Inequidades en salud entre países de Latinoamérica y el Caribe (2005-2010)

Objective

To identify health inequalities among Latin American and Caribbean countries in recent years (2005-2010), based on the view that measurement of inequalities is the first step in identifying health inequities.

Method

We performed an ecological study, whose units of analysis were 20 Latin American and Caribbean countries. These units were used to build the Inequalities in Health Index. This index summarizes, in a value ranging from 0 to 1, a set of socio-economic and health indicators, developed by international organizations. These indicators are considered as proximal and contextual determinants of health.

Results

According to the index calculated, the five countries with the worst health status were Haiti, Guatemala, Bolivia, Venezuela and Honduras. In contrast, the five countries with the most favorable health status were Cuba, Argentina, Uruguay, Chile and Mexico.

Conclusion

Even today, there are wide health inequalities in Latin America and the Caribbean. The country with the most favorable health indicators was Cuba and that with the least favorable was Haiti. We recommend systematic evaluation of health inequalities in Latin America and the Caribbean through the Inequalities in Health Index and other indices, in order to analyze actions, policies and programs to reduce inequities in this region.     

Household-Level Spatiotemporal Patterns of Incidence of Cholera,Haiti, 2011

A cholera outbreak began in Haiti during October, 2010. Spatiotemporal patterns of household-level cholera in Ouest Department showed that the initial clusters tended to follow major roadways; subsequent clusters occurred further inland. Our data highlight transmission pathway complexities and the need for case and household-level analysis to understand disease spread and optimize interventions.     

Rapid development and use of a nationwide training program for cholera management, Haiti, 2010

When epidemic cholera appeared in Haiti in October 2010, the medical community there had virtually no experience with the disease and needed rapid training as the epidemic spread throughout the country. We developed a set of training materials specific to Haiti and launched a cascading training effort. Through a training-of-trainers course in November 14-15, 2010, and department-level training conducted in French and Creole over the following 3 weeks, 521 persons were trained and equipped to further train staff at the institutions where they worked. After the training, the hospitalized cholera patients' case-fatality rate dropped from 4% to <2% by mid-December and was <1% by January 2011. Continuing in-service training, monitoring and evaluation, and integration of cholera management into regular clinical training will help sustain this success.     

Recent clonal origin of cholera in Haiti

Altered El Tor Vibrio cholerae O1, with classical cholera toxin B gene, was isolated from 16 patients with severe diarrhea at St. Mark's Hospital, Arbonite, Haiti, <3 weeks after onset of the current cholera epidemic. Variable-number tandem-repeat typing of 187 isolates showed minimal diversity, consistent with a point source for the epidemic.     

Update: outbreak of cholera ---Haiti, 2010

The first cholera outbreak in Haiti in at least a century was confirmed by the Haitian National Public Health Laboratory on October 21, 2010. Surveillance data through December 3, provided by the Haitian Ministry of Public Health and Population (MSPP), indicated that the outbreak had spread nationwide and that cases of cholera and cholera-associated hospitalizations and deaths had climbed rapidly in November. As of December 3, MSPP reported 91,770 cases of cholera from all 10 departments and the capital city of Port-au-Prince; 43,243 (47.1%) patients had been hospitalized, and 2,071 (2.3%) had died. A rapid mortality assessment in Artibonite Department found that deaths occurred as rapidly as 2 hours after symptom onset and identified important gaps in access to life-saving treatments, including oral rehydration solution (ORS). Urgent activities are under way, and additional efforts are imperative to reduce cholera mortality by expanding access to cholera treatment and to reduce cholera transmission by improving access to safe water and adequate sanitation.     

Phylogenetic reconstruction of Mycobacterium tuberculosis within four settings of the Caribbean region: tree comparative analyse and first appraisal on their phylogeography.

