Showing papers by "Pan American Health Organization published in 2007"

Evaluation and treatment of chagas disease in the United States : A systematic review

Abstract: ContextBecause of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease).ObjectiveTo examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection.Evidence AcquisitionLiterature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field.Evidence SynthesisThe patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation.ConclusionsChagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

Wildlife, exotic pets, and emerging zoonoses

Abstract: Most emerging infectious diseases are zoonotic; wildlife constitutes a large and often unknown reservoir. Wildlife can also be a source for reemergence of previously controlled zoonoses. Although the discovery of such zoonoses is often related to better diagnostic tools, the leading causes of their emergence are human behavior and modifications to natural habitats (expansion of human populations and their encroachment on wildlife habitat), changes in agricultural practices, and globalization of trade. However, other factors include wildlife trade and translocation, live animal and bushmeat markets, consumption of exotic foods, development of ecotourism, access to petting zoos, and ownership of exotic pets. To reduce risk for emerging zoonoses, the public should be educated about the risks associated with wildlife, bushmeat, and exotic pet trades; and proper surveillance systems should be implemented.

Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean.

Abstract: Stroke is a major health problem in Latin American and Caribbean countries. In this paper, we review the epidemiology, aetiology, and management of stroke in the region based on a systematic search of articles published in Spanish, Portuguese, and English. Stroke mortality is higher than in developed countries but rates are declining. Populationbased studies show variations in incidence of strokes: lower rates of ischaemic stroke and similar rates of intracranial haemorrhages, compared with other regions. A signifi cant proportion of strokes in these populations can be attributed to a few preventable risk factors. Some countries have published national clinical guidelines, although much needs to be done in the organisation of care and rehabilitation. Even though the burden of stroke is high, there is a paucity of information for implementing evidence-based management. The Global Stroke Initiative, the WHO STEPS Stroke surveillance, and WHO-PREMISE projects provide opportunities for surveillance at institutional and community levels.

Prevention, control, and elimination of neglected diseases in the Americas: Pathways to integrated, inter-programmatic, inter-sectoral action for health and development

Abstract: In the Latin America and Caribbean region over 210 million people live below the poverty line. These impoverished and marginalized populations are heavily burdened with neglected communicable diseases. These diseases continue to enact a toll, not only on families and communities, but on the economically constrained countries themselves. As national public health priorities, neglected communicable diseases typically maintain a low profile and are often left out when public health agendas are formulated. While many of the neglected diseases do not directly cause high rates of mortality, they contribute to an enormous rate of morbidity and a drastic reduction in income for the most poverty-stricken families and communities. The persistence of this "vicious cycle" between poverty and poor health demonstrates the importance of linking the activities of the health sector with those of other sectors such as education, housing, water and sanitation, labor, public works, transportation, agriculture, industry, and economic development. The purpose of this paper is three fold. First, it focuses on a need for integrated "pro-poor" approaches and policies to be developed in order to more adequately address the multi-faceted nature of neglected diseases. This represents a move away from traditional disease-centered approaches to a holistic approach that looks at the overarching causes and mechanisms that influence the health and well being of communities. The second objective of the paper outlines the need for a specific strategy for addressing these diseases and offers several programmatic entry points in the context of broad public health measures involving multiple sectors. Finally, the paper presents several current Pan American Health Organization and other institutional initiatives that already document the importance of integrated, inter-programmatic, and inter-sectoral approaches. They provide the framework for a renewed effort toward the efficient use of resources and the development of a comprehensive integrated solution to neglected communicable diseases found in the context of poverty, and tailored to the needs of local communities.

Cervical screening by visual inspection, HPV testing, liquid-based and conventional cytology in Amazonian Peru.

