National drug formularies: lessons from Latin America

Although pharmaceuticals comprise up to 40% of the health care budget in developing countries, the majority of the population does not have access to many of the essential drugs needed to treat prevalent diseases. This situation demands the development of a national formulary of essential drugs for the public sector. The approach used in developing countries is to select drugs of choice for the treatment of prevalent morbidities and avoid therapeutic duplication, unacceptably dangerous drugs, or drugs of unproven efficacy. Drugs are selected based on a review of the prevalent morbidities, health care worker training, patient characteristics, and efficacy/risk information resulting from scientifically sound studies. An added component to the formulary is the inclusion of concise, unbiased prescribing information for each drug selected. A number of product selection guidelines were proven to be effective in establishing and maintaining an essential drug formulary for developing countries. These guidelines include: 1. Selection of drugs with proven efficacy and acceptable risk; 2. Selection of minimum number of drugs needed to treat the prevalent diseases; 3. Inclusion of new products only if they are found to have distinct advantages over products currently in use; 4. Inclusion of combination products only when they provide true benefit over single ingredients; 5. Selection of drugs with clear "drug of choice" indications for prevalent diseases; 6. Evaluation of the administrative and cost impact of products; and 7. Selection of drugs with established high quality.     

Illicit drug use research in Latin America: epidemiology service use, and HIV

This study analyzes trends in treatment admissions and summarizes HIV/AIDS risk factors along the US-Mexican border. Data are presented at the national level and at the state level for states along the border. Client data also are compared for treatment programs located in sister cities on the Texas-Mexico border. These data show that methamphetamine admissions are increasing nationally and methamphetamine use is a major problem in the western states on both sides of the border. Use of Ice (smoked methamphetamine) has increased significantly. Use of crack (smoked cocaine) is a growing problem on the border, and injection is the primary route for using black tar heroin in this area. Each of these drugs is a risk factor, either from drug-influenced risky sexual behaviors or from sharing injection equipment. In addition, the availability of drugs on the border and patterns of risky behaviors among migrants mean that drug users on the border are at risk of HIV/AIDS, and this risk is expected to increase with the spreading methamphetamine epidemic and smoking of crack cocaine. Comparable data on HIV/AIDS are needed for further studies of the relationship of drug use and HIV/AIDS on the border.     

Improving circularity in municipal solid waste management through machine learning in Latin America and the Caribbean

Machine Learning (ML) consists of a set of methods that allow a system to learn data patterns and has applications in many stages of MSWM. Improvements in MSWM focused on resources recovery in LA&C can be speed up by the use of the ML methods. This study aims to analyze the opportunities and challenges faced when using the ML methods to improve circularity in MSWM in LA&C. The methodology adopted was a systematic literature review using the PRISMA protocol in the Web of Science® database from 2010 to 2021, and bibliometric analysis using the Biblioshiny® application, the web interface for Bibiometrix® package from Rstudio® software. A total of 188 papers were obtained from the bibliographic search. The advancement of MSWM in LA&C has as challenges the lack of reliable data on the composition and production of the waste, the low rate of waste used as a resource, the need to change consumption patterns, social inclusion of informal waste collectors, and the inclusion of repair and reuse actions to reduce waste generation. Meanwhile, the main challenges when considering the use of ML in LA&C are the inexistence or dispersion of data with reliable time series and the lack of knowledge of decision makers about the potential use of the ML methods. Specifically in LA&C, it was observed that hybrid models that apply ML to waste composition data, ML methods to improve IoT applications and GIS data usage aggregated with ML methods could speed up the transition to Circular Economy in LA&C.     

Preventive education to cope with the drug problems of Latin America

Insufficient resources, services, staff, facilities and attention at the policymaking level are devoted to demand reduction measures, especially preventive education for young persons. Instead, emphasis is placed on and disproportionate resources are allocated to supply reduction measures and activities such as suppressing and/or limiting the availability of illicit drugs. Prevention policy constitutes a viable approach to solving the problem of illicit drug trafficking and consumption. The crux of the problem is not the availability of illicit drugs, but the demand of consumers for the substances. Preventive education for the young is an indispensable ingredient of effective prevention policy. The school environment can be instrumental in developing systematic and lasting preventive education. An essential condition, which, according to the author, is lacking in Latin America, is that educators should be provided with the training and training tools needed to enable them to perform properly as agents of prevention policy. A number of recommendations to reduce illicit drug demand and consumption through prevention are made, including giving priority to a comprehensive and systematically applied prevention policy focusing on the young and involving an educational approach and tools that are progressive and highly specialized, as well as research that is intensified and of better quality.     

