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Mortality In The Americas

Knowledge about a number of public health problems is gathered mainly from mortality statistics, which traditionally have provided the highest–quality and highest–coverage information about health available in many countries.

The quality of mortality data in the Region of the Americas has improved in recent years, as national vital statistics systems have been strengthened. Noteworthy improvements include: (1) the availability of more timely information that reflects more recent data, (2) higher quality information with better coverage and fewer deaths attributed to ill–defined causes, and (3) better dissemination of information as a result of the adoption in many countries of policies on transparency in data availability. However, progress has not been even across the Region, and inequalities among countries have deepened in terms of the quality of mortality statistics.

This chapter aims to describe the mortality data of the Region's countries, in particular data on infant mortality, maternal mortality, and mortality from chronic, noncommunicable diseases and external causes. For the analysis of infant and maternal mortality, indicators (infant mortality rate and the maternal mortality ratio) from the Regional Core Health Data Initiative of the Pan American Health Organization (PAHO) were used (1). Data on both indicators are obtained from various sources, including national information systems (vital statistics and epidemiological surveillance systems) and estimates (surveys or special studies). The mortality analysis included data from 43 countries and territories obtained from PAHO's Mortality Information System (latest data as of May 2011). More detailed information on the methodology used can be found in the technical notes at the end of this section. Countries with small populations and few deaths were grouped together for purposes of rate calculation in order to avoid skewing the analysis.

MAGNITUDE, DISTRIBUTION, AND TRENDS

In 2007 a total of 5,736,164 deaths occurred in the 32 countries of the Region of the Americas with data available for that year (53.1% male deaths and 46.9% female deaths). The age–adjusted death rate for the total population was 5.8 per 1,000 population (7.1 per 1,000 among males and 4.7 per 1,000 among females).

Proportional Mortality

Recent decades have seen a reduction in mortality from communicable diseases and a concomitant rise in deaths from noncommunicable diseases as a result of improved living conditions, reduced risk of death from vaccine–preventable diseases, and population aging, among other factors (2). Data for the Region as a whole for 2007–2009 show that 76.4% of deaths were caused by noncommunicable diseases; 12.5%, by communicable diseases; and 11.1%, by external causes. However, there are marked inequalities among countries with regard to causes of death. Of 33 countries, the proportion of deaths from communicable diseases was lower than the regional average only in 16. Mortality from such diseases was particularly high in Guatemala and Peru. Of total deaths, 44% occurred among persons under the age of 70, and of those deaths, 65% were due to chronic diseases. External causes account for a higher number of deaths among the youngest population groups; for example, 67.4% of deaths in the group aged 10 to 24 years were from external causes. Analysis by sex shows significant differences (Figure 4.1), with external causes accounting for more deaths among males than females, especially in Belize, Brazil, Colombia, Ecuador, El Salvador, Nicaragua, Paraguay, and Venezuela.

Figure 1

Leading Causes of Death

Ischemic heart disease, cerebrovascular disease, and diabetes mellitus were the three leading specific causes of death in the Region in 2007. Analysis of the three leading causes of death by country and sex (Table 4.1) reveals that causes of death were generally similar among males and females, with noncommunicable diseases accounting for the largest proportion in both groups. The principal difference in mortality by sex was seen in external causes, which were among the three leading causes of male death in 10 countries, but did not figure among the top three causes of female death in any country. Influenza and pneumonia combined ranked as the leading cause of death among both males and females in Guatemala and Peru.

Figure 2

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INFANT AND MATERNAL MORTALITY

Infant Mortality

Infant mortality is declining in the Region and, according to United Nations estimates, the Americas will achieve the Millennium Development Goal of reducing mortality in children under 5 years old by two–thirds between 1995 and 2015 (3).

The quality of the data presented here varies, depending on how each country's information system performs and the extent of underreporting of mortality data, which is particularly serious in the case of deaths of children under 1 year of age. However, countries have endeavored to improve data coverage and quality through, for example, active surveillance of deaths and integration and analysis of various sources of information, among other procedures. It is thus possible to identify groups of countries that have low infant mortality rates as a result of effective public health interventions, although there are also countries with low rates that are not the result of public health interventions but rather reflect problems with the registration of infant deaths and live births.

There were some 219,000 deaths of children under 1 year old in the Region circa 2009, with significant variation in the number per country (Table 4.2). There were also marked differences in the ratio of births reported by countries to births estimated by the United Nations and the Census Bureau of the United States of America, especially in Colombia, Ecuador, Guatemala, and Guyana.

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The infant mortality rate in the Region of the Americas circa 2009 was 15.9 per 1,000 live births; the rate estimated by the United Nations in 2010 was 14 per 1,000 live births (3). In 2000, the rate was 21.3 per 1,000 live births for the Region as a whole, a reduction of 25.3% between 2000 and 2009. The risk of dying varied significantly among the countries of the Region. For example, an infant's risk of dying was 10 times higher in Haiti than in Canada or Cuba; in Bolivia the risk was 9 times higher and in the Dominican Republic, Guatemala, and Nicaragua, it was 5 times higher.