Abstract: Cervical cancer is an important public health problem in many developing countries, where cytology screening has been ineffective. We compared four tests to identify the most appropriate for screening in countries with limited resources. Nineteen midwives screened 5,435 women with visual inspection (VIA) and collected cervical samples for HPV testing, liquid-based cytology (LBC) and conventional cytology (CC). If VIA was positive, a doctor performed magnified VIA. CC was read locally, LBC was read in Lima and HPV testing was done in London. Women with a positive screening test were offered colposcopy or cryotherapy (with biopsy). Inadequacy rates were 5% and 11% for LBC and CC respectively, and less than 0.1% for VIA and HPV. One thousand eight hundred eighty-one women (84% of 2,236) accepted colposcopy/cryotherapy: 79 had carcinoma in situ or cancer (CIS+), 27 had severe- and 42 moderate-dysplasia on histology. We estimated a further 6.5 cases of CIS+ in women without a biopsy. Sensitivity for CIS+ (specificity for less than moderate dysplasia) was 41.2% (76.7%) for VIA, 95.8% (89.3%) for HPV, 80.3% (83.7%) for LBC, and 42.5% (98.7%) for CC. Sensitivities for moderate dysplasia or worse were better for VIA (54.9%) and less favourable for HPV and cytology. In this setting, VIA and CC missed the majority of high-grade disease. Overall, HPV testing performed best. VIA gives immediate results, but will require investment in regular training and supervision. Further work is needed to determine whether screened-positive women should all be treated or triaged with a more specific test.

Current status of human rabies transmitted by dogs in Latin America

Abstract: Latin American countries made the political decision to eliminate human rabies transmitted by dogs by the year 2005. The purpose of the current study is to evaluate to what extent this goal has been reached. The epidemiological situation and control measures were analyzed and broken down within the countries by georeferencing. The 27 human cases reported in 2003 occurred in some 0.2% of the second-level geopolitical units (municipalities or counties) in the region, suggesting that the disease is a local problem. Several areas within the countries reported no more transmission of rabies in dogs. Nearly 1 million people potentially exposed to rabies received treatment. On average, 34,383 inhabitants per health post receive anti-rabies treatment (range: 4,300-148,043). Nearly 42 million dogs are vaccinated annually. Surveillance is considered fair according to the epidemiological criteria adopted by the study. Samples sent for rabies testing represent 0.05% of the estimated canine population (range: 0.001 to 0.2%). The countries are quite close to achieving the goal.

Prevalence and pattern of epilepsy treatment in different socioeconomic classes in Brazil

Abstract: Summary: Purpose: The worldwide prevalence of epilepsy is variable, estimated at 10//1,000 people, and access to treatment is also variable. Many people go untreated, particularly in resource-poor countries. Objective: To estimate the prevalence of epilepsy and the proportion of people not receiving adequate treatment in different socioeconomic classes in Brazil, a resource-poor country. Methods: A door-to-door survey was conducted to assess the prevalence and treatment gap of epilepsy in three areas of two towns in Southeast Brazil with a total population of 96,300 people. A validated screening questionnaire for epilepsy (sensitivity 95.8%, specificity 97.8%) was used. A neurologist further ascertained positive cases. A validated instrument for socioeconomic classification was used. Results: Lifetime prevalence was 9.2/1,000 people [95% CI 8.4–10.0] and the prevalence of active epilepsy was 5.4/1,000 people. This was higher in the more deprived social classes (7.5/1,000 compared with 1.6/1,000 in the less deprived). Prevalence was also higher in elderly people (8.5/1,000). Thirty-eight percent of patients with active epilepsy had inadequate treatment (19% on no medication); the figures were similar in the different socioeconomic groups. Conclusion: The prevalence of epilepsy in Brazil is similar to other resource-poor countries, and the treatment gap is high. Epilepsy is more prevalent among less wealthy people and in elderly people. There is an urgent need for education in Brazil to inform people that epilepsy is a treatable, as well as preventable, condition.

Social and biological early life influences on the prevalence of open bite in Brazilian 6-year-olds.

Abstract: OBJECTIVE: Little is known about the effects of social and biological risk factors for open bite on the primary dentition. The aim of this study was to assess the early-life risk factors affecting anterior open bite. METHODS: A cross-sectional study using a birth cohort was carried out in Pelotas, Brazil. A sample of 400, 6-year-old children was employed. The Foster and Hamilton criteria were used to classify open bite. Data concerning social conditions, and perinatal and childhood health and behaviour were obtained from birth to 12 months of age and during the fifth year of the children's lives. Unconditional bivariate and multiple logistic regression analysis were performed. RESULTS: The prevalence of anterior open bite was 46.3%. Risk factors included: a maternal age of between 30 and 39 years, as compared with children whose mothers were younger; breast-feeding for < 9 months; dental caries experience; pacifier sucking between 12 months and 5 years, as compared to no sucking or a shorter duration of sucking; and the presence of finger-sucking at 6 years of age. CONCLUSION: Open bite in the primary dentition was associated with older mothers, early weaning, dental caries occurrence, long-term use of a pacifier and finger-sucking at 6 years of age. These findings support the common risk approach for intervention to prevent open bite in the primary dentition.

