Clinical outcomes and risk factors for immune recovery and all-cause mortality in Latin Americans living with HIV with virological success: a retrospective cohort study

INTRODUCTION

Immune reconstitution following antiretroviral therapy (ART) initiation is crucial to prevent AIDS and non-AIDS-related comorbidities. Patients with suppressed viraemia who fail to restore cellular immunity are exposed to an increased risk of morbidity and mortality during long-term follow-up, although the underlying mechanisms remain poorly understood. We aim to describe clinical outcomes and factors associated with the worse immune recovery and all-cause mortality in people living with HIV (PLWH) from Latin America following ART initiation.

METHODS

Retrospective cohort study using the CCASAnet database: PLWH ≥18 years of age at ART initiation using a three drug-based combination therapy and with medical follow-up for ≥24 months after ART initiation and undetectable viral load were included. Patients were divided into four immune recovery groups based on rounded quartiles of increase in CD4 T-cell count at 2 years of treatment (<150, [150, 250), [250, 350] and >350 cells/mm3 ). Primary outcomes included all-cause mortality, AIDS-defining events and non-communicable diseases that occurred >2 years after ART initiation. Factors associated with an increase in CD4 T-cell count at 2 years of treatment were evaluated using a cumulative probability model with a logit link.

RESULTS

In our cohort of 4496 Latin American PLWH, we found that patients with the lowest CD4 increase (<150) had the lowest survival probability at 10 years of follow-up. Lower increase in CD4 count following therapy initiation (and remarkably not a lower baseline CD4 T-cell count) and older age were risk factors for all-cause mortality. We also found that older age, male sex and higher baseline CD4 T-cell count were associated with lower CD4 count increase following therapy initiation.

CONCLUSIONS

Our study shows that PLWH with lower increases in CD4 count have lower survival probabilities. CD4 increase during follow-up might be a better predictor of mortality in undetectable PLWH than baseline CD4 count. Therefore, it should be included as a routine clinical variable to assess immune recovery and overall survival.

[Concordance between essential medicines lists and diabetes guidelines in Latin America and the CaribbeanConcordância entre as listas de medicamentos essenciais e diretrizes para diabetes na América Latina e no Caribe]

Objective

Conduct an analysis to determine the existence and updating of national essential medicines lists (EMLs) and clinical practice guidelines (CPGs) for the treatment of diabetes in Latin America and the Caribbean (LAC); and compare the medicines included in each country's list and guidelines both with each other and with those of the World Health Organization (WHO).

Methods

Cross-sectional study. EMLs and CPGs for diabetes were found on the websites of the Pan American Health Organization and national health authorities. Medicines were noted and analyzed according to pharmacological group, based on the fourth level of nomenclature of the Anatomical Therapeutic Chemical (ATC) classification system. F1 scoring was used to assess the proximity of EMLs to the WHO Model List of Essential Medicines (MLEM).

Results

Of the total number of countries, 87.2% have EMLs, and 91% have CPGs (78% and 45% updated in the last five years, respectively). Compared to the six hypoglycemic groups of the MLEM, the EMLs had a median (range) of 6 (4-13) and an F1 score of 0.80; This indicates proper alignment. CPGs had a median (range) of 12 (1-12) hypoglycemic drugs compared to eight in the WHO guidelines. CPGs had a median of 15 more drugs than their respective EMLs.

Conclusions

While most LAC countries have EMLs and CPGs for diabetes, the lack of concordance among them limits their effectiveness. It is necessary to align the processes and criteria for the development of these two tools for policymaking on medicines.

Real-world data on triple-negative breast cancer in Latin America and the Caribbean

Breast cancer (BC) is the most prevalent cancer in women in Latin America and the Caribbean. We compiled real-world data (RWD) on the epidemiology, diagnosis, treatment, and patient outcomes of triple-negative breast cancer (TNBC), addressing the main barriers to optimal care in Latin America. The prevalence of TNBC varies between 11% and 38.5% of all BC cases diagnosed in the region, and TNBC primarily affects young patients. Delays in BC diagnosis, with consequent advanced disease stages and barriers to access efficient therapies, particularly due to high costs, negatively impact patient outcomes. Cancer clinical trials are an opportunity to access standard and novel therapies for patients with this aggressive BC subtype and thus must be prioritised. Finally, generating RWD and cost-effectiveness studies in a region with limited resources is critical for decision-makers to define the incorporation of new technologies for the treatment of BC.

Need for open data on COVID-19 vaccine uptake among pregnant people in the Caribbean: a call to action

Pregnant people with coronavirus disease 2019 (COVID-19) have a higher risk of adverse maternal and fetal outcomes compared with pregnant people without COVID-19. In 2021, large increases in maternal mortality were reported in Jamaica, almost half of which were attributable to COVID-19. COVID-19 vaccination has been shown to reduce these risks, but low- and middle-income countries lack free, publicly available data, known as open data, on COVID-19 vaccine uptake for their pregnant populations. The objectives of this paper were to: review how high-income countries use open data to detect trends in COVID-19 vaccine uptake among pregnant people and develop vaccination distribution strategies; outline barriers to making open data available for maternal COVID-19 vaccination in the Caribbean; and propose a multipronged strategy that would increase the availability of open data on maternal COVID-19 vaccination in the Caribbean. A multipronged strategy to fill the data void would involve: (i) utilizing existing Caribbean maternal immunization data collection entities; (ii) adapting digital software tools to establish maternal electronic immunization registries; and (iii) collaborating with local partners skilled in data analytics. Making open data available for COVID-19 vaccine uptake among pregnant people in the Caribbean could offer substantial benefits, including the development of measurable maternal COVID-19 vaccination goals and the facilitation of vaccine decision-making discussions between providers and pregnant people.

Testicular cancer mortality in Latin America and the Caribbean: trend analysis from 1997 to 2019

BACKGROUND

In the last decades, an increasing incidence of testicular cancer has been observed in several countries worldwide. Although mortality rates have been variable in many countries, little information is available from Latin America and the Caribbean (LAC). Therefore, we examined mortality trends of testicular cancer in the last two decades.

METHODS

Age-standardized mortality rates (ASMR) of testicular cancer per 100,000 men-years were estimated using the World Health Organization mortality database from 1997 to 2019. We examined the mortality trends and computed annual percent change (APC) for all ages and the following age groups, 15-29, 30-44, 15-44, and ≥ 45 years.

RESULTS

Ten countries had mortality rates greater than 0.43 per 100,000 men, with the highest rates for Chile, Mexico, and Argentina. Significant increases in mortality rates were observed in Argentina, Brazil Colombia, and Mexico in all ages, and < 45 years, while Colombia, Ecuador, Mexico, and Peru reported significant downward trends in males aged ≥ 45 years. Only Chile showed significant decreases for all ages and age groups studied.

CONCLUSION

Mortality by testicular cancer increased among LAC countries in males of all ages and across age groups. A reduction in mortality rates was observed only in Chilean males of all ages and in men ≥ 45 years in several countries. Strengthening of early detection among symptomatic males may decrease the mortality by this neoplasm.