Figure 4.2 shows that infant mortality has fallen in the majority of countries over the last decade, with the sharpest declines occurring in Argentina, Brazil, Cuba, Ecuador, and Uruguay.

Figure 3

Analysis of the components of infant mortality showed that in the majority of countries neonatal deaths account for the largest share, which indicates that access to and quality of maternal and child health care has improved. Mortality in this age group is nevertheless associated with inadequate prenatal and delivery care and improper care of the newborn. Of total deaths of children under 1 year of age in Paraguay, the proportion of neonatal deaths was 71.2%; in Suriname it was 72.2%, and in Venezuela, 70.3%. In countries such as Bolivia, Ecuador, Guatemala, Nicaragua, Panama, Peru, and Uruguay, on the other hand, the neonatal component accounted for less than 50% of total infant deaths. In Haiti, post–neonatal mortality was proportionately higher than neonatal mortality.

Conditions originating in the perinatal period were the leading cause of infant death in all countries, both at the beginning of the period analyzed (circa 2000) and at the end (circa 2007), accounting for 55% of the total. Brazil, Canada, the Dominican Republic, the countries and territories of the English–speaking Caribbean, and the French Overseas Departments in the Americas, among others, showed higher proportions of mortality from conditions originating in the perinatal period than the regional average. The proportion of infant deaths due to congenital malformations, deformities, and chromosomal abnormalities rose from 15% in 2000 to 20% in 2009. Respiratory diseases continued to be a major cause of death in this age group in Ecuador, El Salvador, Guatemala, and Peru. In the Region, under 5% of deaths during the first 12 months of life were caused by malnutrition or nutritional anemia (Figure 4.3).

Figure 4

Maternal Mortality

It is important to note that maternal mortality ratios are affected by several factors. In countries where death certification rates are low, underreporting and incorrect classification lower the quality of the data. In countries with high death certification rates (≥ 90%), on the other hand, data problems occur mainly as a consequence of misclassification resulting from incorrect recording of causes of death on death certificates.

In 2009, the reported maternal mortality ratio in the Americas was 65.7 per 100,000 live births; the World Health Organization (WHO) estimate for the Region in the same year was 66 per 100,000 live births (4). The maternal mortality ratio was 76.4 per 100,000 live births in 2000; hence, maternal deaths fell 14% during the period. However, the risk of dying during delivery or the puerperium is still unacceptably high-12 to 18 times higher than in most developed countries. A comparison of the maternal mortality ratios of several countries of the Region with that of Canada shows that Haiti's ratio is approximately 83 times higher; Bolivia's, 30 times higher; Guatemala's, 20 times higher; Brazil's, 10 times higher; and Mexico's, 8 times higher (Table 4.3).

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Total maternal deaths reported by the countries of the Region for the latest year for which data are available were 9,430, with Brazil (2,240) and Mexico (1,119) accounting for more than a third (Table 4.3).

Figure 4.4 shows the trend of maternal mortality ratios between 2000 and 2009 for various countries of the Region.

Figure 5

It is worth noting that, with a view to improving the quality of information and knowledge about the true causes of maternal death, since 2002 some countries, including Brazil and Mexico, have been carrying out active surveillance of maternal deaths.

Analysis of the proportional distribution of maternal deaths by groups of causes and countries reveals that direct obstetric causes accounted for 75% of the maternal deaths in the Region circa 2007 (Figure 4.5).

Figure 6

CHRONIC, NONCOMMUNICABLE DISEASES

Diseases of the Circulatory System

In 2007, diseases of the circulatory or cardiovascular system (codes I00–I99 in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]) (5) were the leading combined cause of death in the Region, accounting for 1,746,767 deaths (30.5% of the total). Of those deaths, 878,105 (50.3%) were of females and 868,662 (49.7%) of males. The top causes in this group were ischemic heart disease (ICD–10: I20–I25), which accounted for 42.5% of total deaths from cardiovascular diseases; cerebrovascular diseases (ICD–10: I60–I69), 22.2%; and hypertensive diseases (ICD–10: I10–I15), 9.2%.

The risk of dying from diseases of the circulatory system was consistently higher among males than females, with variations among countries (Table 4.4).