In order to compare phylogenetic methods and to reconstruct the evolutionary history of the tubercle bacilli, a set of macro-array-based genotyping data of Mycobacterium tuberculosis clinical isolates (called spoligotyping for spacer oligonucleotide typing, which assays the variability of the Direct Repeat -DR- locus), was analyzed in four settings of the Caribbean region (Guadeloupe, Martinique, Cuba and Haiti). A set of 47 alleles, split into 26 shared and 21 unique alleles) representative of 321 individual M. tuberculosis clinical isolates from patients residing in the above regions was studied. The following methods (and software in brackets) were investigated: numerical taxonomy distance methods (TAXOTRON), maximum parsimony procedure (PAUP), median-joining networks (NETWORK), and nested clade analysis (GEODIS). Results using these methods were analyzed, compared and discussed. The latter method (GEODIS) was investigated in detail by introducing geographical data together with genetic variability results to detect a link between population structure and population history, and to test the null hypothesis of no association between geography and genotypes. Irrespective of the methods used, our findings demonstrate that a core structure of four families (or clades) of M. tuberculosis strains is highly prevalent within the islands studied, indirectly reflecting passed colonization history of these different settings. Specificity of M. tuberculosis genotypes in each of the islands is discussed in the light of their respective colonial and contemporary histories.     

Cholera prevention training materials for community health workers, Haiti, 2010–2011

Stopping the spread of the cholera epidemic in Haiti required engaging community health workers (CHWs) in prevention and treatment activities. The Centers for Disease Control and Prevention collaborated with the Haitian Ministry of Public Health and Population to develop CHW educational materials, train >1,100 CHWs, and evaluate training efforts.     

Update: cholera outbreak --- Haiti, 2010

On October 19, 2010, the Haitian Ministry of Public Health and Population (MSPP) was notified of unusually high numbers of patients from Artibonite and Centre departments who had acute watery diarrhea and dehydration, in some cases leading to death. Within 4 days, the National Public Health Laboratory (LNSP) in Haiti isolated Vibrio cholerae serogroup O1, serotype Ogawa, from stool specimens obtained from patients in the affected areas by an investigation team from MSPP and CDC Haiti. This report describes the investigation of the initial cases, the ongoing outbreak of cholera in Haiti, and initial control measures. Since the initial identification of cholera, the outbreak has expanded to include cases in seven of Haiti's 10 departments and the capital city of Port-au-Prince. As of November 13, MSPP had reported 16,111 persons hospitalized with acute watery diarrhea and 992 cholera deaths, 620 of which occurred among hospitalized patients. Prevention and control measures implemented by MSPP with assistance from governmental and nongovernmental partners include 1) providing better access to treated drinking water; 2) providing education on improvement of sanitation, hygiene, and food preparation practices; 3) advising ill persons to begin using oral rehydration solution immediately and seek health care at the onset of watery diarrhea; 4) enhancing cholera treatment capacity at existing health-care institutions; and 5) establishing cholera treatment centers.     

Update: Outbreak of poliomyelitis--Dominican Republic and Haiti, 2000-2001

From July 12, 2000, through September 18, 2001, a total of 21 cases of poliomyelitis (including two fatal cases) were reported from the Caribbean island of Hispaniola, divided between Haiti and the Dominican Republic. In the Dominican Republic, 13 of 168 reported cases of acute flaccid paralysis (AFP) were confirmed as polio by isolation of poliovirus type 1 from either patients or their healthy contacts. The median age of the patients was 3 years (range: 9 months-14 years). None was vaccinated adequately. The most recent confirmed case-patient in the Dominican Republic had paralysis onset on January 25, 2001. In Haiti, eight of 40 AFP cases were confirmed virologically; seven of the confirmed cases occurred during January-July 2001. The median age of the patients was 7 years (range: 2-12 years). One patient had received at least 3 doses of oral poliovirus vaccine (OPV). The most recent confirmed case occurred in Haiti and the patient had paralysis onset on July 12, 2001. Eighteen AFP cases from the Dominican Republic and three from Haiti are pending final classification.     

Mortality Rates during Cholera Epidemic,Haiti, 2010–2011

The 2010 cholera epidemic in Haiti was one of the largest cholera epidemics ever recorded. To estimate the magnitude of the death toll during the first wave of the epidemic, we retrospectively conducted surveys at 4 sites in the northern part of Haiti. Overall, 70,903 participants were included; at all sites, the crude mortality rates (19.1–35.4 deaths/1,000 person-years) were higher than the expected baseline mortality rate for Haiti (9 deaths/1,000 person-years). This finding represents an excess of 3,406 deaths (2.9-fold increase) for the 4.4% of the Haiti population covered by these surveys, suggesting a substantially higher cholera mortality rate than previously reported.     