Prevalence of Smoking and Drinking Among Older Adults in Seven Urban Cities in Latin America and the Caribbean

In 2000, a representative sample of the elderly population (60 years or older) was selected from seven urban cities in Latin America and the Caribbean: Buenos Aires (Argentina), Mexico City (Mexico), Santiago (Chile), Havana (Cuba), Montevideo (Uruguay), Bridgetown (Barbados), and Sao Paulo (Brazil). A face-to-face interview was uniformly administered in the respective official languages. A total of 10,577 older adults were included in this study. The elderly in Havana had the highest prevalence of smoking (46.5% of men and 21.5% women). The highest prevalence of daily drinking was in Buenos Aires (19%). In contrast, only 1.5% of respondents in Mexico City and 2.3% of respondents in Havana consumed alcohol daily. Smoking and daily drinking were highly prevalent among older adults. As the older adult population grows steeply, the health behavior of this population starts carrying important implications for health care systems.     

Prevalence of smoking and drinking among older adults in seven urban cities in Latin America and the Caribbean

In 2000, a representative sample of the elderly population (60 years or older) was selected from seven urban cities in Latin America and the Caribbean: Buenos Aires (Argentina), Mexico City (Mexico), Santiago (Chile), Havana (Cuba), Montevideo (Uruguay), Bridgetown (Barbados), and Sao Paulo (Brazil). A face-to-face interview was uniformly administered in the respective official languages. A total of 10,577 older adults were included in this study. The elderly in Havana had the highest prevalence of smoking (46.5% of men and 21.5% women). The highest prevalence of daily drinking was in Buenos Aires (19%). In contrast, only 1.5% of respondents in Mexico City and 2.3% of respondents in Havana consumed alcohol daily. Smoking and daily drinking were highly prevalent among older adults. As the older adult population grows steeply, the health behavior of this population starts carrying important implications for health care systems.     

A review of emergency room studies on alcohol and injuries conducted in Latin America and the Caribbean region

Issues. Alcohol-attributable burden of injury is one of the most serious public health problems in Latin America and the Caribbean region (LAC). Although knowledge on alcohol's involvement in injuries has progressed along with the implementation of evidenced-based alcohol policies in developed countries, this was not true for the most part of LAC countries for which reducing alcohol-related injuries is an urgent necessity. Approach. A systematic review was performed in order to identify the most up-to-date information on alcohol and injuries derived from emergency room (ER) studies conducted in LAC. Key Findings. Findings corroborate that alcohol has a high prevalence among injured patients in the ER setting in LAC, with violence-related injuries showing an increased association with alcohol use compared to unintentional injuries. However, a large number of studies did not include all types of injury and the measurement of injury risk associated with alcohol consumption. The amount of alcohol consumed in the event and hazardous drinking patterns seem to be strongly associated with injury occurrence, as well as drinking in public spaces, but a paucity of data relating to social-contextual factors limits the interpretation of the heterogeneity in the magnitude of the association of alcohol and injuries found across studies. Conclusions. There is a lack of ER studies able to support strategies to reduce alcohol-related injuries in a region where effective alcohol policies are scant. Future research should focus on understanding how drinking influenced by local contexts and drinking behaviours may affect the risk of injury within each LAC country.[Andreuccetti G, Carvalho HB, Korcha R, Ye Y, Bond J, Cherpitel CJ. A review of emergency room studies on alcohol and injuries conducted in Latin America and the Caribbean region. Drug Alcohol Rev 2012;31:737-746].     