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Diabetes Mellitus, Malignant Neoplasms, and Respiratory Diseases

Global projections indicate that there were a total of 171 million people living with diabetes mellitus in 2000 and that the number will increase to 366 million by 2030 (6). In the Americas, diabetes (ICD–10: E10–E14) was responsible for 263,877 deaths in 2007-141,235 female deaths (53.5%) and 122,642 male deaths (46.5%). The actual numbers, however, might be larger because diabetes may be underreported or not listed as an underlying cause of death when it occurs concomitantly with other diseases or complications. The national adjusted rates per 100,000 population varied widely among countries. Those with the highest rates were Trinidad and Tobago, Mexico, Guyana, Nicaragua, and Paraguay, in that order (Table 4.4).

In 2007, malignant neoplasms (ICD–10: C00–C99) caused 1,130,882 deaths in the Americas, 48.4% of which were of females and 51.6% of males. The leading causes in this group were malignant neoplasms of trachea, bronchus, and lung (ICD–10: C33–C34), which accounted for 22.1% of the total, and malignant neoplasms of colon, rectosigmoid junction, rectum, and anus (ICD–10: C18–C21), which accounted for 8.7%. Among females, the leading cause was breast cancer (ICD–10: C50), which caused 14.8% of all female deaths from malignant neoplasms, and among males, the leading causes were prostate cancer (ICD–10: C61), which accounted for 11.9%, and stomach cancer (ICD–10: C16), which accounted for 5.3%.

Chronic lower respiratory diseases (ICD–10: J40–J47) are another significant cause of death in several countries. The total number of deaths from this cause for the Region as a whole in 2007 was 244,523, including 118,533 (48.5%) male deaths and 125,990 (51.5%) female deaths. Although the rates varied among countries in the Region, they were consistently higher among males (Table 4.4).

MORTALITY FROM EXTERNAL CAUSES

Mortality from external causes remains a public health problem in the Americas. An average of 551,000 deaths from such causes were reported per year between 2000 and 2007, and the total for the period was 4.4 million. Deaths from external causes made up 9.6% of total deaths in 2000, 9.9% in 2002, and 10.2% in 2007. The majority of deaths from this group of causes were due to transport accidents (27%), other causes of accidental injury (falls, drowning, and accidental poisoning, among others) (37%), and assault (13%). Those three groups of causes accounted for 77% of all deaths from external causes. The remaining 23% was distributed among suicides (10%), events of undetermined intent (9%), and other causes (4%). The proportion of deaths from external causes has remained quite stable over time, as has their distribution by sex (Figure 4.6). Deaths from assault account for up to 30% of total deaths from external causes among males and 10% to 12% among females. The risk of dying from external causes differs by country and by sex (Table 4.5). For example, the risk of dying from transport accidents in 2007 was 3 to 4 times greater among males than females, and from violent causes, 6 to 12 times greater.

Figure 7

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SUMMARY

Analysis of mortality in the countries of the Region revealed some progress, notably the reduction in infant mortality, a reflection of improvements in access to and quality of maternal and child health care. This is an important element that will enable the Region to reach one of the Millennium Development Goals related to reduction of mortality among children under 5 years of age. Maternal mortality has also declined substantially in the last 10 years. Nevertheless, countries need to redouble their efforts to ensure healthy motherhood.

In all countries of the Region, noncommunicable diseases now account for the highest proportion of deaths, raising the challenge of controlling the principal risk factors associated with such diseases, including tobacco use, obesity, sedentary lifestyles, and unhealthy diet.

Finally, although deaths from external causes are considered foreseeable and preventable, they remain a public health problem in a number of countries of the Region, especially among males. Reducing the disparities in mortality profiles among countries will be an ongoing challenge for governments, organizations, and society.

Technical Notes

To enhance the data on reported mortality supplied by countries, algorithms were applied to correct for underreporting and to redistribute deaths from ill–defined causes in accordance with the methodology described in the technical notes to Health Statistics from the Americas, 2006 Edition (7). Information received from countries was not corrected, however, in the case of those with data of high quality (defined as less than 10% underreporting or attribution of deaths to ill–defined causes) and those for which the input needed for correction was unavailable. Underlying causes of death were coded according to ICD–10.

United Nations Population Division population estimates were used to calculate rates. For countries with a total population of under 300,000, data from the United States Census Bureau were used. Rates were adjusted for age using the direct method and the WHO World Standard Population (8). Countries with small populations were grouped together for purposes of rate calculation so that their low numbers would not create bias in the analysis. This was the case for the following countries and territories: Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Bermuda, Cayman Islands, Dominica, French Guiana, Grenada, Guadeloupe, Martinique, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Turks and Caicos Islands, Virgin Islands (UK), and Virgin Islands (US).

Morbidity

COMMUNICABLE DISEASES

Epidemic–prone Diseases

The International Health Regulations and Events of Potential International Public Health Concern

Fanned by such processes as globalization, increased travel and trade, and climate change, the world is undergoing rapid changes that are altering the pattern and speed of disease transmission. In this context, national and global health security has become a matter of collective responsibility (9). The world's countries, including the countries of the Americas, must act in concert to confront the international spread of emerging and reemerging pathogens and of hazards of noninfectious origin. The implementation of and adherence to the current International Health Regulations (IHR) is the linchpin in this collective effort.