The SickKids Caribbean Initiative to improve care for children with cancer and blood disorders

To improve pediatric hematology and oncology outcomes, there is a recognized potential for partnerships between low- and high-resource institutions within health care systems. The SickKids Caribbean Initiative is a partnership between health care professionals at the Hospital for Sick Children in Toronto, Canada, and seven Caribbean institutions across six countries (Bahamas, Barbados, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, and Trinidad and Tobago). The primary aim of the SickKids Caribbean Initiative has been to improve the outcomes and the quality of life of children in the Caribbean aged <18 years who have cancer and blood disorders. This article describes five key activities undertaken within the SickKids Caribbean Initiative, including providing education and training, assisting with case consultations and diagnostic services, developing local oncology databases, engaging in advocacy and ensuring stakeholder engagement, and coordinating administration and project management.

Contexts motivating protective behaviours related to Aedes-borne infectious diseases in Curaçao

BACKGROUND

Aedes aegypti, the vector of arboviral diseases such as dengue and Zika virus infections, is difficult to control. Effective interventions must be practicable, comprehensive, and sustained. There is evidence that community participation can enhance mosquito control. Therefore, countries are encouraged to develop and integrate community-based approaches to mosquito control to mitigate Aedes-borne infectious diseases (ABIDs). Health professionals must understand the contexts motivating individuals' behaviour to improve community participation and promote behavioural change. Therefore, this study aimed to determine how contexts shaped individuals' protective behaviours related to ABIDs in Curaçao.

METHODS

From April 2019 to September 2020, a multi-method qualitative study applying seven (n = 54) focus group discussions and twenty-five in-depth interviews with locals was performed in Curaҫao. The study was designed based on the Health Belief Model (HBM). Two cycles of inductive and deductive coding were employed, and Nvivo software was used to manage and analyse the data.

RESULTS

In this study, low media coverage (external cue to action) and limited experience with the symptoms of ABIDs (internal cue to action) were linked with a low perceived susceptibility and severity of ABIDs (low perceived threat). The low perceived threat was linked with reduced health-seeking behaviour (HSB) to prevent and control ABIDs. We also found that the perceived barriers outweigh the perceived benefits of ABID prevention and control interventions, obstructing HSB. On the one hand, insufficient knowledge reduced self-efficacy but contrary to expected, having good knowledge did not promote HSB. Lastly, we found that our participants believe that they are responsible for preventing ABIDs (internal locus of control) but at the same time indicated that their success depends on the efforts of the community and the health system (external locus of control).

CONCLUSIONS

This study used the HBM to explain individual changes in HSB concerning ABIDs prevention and control in Curaçao. We can conclude that the perceived threat (perceived susceptibility and severity) and perceived barriers played an essential role in changing HSB. Health professionals must consider these two concepts' implications when designing a bottom-up approach for ABIDs control; otherwise, community participation will remain minimal.

Disparities in breast cancer mortality among Latin American women: trends and predictions for 2030

BACKGROUND

Breast cancer is among the leading cause of cancer-related mortality among Latin American and Caribbean (LAC) women, but a comprehensive and updated analysis of mortality trends is lacking. The objective of this study was to determine the breast cancer mortality rates between 1997 and 2017 for LAC countries and predict mortality until 2030.

METHODS

We retrieved breast cancer deaths across 17 LAC countries from the World Health Organization mortality database. Age-standardized mortality rates per 100,000 women-years were estimated. Mortality trends were evaluated with Joinpoint regression analyses by country and age group (all ages, < 50 years, and ≥ 50 years). By 2030, we predict number of deaths, mortality rates, changes in population structure and size, and the risk of death from breast cancer.

RESULTS

Argentina, Uruguay, and Venezuela reported the highest mortality rates throughout the study period. Guatemala, El Salvador, and Nicaragua reported the largest increases (from 2.4 to 2.8% annually), whereas Argentina, Chile, and Uruguay reported downward trends (from - 1.0 to - 1.6% annually). In women < 50y, six countries presented downward trends and five countries showed increasing trends. In women ≥ 50y, three countries had decreased trends and ten showed increased trends. In 2030, increases in mortality are expected in the LAC region, mainly in Guatemala (+ 63.0%), Nicaragua (+ 47.3), El Salvador (+ 46.2%), Ecuador (+ 38.5%) and Venezuela (+ 29.9%).

CONCLUSION

Our findings suggest considerable differences in breast cancer mortality across LAC countries by age group. To achieve the 2030 sustainable developmental goals, LAC countries should implement public health strategies to reduce mortality by breast cancer.

An initiative to improve mental health practice in primary care in Caribbean countries

Objectives

The aim of this initiative was to assess whether a novel training program - Understanding Stigma and Strengthening Cognitive Behavioral Interpersonal Skills - could improve primary health care providers' confidence in the quality of mental health care they provide in the Caribbean setting by using the Plan-Do-Study-Act rapid cycle for learning improvement.

Methods

We conducted a prospective observational study of the impact of this training program. The training was refined during three cycles: first, the relevance of the program for practice improvement in the Caribbean was assessed. Second, pilot training of 15 local providers was conducted to adapt the program to the culture and context. Third, the course was launched in fall 2021 with 96 primary care providers. Pre- and post-program outcomes were assessed by surveys, including providers' confidence in the quality of the mental health care they provided, changes in stigma among the providers and their use of and comfort with the tools. This paper describes an evaluation of the results of cycle 3, the official launch.

Results

A total of 81 participants completed the program. The program improved primary care providers' confidence in the quality of mental health care that they provided to people with lived experience of mental health disorders, and it reduced providers' stigmatization of people with mental health disorders.

Conclusions

The program's quality improvement model achieved its goals in enhancing health care providers' confidence in the quality of the mental health care they provided in the Caribbean context; the program provides effective tools to support the work and it helped to empower and engage clients.

Bottom-up innovative responses to COVID-19 in Latin America and the Caribbean: addressing deprioritized populations

Objective

To identify and describe innovative initiatives implemented as a response to the interruption of health services during the COVID-19 pandemic in Latin America and the Caribbean (LAC).

Methods

This was a descriptive study that reviewed 34 initiatives implemented during the COVID-19 pandemic in LAC to address health services needs among deprioritized groups. The review of initiatives included four phases: a call for submissions of innovative initiatives from LAC countries; a selection of initiatives that had the ability to address health services gaps and that were innovative and effective; systematization and cataloging of the selected initiatives; and a content analysis of the information collected. Data were analyzed from September to October 2021.

Results

The 34 initiatives show important variations regarding the target populations, the stakeholders involved, level of implementation, strategies, scope, and relevance of the innovative initiative. There was also evidence of the emergence of a bottom-up set of actions in the absence of top-down actions.

Conclusion

The findings of this descriptive review of 34 initiatives implemented during the COVID-19 pandemic in LAC suggest that systematizing the strategies and lessons learned has the potential to expand learning for re-establishing and improving post-pandemic health services.

Replacement of core team members on embedded implementation research teams: experiences from Latin America and the Caribbean

Objective

To understand how replacement of decision-makers (DMs) serving as principal investigators (PI) or co-PIs on research teams may affect the feasibility and value of embedded implementation research (EIR) used to improve health policies, programs, and services in Latin America and the Caribbean.

Methods

This was a descriptive qualitative study based on 39 semistructured interviews with 13 embedded research teams selected by financing agencies to explore team composition, interaction among members, and research results. Interviews were conducted at three points during the study period from September 2018 to November 2019; data were analyzed from 2020 to 2021.

