Economic burden of expected epidemiological changes in diseases related to tobacco, Mexico

OBJECTIVE: To determine health care costs and economic burden of epidemiological changes in diseases related to tobacco consumption. METHODS: A time-series analysis in Mexico (1994-2005) was carried out on seven health interventions: chronic obstructive pulmonary diseases, lung cancer with and without surgical intervention, asthma in smokers and non-smokers, full treatment course with nicotine gum, and full treatment course with nicotine patch. According with Box-Jenkins methodology, probabilistic models were developed to forecast the expected changes in the epidemiologic profile and the expected changes in health care services required for selected interventions. Health care costs were estimated following the instrumentation methods and validated with consensus technique. RESULTS: A comparison of the economic impact in 2006 vs. 2008 showed 20-90% increase in expected cases depending on the disease (p<0.05), and 25-93% increase in financial requirements (p<0.01). The study data suggest that changes in the demand for health services for patients with respiratory diseases related to tobacco consumption will continue showing an increasing trend. CONCLUSIONS: In economic terms, the growing number of cases expected during the study period indicates a process of internal competition and adds an element of intrinsic competition in the management of preventive and curative interventions. The study results support the assumption that if preventive programs remain unchanged, the increasing demands for curative health care may cause great financial and management challenges to the health care system of middle-income countries like Mexico.

Socioeconomic inequities in the health and nutrition of children in low/middle income countries

OBJECTIVE: To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS: We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS: Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS: Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.

Beyond the income inequality hypothesis and human health: a worldwide exploration

OBJECTIVE: To analyze whether the relationship between income inequality and human health is mediated through social capital, and whether political regime determines differences in income inequality and social capital among countries. METHODS: Path analysis of cross sectional ecological data from 110 countries. Life expectancy at birth was the outcome variable, and income inequality (measured by the Gini coefficient), social capital (measured by the Corruption Perceptions Index or generalized trust), and political regime (measured by the Index of Freedom) were the predictor variables. Corruption Perceptions Index (an indirect indicator of social capital) was used to include more developing countries in the analysis. The correlation between Gini coefficient and predictor variables was calculated using Spearman's coefficients. The path analysis was designed to assess the effect of income inequality, social capital proxies and political regime on life expectancy. RESULTS: The path coefficients suggest that income inequality has a greater direct effect on life expectancy at birth than through social capital. Political regime acts on life expectancy at birth through income inequality. CONCLUSIONS: Income inequality and social capital have direct effects on life expectancy at birth. The "class/welfare regime model" can be useful for understanding social and health inequalities between countries, whereas the "income inequality hypothesis" which is only a partial approach is especially useful for analyzing differences within countries.

How many low birthweight babies in low- and middle-income countries are preterm?

OBJECTIVE: To assess the prevalence of preterm birth among low birthweight babies in low and middle-income countries. METHODS: Major databases (PubMed, LILACS, Google Scholar) were searched for studies on the prevalence of term and preterm LBW babies with field work carried out after 1990 in low- and middle-income countries. Regression methods were used to model this proportion according to LBW prevalence levels. RESULTS: According to 47 studies from 27 low- and middle-income countries, approximately half of all LBW babies are preterm rather than one in three as assumed in studies previous to the 1990s. CONCLUSIONS: The estimate of a substantially higher number of LBW preterm babies has important policy implications in view of special health care needs of these infants. As for earlier projections, our findings are limited by the relative lack of population-based studies.

Cause-specific mortality and income inequality in São Paulo, Brazil

OBJECTIVE: To analyze cause-specific mortality rates according to the relative income hypothesis. METHODS: All 96 administrative areas of the city of São Paulo, southeastern Brazil, were divided into two groups based on the Gini coefficient of income inequality: high (>0.25) and low (<0.25). The propensity score matching method was applied to control for confounders associated with socioeconomic differences among areas. RESULTS: The difference between high and low income inequality areas was statistically significant for homicide (8.57 per 10,000; 95%CI: 2.60;14.53); ischemic heart disease (5.47 per 10,000 [95%CI 0.76;10.17]); HIV/AIDS (3.58 per 10,000 [95%CI 0.58;6.57]); and respiratory diseases (3.56 per 10,000 [95%CI 0.18;6.94]). The ten most common causes of death accounted for 72.30% of the mortality difference. Infant mortality also had significantly higher age-adjusted rates in high inequality areas (2.80 per 10,000 [95%CI 0.86;4.74]), as well as among males (27.37 per 10,000 [95%CI 6.19;48.55]) and females (15.07 per 10,000 [95%CI 3.65;26.48]). CONCLUSIONS: The study results support the relative income hypothesis. After propensity score matching cause-specific mortality rates was higher in more unequal areas. Studies on income inequality in smaller areas should take proper accounting of heterogeneity of social and demographic characteristics.