In confronting the changing face of disease transmission worldwide, WHO set out to revise the 1969 International Health Regulations. The review began in the mid–1990s and intensified with the 2004 establishment of an intergovernmental working group charged with revising the earlier text (10). In the Americas, the revision of IHR (1969) was driven by existing subregional integration mechanisms, as the countries worked to consolidate a Region–wide position. The current IHR were adopted in 2005 by all 35 PAHO Member States1Adopted as Resolution WHA 58.3 by the Fifty–eighth World Health Assembly. (10) and entered into force in 2007 (11).

IHR seek "to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." To that end, the Regulations, which are a legally binding instrument for States Parties (12), set the course for the countries' work along important areas: first, to minimize the economic consequences of public health risks and events through collective efforts that ensure adequate risk management (timely detection, assessment, control, and communication), and second, to establish and maintain core capacities for surveillance and response at all levels of the national public health system, including at designated points of entry (international airports, ports, and ground crossings). The area of work related to points of entry underlines the multisectoral approach of the Regulations and the need for a more cost–effective integration of relevant public health functions. Indeed, in an interconnected world, borders no longer constitute the first line of response to contain events with potential public health implications. Under the provisions of the current Regulations, countries continue to annually provide information on travelers' health used to update the WHO publication "International Travel and Health" (13).

Strengthening every level of a country's disease surveillance system is central to that nation's implementation of IHR. In order to contain an event at its source and, thus, prevent further international spread, the IHR require that States Parties establish and maintain core capacities to detect unusual health events in a timely manner, and then to undertake responses commensurate with the risks. As of 30 June 2011, all but one of the 35 States Parties in the Region had completed the related assessment, 28 had developed national IHR action plans to ensure that the core capacities would be in place by June 2012, and at least 10 had conducted the costing exercise for such plans. Figure 4.7 shows the average score for core capacities, as defined by WHO (15), in the Region and globally, consolidating the information submitted by States Parties in their annual report. Although the 2012 deadline will probably not be met by all countries, it should be regarded as a target set to maintain the momentum in implementing the Regulations and as a step in the preparedness process, which should be sustainable and continuous.

Figure 8

Adopting an intersectoral and multidisciplinary approach also is inherent for successfully carrying out the early warning function the Regulations require. The first public health emergency of international concern (PHEIC) was declared by WHO's Director General during the 2009 pandemic of influenza A(H1N1) (25 April 2009–10 August 2010). This pandemic put virtually all of IHR's provisions to the test and was scrutinized by the first IHR Review Committee on the Functioning of the International Health Regulations (2005) in relation to Pandemic Influenza A (H1N1) 2009 (16, 17, 18).

Since IHR entered into force, PAHO has worked closely with the Region's countries to bolster their field response efforts. For example, during the 2009 influenza A(H1N1) pandemic, 80 multi–disciplinary experts identified through the Global Alert and Response Network (GOARN) (19) were deployed to 18 countries and territories from 24 April to 19 December 2009. During the cholera outbreak in Haiti and the Dominican Republic in 2010, more than 130 multidisciplinary experts were deployed to those two countries from October 2010 to March 2011.

Pandemic Influenza A(H1N1)

Of the three types of influenza viruses, influenza A viruses are associated with the highest morbidity and mortality; they also show the most frequent genetic changes that give rise to annual epidemics and eventual pandemics.

In April 2009, a variant of the influenza A(H1N1) virus-containing a unique combination of human, swine, and avian viruses-emerged in Mexico. Able to cause disease in humans and easily transmitted from person to person, this virus led to the first pandemic of the 21st century. The Region of the Americas was the first WHO region affected by this novel virus, making it imperative for data to be gathered quickly and shared globally to make decisions about prevention and treatment strategies. Over 16 months, the virus spread across the globe, causing at least 600,000 cases and more than 18,000 deaths worldwide (for additional information, see Situation Updates-Pandemic (H1N1) 2009) (20). In the Americas alone, the pandemic resulted in at least 190,000 cases and 8,500 deaths and sparked an overwhelming demand for health services (see Influenza and other Respiratory Viruses under Surveillance, 2010-2012) (21). The virus circulated with greatest intensity in the continent's temperate areas, at times stretching the health systems there to their maximum capacity. Despite the difficulties the countries faced in coping with this pandemic, work they had undertaken prior to 2009 to develop pandemic influenza preparedness plans stood them in good stead. Additionally, PAHO was able to provide direct support to the countries' response by means of multidisciplinary field teams integrated by epidemiologists, laboratory technicians, infection control specialists, and clinicians. Material support was provided as well, through the purchase of equipment, reagents, and personal protective equipment.