Results

Research teams were found to be operating in one of three situations: (i) permanent core team (no change) with either active DM or inactive DM participation; (ii) replacement of DM-PI or co-PI that did not affect EIR research; and (iii) replacement of DM-PI that affected EIR.

Conclusions

To ensure EIR continuity and stability, research teams should include high-level DMs together with more technical staff performing essential implementation activities. This structure could improve collaboration among professional researchers and ensure greater embeddedness of EIR to strengthen the health system.

Differential Fiscal Performances of Plausible Disaster Events: A Storyline Approach for the Caribbean and Central American Governments under CCRIF

Fiscal resilience against disasters is vital for the recovery in the aftermath of climate hazards. Without swift access to available funds for disaster relief, damages to human and the economy would be further exacerbated. How insurance may influence fiscal performance over time and can increase fiscal resilience for today and under a future climate has not been looked at yet in detail. Focusing on the Caribbean region and on the fiscal performance of governments after disaster events, we empirically analyze the effectiveness of the Caribbean Catastrophe Risk Insurance Facility (CCRIF) regarding the reduction of short-term fiscal effects. We embed this analysis within a novel climate impact storyline approach where we produce past plausible events and investigate the usefulness of insurance under such events. The storylines were modified according to global and climate change related boundary conditions to address the issue whether the CCRIF is fit for purpose or will need to be adapted in the future. We found that both hurricane strikes and the CCRIF affect fiscal outcomes of Caribbean countries. Furthermore, there are indications that CCRIF can counteract the negative fiscal consequences over the short term period induced by the disaster. Our analysis should shed some light on the current discussions on how development related assistance can be structured to enhance climate resilience in highly exposed countries for both direct and fiscal impacts of disasters.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41885-023-00126-0.

Healthy aging and care of the older adult with chronic disease: a qualitative needs assessment in 14 eastern and southern Caribbean islands

The objectives of this qualitative needs assessment were to assess perceived needs of health and social services professionals in the Caribbean Region to enhance services supporting healthy aging and care of older adults and to assess perceived facilitators and barriers to increasing capacity to serve their aging populations. The assessment, informed by the Consolidated Framework for Implementation Science, was conducted in 14 islands in the eastern and southern Caribbean. The results demonstrated need for education of professionals and the general population about the prevention and treatment of non-communicable diseases (NCDs), assessment and services for individuals with dementia, Alzheimer's disease, depression, and harmful alcohol use, all of which pose significant challenges for older adults. Education of health and social services professionals, families, and the public on the risk factors for NCDs and common mental and physical health problems is critical. Barriers to implementation of educational programs include lack of community awareness and resources within the islands. The needs assessment findings are foundational to planning educational interventions. These will be developed by local health providers with the collaboration and support of external resources including those of the Pan American Health Organization/World Health Organization Collaborating Centre in Gerontological Nursing Education.

Children and the coronavirus disease 2019 pandemic: a Caribbean perspective

This study aims to assess coronavirus disease 2019 (COVID-19) surveillance methods, health resources, vaccination coverage and income stratification and quantify burdens of disease and death in children and adolescents in the Caribbean. The investigation was a descriptive, cross-sectional study that included 15 Caribbean countries/territories and utilized surveys and secondary data sources. Quarantine and isolation measures were robust and surveillance strategies were similar. Pediatric specialists were available across the region, but few had designated pediatric hospitals or high-dependency units. There were more cases in children on islands with larger populations. Compared to high-income countries/territories, upper and lower middle-income countries/territories had higher disease burdens, fewer doctors and nurses per 1 000 population, lower bed capacities, and lower vaccination coverage. Child and adolescent cases ranged from 0.60% to 16.9%, compared with a global case rate of 20.2% in 2021. By August 2021 there were 33 deaths among children from Haiti, Jamaica, Trinidad and Tobago, and Barbados. The respective case fatality rates for 0-9-year-olds and 10-19-year-olds were 2.80 and 0.70 in Haiti, 0.10 and 0.20 in Jamaica, and 0.00 and 0.14 in Trinidad, compared with 0.17 and 0.1 globally. Overall COVID-19 incidence and mortality in children were consistent with global estimates. Limited resources have been offset by availability of pediatricians across the region, and minimally direct effects on children. Prioritization of admission of specific at-risk groups, training of first responders and vaccination campaigns targeting pregnant women and vulnerable children and adolescents could benefit countries with low vaccine coverage rates and limited resources.

[Household structure of older persons in Latin America and the CaribbeanA estrutura de moradia de idosos na América Latina e no Caribe]

Objetivo.

Analizar las pautas de convivencia de la población de 60 años o más que reside en hogares privados en 23 países de América Latina y el Caribe.

Métodos.

Estudio transversal realizado con base en los microdatos censales más recientes disponibles en Integrated Public Use Microdata Series (IPUMS)-International, la mayoría de ellos correspondientes a la ronda censal de 2010. Se calcularon y se compararon, para cada país y por sexo, el número medio de convivientes, su distribución por edad y las relaciones de parentesco que se establecen entre ellos. Se compararon, por país y por sexo, el promedio de convivientes en función del nivel de escolaridad y del estado civil.

Resultados.

El promedio del número de personas con las que convive la gente mayor difiere entre países. Oscila entre dos personas en países como Argentina, Puerto Rico y Uruguay, y cuatro o más personas en países como Honduras y Nicaragua. Esta diferencia resulta de la mayor o menor presencia de personas jóvenes, hijos y otros familiares en el hogar. El número de convivientes disminuye con el mayor nivel de escolaridad, salvo en Cuba y en Puerto Rico, donde no se observan diferencias. En general, las mujeres mayores viven en hogares con menos personas que los hombres, aunque no es el caso de las personas solteras o divorciadas.

Conclusiones.

La convivencia con hijos y otros familiares es habitual en la Región. Las diferencias entre países y por nivel educativo muestran que la familia juega un papel importante en la protección social de la vejez en los países menos desarrollados y en los grupos menos escolarizados.

Early- and Long-Term Outcomes of Mitral Valve Repair in a Low-Volume Centre in the Caribbean

INTRODUCTION

This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean.

METHODS

Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database.

RESULTS

Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiacrelated deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%.

CONCLUSION

Despite challenges of maintaining skills in a lowvolume centre, mitral valve repair can be performed safely with good early- and long-term results.

Socioeconomic inequalities in HIV knowledge, HIV testing, and condom use among adolescent and young women in Latin America and the Caribbean

Objective.

To appraise the presence and magnitude of inter- and intra-country health inequalities related to HIV in Latin America and the Caribbean (LAC) among young females.

Methods.

We analyzed household surveys in twenty LAC countries, that included data from female adolescents and young women (ages 15-24) between 2008 and 2018, measuring inequality with the concentration index of 4 indicators: 1) whether individuals have heard of HIV or not, 2) a composite variable of correct knowledge, 3) reported condom use with the last partner, and 4) whether individuals were ever tested for HIV.

Results.

Participants from households in countries with higher socioeconomic status are more likely to have heard of HIV, have correct knowledge of HIV transmission, and have used condoms during their last sexual intercourse. The inter-country concentration index for those indicators were 0.352, 0.302 and 0.110, respectively.

Conclusions.

Economically disadvantaged female adolescents and young women in LAC face an increased risk for HIV, as they are less aware of HIV and its actual transmission mechanism and are less likely to use condoms with their sexual partners. There is an urgent need to tailor prevention strategies of sexually transmitted infections and HIV for adolescents and young women that are sensitive to their socioeconomic context.