A model for enhancing evidence-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO's ProVac initiative.

Abstract: New and underutilized vaccines are becoming available to combat important public health challenges. Each year, rotavirus is estimated to cause approximately 111 million episodes of gastroenteritis, which requires home care, 25 million clinic visits, 2 million hospitalizations, and approximately 440,000 deaths in children younger than 5 years of age worldwide. Children in the poorest countries account for 82% of rotavirus deaths. An estimated 16,000 deaths by rotavirus-induced diarEditor’s note: The thoughtful article by Dr. Andrus and his colleagues in describing the utility of the Pan American Health Organization’s (PAHO’s) ProVac model1 reminds us of the startling childhood and adult disease statistics. Whether it is the 440,000 gastroenteritis annual deaths in children younger than age 5 or the 32,000 annual deaths from papillomavirus—with more than 80% in poor and developing countries—these numbers are staggering. Examples such as the experience in Mexico that was described by Santos et al.2 show the ProVac model can work very well. The authors suggest that three essential factors need to be addressed if agencies and governments are to attain a sustainable impact: decisions should be nationally based; evidence used to support the decisions must be broad-based; and infrastructure must be in place to support a nationally based process. The ProVac program objectives are rather aggressive, with just a five-year horizon to achieve a series of ambitious goals. At the same time, PAHO is honest: the organization recognizes it has little choice but to move in this direction. PAHO can serve as a model for the rest of the developing world. Lessons learned in the ProVac experience will serve many others well as they attempt a similar, if not more aggressive approach.

Television viewing and its association with overweight in Colombian children: results from the 2005 National Nutrition Survey: a cross sectional study.

Abstract: Background There has been an ongoing discussion about the relationship between time spent watching television and childhood obesity. This debate has special relevance in the Latin American region were the globalization process has increased the availability of screen-based entertainment at home. The aim of this study is to examine the association between television viewing and weight status in Colombian children.

Size at birth and blood pressure in early adolescence : A prospective birth cohort study

Abstract: Previous studies have suggested that birth size may influence blood pressure in later life. Most of these reported inverse associations only became evident after weight or body mass index at some later age was included in the regression model. In a prospective birth cohort study in Brazil, the effect of birth size on blood pressure at age 11 years was explored. Of the 5,249 cohort members, 4,452 were interviewed. Mean systolic and diastolic blood pressures were 101.9 mmHg (standard deviation, 12.3) and 63.4 mmHg (standard deviation, 9.9), respectively. Birth weight was positively associated with blood pressure in the crude analysis, but this effect was no longer significant after adjustment for confounders. When current body mass index-a possible mediating variable-was added to the model, the association between birth weight and blood pressure tended to become negative, though not quite significant. Birth length showed a positive effect on later blood pressure regardless of the adjustments made. Head circumference, gestational age, and ponderal index were not associated with blood pressure. Children born small for gestational age had lower blood pressure values. The postulated inverse association between birth weight and later blood pressure was not confirmed in this cohort. Instead, a positive effect of birth length was detected.

Health lessons learned from the recent earthquakes and Tsunami in Asia.