The 2009 pandemic left many useful lessons, including the importance of having operational preparedness plans, laboratory surge capacity, and improved surveillance of severe cases of influenza. Most important, the pandemic demonstrated that countries must incorporate preparedness and emergency response into their routine activities, to ensure that they will be able to effectively cope with the next public health emergency.

Seasonal Influenza

Influenza causes significant morbidity and mortality globally. In temperate regions, outbreaks clearly are seasonal, with a peak circulation period in the coldest months of the year that lasts approximately six to eight weeks. In tropical countries, influenza seasonality is not as well established and may vary from country to country. The influenza virus circulates throughout the year in all climates, however, which means that year–round epidemiological and virological surveillance must be in place to make decisions about prevention, identify vulnerable populations, and prepare for outbreak response.

The 2009 pandemic of influenza A(H1N1) highlighted weaknesses in the countries' existing influenza surveillance systems, such as a lack of actionable information about severe cases. Since then, the Region's countries, with PAHO's support, have been working to strengthen hospital–based surveillance of severe acute respiratory infections (SARI) to determine the incidence of circulating respiratory viruses and types and subtypes of influenza, to describe the epidemiology of SARI cases, to promptly detect the emergence of novel influenza subtypes, to provide strains for the development of influenza vaccines, and to provide data to estimate the burden of influenza.

Since the end of 2010, PAHO has been working closely with almost half the Member States to implement an intensified program of national SARI surveillance. Beyond country–based efforts, there also have been important regional advances in the preparedness and response to seasonal influenza: to date, as part of the Global Influenza Surveillance Network (GISN), there are 28 National Influenza Centers (NICs) in the Region (21) that carry out viral characterization (through indirect inmunofluorescence, reverse transcription polymerase chain reaction [RT–PCR], and viral isolation) and one WHO Collaborating Center (the Influenza Division at the United States Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases).

As a result of data collected from the hospital surveillance of SARI and laboratory virology information, the patterns of viral circulation in the Americas could be monitored and described in 2010. Since the end of the 2009 pandemic, the primary influenza virus in circulation was influenza A(H3N2), which was detected initially in Colombia (April 2010), and then spread to the northern and southern portions of the continent-Central America (Nicaragua, May 2010), the Southern Cone (Chile, June 2010), the Caribbean (Dominican Republic, July 2010), and North America (Canada, July 2010). In 2010, influenza B circulated in winter in the temperate regions, and year–round in Central America, the Caribbean, and the Andean region. During this period, the H1N1 pandemic virus circulated at low levels throughout the Region, with the exception of some countries, such as Colombia, where it circulated year–round after the pandemic.

Cholera

After the 1990s cholera epidemic that affected most of the Region's countries, except for the Dominican Republic, Haiti, and other Caribbean countries, there were few recorded cholera cases in the Americas, and most were imported from other regions. In 2009, a cluster of Vibrio cholerae O1, serotype Ogawa, biotype El Tor, was confirmed in the Paraguayan Chaco, most likely a remnant of the 1990s epidemic.

In Haiti, in the aftermath of the country's major earthquake in 2010 and in the context of massive population displacement, an epidemic of cholera emerged in the departments of Artibonite and Centre (22, 23) and then spread countrywide within five weeks. Haiti's national public health laboratory confirmed the isolation of Vibrio cholerae O1, serotype Ogawa. Given the extent of population movement between Haiti and the Dominican Republic, the outbreak then spread to the latter country, which confirmed the first autochthonous cases in the province of Santo Domingo in November 2010. During the outbreak's first three months, Haiti's national authorities reported more than 200,000 cases and 4,000 deaths in 10 departments.

Differences in health service infrastructure, sanitation conditions, and access to safe water between Haiti and the Dominican Republic resulted in differences in how the outbreak affected each country. Haiti saw an outburst of cases with a high fatality rate (24), particularly in hard–to–reach areas such as remote rural communities and urban slums. The Dominican Republic, on the other hand, saw case clusters around the most populated areas, with a low fatality rate that did not surpass the local capacity of health services.

Actions carried out in Haiti, with massive support from the international community, included the strengthening of surveillance, the improvement in case management through the training of health workers, and community education. These actions led to a reduction in case fatality rates within four months of the outbreak's start.

In the aftermath of this cholera outbreak, the Region's countries have updated their response and preparedness plans and have strengthened their early outbreak detection surveillance systems.

The most sustainable investment to protect populations from cholera and other diarrheal diseases continues to be the improvement of the water supply and sanitation. The risk of reintroduction of cholera in the Region (25) is directly related to the countries' poor water and sanitation conditions.