The demographic features and outcome indicators of the Barbados HIV Pre-exposure Prophylaxis Program, 2018-2019

Objective.

To assess the demographics, risk profiles and outcome indicators of one of the few government-supported programs on pre-exposure prophylaxis (PrEP) in the English-speaking Caribbean.

Methods.

Chart review of all persons enrolled into the national PrEP Program from its inception on March 1^st 2018 to November 30^th 2019, with a descriptive summary analysis of the data extracted.

Results.

Of the 134 persons enrolled into the program most identified as men who have sex with men (67.9%), followed by men who have sex with men and women (14.9%); there were 20 persons, mostly men (85%), in sero-discordant relationships. PrEP uptake was 96%; however, the continuation rate (continuing for three consecutive months after initiation) was 61.5%. Continuation status for many could not be ascertained due to loss-to-follow-up. PrEP-associated toxicity prevalence was 2.3%, although side-effects occurred in 52% (mostly gastrointestinal). HIV positivity during the study period was 1.5%.

Conclusions.

Uptake of Barbados’ national PrEP Program is excellent but fairly low continuation rates and the HIV positivity rate indicate the need for improved pre-ART initiation education and follow-up processes. Service utilisation is mainly by men who have sex with men, and provision expansion to other civil society partners and private practitioners, as well as increased public awareness could increase access by other high-risk groups.

A cross-sectional analysis of investigator needs for non-communicable disease research at the University of the West Indies, Mona

OBJECTIVE

To describe the needs of academic staff conducting non-communicable disease (NCD) research at the University of the West Indies, Mona Campus in Jamaica.

METHODS

Utilizing a cross-sectional design an online survey was created using the research electronic data capture application (REDCap); it was disseminated via email to 708 academic staff members in the Faculties of Medical Sciences and Science & Technology between September and November 2018. Participants were asked to indicate their level of access to expertise, training and equipment for conducting research. Descriptive analysis was conducted using STATA version 14.

RESULTS

Most respondents were women (74.2%), predominantly scientists (33.1%) or specialist physicians (22.6%). Less than 2/3 of respondents reported publishing research findings in peer reviewed journals, with a quarter not disseminating their research findings in any medium. Resources for field research/data collection, epidemiological methods and principles, and data management/data analysis were generally available. However, there was limited access to training, expertise and equipment in emerging techniques for NCD research such as metabolomics, bioinformatics/analysis of large-scale data sets and health economics. Additional challenges included limited access to financing for research, inadequate workspace and poor administrative support for conducting research.

CONCLUSIONS

There is a need for more local research seed funding, stronger administrative support for researchers, and opportunities for training in cutting edge NCD research techniques. Jamaican researchers could benefit from being part of a regional research centre of excellence with critical research skills and equipment that builds research networks and strengthens the NCD research response.

[Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimatesViolência por parceiro íntimo nas Américas: revisão sistemática e reanálise das estimativas nacionais de prevalência]

Objetivo.

Describir lo que se sabe acerca de la prevalencia nacional de la violencia por parte de la pareja íntima (VPI) contra las mujeres en las Américas, en los diversos países y en el transcurso del tiempo, incluida la cobertura geográfica, calidad y comparabilidad de los datos nacionales.

Métodos.

Se realizó una revisión sistemática y reanálisis de las estimativas nacionales de la VPI basadas en la población de 1998 a 2017 en las Américas. Las cifras se reanalizaron para comparabilidad o se extrajeron de los informes, incluida la prevalencia por tipo (física; sexual; o física y/o sexual), marco temporal (alguna vez; durante el último año) y perpetrador (cualquiera pareja en la vida; pareja actual/más reciente). En los países con tres (3+) rondas de datos, se aplicaron las pruebas de Cochran-Armitage y de ji cuadrada de Pearson para evaluar si los cambios en el transcurso del tiempo fueron significativos (p < 0,05).

Resultados.

Se encontraron encuestas elegibles en 24 países. Las mujeres reportaron haber sufrido alguna vez violencia física y/o sexual por parte de la pareja íntima con tasas que variaron desde el 14% a 17% en Brasil, Panamá y Uruguay hasta más de la mitad (58,5%) en Bolivia. La prevalencia de violencia física y/o sexual por parte de la pareja íntima durante el último año varió desde 1,1% en el Canadá hasta 27,1% en Bolivia. La evidencia preliminar sugiere una posible disminución en la prevalencia reportada para ciertos tipos de VPI en ocho países; sin embargo, algunos cambios fueron pequeños, ciertos indicadores no se modificaron significativamente y se observaron incrementos significativos en la prevalencia reportada de violencia física por parte de la pareja íntima durante el último año en la República Dominicana.

Conclusiones.

La VPI contra las mujeres sigue siendo un problema de salud pública y de derechos humanos en las Américas; sin embargo, la base de evidencia al respecto tiene deficiencias, lo que apunta a la necesidad de datos de mejor calidad y más comparables, a fin de movilizar y monitorear a la prevención y la respuesta ante la violencia.

Embedding research into health services in Latin America and the Caribbean: experiences and challenges of the Technical Support Center. Rev Panam Salud Publica 2021;45:e41. [PMID: 33727910 PMCID: PMC7954195 DOI: 10.26633/rpsp.2021.41]

This article describes the main models for embedding research and the successful experiences and challenges faced in joint work by researchers and decisionmakers who participated in the Embedding Research for the Sustainable Development Goals (ER-SDG) initiative, and the experience of the Technical Support Center. In June 2018, funding was granted to 13 pre-selected research projects from 11 middle- and low-income countries in Latin America and the Caribbean (Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Paraguay, and Peru). The projects focused on the system-, policy-, or program-level changes required to improve health and build on the joint work of researchers and decisionmakers, with a view to bringing together evidence production and decision-making in health systems and services. The Technical Support Center supported and guided the production of quality results useful for decision-making. This experience confirmed the value of initiatives such as ER-SDG in consolidating bridges between research on the implementation of health policies, programs, and systems, and the officials responsible for operating health-related programs, services, and interventions. It highlighted the importance of both respecting and taking advantage of each context—and the specific arrangements and patterns in the relationships between researchers and decisionmakers—through incentives for embedded research.

[The landscape of COVID-19 clinical trials in Latin America and the Caribbean: assessment and challenges]

Se está llevando a cabo un número considerable de ensayos clínicos en todo el mundo en respuesta a la pandemia de COVID-19, incluso en países de ingresos bajos y medios como los de América Latina y el Caribe. Sin embargo, la abundancia de estudios no necesariamente acorta el camino para encontrar intervenciones seguras y eficaces frente a la COVID-19. Se analizaron los ensayos para el tratamiento y la prevención de la COVID-19 de los países de América Latina y el Caribe que están registrados en la Plataforma de Registros Internacionales de Ensayos Clínicos de la Organización Mundial de la Salud, y se identificó una tendencia hacia la realización de estudios pequeños, repetitivos y no rigurosos que duplican los esfuerzos y merman recursos limitados sin producir conclusiones significativas sobre la seguridad y la eficacia de las intervenciones evaluadas. Se evaluaron asimismo los desafíos que plantea la realización de investigaciones científicamente sólidas y socialmente valiosas en América Latina y el Caribe a fin de brindar recomendaciones que alienten la realización de ensayos clínicos que tengan más probabilidades de producir evidencia sólida durante la pandemia.