Abstract: The evaluations following the Tsunami that affected 12 countries (December 2004) and the earthquakes in Bam, Iran (2003), and in Pakistan (2005) offered valuable lessons for public health preparedness against all types of risks (natural, complex, or technological) in all countries (regardless their level of development). The lessons learned, needs assessments, effectiveness of external life-saving assistance, disease surveillance and control, as well as donations management, were reviewed. Although hundreds of surveys or studies were conducted, the needs assessments were partial and uncoordinated. The findings often were not shared by individual agencies. The evaluations in each of the three disasters point to some additional issues: 1. Foreign mobile hospitals rarely arrived in time for immediate trauma care. Existing international guidelines for the use of field hospitals often were ignored and must be updated and promoted. Local and neighboring facilities are best at providing immediate, life-saving care; 2. Occassionally, the risk of epidemics was grossly overestimated by the agencies and the mass media. Surveillance and improved routine control programs work without resorting to costly, improvised immunization campaigns of doubtless value. Improving or re-establishing water and sanitation must be the first priority; 3. Health donations were not always appropriate, nor did they follow the World Health Organization guidelines. The costly destruction of inappropriate donations was a recurrent problem; and 4. Medical volunteers from within the affected country were abounding, but did not benefit from the external logistical and material support. The international community should provide logistical and material support before sending expatriate teams that are unfamiliar with the area and its alth problems. Investing in the preparedness of the national health services and communities should become a priority for disaster-prone countries and those assisting them in their development. Language: en

Mosquitoborne Infections after Hurricane Jeanne, Haiti, 2004

Abstract: After Hurricane Jeanne in September 2004, surveillance for mosquitoborne diseases in Gonaives, Haiti, identified 3 patients with malaria, 2 with acute dengue infections, and 2 with acute West Nile virus infections among 116 febrile patients. These are the first reported human West Nile virus infections on the island of Hispaniola.

Environmental determinants of the distribution of Chagas disease vectors in south-eastern Guatemala.

Abstract: The associations between the presence of triatomines and environmental variables were studied using correlation analysis and logistic regression models for a sample of villages in the south-eastern provinces of Guatemala. Information on the presence of Triatoma dimidiata, T. nitida and Rhodnius prolixus came from entomological surveys carried out by the Ministry of Health of Guatemala as part of its vector control programme. Environmental information for each village was extracted from digital thematic maps developed by the Ministry of Agriculture. The presence of T. nitida was found to be significantly associated with the average minimum temperature. The odds of presence of T. nitida in a village decreased as the average minimum temperature increased. T. nitida exists at altitudes above 1000 m above sea level in temperate regions. The presence of R. prolixus showed a significant positive association with maximum absolute temperature and relative humidity. The logistic regression model for R. prolixus showed a good fit and predicted suitable habitats in the provinces of Chiquimula, Zacapa and Jalapa, which agrees with the known distribution of the species. Habitat partitioning between R. prolixus and T. dimidiata is suggested by their significant and opposite associations with maximum absolute temperature. Improved models to predict suitable habitats for T. dimidiata hold promise for spatial targeting of integrated vector management.

Lessons learned from the application of a participatory evaluation methodology to healthy municipalities, cities and communities initiatives in selected countries of the Americas.

Abstract: Health promotion has made significant strides in the past few decades in the Americas. Creating a healthy and supportive setting, also known as the settings approach, continues to be one of the most widely used health promotion strategies. Interest in evaluating the effectiveness of these strategies has been increasing greatly in the past few years. Participatory evaluation holds great promise for helping to generate this evidence and promote understanding of the factors that affect, positively or negatively, the advances of health promotion in the Region. During 2004-2006, a Participatory Evaluation methodology was introduced into several countries in the Americas through formal trainings conducted by the Pan American Health Organization (PAHO) in collaboration with country partners. This article summarizes the main lessons learned from the application of the participatory evaluation methodology in various countries in Latin America and the Caribbean. Factors affecting the evaluation of the initiatives were identified at multiple levels (individual, community, organizational, political, economic, etc.). Specific issues that were addressed included the political context, turnover of personnel in key institutions, concerns related to the effectiveness of participatory processes, and the existence of strong and sustained leadership at the country level. These factors are intertwined and affect each other in very complex ways, a fact that was reflected in the municipalities' experiences with participatory evaluation. Challenges included the ability to secure resources for the evaluation, the time needed to conclude the process, and working in an intersectoral manner. However, participating municipalities reported that the process of implementing a participatory evaluation and working with various stakeholders had an empowering effect: communities and stakeholders were more willing and interested in participating in health promotion initiatives in a sustained manner; alliances and intersectoral collaboration were strengthened; communication channels were opened; and municipalities were stimulated to review their planning and implementation processes in order to more appropriately incorporate health promotion principles. The article concludes with recommendations to improve the planning and implementation process of participatory evaluation efforts.