Dengue

Dengue is the arthropod–borne viral disease of greatest public health significance (26); its main vector is the mosquito Aedes aegypti. During 2006–2010, there was a sustained increase in the reported dengue incidence. More than 40 countries and territories in the Americas reported 5,194,675 cases of dengue during that period, of which 151,437 (2.9%) were cases of severe dengue (previously known as dengue hemorrhagic fever) that resulted in 2,599 deaths. These numbers represent 1.8–fold more dengue cases, 2.3–fold more severe dengue cases, and 3.3–fold more deaths due to dengue than in those recorded in 2001–2005. Although the number of reported cases increased considerably in the reporting period-from 427,627 in 2006 to 1,699,072 in 2010-the proportion of reported severe cases remained relatively stable (ranging from 2.6% in 2006 to 3.1% in 2009). All serotypes (DEN1, DEN2, DEN3, and DEN4) were identified in the Region during the period 2006–2010 (Table 4.6).

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The Southern Cone reported 3,263,848 cases, accounting for 62.8% of all dengue cases in the Region. Of these, 37,929 were classified as severe dengue or 25.0% of all severe dengue cases in the Region. There were 1,428 deaths (54.9% of all dengue deaths in the Americas) in this subregion. In 2010, Brazil reported 1,011,647 cases, with an incidence rate of 528.3 per 100,000 population, representing the highest number of cases and the highest incidence rate for dengue in this subregion. Paraguay reported outbreaks in 2007 (28,182 cases), and Argentina did so in 2009 (26,612 cases). No cases were reported in Uruguay or continental Chile during this period.

The Andean subregion reported 870,945 dengue cases in the reporting period (13.9% of the total number of cases in the Region), 59,050 (38.8% of severe cases in the Region) of which were classified as severe cases and which resulted in 395 deaths (15.1% of all dengue deaths in the Region). In 2010, Colombia reported the highest number of cases (157,152), accounting for the highest incidence rate in the subregion (685.1 cases per 100,000 population).

Central America and Mexico, which are considered together because they share epidemiological risk factors, reported 807,885 cases (16.1% of the Region's cases), 49,886 of which were severe dengue cases (32.9% of such cases in the Region), and 418 deaths (16.1% of all deaths due to dengue in the Region). In 2010, Honduras reported 66,814 cases, which resulted in the highest incidence rate in Central America and Mexico (1,016 per 100,000 population).

The Caribbean, including the English, French, Dutch, and Latin Caribbean, reported 251,305 cases (4.8% of the Region's cases), 4,572 of which (3.0% of the cases in the Region) were severe dengue cases, and 358 deaths (13.8% of all deaths due to dengue in the Region). Although the total number of cases may not be as high as in other subregions, several countries report high incidence rates, entailing high risk of transmission.

Within the Latin Caribbean, the Dominican Republic reported the highest number of cases, 40,566. Of these, 2,743 were severe dengue cases (92.7% of all severe cases in the Latin Caribbean during 2006–2010). In 2010, the highest number of cases and incidence rates were reported by Puerto Rico (21,298 cases and 538.92 cases per 100,000 population) and the Dominican Republic (12,170 cases and 135.60 cases per 100,000 population), with all four serotypes circulating in both countries. During the reporting period, Cuba reported fewer than 100 cases in 2007 and 2009; Haiti reported no cases, due to a lack of routine surveillance.

Among the English, French, and Dutch Caribbean countries, Guadeloupe, Martinique, and French Guiana recorded the highest number of dengue cases in 2006–2010, with 136,952 cases reported among the three countries, and accounting for 82.8% of the cases in this subregion.

Yellow Fever

Jungle yellow fever remains an important health threat in the Region. The risk for the occurrence of an urban cycle of yellow fever is sustained by the wide distribution and high infestation rates of Aedes aegypti in many highly populated cities. Between 2006 and 2010, 318 confirmed cases and 183 deaths were reported to PAHO from seven countries. Cases were reported in Peru (45%), Brazil (26%), Colombia (9%), Bolivia (9%), Paraguay (6%), Venezuela (3%), and Argentina (2%). Most were males (79%), the average age was 28 years old (range 0–73), and 52% of the cases with known occupation were among agriculture workers. All reported cases, except nine in Paraguay, were cases of jungle yellow fever.

By the end of 2007, Brazil reported an increase in the number of epizootics in the country's midwestern region, followed by human outbreaks in 2008 of jungle yellow fever in Brazil's midwestern, southeastern, and southern states, and in the northern reaches of Argentina and Paraguay. Forty–five cases of jungle yellow fever and 26 deaths were confirmed in Brazil in 2008, most of them among migrants or ecotourists coming from non–enzootic areas. Argentina also reported epizootics and nine cases and two deaths from jungle yellow fever between 2006 and 2010; these were the first cases the country had reported since 1967. Paraguay, whose last reported case was in 1974, reported 28 cases and 12 deaths between 2006 and 2010. Among the cases, the diagnosis of nine urban cases in the metropolitan area of Asunción is noteworthy, in that they are the first urban cases in the Region since an outbreak in Trinidad and Tobago in 1954. The outbreaks in Argentina, Paraguay, and Brazil's midwestern, southeastern, and southern states were responsible for the spread of the yellow fever transmission risk areas in the Americas (Figure 4.8).