Prevention of Travelers' Diarrhea: Ciprofloxacin versus Trimethoprim/Sulfamethoxazole in Adult Volunteers Working in Latin America and the Caribbean

Background : The objective of the study was to compare the safety and efficacy of three treatment protocols for the prevention of travelers' diarrhea: once-daily ciprofloxacin versus trimethoprim/sulfamethoxazole (TMP/SMZ) once daily versus placebo for the prevention of travelers' diarrhea.
Method : The study population was comprised of participants in 2-week medical-missions projects based in Latin America and the Caribbean. The diverse age group and varied study sites closely resembles the population of travelers who seek pretravel advice from physicians. A prospective, randomized, double-blind, placebo-controlled comparison was designed. Subjects who developed diarrhea, defined as three stools in 8 hours plus one or more signs of an enteric infection, were considered prophylaxis failures. Stool specimens were collected and examined for the presence of enteric pathogens. DNA probes were used to determine the presence of diarrheagenic E. coli. Bacterial colony blots were used. Adverse events were recorded by participants in a diary.
Results : Three hundred and forty-four subjects were entered in the study, of which two hundred and seventy-eight subjects met the criteria for the efficacy and safety review. Subjects were randomly assigned to receive ciprofloxacin (500 mg), TMP/SMZ (160/ 800 mg), or placebo. Five of the 99 (5%) subjects taking ciprofloxacin, 14 of the 87 (16%) taking TMP/SMZ, and 30 of the 92 (33%) taking placebo experienced diarrhea. Bacterial pathogens were identified more commonly in the TMP/SMZ and placebo groups than in the ciprofloxacin-treated group. The incidence of adverse reactions was 9.0%, 14.8%, and 7.5% for ciprofloxacin, TMP SMZ, and placebo subjects, respectively (p = .287).
Conclusion : Ciprofloxacin 500 mg once daily provides safe and effective prophylaxis for travelers' diarrhea and is superior to TMP/SMZ (160/800 mg). ( J Travel Med 1:136–142, 1994)     

Dissemination and diversity of metallo-beta-lactamases in Latin America: report from the SENTRY Antimicrobial Surveillance Program

Carbapenem resistance among Pseudomonas aeruginosa and Acinetobacter spp. is becoming a critical therapeutic problem worldwide. The SENTRY Antimicrobial Surveillance Program monitors pathogen frequency and antimicrobial resistance patterns of nosocomial and community-acquired infections through sentinel hospitals on five continents. Pseudomonas spp. and Acinetobacter spp. strains resistant to imipenem (MIC, ≥16 mg/l), meropenem (MIC, ≥16 mg/l), and ceftazidime (MIC, ≥32 mg/l) collected from January 2001 to December 2003 were routinely screened for antimicrobial resistance genes. Resistant isolates were initially tested for metallo-β-lactamase (MβL) production by phenotypic tests (disk approximation or MβL Etest strip) and then characterization of the MβL (hydrolysis assays, PCR for bla_IMP, bla_VIM, bla_SPM, gene sequencing). Eighty-nine isolates (33 Acinetobacter spp., 54 Pseudomonas aeruginosa, and 2 P. fluorescens) had positive phenotypic screening tests. Among those, 34 isolates producing MβL were identified, including 7 Acinetobacter spp., 25 P. aeruginosa and 2 P. fluorescens. The MβLs identified were IMP-1, VIM-2 and two newly described enzymes: SPM-1 and IMP-16. The greatest concentration of MβL strains was in Brazil, where imipenem-resistant P. aeruginosa increased significantly in the time period evaluated by the SENTRY Program. MβL-producing P. aeruginosa was detected in São Paulo (SPM-1) and Brasilia (SPM-1 and IMP-16), Brazil and Caracas, Venezuela (VIM-2); while MβL-producing Acinetobacter spp. isolates were detected in São Paulo, Brazil (IMP-1). P. fluorescens isolates producing IMP-1 and VIM-2 were detected in São Paulo, Brazil and Santiago, Chile, respectively. The emergence and dissemination of mobile MβL-producing isolates represent an alarming factor for increasing resistance to carbapenems in several medical centres evaluated by the SENTRY Program in Latin America.     