Impact of long-term treatment of onchocerciasis with ivermectin in Ecuador: potential for elimination of infection.

Abstract: Onchocerciasis is a leading cause of blindness worldwide, hence elimination of the infection is an important health priority. Community-based treatment programs with ivermectin form the basis of control programs for the disease in Latin America. The long-term administration of ivermectin could eliminate Onchocerca volvulus infection from endemic areas in Latin America. A strategy of annual to twice-annual treatments with ivermectin has been used for onchocerciasis in endemic communities in Ecuador for up to 14 years. The impact of ivermectin treatment on ocular morbidity, and O. volvulus infection and transmission was monitored in seven sentinel communities. Over the period 1990–2003, high rates of treatment coverage of the eligible population were maintained in endemic communities (mean 85.2% per treatment round). Ivermectin reduced the prevalence of anterior segment disease of the eye to 0% in sentinel communities and had a major impact on the prevalence and transmission of infection, with possible elimination of infection in some foci. The distribution of ivermectin in endemic communities in Ecuador might have eliminated ocular morbidity and significant progress has been made towards elimination of the infection. A strategy of more frequent treatments with ivermectin may be required in communities where the infection persists to achieve the objective of elimination of the infection from Ecuador. The elimination of the infection from an endemic country in Latin America would be a major public health achievement and could stimulate the implementation of elimination strategies in other endemic countries.

The role of public policies in reducing smoking prevalence and deaths: the Argentina Tobacco Policy Simulation Model

Abstract: Smoking is the single most preventable cause of premature mortality and of increases in the risk of lung cancer, emphysema, heart disease, stroke, and other diseases (1, 2). Globally, it is

Demonstration project on epilepsy in Brazil: situation assessment

Abstract: PURPOSE: To provide a situation assessment of services for people with epilepsy in the context of primary health care, as part of the Demonstration Project on Epilepsy in Brazil, part of the WHO/ILAE/IBE Global Campaign 'Epilepsy out of the shadows'. METHODS: We performed a door-to-door epidemiological survey in three areas to assess the prevalence of epilepsy and its treatment gap. We surveyed a sample of 598 primary health care workers from different regions of Brazil to assess their perceptions of the management of people with epilepsy in the primary care setting. RESULTS: The lifetime prevalence of epilepsy was 9.2/1,000 people [95% CI 8.4-10.0] and the estimated prevalence of active epilepsy was 5.4/1,000 people. Thirty-eight percent of patients with active epilepsy were on inadequate treatment, including 19% who were taking no medication. The survey of health workers showed that they estimated that 60% of patients under their care were seizure-free. They estimated that 55% of patients were on monotherapy and that 59% had been referred to neurologists. The estimated mean percentage of patients who were working or studying was 56%. Most of the physicians (73%) did not feel confident in managing people with epilepsy. DISCUSSION: The epidemiological survey in the areas of the Demonstration Project showed that the prevalence of epilepsy is similar to that in other resource-poor countries, and that the treatment gap is high. One factor contributing to the treatment gap is inadequacy of health care delivery. The situation could readily be improved in Brazil, as the primary health care system has the key elements required for epilepsy management. To make this effective and efficient requires: i) an established referral network, ii) continuous provision of AEDs, iii) close monitoring of epilepsy management via the notification system (Sistema de Informacao da Atencao Basica - SIAB) and iv) continuous education of health professionals. The educational program should be broad spectrum and include not only medical management, but also psycho-social aspects of epilepsy.

Unfulfilled potential: using diethylcarbamazine-fortified salt to eliminate lymphatic filariasis

Abstract: Fortifying salt with diethylcarbamazine (DEC) is a safe, low-cost and effective strategy to eliminate transmission of lymphatic filariasis. DEC-fortified salt has been used successfully in pilot projects in several countries and has been used operationally by China to eliminate lymphatic filariasis. The successful use of iodized salt to eliminate iodine-deficiency disorders is encouraging; similarly, fortified salt could be used as a vehicle to eliminate lymphatic filariasis. Despite the potential programmatic advantages of fortifying salt with DEC instead of undertaking mass administration of tablets, DEC-fortified salt remains an underutilized intervention. We discuss the reasons for this and suggest settings in which the use of DEC-fortified salt should be considered.