Reappearance of Chikungunya,Formerly Called Dengue,in the Americas

After an absence of ≈200 years, chikungunya returned to the American tropics in 2013. The virus is maintained in a complex African zoonotic cycle but escapes into an urban cycle at 40- to 50-year intervals, causing global pandemics. In 1823, classical chikungunya, a viral exanthem in humans, occurred on Zanzibar, and in 1827, it arrived in the Caribbean and spread to North and South America. In Zanzibar, the disease was known as kidenga pepo, Swahili for a sudden cramp-like seizure caused by an evil spirit; in Cuba, it was known as dengue, a Spanish homonym of denga. During the eighteenth century, dengue (present-day chikungunya) was distinguished from breakbone fever (present-day dengue), another febrile exanthem. In the twentieth century, experiments resulted in the recovery and naming of present-day dengue viruses. In 1952, chikungunya virus was recovered during an outbreak in Tanzania, but by then, the virus had lost its original name to present-day dengue viruses.     

Lessons learned during public health response to cholera epidemic in Haiti and the Dominican Republic

After epidemic cholera emerged in Haiti in October 2010, the disease spread rapidly in a country devastated by an earthquake earlier that year, in a population with a high proportion of infant deaths, poor nutrition, and frequent infectious diseases such as HIV infection, tuberculosis, and malaria. Many nations, multinational agencies, and nongovernmental organizations rapidly mobilized to assist Haiti. The US government provided emergency response through the Office of Foreign Disaster Assistance of the US Agency for International Development and the Centers for Disease Control and Prevention. This report summarizes the participation by the Centers and its partners. The efforts needed to reduce the spread of the epidemic and prevent deaths highlight the need for safe drinking water and basic medical care in such difficult circumstances and the need for rebuilding water, sanitation, and public health systems to prevent future epidemics.     

Understanding the Cholera Epidemic, Haiti

After onset of a cholera epidemic in Haiti in mid-October 2010, a team of researchers from France and Haiti implemented field investigations and built a database of daily cases to facilitate identification of communes most affected. Several models were used to identify spatiotemporal clusters, assess relative risk associated with the epidemic’s spread, and investigate causes of its rapid expansion in Artibonite Department. Spatiotemporal analyses highlighted 5 significant clusters (p<0.001): 1 near Mirebalais (October 16–19) next to a United Nations camp with deficient sanitation, 1 along the Artibonite River (October 20–28), and 3 caused by the centrifugal epidemic spread during November. The regression model indicated that cholera more severely affected communes in the coastal plain (risk ratio 4.91) along the Artibonite River downstream of Mirebalais (risk ratio 4.60). Our findings strongly suggest that contamination of the Artibonite and 1 of its tributaries downstream from a military camp triggered the epidemic.On October 21, 2010, the Haitian Ministry of Public Health and Population (MSPP) reported a cholera epidemic caused by Vibrio cholerae O1, serotype Ogawa, biotype El Tor (1). This epidemic was surprising as no cholera outbreak had been reported in Haiti for more than a century (1,2). Numerous media rapidly related the epidemic to the deadly earthquake that Haiti had experienced 9 months earlier. However, simultaneously, a rumor held recently incoming Nepalese soldiers responsible for importing cholera, along with accusations of illegal dumping of waste tank contents (3). A cholera outbreak was indeed reported in Nepal’s capital city of Kathmandu on September 23, 2010, shortly before troops left for Haiti (4,5). Two hypotheses then emerged to explain cholera in Haiti.Some researchers posited the transmission of an environmental strain to humans (6). Reasoning by analogy with cholera epidemiology in South Asia, they hypothesized that weather conditions, i.e., the La Niña phenomenon, might have promoted the growth of V. cholerae in its environmental reservoir (6). The second hypothesis suggested importation of the disease from a cholera-endemic country. The sequencing of 2 isolates of V. cholerae supported this second hypothesis by establishing an exogenous origin, probably from southern Asia or eastern Africa (7). Responding to a request from Haitian authorities to the French Embassy for the support of epidemiologists, we conducted a joint French–Haitian investigation during November 7–November 27, 2010, to clarify the source of the epidemic and its unusual dynamic.     

West Nile virus activity in Latin America and the Caribbean.