HIV among men who have sex with men in the Caribbean: reaching the left behind

Objectives.

To present the epidemiology, social and cultural factors driving the HIV epidemic among men who have sex with men (MSM) in the Caribbean region and to highlight the regional and national responses, and what remains to be addressed to close the gaps in order to ending AIDS by 2030.

Methods.

A literature review was performed in the following databases: PubMed and Scopus. Articles published in the past 10 years were selected. The outcomes of interest were sociocultural risk factors, description of regional and national efforts and potential challenges and barriers to effective control of the epidemic among MSM. This report concentrates exclusively on publications related to MSM living in the Caribbean countries.

Results.

11 peer-reviewed studies, 9 grey literature reports and programme frameworks were thematically analysed. The prevalence of HIV among MSM is high and the rates also do vary among Caribbean countries. Several factors influence the epidemic among MSM in the Caribbean but stigma and discrimination underlie the social vulnerability and play a central role in driving the HIV epidemic.

Conclusions.

To end the AIDS epidemic by 2030, MSM can no longer be kept unchecked in the era of the Sustainable Development Goals with the motto ‘Leave no one behind’.

Cardiothoracic Surgery in the Caribbean

Introduction

Despite being one of the main vacation destinations in the world, health care in the Caribbean faces many difficulties. The challenges involved in these islands’ medical care range from low-resource institutions to lack of specialized care. In the field of thoracic and cardiac surgery, many limitations exist, and these include the lack of access to cardiac surgery for many small islands and little governmental funding for minimally invasive approaches in thoracic surgery.

Methods

Literature review was done using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics of thoracic and cardiac surgery departments on Caribbean islands. Articles on the history, current states of practice, and advances in cardiothoracic surgery in the Caribbean were reviewed.

Results

Regardless of the middle to high-income profile of the Caribbean, there are significant differences in the speed of technological growth in cardiothoracic surgery from island to island, as well as disparities between the quality of care and resources. Many islands struggle to advance the field of cardiothoracic surgery both through lack of local cardiac surgery centers and limited financial funding for minimally invasive thoracic surgery.

Conclusions

Cardiac and thoracic surgery in the Caribbean depend not only on the support from local government policies and proper distribution of healthcare budgets, but efforts by the surgeons themselves to change and improve institutional cultures. Although resource availability still remains a challenge, the Caribbean remains an important region that deserves special attention with regard to the unmet needs for long-term sustainability of chest surgery.

The landscape of COVID-19 clinical trials in Latin America and the Caribbean: assessment and challenges

A considerable number of clinical trials is being conducted globally in response to the COVID-19 pandemic, including in low- and middle-income countries such as those in the Latin America and Caribbean region (LAC). Yet, an abundance of studies does not necessarily shorten the path to find safe and efficacious interventions for COVID-19. We analyze the trials for COVID-19 treatment and prevention that are registered from LAC countries in the International Clinical Trials Registry Platform, and identify a trend towards small repetitive non-rigorous studies that duplicate efforts and drain limited resources without producing meaningful conclusions on the safety and efficacy of the interventions being tested. We further assess the challenges to conducting scientifically sound and socially valuable research in the LAC region in order to inform recommendations to encourage clinical trials that are most likely to produce robust evidence during the pandemic.

SARS-CoV-2 outbreak on the Caribbean islands of the Dutch Kingdom: a unique challenge

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic progresses, countries are depending on one another to acquire knowledge regarding effective measures to contain the virus. Public health measures to suppress transmissions have proven successful in Singapore, Hong Kong and Taiwan. Implementing and adhering to these interventions is challenging, with governments struggling to find a balance between necessary mitigation and suppression strategies, and interruptions of social-economic activities. While large high-income countries are struggling to keep their health systems and economies moving forward, small island developing states are facing even more significant challenges. Many Caribbean islands, including the six islands within the Dutch Kingdom, have been quick to implement stringent public health measures, yet they are facing unique challenges.

Status of national policy on companion of choice at birth in Latin America and the Caribbean: Gaps and challenges

The World Health Organization (WHO) recommends a companion of choice during labor and birth, to improve maternal and perinatal outcomes and women’s satisfaction with health services. To better understand the status of companion of choice in Latin America and the Caribbean (LAC), an online survey was conducted with members of a midwifery virtual community of practice and with key informants, aiming to identify: 1) existing regulatory instruments related to companion of choice in the countries where the members are practicing; and, 2) key characteristics of implementation of companion of choice, where regulation exists. Responses (n = 112) were received from representatives of 20 of the 43 countries of LAC. Respondents reported existence of a national policy or legislation in seven countries, ministerial norms or institutional protocols in five countries, and no existing policy/protocol in eight countries. Respondents from the same country often provided contradictory responses. Responses differed from information provided by ministries of health in a WHO-led global policy survey in 11 instances. These variations may reflect that midwives were not always aware of the national policy/guideline in their country. We propose that a more robust effort should be undertaken to understand the status of companion of choice for labor and birth in LAC countries, at national, regional, and local level, in public and private facilities. It is important to know if policies exist, at what level of the system, and if key stakeholders, maternity-care health providers, and women are aware of their existence. Efforts should also be made to understand barriers to implementing companion of choice.

Progressive disseminated histoplasmosis in Latin America and the Caribbean in people receiving highly active antiretroviral therapy for HIV infection: A systematic review

Histoplasmosis is the most clinically significant mycosis in Latin America; still it has been neglected in people with human immunodeficiency virus (HIV). There is limited information about its contribution to morbidity and mortality in this population. We conducted a systematic review of scientific literature to provide an estimation of the frequency and mortality of histoplasmosis among people with HIV receiving highly active antiretroviral therapy (HAART) in Latin America, and factors associated with mortality. We searched articles in PubMed, Scopus, WHO Global health library, and Scielo using different combination of terms including "histoplasmosis" and HAART. We identified 949 articles, removed 662 duplicated; screened 287 abstracts; reviewed full text of 53 articles; and selected 15 articles that provided information on the number of patients studied, included patients receiving ART, and reported any measure of frequency estimate for qualitative synthesis. Studies were conducted in Argentina (n = 4), Brazil (n = 6), Colombia (n = 2), French Guyana and the Bahamas (=2), and Guatemala (n = 1). Heterogeneity of studies characteristics precluded any aggregated estimates. Histoplamosis was frequent in these cohort studies and mortality was high despite the use of HAART. Low CD4 counts, delayed HAART initiation and poor adherence were related to increased incidence, poor prognosis and increased mortality, respectively. Histoplasmosis may be an important contributor to mortality in people with HIV in Latin America. Diagnostic delays represent an important limitation for improving care of patients suspected to have histoplasmosis. Reducing histoplasmosis diagnostic delays and therapy initiation is needed to further decrease mortality.

Violence against children in Latin America and the Caribbean: What do available data reveal about prevalence and perpetrators?

OBJECTIVE

To describe the prevalence of recent physical, sexual, and emotional violence against children 0 - 19 years of age in Latin America and the Caribbean (LAC) by age, sex, and perpetrator.

METHODS

A systematic review and analysis of published literature and large international datasets was conducted. Eligible sources from first record to December 2015 contained age-, sex-, and perpetrator-specific data from LAC. Random effects meta-regressions were performed, adjusting for relevant quality covariates and differences in violence definitions.