Access to medicines for acute illness in middle income countries in Central America

OBJECTIVE : To analyze the main predictors of access to medicines for persons who experienced acute health conditions. METHODS : This was a cross-sectional analytic study, based on data from household surveys. We examined the predictors of: (1) seeking care for acute illness in the formal health care system and (2) obtaining all medicines sought for the acute condition. RESULTS : The significant predictors of seeking health care for acute illnesses were urban geographic location, head of household with secondary school education or above, age under 15, severity of illness perceived by the respondent, and having health insurance. The most important predictor of obtaining full access to medicines was seeking care in the formal health care system. People who sought care in the formal system were three times more likely to receive all the medicines sought (OR 3.0, 95%CI 2.3;4.0). For those who sought care in the formal health system, the strongest predictors of full access to medicines were seeking care in the private sector, having secondary school education or above, and positive perceptions of quality of health care and medicines in public sector health facilities. For patients who did not seek care in the formal health system, full access to medicines was more likely in Honduras or Nicaragua than in Guatemala. Urban geographic location, higher economic status, and male gender were also significant predictors. CONCLUSIONS : A substantial part of the population in these three countries sought and obtained medicines outside of the formal health care system, which may compromise quality of care and pose a risk to patients. Determinants of full access to medicines inside and outside the formal health care system differ, and thus may require different strategies to improve access to medicines. 

Mid-point for open-ended income category and the effect of equivalence scales on the income-health relationship

To estimate the mid-point of an open-ended income category and to assess the impact of two equivalence scales on income-health associations. Data were obtained from the 2010 Brazilian Oral Health Survey ( Pesquisa Nacional de Saúde Bucal – SBBrasil 2010). Income was converted from categorical to two continuous variables ( per capita and equivalized) for each mid-point. The median mid-point was R$ 14,523.50 and the mean, R$ 24,507.10. When per capita income was applied, 53% of the population were below the poverty line, compared with 15% with equivalized income. The magnitude of income-health associations was similar for continuous income, but categorized equivalized income tended to decrease the strength of association.

Social capital, social participation and life satisfaction among Chilean older adults

OBJECTIVE To examine factors associated with social participation and their relationship with self-perceived well-being in older adults. METHODS This study was based on data obtained from the National Socioeconomic Characterization (CASEN) Survey conducted in Chile, in 2011, on a probability sample of households. We examined information of 31,428 older adults living in these households. Descriptive and explanatory analyses were performed using linear and multivariate logistic regression models. We assessed the respondents’ participation in different types of associations: egotropic, sociotropic, and religious. RESULTS Social participation increased with advancing age and then declined after the age of 80. The main finding of this study was that family social capital is a major determinant of social participation of older adults. Their involvement was associated with high levels of self-perceived subjective well-being. We identified four settings as sources of social participation: home-based; rural community-based; social policy programs; and religious. Older adults were significantly more likely to participate when other members of the household were also involved in social activities evidencing an intergenerational transmission of social participation. Rural communities, especially territorial associations, were the most favorable setting for participation. There has been a steady increase in the rates of involvement of older adults in social groups in Chile, especially after retirement. Religiosity remains a major determinant of associativism. The proportion of participation was higher among older women than men but these proportions equaled after the age of 80. CONCLUSIONS Self-perceived subjective well-being is not only dependent upon objective factors such as health and income, but is also dependent upon active participation in social life, measured as participation in associations, though its effects are moderate.

