in the Amazonian city of Iquitos, Peru. Cholera-like illness was associated with eating unwashed fruits and vegetables (odds ratio [OR] = 8.0; 95% confidence limits [CL] = 2.2, 28.9) and drinking untreated water (OR = 2.9; 95% CL = 1.3, 6.4). Consumption of a drink made from toronja, a citrus fruit, was protective against illness (OR = 0.4; 95% CL = 0.2, 0.7). Illness was inversely associated with the quantity of toronja drink consumed (P < .01). Produce has not previously been convincingly documented as a risk factor for cholera; this study underscores the importance of washing produce before eating it. Acidic juices, such as toronja drink (pH 4.1), inhibit vibrio growth and may make contaminated water safer. Wild citrus fruits such as toronja are abundant, cheap, and popular in the Amazon region. Promoting the consumption of toronja drink may be a useful cholera prevention strategy in this region.