Training practitioners in evidence-based chronic disease prevention for global health.

Abstract: Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a "critical mass" of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Eliminating lymphatic filariasis, onchocerciasis, and schistosomiasis from the americas: breaking a historical legacy of slavery.

Abstract: velopment in the United States and in the Caribbean led to the spontaneous disappearance of LF in some areas and substantial declines in the prevalence of infection in others [7]. Ongoing transmission in the Western Hemisphere, now limited to four countries (Brazil, the Dominican Republic, Haiti, and Guyana), is concentrated in impoverished settings and appears to be a growing problem in urban slums. LF elimination programs based on the mass distribution of antifilarial drugs have been developed in all four countries and have resulted in declines in the prevalence of filarial infection ([8] and unpublished data). However, all four programs are resource challenged and none have achieved full coverage of at-risk populations.

Demonstration project on epilepsy in Brazil: outcome assessment

Abstract: PURPOSE: To assess the outcome of patients with epilepsy treated at primary care health units under the framework of the demonstration project on epilepsy in Brazil, part of the WHO/ILAE/IBE Global Campaign Against Epilepsy. METHOD: We assessed the outcome of patients treated at four primary health units. The staff of the health units underwent information training in epilepsy. The outcome assessment was based on: 1) reduction of seizure frequency, 2) subjective perception from the patient’s and the physician’s point of view, 3) reduction of absenteeism, 4) social integration (school and work), and 5) sense of independence. RESULTS: A total of 181 patients (93 women - 51%) with a mean age of 38 (range from 2 to 86) years were studied. The mean follow-up was 26 months (range from 1 to 38 months, 11 patients had follow-up of less than 12 months). Seizure frequency was assessed based on a score system, ranging from 0 (no seizure in the previous 24 months) to 7 (>10 seizure/day). The baseline median seizure-frequency score was 3 (one to three seizures per month). At the end of the study the median seizure-frequency score was 1 (one to three seizures per year). The patients’ and relatives’ opinions were that in the majority (59%) the health status had improved a lot, some (19%) had improved a little, 20% experienced no change and in 2% the health status was worse. With regard to absenteeism, social integration and sense of independence, there were some modest improvements only. DISCUSSION: The development of a model of epilepsy treatment at primary health level based on the existing health system, with strategic measures centred on the health care providers and the community, has proved to be effective providing important reductions in seizure frequency, as well as in general well being. This model can be applied nationwide, as the key elements already exist provided that strategic measures are put forward in accordance with local health providers and managers.

Dried blood spots versus sera for detection of rubella virus-specific immunoglobulin M (IgM) and IgG in samples collected during a rubella outbreak in Peru

Abstract: Most persons with rubella virus-specific immunoglobulin M (IgM)- or IgG-positive sera tested positive (98% [n = 178] and 99% [n = 221], respectively) using paired filter paper dried blood spot (DBS) samples, provided that DBS indeterminate results were called positive. For persons with IgM- or IgG-negative sera, 97% and 98%, respectively, were negative using DBS.

The economic burden of out-of-pocket medical expenditures for patients seeking diabetes care in Mexico.