OBJECTIVES: West Nile virus (Flavivirus: Flaviviridae; WNV) has spread rapidly throughout the Caribbean Basin since its initial detection there in 2001. This report summarizes our current knowledge of WNV transmission in tropical America. METHODS: We reviewed the published literature and consulted with key public health officials to obtain unpublished data. RESULTS: West Nile virus infections first appeared in human residents of the Cayman Islands and the Florida Keys in 2001, and in apparently healthy Jamaican birds sampled early in 2002. Serologic evidence of WNV infection in 2002 was detected in horses, chickens and resident free-ranging birds in Guadeloupe, the Dominican Republic, and eastern Mexico. In 2003, WNV spread in Mexico and northern Central America, and serologic evidence was detected in the Bahamas, Puerto Rico and Cuba. In 2004, the first serologic evidence of WNV activity in South American ecosystems surfaced in September-October in Colombia and Trinidad, where domestic animals circulated WNV-neutralizing antibodies. CONCLUSIONS: The sparse reports of equine, human and avian disease in Latin America and the Caribbean is puzzling. Isolates are needed to evaluate viral attenuation or other possible explanations for reduced disease burden in tropical ecosystems.     

Financing of health care in four Caribbean territories: a comparison with reforms in Europe

This paper considers health care finance in four Caribbean territories and plans for reform in comparison with developments in European countries, to which these territories are historically linked. European health care reforms are aimed at making resource allocation in health care more efficient and more responsive to consumers' demands and preferences. These reforms in Europe have been continuing without appearing to have influenced the developments in the Caribbean very much, except in Martinique. In Trinidad and Tobago current reform entails delegation of responsibility for providing services to four regional health authorities and no purchaser/provider split at the regional or facility level as in the UK has been implemented. In the Bahamas, managed care arrangements are likely to emerge given the proximity of the United States. Recent universal coverage reform in Martinique was aimed at harmonisation of finance by bringing social security and social aid functions together under one management structure and may provide more opportunities for contracting and other initiatives towards greater efficiency. The first priority in Suriname is to restore proper functioning of the current system. Reforms in the four Caribbean territories have a largely administrative character and affect the organisation of the third party role in health care rather than fundamentally changing the relationship between this third party and the various other parties in health care.     

Assessing the causes of under-five mortality in the Albert Schweitzer Hospital service area of rural Haiti.

OBJECTIVES: Limited information is available regarding the causes of under-five mortality in nearly all of the countries in which mortality is the highest. The purpose of this study was to use a standard computerized protocol for defining the leading causes of death among children in a high-mortality rural population of Haiti and to highlight the need for similar studies else-where in Haiti and throughout the high-mortality areas of Latin America and the Caribbean. METHODS: In 2001 a standardized, closed-ended verbal autopsy questionnaire endorsed by the World Health Organization was administered to a representative, population-based sample of the mothers or other caregivers of 97 children who had died before reaching 5 years of age between 1995 and 1999 in the service area of the Albert Schweitzer Hospital, which is located in the rural Artibonite Valley of Haiti. With the data from the questionnaires we used a computerized algorithm to generate diagnoses of the cause of death; the algorithm made it possible to have more than one cause of death. RESULTS: Acute lower respiratory infection (ALRI) was the leading diagnosis, present in 45% of all under-five deaths, followed by enteric diseases, present in 21% of deaths. Neonatal tetanus, preterm birth, and other early neonatal causes unassociated with ALRI or diarrhea were present in 41% of the neonatal deaths. Among children 1-59 months of age, ALRI was present in 51% of the deaths, and enteric diseases in 30%. Deaths were concentrated during the first few months of life, with 35% occurring during the first month. Among the neonatal deaths, 27% occurred on the first day of life, and 80% occurred during the first 10 days of life. CONCLUSIONS: In the Albert Schweitzer Hospital program area--and presumably in other areas of Haiti as well--priority needs to be given to the prevention of and the early, effective treatment of ALRI, diarrhea, and early neonatal conditions. This study points to the need for more, similar standardized assessments to guide local, regional, and national programs.     

Delineating and Analyzing Locality-Level Determinants of Cholera,Haiti

Centre Department, Haiti, was the origin of a major cholera epidemic during 2010–2019. Although no fine-scale spatial delineation is officially available, we aimed to analyze determinants of cholera at the local level and identify priority localities in need of interventions. After estimating the likely boundaries of 1,730 localities by using Voronoi polygons, we mapped 5,322 suspected cholera cases reported during January 2015–September 2016 by locality alongside environmental and socioeconomic variables. A hierarchical clustering on principal components highlighted 2 classes with high cholera risk: localities close to rivers and unimproved water sources (standardized incidence ratio 1.71, 95% CI 1.02–2.87; p = 0.04) and urban localities with markets (standardized incidence ratio 1.69, 95% CI 1.25–2.29; p = 0.0006). Our analyses helped identify and characterize areas where efforts should be focused to reduce vulnerability to cholera and other waterborne diseases; these methods could be used in other contexts.     