Enteric viruses and coliphages in Latin America

Drinking and other types of waters in three Latin American countries were sampled for the presence of enteroviruses, rotaviruses, and coliphages. Large volumes of water and sewage were concentrated using a positively charged filter for the detection of enteric viruses. Statistical analyses indicated no correlation between the presence or absence of fecal coliforms, total coliforms, fecal streptococci, and viruses. Total coliforms and fecal streptococci were isolated in large numbers from pristine tropical rain forest streams, but no enteric viruses were detected in any of the same samples. All streams contaminated with sewage contained enteric viruses and high levels of indicator bacteria. These results indicate that at the present time there is no reliable indicator of the presence of viruses in waters. The presence of coliphages in waters seemed associated with fecal contamination. The large numbers of fecal streptococci and coliforms (both fecal and total) present in the waters sampled may not necessarily indicate that these waters are contaminated with fecal waste.     

Prevalence and antimicrobial susceptibility patterns among gastroenteritis-causing pathogens recovered in Europe and Latin America and Salmonella isolates recovered from bloodstream infections in North America and Latin America: report from the SENTRY Antimicrobial Surveillance Program (2003)

Gastroenteritis-causing pathogens are the second leading cause of morbidity and mortality worldwide. Complicating the clinical diarrhoea syndrome is the emergence of antimicrobial resistance among the responsible bacterial pathogens. The reported increases in fluoroquinolone resistance in Salmonella, Shigella and Campylobacter have been extremely worrisome considering the primary role of ciprofloxacin as a treatment. In this study, 1479 bacterial isolates from gastroenteritis infections were collected in Europe and Latin America, which included Salmonella spp. (834; 56%), Shigella spp. (311; 21%), Campylobacter spp. (182; 12%) and Aeromonas spp. (72; 5%). The fluoroquinolones displayed the greatest activity against these pathogens, with only three non-Campylobacter spp. strains being non-susceptible using current Clinical and Laboratory Standards Institute (CLSI) breakpoint criteria. Whilst ciprofloxacin resistance in European and Latin American Salmonella was only 0.2% and 0.0%, respectively, a total of 16.2% and 12.9% of isolates were resistant to nalidixic acid, indicating possible first-step gyrA mutations. Among confirmed extended-spectrum beta-lactamase-producing Salmonella strains, CTX-M genes were detected in 15 originating from Russia. Erythromycin and azithromycin were the most potent agents tested against Campylobacter spp. (values of minimum inhibitory concentration for 90% of the organisms, 0.5 mg/L and 0.12 mg/L, respectively), with erythromycin displaying the highest susceptibility (91.1%). Salmonella isolates from bloodstream infections displayed antibiograms that were nearly identical to strains causing gastroenteritis. Considering the role that antimicrobial therapy plays in the management of moderate to severe bacterial gastroenteritis, global surveillance and local/national public health programmes can provide critical data illuminating the dissemination of resistance and guidance for empirical therapy.     

Pharmacist-managed drug therapy helps meet requirements for drug-use evaluation.

Pharmacist-managed drug therapy at a 205-bed nonprofit, general medical and surgical hospital is described. The pharmacy department provides a drug therapy management service in which clinical pharmacists initiate and adjust drug therapy and order laboratory tests according to criterion-based protocols. A physician requests initiation of the protocol and cosigns all orders written by pharmacists. The protocols for pharmacy-managed drug therapy are developed primarily by the clinical pharmacists and approved by the hospital's pharmacy and therapeutics and executive committees. They delineate specific indicators of the process (e.g., timely initiation of therapy) and outcome (e.g., clinical efficacy) of drug therapy management. These indicators are included in the record kept by the pharmacist for each patient treated in this program, and this documentation is reviewed daily. The same documentation is used in the drug-use evaluation (DUE) process. (Drugs for which drug therapy management protocols have been developed are among those selected for DUE.) In 1990, pharmacists managed 3616 courses of drug therapy by using approximately 100 drug protocols. The criterion-based drug therapy management service helps to fulfill the hospital's drug-use evaluation responsibilities by establishing specific process and outcome indicators, proposing drugs for DUE inclusion, and collecting data.