RESULTS

Seventy-two surveys (2 publications and 70 datasets) met inclusion criteria, representing 1 449 estimates from 34 countries. Prevalence of physical and emotional violence by caregivers ranged from 30% - 60%, and decreased with increasing age. Prevalence of physical violence by students (17% - 61%) declined with age, while emotional violence remained constant (60% - 92%). Prevalence of physical intimate partner violence (IPV) ranged from 13% - 18% for girls aged 15 - 19 years. Few or no eligible past-year estimates were available for any violence against children less than 9 years and boys 16 - 19 years of age; sexual violence against boys (any age) and girls (under 15 years); IPV except for girls aged 15 - 19 years; and violence by authority figures (e.g., teachers) or via gangs/organized crime.

CONCLUSION

Past-year physical and emotional violence by caregivers and students is widespread in LAC across all ages in childhood, as is IPV against girls aged 15 - 19 years. Data collection must be expanded in LAC to monitor progress towards the sustainable development goals, develop effective prevention and response strategies, and shed light on violence relating to organized crime/gangs.

[Systems for surveillance of birth defects in Latin America and the Caribbean: present and futureSistemas de vigilância de anomalias congênitas na América Latina e Caribe: presente e futuro]

Objetivos.

Conocer la disponibilidad de los sistemas nacionales de vigilancia de anomalías congénitas en América Latina y el Caribe y describir sus características.

Métodos.

Estudio transversal mediante una encuesta semiestructurada y autoadministrada en línea remitida en el 2017 por las representaciones locales de la Organización Panamericana de la Salud a las autoridades de los ministerios de salud de todos los países de América Latina y el Caribe. La encuesta recabó información sobre la disponibilidad de un sistema nacional de vigilancia de anomalías congénitas en el país y sus características.

Resultados.

Once países cuentan con sistema nacional de vigilancia de anomalías congénitas: Argentina, Colombia, Costa Rica, Cuba, Guatemala, México, Panamá, Paraguay, República Dominicana, Uruguay y Venezuela. Los sistemas tienen características heterogéneas: 6 son sistemas de base hospitalaria; 10 incluyen en su definición de caso los nacidos vivos y los fetos muertos. En todos los sistemas de vigilancia se incluyen los casos con anomalías mayores y menores, excepto en Argentina, Colombia y Guatemala que solo registran anomalías congénitas mayores. Solo Argentina, Costa Rica y Uruguay elaboran informes periódicos que consolidan y presentan los resultados de la vigilancia; los registros de Argentina y Costa Rica disponen de manuales operativos.

Conclusiones.

Se comprobó la aún escasa disponibilidad de sistemas nacionales de vigilancia de anomalías congénitas en América Latina y el Caribe y su elevada heterogeneidad. Es prioritario avanzar hacia la expansión y el fortalecimiento de este tipo de vigilancia en nuestros países.

Increased taxation on cigarettes in Grenada: potential effects on consumption and revenue

Objective

To investigate the feasibility of addressing the public health concerns of tobacco consumption through increased taxation, while preserving or augmenting government revenues in Grenada.

Methods

Purposive sampling methods were used to ensure data availability and geographical representativeness. Average price per 20-pack of the most-sold brands of cigarettes was calculated using data from three major supermarkets. The World Health Organization's Tax Simulation Model was used, with excise tax rates adjusted to effect 5%, 10%, and 15% consumption decreases.

Results

A 17% to 117% excise tax increase on the cost, insurance, and freight (CIF) value would achieve a 5% consumption decrease. Total government revenues would grow 8.7% and excise tax revenues would increase 11%. The average excise tax per 20-pack would move from EC$ 3.24 (2014 US$ 1.20) to EC$ 3.80 (US$ 1.41), while the average price per pack would increase to EC$ 9.21 (US$ 3.41) from EC$8.48 (US$ 3.14). In the 10% and 15% consumption reduction scenarios, excise taxes would have to be increased by 33% and 50% (to 133% and 150% of CIF, respectively), pushing the average excise tax per pack to EC$ 4.37 (US$ 1.62) and EC$ 4.90 (US$ 1.81), respectively.

Conclusion

In Grenada, consumption can be reduced alongside growth in government revenues, making available additional resources for health. This aligns with the literature, which indicates that taxation can be effective in pursuing the public health objective of reduced incidence of smoking-related illnesses via reduced consumption.

The potential for using alcohol and tobacco taxes to fund prevention and control of noncommunicable diseases in Caribbean Community countries

OBJECTIVES

To determine the extent to which increased taxes on alcohol and tobacco products in Caribbean Community (CARICOM) countries might successfully reduce consumption of those products and raise revenues, which could then be channeled into noncommunicable disease (NCD) prevention and control initiatives.

METHODS

The Tobacco Tax Simulation (TaXSiM) model, which was developed by the World Health Organization (WHO), was used to simulate the impact of tax changes on alcohol and tobacco products in three CARICOM member countries. Estimates of the NCD response cost in the 15 countries that are full members of CARICOM were also produced.

RESULTS

For the 15 full-member CARICOM countries, the revenues from increased excise taxes on beer, rum, and cigarettes associated with a 5.0% reduction in consumption were estimated at US$ 86.32 million. This expected revenue intake from excise taxes exceeded the estimated US$ 52.73 million required to respond to NCDs in those 15 CARICOM countries. The amount also exceeds US$ 78.87 million, which will be required if there is a 50.0% increase in the per capita NCD response cost.

CONCLUSIONS

The findings showed that for CARICOM countries, there is a substantial potential for revenue generation from increases in taxes on alcohol and tobacco, as well as for decreases in consumption of the products. Although increased taxes on alcohol and cigarettes can sufficiently cover the cost of controlling NCDs among CARICOM countries, a comprehensive response also requires widespread participation from various sectors.

10-year trends in noncommunicable disease mortality in the Caribbean region

Objective.

Between 2006 and 2016, 70% of all deaths worldwide were due to noncommunicable diseases (NCDs). NCDs kill nearly 40 million people a year globally, with almost three-quarters of NCD deaths occurring in low- and middle-income countries. The objective of this study was to assess mortality rates and trends due to deaths from NCDs in the Caribbean region.

Methods.

The study examines age-standardized mortality rates and 10-year trends due to death from cancer, heart disease, cerebrovascular disease, and diabetes in two territories of the United States of America (Puerto Rico and the U.S. Virgin Islands) and in 20 other English- or Dutch-speaking Caribbean countries or territories, for the most recent, available 10 years of data ranging from 1999 to 2014. For the analysis, the SEER*Stat and Joinpoint software packages were used.

Results.

These four NCDs accounted for 39% to 67% of all deaths in these 22 countries and territories, and more than half of the deaths in 17 of them. Heart disease accounted for higher percentages of deaths in most of the Caribbean countries and territories (13%-25%), followed by cancer (8%-25%), diabetes (4%-21%), and cerebrovascular disease (1%-13%). Age-standardized mortality rates due to cancer and heart disease were higher for males than for females, but there were no significant mortality trends in the region for any of the NCDs.

Conclusions.

The reasons for the high mortality of NCDs in these Caribbean countries and territories remain a critical public health issue that warrants further investigation.