Prevalence of health promotion programs in primary health care units in Brazil

OBJECTIVE Assessment of prevalence of health promotion programs in primary health care units within Brazil’s health system. METHODS We conducted a cross-sectional descriptive study based on telephone interviews with managers of primary care units. Of a total 42,486 primary health care units listed in the Brazilian Unified Health System directory, 1,600 were randomly selected. Care units from all five Brazilian macroregions were selected proportionally to the number of units in each region. We examined whether any of the following five different types of health promotion programs was available: physical activity; smoking cessation; cessation of alcohol and illicit drug use; healthy eating; and healthy environment. Information was collected on the kinds of activities offered and the status of implementation of the Family Health Strategy at the units. RESULTS Most units (62.0%) reported having in place three health promotion programs or more and only 3.0% reported having none. Healthy environment (77.0%) and healthy eating (72.0%) programs were the most widely available; smoking and alcohol use cessation were reported in 54.0% and 42.0% of the units. Physical activity programs were offered in less than 40.0% of the units and their availability varied greatly nationwide, from 51.0% in the Southeast to as low as 21.0% in the North. The Family Health Strategy was implemented in most units (61.0%); however, they did not offer more health promotion programs than others did. CONCLUSIONS Our study showed that most primary care units have in place health promotion programs. Public policies are needed to strengthen primary care services and improve training of health providers to meet the goals of the agenda for health promotion in Brazil.

Access to continued-use medication among older adults, Brazil

OBJECTIVE To determine the prevalence and associated access factors for all continued-use prescription drugs and the ways in which they can be obtained.METHODS Data was obtained from the 2008 Household National Survey. The sample comprised 27,333 individuals above 60 years who reported that they used continued-use prescription drugs. A descriptive analysis and binary and multiple multinomial logistic regressions were performed.RESULTS 86.0% of the older adults had access to all the medication they needed, and among them, 50.7% purchased said medication. Those who obtained medication from the public health system were younger (60-64 years), did not have health insurance plans, and belonged to the lower income groups. It is remarkable that 14.0% of the subjects still had no access to any continued-use medication, and for those with more than four chronic diseases, this amount reached 22.0%. Those with a greater number of chronic diseases ran a higher risk of not having access to all the medication they needed.CONCLUSIONS There are some groups of older adults with an increased risk of not obtaining all the medication they need and of purchasing it. The results of this study are expected to contribute to guide programs and plans for access to medication in Brazil.

Methods and challenges for the health impact assessment of vaccination programs in Latin America

ABSTRACT OBJECTIVE To describe methods and challenges faced in the health impact assessment of vaccination programs, focusing on the pneumococcal conjugate and rotavirus vaccines in Latin America and the Caribbean. METHODS For this narrative review, we searched for the terms "rotavirus", "pneumococcal", "conjugate vaccine", "vaccination", "program", and "impact" in the databases Medline and LILACS. The search was extended to the grey literature in Google Scholar. No limits were defined for publication year. Original articles on the health impact assessment of pneumococcal and rotavirus vaccination programs in Latin America and the Caribbean in English, Spanish or Portuguese were included. RESULTS We identified 207 articles. After removing duplicates and assessing eligibility, we reviewed 33 studies, 25 focusing on rotavirus and eight on pneumococcal vaccination programs. The most frequent studies were ecological, with time series analysis or comparing pre- and post-vaccination periods. The main data sources were: health information systems; population-, sentinel- or laboratory-based surveillance systems; statistics reports; and medical records from one or few health care services. Few studies used primary data. Hospitalization and death were the main outcomes assessed. CONCLUSIONS Over the last years, a significant number of health impact assessments of pneumococcal and rotavirus vaccination programs have been conducted in Latin America and the Caribbean. These studies were carried out few years after the programs were implemented, meet the basic methodological requirements and suggest positive health impact. Future assessments should consider methodological issues and challenges arisen in these first studies conducted in the region.

National Immunization Program: Computerized System as a tool for new challenges

The scope and coverage of the Brazilian Immunization Program can be compared with those in developed countries because it provides a large number of vaccines and has a considerable coverage. The increasing complexity of the program brings challenges regarding its development, high coverage levels, access equality, and safety. The Immunization Information System, with nominal data, is an innovative tool that can more accurately monitor these indicators and allows the evaluation of the impact of new vaccination strategies. The main difficulties for such a system are in its implementation process, training of professionals, mastering its use, its constant maintenance needs and ensuring the information contained remain confidential. Therefore, encouraging the development of this tool should be part of public health policies and should also be involved in the three spheres of government as well as the public and private vaccination services.