Figure 9

Epizootic surveillance for early detection in areas where yellow fever virus is spreading, as well as active surveillance of human cases and laboratory confirmation, has been widely and routinely adopted in South America and Trinidad and Tobago. All countries with enzootic areas already have incorporated yellow fever vaccination into their routine immunization programs. The spread of yellow fever virus circulating areas led the Region's countries to redefine yellow fever transmission risk areas.

Resistance to Antimicrobial Drugs

Resistance to antimicrobial drugs seriously threatens the control of infectious diseases worldwide. The emergence and spread of resistant pathogens endangers progress made in the control of infectious diseases. Beginning in the mid–1990s, the Region's countries began monitoring the antibiotic resistance of microorganisms in order to understand the magnitude of the problem, follow trends, and try to assess the impact of interventions. To this end, the Latin American Network for the Surveillance of Resistance to Antimicrobial Drugs (known by its Spanish acronym, RELAVRA, for the Red Latinoamericana de vigilancia de la resistencia a los antimicrobianos) was created in 1996. Over time, the network has increased its ability to detect, monitor, and manage antibiotic resistance, with both the number of participating countries and the number of tested isolates increasing. By the end of 2010, 21 countries were participating; in 2000, 72,000 strains were analyzed, a figure that nearly doubled to 134,089 by 2007.

Starting in 2000, RELAVRA's surveillance included hospital pathogens, enteropathogens, and community pathogens. Such surveillance, which provides relevant data for decision–making in public health, has shown a consistent increase in the resistance of pathogens. Methicillin–resistant Staphylococcus aureus, for example, was encountered in 30% of hospital strains in 2000 and in 50% in 2007. The variability of the occurrence of this antimicrobial–resistant pathogen from country to country is important to consider, ranging from 12% in Honduras to over 60% in Chile, Guatemala, and Peru. Other pathogens that can play a role in outbreaks and that show high rates of infection in hospitals, such as Enterococcus faecium and Pseudomonas aeruginosa, have also shown a steady increase in resistance to broader spectrum antimicrobial drugs. In the case of E. faecium isolates, a steady increase of resistance to vancomycin has been observed, from 5% in 2002 to 30% in 2008. Resistance to antimicrobial drugs also has an impact in the community. Strains of Shigella flexneri are the most frequent cause of endemic shigellosis, which causes severe dysentery (27).

Vector–borne Diseases

Malaria

The Global Malaria Eradication Strategy that was introduced in 1955 had a dramatic effect on the fight against malaria in the Region. By the 1970s efforts to combat the disease in the Americas had led to its elimination from North America and the Caribbean, with the exception of the Dominican Republic and Haiti. When it became clear that malaria would not be eradicated worldwide, however, eradication efforts were superseded by control efforts, and the 1992 Global Malaria Control Strategy was launched. Africa's high malaria burden and related mortality sparked international interest and commitment to reduce the burden of malaria, and led to the launching of the "Roll Back Malaria (RBM) Initiative" (28) in 1998, with a goal of reducing the disease's burden by 50% between 2000 and 2010. A platform for further efforts against the disease was provided by United Nations Millennium Development Goals (MDG) (29, 30, 31, 32), which established an additional 25% reduction by 2015 (33).

A 2008 PAHO report on the malaria situation in the Americas (34) indicates that malaria continues to be endemic in 21 countries: Mexico, all of the Central American countries, and all South American countries, with the exception of Chile and Uruguay; in the Caribbean, the disease is present in the Dominican Republic and Haiti, as mentioned earlier. The Region's countries have been systematically collecting information and reporting on the incidence of malaria since the late 1950s. The highest annual number of cases on record in the Americas was 1.3 million, reported in 1995 and in 1998.

In 2009, the Region reported 565,892 confirmed malaria cases, representing a 52% reduction in malaria morbidity in comparison with 2000, and 122 deaths, or a 68% decrease compared with the 2000 baseline. Plasmodium vivax accounts for approximately 73.8% of infections, followed by Plasmodium falciparum, accounting for 26%, and Plasmodium malariae, accounting for less than 0.1% (reported in Brazil, French Guiana, Guyana, Suriname, and Venezuela) (Table 4.7) (35).

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Of the 21 countries in the Region that are endemic for malaria, 20 reported a decrease in cases between 2005 and 2009. Haiti, on the other hand, reported an increase of more than 100% in the total number of cases for the same period, which may be related to improvements in the country's disease surveillance (Figure 4.9). On average, the non–endemic countries in the Region annually report 1,800 imported cases from endemic countries within and outside the Region. During that same period, the Bahamas (36) and Jamaica (37), which previously had eliminated local transmission of the disease, experienced malaria outbreaks following an influx of imported cases; those outbreaks were satisfactorily contained.