Assessing electronic immunization registries: the Pan American Health Organization experience

Objective.

To develop a methodology to assess electronic immunization registries (EIRs) in low- and middle-income countries (LMICs) in Latin America and the Caribbean.

Methods.

A team from the Immunization Unit at the Pan American Health Organization (PAHO) reviewed existing methodologies to evaluate health information systems, particularly the Performance of Routine Information System Management (PRISM) framework and methodologies used to assess information systems. In 2014, the PAHO team convened a small working group to develop an evaluation approach to be added to the existing World Health Organization immunization data quality self-assessment (DQS) tool. The resulting DQS with an added EIR component was named “DQS Plus.” The DQS Plus methodology was used in Panama in May 2014 and in Honduras in November 2015.

Results.

The DQS Plus tool proved feasible and easy to implement in Panama and Honduras, including by not adding much time or resources to those needed for a usual DQS. The information obtained from the DQS Plus assessment was practical and helped provide health authorities with recommendations to update and improve their EIR, strengthen the use of the registry, and enhance the data the assessment produced, at all levels of the health system. These recommendations are currently being implemented in the two countries.

Conclusions.

The DQS Plus proved to be a practical and useful approach for assessing an EIR in an LMIC and generating actionable recommendations. Further work on defining operational and related EIR functional standards in LMICs will help develop an improved EIR assessment tool for Latin America and the Caribbean, and potentially elsewhere.

Primary care and multimorbidity in six Latin American and Caribbean countries

Objectives

To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments.

Methods

Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care.

Results

The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams.

Conclusions

Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

Caribbean Wellness Day: promoting a region-wide day of action

In response to the epidemic of non-communicable diseases (NCDs) in the Caribbean, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, “Uniting to Stop the Epidemic of Chronic Non-communicable Diseases” and declared the second Saturday in September to be “Caribbean Wellness Day” (CWD). CWD is a call-to-action for engaging the population of the Member States in confronting NCDs and their risk factors.

This report reviews the genesis, implementation, and institutionalization of CWD in CARICOM and beyond. The study used quantitative and qualitative methods, including 29 surveys, 7 in-depth interviews, and analysis of media content. Data was provided by NCD focal points at the Ministry of Health in 15 CARICOM countries, as well as by 7 non-governmental and 4 private organizations.

Branding materials were well received and locally adapted; much of CWD media content originated from organization websites and were not community-based. Events typically focused on physical activity and health screenings and were attended by up to 3 000 participants. Though most were held in city centers, some CWD activities have involved rural and indigenous populations.

CWD has become a catalyst for multisectoral engagement and health promotion activities. Inspired by CWD, PAHO initiated “Wellness Week in the Americas,” which includes CWD and promotes its tenets across the Region of the Americas. As CWD further develops, consideration should be given to reliable, adequate, and sustainable financing; to measuring and evaluating its impact on NCDs; and to widening its reach to include those outside of city centers.

Premature mortality from cardiovascular disease and diabetes in the Caribbean and associations with health care expenditure, 2001 - 2011

Objective.

To examine the historical trends of premature death due to cardiovascular disease and diabetes mellitus (CVD-DM) in the Caribbean and to identify any associations between these trends and health care expenditure.

Methods.

Death data were obtained from the World Health Organization Mortality Database; population data, from the United Nations World Population prospects; and health care expenditure data, from the World Bank. In all, 17 Caribbean countries had mortality data; however, only 11 had both mortality and health care expenditure data available. The analyses explored country-level trends in age-standardized CVD-DM mortality rates using 3-year moving averages from 1995 − 2014 for women and men. Associations between secular mortality rate change and health care expenditure were considered.

Results.

CVD-DM mortality rates ranged from 10.7 − 247.1 per 100 000, with a mean of 92.3 and standard deviation of 47.6. Of the 17 countries, 12 showed a reduction in premature CVD-DM mortality in both men and women, with others either showing no improvement or increases. Mortality rates for men were 1.46 times higher than for women. On average, there was a 68% increase in health care expenditure, with a 15.4% fall in CVD-DM mortality in women and 4.9% in men. Mixed effects modelling demonstrated a weak association between health care expenditure and declining CVD-DM mortality for both women −0.006 (95%CI = −0.014 − 0.001) and men −0.008 (95%CI = −0.017 − 0.001).

Conclusions.

Findings suggest that progress has been made to reduce premature CVD-DM related mortality in a number of Caribbean countries. Differences between countries may be partly related to differences in health care system performance, although further research that considers confounders is needed.

The 2007 Caribbean Community Port-of-Spain Declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation

OBJECTIVES

Noncommunicable diseases (NCDs) are a threat to social and economic development, including in the Caribbean. In 2007 the Caribbean Community (CARICOM) held the world's first-ever summit of heads of government on NCD prevention and control and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. The objectives of this paper are to provide an overview of a formal evaluation of the Declaration and to highlight key findings that could inform further implementation of the Declaration's 15 mandates.

METHODS

The evaluation's six research objectives were decided through stakeholder engagement and assessed by concurrent quantitative and qualitative research methods, using the following four themes: 1) trends in risk factors, morbidity, and mortality; 2) national and Caribbean-wide policy responses, and factors associated with policy successes and difficulties; 3) the international impact of the Declaration; and 4) the potential for raising revenue from tobacco and alcohol taxation in order to support NCD prevention and control.

RESULTS

There are marked disparities in NCD mortality and trends among the 20 CARICOM member countries and territories. No CARICOM member had fully implemented all of the Declaration's 15 mandates (which were monitored by 26 indicators), with 10 CARICOM members implementing fewer than half of the indicators, and with most members lacking a well-functioning multisectoral NCD Commission. Larger CARICOM members tended to have higher levels of implementation than did smaller members. Mandates that received active support from regional institutions tended to be better implemented by the CARICOM members than did mandates that lacked that kind of support. Feasible national tobacco and alcohol tax increases could more than cover the cost of implementing the World Health Organization NCD "best buy" interventions in the CARICOM member countries and territories.

CONCLUSIONS

Priorities for further implementation of the mandates from the Port-of-Spain Declaration include establishing throughout the CARICOM member countries and territories fully functioning national bodies to support multisectoral action for NCD prevention; greater regional support in policy development and implementation for smaller countries; and greater targeted use of taxes on tobacco and alcohol to support NCD control and prevention.

Main themes, barriers, and solutions to palliative and end-of-life care in the English-speaking Caribbean: a scoping review

Objectives

To identify common themes documented in the literature on palliative and end-of-life care in English-speaking Caribbean small island developing states (SIDS), and to describe barriers, improvement strategies, and suggested ways forward.

Methods

In 2015, we conducted a systematic scoping review of relevant literature identified through the MEDLINE and Web of Science databases. We supplemented that with searches of other electronic and hard-copy sources to map key concepts and summarize themes.

Results

Primary data and other literature from and about English-speaking Caribbean nations are relatively scarce. The available literature offers an overview of the existing situation in the region and explores why palliative and end-of-life care is limited there. This review identified barriers in five main areas recurring across this literature: i) culture and attitudes of health care providers, patients, and those close to them towards terminal illness and death; ii) opioid availability and use; iii) limited development of palliative care services; iv) unmet palliative care needs; and v) limited research on palliative or end-of-life care.

Conclusions

Our analysis helps to document the need for palliative and end-of-life care in Caribbean SIDS and highlights suggestions for moving forward with related practice, policy, and research.