Herpes simplex virus type 2 infection in pregnancy: asymptomatic viral excretion at delivery and seroepidemiologic survey of two socioeconomically distinct populations in São Paulo, Brazil

The objective of the present study was to estimate the prevalence of herpes simplex virus type 2 (HSV 2) antibodies in child bearing women of 2 Brazilian populations with different socioeconomic status and to determine the risk of neonatal HSV exposure by means of maternal cultures at the onset of labor. The study was conducted at 2 hospitals: A, serving very low income patients and B, serving middle socioeconomic class. 173 participants from group A and 127 from B answered a questionnaire which showed that the patients had similar ages (27.7 and 26.8 years, respectively) but differed with regard to socioeconomic status, age at first intercourse (18.6 vs 20.6 years), number of sex partners (1.5 vs 1.2) and previous sexually transmitted diseases (15% vs. 1.5%). History of genital herpes was given by 11% of group A participants and by a similar number, 7%, of patients from group B. In addition, 200 serum samples from population A and 455 from B were tested by ELISA for and HSV antibodies and 92% and 86%, respectively, were found to be positive. Sixty seropositive samples from group A and 90 from B were further analyzed by Western blot, which showed the presence of type 2 specific antibodies in 46% and 36%, respectively, suggesting an overall HSV 2 prevalence of 42% in group A and 31% in B. Cervical specimens were obtained for culture from 299 asymptomatic patients of population A and 313 of B. HSV was isolated from one specimen in each group, indicating a 0.3% incidence of asymptomatic viral excretion in both populations. In conclusion, the prevalence of type 2 antibodies in childbearing women was very high, but it did not differ with the socioeconomic status. The risk of HSV perinatal transmission was also similar in the 2 study populations and it was comparable with the data from developed countries. Our findings do not indicate the need of special screening programs for asymptomatic HSV excretion in Brazilian pregnant women.

COLONIZATION AND LABORATORY MAINTENANCE OFAnopheles albimanus WIEDEMANN IN VENEZUELA

Anopheles albimanus is one of the main vectors of malaria in Central America and the Caribbean, based on its importance, there are previous reports of the successful colonization of this species in Latin America countries. Mosquitoes were collected in the Aragua State of Venezuela colonized in the laboratory, using a simple and efficient maintenance method. Based on life table calculations under well established laboratory conditions, the Survival Rate Probability was constant and always close to 1 in immature stages, the Reproductive Net Rate (Ro) was 3.83, the generation time (Tc) was 24.5 days and the Intrinsic Growth Rate (rm) was 0.0558. This is the first report of the colonization of A. albimanus in Venezuela.

Seroprevalence of toxoplasmosis in a low-income community in the São Paulo municipality, SP, Brazil

Toxoplasmosis is one of the most common zoonoses worldwide. The seroprevalence for T. gondii in human population from Brazil might range from 40 to 80%. The aim of this paper was to study the seroprevalence of T. gondii infection in children from age one to 15 living in a low socioeconomic community, named community of Jardim São Remo in the year of 2002. The community is located in the West area of São Paulo municipality, São Paulo State, Brazil. Antibodies to T. gondii were found in 110 (32.4%, CI 95%: 27.5 - 37.7) of the 339 children tested with indirect immunofluorescent antibody test. The titration of the samples revealed 29 children with serum titer equal to 16, 14 children with 32, 18 children with 64, 21 children with 128, 20 children with 256 and eight children with serum titer > 512. The age dependence of the prevalence of T. gondii infection and the association between seroprevalence for T. gondii and seroprevalence for T. canis suggest that the infection is chiefly postnatal. Seroconversion in infant population of community Jardim São Remo occurs in children as young as two years old, earlier than in the children attended at health centers of São Paulo city. The seroprevalence of T. gondii in children from Jardim São Remo was compared to the prevalence in children from other urban centers of Brazil.