Abstract: To the Editor: Diabetes is a pressing problem for the developing countries of the Americas, where the prevalence is expected to double between 2000 and 2030 [1] Mexico is an example of the staggering burden of diabetes; the prevalence of diabetes in this country has increased from 72% in 1993 [2] to 107% in 2000, among those who are 20–64 years of age [3] There has been a huge increase in the number of diabetes-related deaths in Mexico over the same period, with the annual number of deaths attributed to diabetes increasing from a constant 40,000 between 1979 and 1999 to 64,000 in 2004 [4] An original article published in 2004 presented the dimensions of the economic impact of diabetes on public health expenditures in Mexico [5] To further evaluate the problem of the burden of diabetes in Mexico, this brief report includes the results of an analysis of private health expenditures for diabetes care, determined through out-of-pocket costs and costs paid through private medical insurance Costs and the relative demand for different types of services required by patients with diabetes, and incidence rates for the most common long-term diabetes complications, were calculated using the methodology described in a previous article [5] Cost data was obtained from a project that aimed to estimate the cost of chronic diseases in Mexico [6] Service cost was estimated using an equation relating out-of-pocket expenses and private insurance to the total health expenditures in public and private institutions This methodology has been described in detail elsewhere [5, 7] Cost results of the 2004 National Health Survey were used as a reference, to compare the problems pertaining to equality in diabetic patients with those in the general population [8] The different cost production functions were adjusted as a function of average diabetes case management at private institutions, determined by the consensus technique with private sector experts [8, 9] Costs paid through private insurance were determined based on other studies reporting that for any disease there is a rate of expenditure for each particular complication [10] We applied an equation determined by other studies [10–12] to calculate the outof-pocket user expenditures for diabetes using the following two variables: relative weight of costs to the health system and relative weight of out-of-pocket user expenditures (in absolute numbers) Table 1 shows the private health costs in two categories of analysis: direct out-of-pocket user expenditures and costs paid through private health insurance On average, of the total expenditures in Mexico, 52% (US$162,252,503) corresponded to users’ pockets and 3% (US$9,360,714) to costs paid by private insurance, while public spending represents 45% It is particularly important to understand this in light of the distribution of diabetes care in the public and private sectors in Mexico Table 1 also provides the cost of care for chronic complications of diabetes for the two major service categories Nephropathy was the complication associated with the greatest cost (75% of the total cost of complications) Diabetologia (2007) 50:2408–2409 DOI 101007/s00125-007-0828-4

Injury in the Americas: the relative burden and challenge

Abstract: OBJECTIVES: To present evidence to support a higher priority for injury prevention in initiatives, research, and budget allocations. METHODS: Recent data (2000) for deaths from injury, infectious disease, heart disease, and cancer from 11 countries in the Region of the Americas were analyzed. Analyses focused on: first, Potentially Productive Years of Life Lost (PPYLL, discounted) from deaths occurring from 0-64 years of age; second, Years of Potential Life Lost (YPLL) from 1-64 years; and third, Years Lived with Disability (YLD). The burdens of injury and infectious disease were compared to the Pan American Health Organization (PAHO) budget allocations for these areas. RESULTS: There is a clear-cut disparity between funds allocated and the magnitude of injury burden as compared to the burden of infectious disease. CONCLUSIONS: In making decisions on budgetary allocations, the Member States of PAHO must consider the potential impact of injury research and control on the health of their populations.

Evolution of an International External Quality Assurance Model To Support Laboratory Investigation of Streptococcus pneumoniae, Developed for the SIREVA Project in Latin America, from 1993 to 2005

Abstract: In 1993 the Pan American Health Organization initiated a laboratory-based surveillance system, called the SIREVA project, to learn about Streptococcus pneumoniae invasive disease in Latin American children. In 1994, National Laboratories in six countries were trained to perform serotyping and antibiotic susceptibility testing using broth microdilution to determine the MIC for specified antibiotics. An international External Quality Assurance (EQA) program was developed to monitor and support ongoing laboratory performance. The EQA program was coordinated by the National Centre for Streptococcus (NCS), Edmonton, Canada, and included external proficiency testing (EPT) and a validation process requiring regular submission of a sample of isolates from each laboratory to the NCS for verification of the serotype and MIC. In 1999, the EQA program was decentralized to use three of the original laboratories as regional quality control centers to address operational concerns and to accommodate the growth of the laboratory network to more than 20 countries including the Caribbean region. The overall EPT serotyping accuracies for phase I (1993 to 1998) and phase II (1999 to 2005) were 88.0 and 93.8%, respectively; the MIC correlations within +/-1 log(2) dilution of the expected result were 83.0 and 91.0% and the interpretive category agreements were 89.1 and 95.3%. Overall, the validation process serotyping accuracies for phases I and II were 81.9 and 88.1%, respectively, 80.4 and 90.5% for MIC agreement, and 85.8 and 94.3% for category agreement. These results indicate a high level of testing accuracy in participating National Laboratories and a sustained increase in EQA participation in Latin America and the Caribbean.