Frequency of common polymorphisms in ( ) gene in adults with high serum triglycerides from Colombian Caribbean Coast

Background

Caveolin 1 gene (CAV1) has been associated with insulin resistance, metabolic syndrome and hypertension in humans. Also, it has been related to high serum triglycerides in rodents, however there is little evidence of this relation in humans.

Aim

To describe frequencies of common variations in CAV1 in adults with high serum triglycerides.

Methods

A case-control study was carried out with adults from Colombian Caribbean Coast. A whole blood sample was employed to measure serum concentrations of triglycerides, glucose, total cholesterol and HDLc. Six common Single Nucleotide Polymorphism (SNP) in CAV1 were genotyped (rs926198, rs3779512, rs10270569, rs11773845, rs7804372 and rs1049337). Allelic and genotypic frequencies were determined by direct count and Hardy-Weinberg Equilibrium (HWE) was assessed. Case and control groups were compared with null-hypothesis tests.

Results

A total of 220 cases and 220 controls were included. For rs3779512 an excess in homozygotes frequency was found within case group (40.4% (GG), 41.3% (GT) and 18.1% (TT); F_is=0.13, p=0.03). Another homozygotes excess among case group was found in rs7804372 (59.5% (TT), 32.3% (TA) and 8.2% (AA); F_is= 0.12, p= 0.04). In rs1049337, cases also showed an excess in homozygotes frequency (52.7% (CC), 35.0% (CT) and 12.3% (TT); F_is= 0.16, p= 0.01). Finally, for rs1049337 there were differences in genotype distribution between case and control groups (p <0.05).

Conclusion

An increased frequency of homozygote genotypes was found in subjects with high serum triglycerides. These findings suggest that minor alleles for SNPs rs3779512, rs7804372 and rs1049337 might be associated to higher risk of hypertriglyceridemia.

Leptospirosis in the Caribbean: a literature review

Objective

To describe leptospirosis epidemiology, seroprevalence, and serovars among humans and animals in the Caribbean from 1979 - 2013.

Methods

A retrospective study of the literature was performed on the general epidemiology, historical records, and geographical locations of leptospirosis outbreaks and cases in the Caribbean from 1979 - 2013. The primary sources of information were identified with PubMed Central, Google Scholar, CAREC, CaribVET, and The School of Veterinary Medicine at the University of the West Indies. Search terms used were: "human leptospirosis," "animal leptospirosis," "serovars," "livestock," "seroprevalence," "Caribbean countries," "risk factors," "confirmed cases," "suspected cases," "MAT," and "ELISA." Confirmed and suspected cases of human and animal leptospirosis were identified through laboratory analysis.

Results

Most cases of leptospirosis occurred during the rainy season (June - December) and had a positive correlation with flood conditions. The disease was more prevalent in males than females due to behavioral and occupational exposure. The highest incidence rates of human leptospirosis were recorded in Barbados, Trinidad and Tobago, and Jamaica. In animals, leptospirosis has been found in rodents, livestock, and dogs in many Caribbean countries. Inadequate active surveillance and misdiagnosis of human leptospirosis has contributed to under-reporting of the disease.

Conclusion

This review highlights the epidemiology and distribution of leptospirosis in the Caribbean. Prevalence rates and serovars vary greatly among the countries. Leptospirosis poses a significant health risk for humans and animals in the Caribbean and requires a "One Health" multisectoral approach to reduce incidence rates and protect at-risk individuals. Increased laboratory capacity to identify leptospirosis cases is required, along with awareness campaigns for both the public and animal and human health professionals.

Radiological findings of abnormalities associated with congenital Zika virus infection: conclusions from World Radiology Day 2016

In July 2015, Brazil reported an association between Zika virus infection and Guillain-Barre syndrome, and then in October 2015, between Zika and microcephaly. Most countries and territories in the Region of the Americas were later affected by the virus, creating a public health emergency.

Each year, the Pan American Health Organization (PAHO), Regional Office of the World Health Organization commemorates World Radiology Day (WRD), which highlights the role of radiology in public health. In 2016, PAHO devoted its WRD efforts to the Zika infection. Experts and partners presented and discussed the various radiological findings of Zika infection, the crucial role of obstetric ultrasound in the screening and monitoring of abnormalities associated with confirmed Zika virus infection, and the appropriateness of utilizing other neuroimaging technologies to study brain abnormalities in neonates and infants with prenatal Zika virus infection. The conclusions of WRD 2016 recommend that upon confirmation, prenatal ultrasound be used as the main tool to investigate and monitor suspected cases, with subsequent multidisciplinary postnatal assessments that include neuropediatric clinical studies and relevant neuroimaging. Additionally, radiology technicians should be adequately trained and a quality assurance program should be implemented to ensure timely, safe, and accurate diagnosis.

Prevalence of active transportation among adults in Latin America and the Caribbean: a systematic review of population-based studies

OBJECTIVE

To describe the prevalence of "active" (self-propelled, human-powered) transportation in the Latin America and Caribbean (LAC) region over the past decade.

METHODS

MEDLINE, Excerpta Medica (Embase), SportDiscus, Lilacs, MediCarib, Web of Science, OVID, CINAHL, Scopus, Google Scholar, National Transportation Library, and TRIS/TRID were searched for articles on active transportation published between January 2003 and December 2014 with (at least) a title and abstract in English, Portuguese, or Spanish. Research was included in the study if the two reviewing authors agreed it 1) was conducted in an adult sample (≥ 18 years old), 2) was designed to be representative of any LAC area, and 3) reported at least one measure of active transportation. Reference lists of included papers and retrieved reviews were also checked. A total of 129 key informants (87 scientific experts and 42 government authorities) were contacted to identify additional candidate publications. Two other authors extracted the data independently.

RESULTS

A total of 10 459 unique records were found; the full texts of 143 were reviewed; and a total of 45 studies were included in the study, yielding estimates for 72 LAC settings, most of which were in Argentina, Brazil, and Colombia. No eligible studies were found for the years 2003-2004, resulting in a 10-year study time frame. Estimates were available for walking, cycling, or the combination of both, with a high degree of heterogeneity (heterogeneity index (I2) ≥ 99%). The median prevalence of active transportation (combining walking and cycling) was 12.0%, ranging from 5.1% (in Palmas, Brazil) to 58.9% (in Rio Claro, Brazil). Men cycled more than women in all regions for which information was available. The opposite was true for walking.

CONCLUSIONS

Prevalence of active transportation in LAC varied widely, with great heterogeneity and uneven distribution of studies across countries, indicating the need for efforts to build comprehensive surveillance systems with standardized, timely, and detailed estimates of active transportation in order to support policy planning and evaluation.

The Latin America and the Caribbean search strategy proposal

Latin America and the Caribbean's public health literature is not widely recognized. Science in this region has even been compared to a night sky with just a few specks of light. To make those lights as reachable as possible, we developed the Latin America and the Caribbean Search Strategy (LACSS). This is a new method to utilize our region's health promotion results within MEDLINE/PubMed. In contrast to a typical MeSH query, LACSS retrieves up to six times more publication results regarding non-communicable diseases, neglected tropical diseases, injuries and other important public health relevant topics in the region. We believe that global health promotion will be improved in this region by improving its visibility, and this search strategy will contribute to this.