Some observations on the cholera (E1 Tor) epidemic in 1961-62

The author discusses some of the features of the cholera epidemic caused by El Tor vibrios in 1961-62 in the Western Pacific. The disease originated in the Celebes and spread from there to other parts of Indonesia, to Sarawak and, possibly, to Kwangtung. Hong Kong and Macau were most probably infected from Kwangtung. Subsequently the disease reached the Philippines, progressing from Manila southwards to the other islands, whence it invaded British Borneo. The El Tor epidemic did not differ clinically or epidemiologically from other cholera outbreaks observed during the past decade. The disease attacked poor, under-nourished people living under insanitary conditions. It spread along the coastline and, to a limited extent, along inland waterways. The authorities in the affected territories recommended that the quarantine regulations, sanitary measures and treatment methods used against cholera caused by the so-called “true” cholera vibrios be applied also to cholera caused by El Tor vibrios.     

An outbreak of cholera from food served on an international aircraft.

In February 1992, an outbreak of cholera occurred among persons who had flown on a commercial airline flight from South America to Los Angeles. This study was conducted to determine the magnitude and the cause of the outbreak. Passengers were interviewed and laboratory specimens were collected to determine the magnitude of the outbreak. A case-control study was performed to determine the vehicle of infection. Seventy-five of the 336 passengers in the United States had cholera; 10 were hospitalized and one died. Cold seafood salad, served between Lima, Peru and Los Angeles, California was the vehicle of infection (odds ratio, 11.6; 95% confidence interval, 3.3-44.5). This was the largest airline-associated outbreak of cholera ever reported and demonstrates the potential for airline-associated spread of cholera from epidemic areas to other parts of the world. Physicians should obtain a travel history and consider cholera in patients with diarrhoea who have travelled from cholera-affected countries. This outbreak also highlights the risks associated with eating cold foods prepared in cholera-affected countries.     

Modern Cholera in the Americas: An Opportunistic Societal Infection

In the Americas, the only two cholera epidemics of the past century have occurred in the past 25 years.Lessons from the 1991 Peruvian cholera epidemic can help to focus and refine the response to the current Haitian epidemic. After three years of acute epidemic response, we have an opportunity to refocus on the chronic conditions that make societies vulnerable to cholera.More importantly, even as international attention wanes in the aftermath of the earthquake and acute epidemic, we are faced with a need for continued and coordinated investment in improving Haiti’s structural defenses against cholera, in particular access to improved water and sanitation.SHORTLY BEFORE THE BEGINNING of the only 20th-century cholera epidemic in the Americas, the front page of the Lima, Peru, El Comercio featured a picture of a major intersection that had become little more than a water-filled crater (Figure 1).1 A water main had broken days before, eroding the earth underneath the road until the street collapsed, breaking a sewer main in the process. The first cases of acute diarrhea would be announced two days later, and the word cholera would appear in the newspapers three days after that. This story may sound familiar, perhaps because we could imagine it in Haiti almost three years ago, although in this case we must go back two decades before, to January 30, 1991.Open in a separate windowFIGURE 1—Front page picture from January 1991’s El Comercio newspaper showing a crater in a major Lima intersection resulting from a broken water main, which was originally built in the 1920s.That event in Lima, which both literally and metaphorically exposed an undercurrent of decaying infrastructure that mixed sewage with clean water, heralded the arrival of cholera to the Americas after a century’s absence. The Peruvian epidemic of 1991 combined a neglect of essential infrastructure with a perfect storm of social, political, and economic chaos. The third anniversary of the beginning of the Haitian cholera epidemic in 2010 affords us an opportunity to reexamine common themes of modern cholera in the Americas.Cholera’s unexpected arrival and rapid spread in Haiti exploited deep fractures in public infrastructure and stressed both local and international response systems. Despite the 20-year remove, Peru’s experience offers useful lessons in the way cholera tends to infiltrate vulnerable societies and in the difficulty of coordinating a national and global epidemic response. Perhaps most important after two years of an acute health care–focused epidemic response in Haiti, a historical perspective provides an opportunity to reemphasize the need to address the chronic causes of cholera: lack of access to sanitation and clean water.