Figure 10

Almost 90% of all cases reported in the Region occur in the endemic countries in South America, with populations living and working in areas of the Amazon basin being at the highest risk of malaria infection. In 2009, 152 districts in the Amazon area reported an annual parasite index (API) higher than 49 cases per 1,000 persons at risk. Of those districts, 98 are in Brazil's Amazon area, and the remainder in Bolivia, Colombia, Peru, and Venezuela. Available reports indicate that similar high levels of transmission exist in some areas in Honduras and possibly in Haiti. Additionally, between 10 and 49 cases per 1,000 population have been reported in persons living in 295 municipalities in Bolivia, Brazil, Colombia, the Dominican Republic, Honduras, Mexico, Peru, and Venezuela.

Most malaria cases diagnosed in the Region are among persons 5–14 years old and among the most economically productive age group, those 15–49 years old. Urban malaria is reported in Belize, Brazil, Colombia, the Dominican Republic, and Venezuela, and indigenous populations in Brazil, Colombia, Guyana, Mexico, and Panama are among specific groups that remain vulnerable to malaria infection. Cases of malaria among pregnant women are likewise reported in some areas of Bolivia, Brazil, Colombia, Guyana, Haiti, Panama, and Suriname.

Microscopy is widely available and accessible and continues to be the gold standard for malaria diagnosis in the Region. Availability and use of rapid diagnostic tests (RDTs) have likewise increased since 2005. Belize, Costa Rica, Ecuador, and El Salvador report that 100% of cases are diagnosed within 72 hours of onset of symptoms.

The proportion of P. falciparum cases has been relatively constant, approximately 25% annually between 2000 and 2009, most occurring in the Amazon Basin. As a result of efforts of the Amazon Network for Monitoring Antimalarial Drug Resistance (38), financed by the United States Agency for International Development (USAID) through the Amazon Malaria Initiative since 2001 (39), countries sharing the Amazon basin confirmed P. falciparum resistance to chloroquine, the most commonly used antimalarial drug. Based on that evidence, all countries participating in the Amazon Malaria Initiative changed their policies and are using the artemisinin–based combination therapy (ACT), as recommended by WHO. Use of ACT has increased gradually since 2005, and supplies have been sufficient to treat all cases. Recent efficacy studies in Honduras and Nicaragua, along with molecular studies in the Dominican Republic and Haiti, indicate that circulating strains of the parasite continue to be susceptible to chloroquine; as a result, ACT is not used for malaria treatment in those areas.

Insecticide treated nets (ITNs) and indoor residual spraying (IRS) are both used as preventive and vector control measures against malaria (34). Distribution of long lasting insecticide treated bednets (LLINs) has been reported since 2005, and peaked at approximately 900,000 units in 2007, with continued distribution but in lesser numbers in 2009. Variable numbers of conventional insecticide treated nets have likewise been distributed in the Region since 2002. Indoor residual spraying has been used annually in most countries, and the estimated number of people protected increased from 1 million to 7.8 million between 2006 and 2009.

Countries of the Region indicate a relatively stable increase in domestic funding for malaria, amounting to approximately US$ 190 million in 2009, which remains as the primary source of malaria funding for the Americas. The Global Fund contributes the most substantial external funding for malaria in the Region, which has totaled approximately US$ 334 million since 2003 (31). Having achieved marked reductions in their malaria burdens, countries in Central America and Mexico, along with Argentina and Paraguay, have intimated interest in pursuing efforts toward elimination of the disease (40). Given previous experience in disease elimination from the Caribbean islands, the goal is also thought possible for the Dominican Republic and Haiti (41).

Chagas' Disease

Chagas' disease, one of the "neglected diseases," is endemic in 21 countries of the Americas (42). Its causative agent, the parasite Trypanosoma cruzi, is most frequently transmitted by insect vectors that infest insalubrious dwellings. However, it may also be transmitted through blood transfusion, organ transplantation, and ingestion of contaminated food, as well as congenitally through the placenta.

Significant progress has been made in the control and elimination of Chagas' disease through successful horizontal technical cooperation approaches, including several subregional prevention and control initiatives (Box 4.1). These initiatives, some launched back in the 1990s by affected countries in collaboration with PAHO, have been carried out in the Southern Cone (1992), Central America (1997), the Andean subregion (1998), the Amazon countries (2003), and Mexico (2004) (43).

Box 1

  • Southern Cone. Interruption of vector–borne transmission of Trypanosoma cruzi by Triatoma infestans in Uruguay (1997), Chile (1999), Argentina (five provinces, 2001 and 2004), Brazil (2006), Paraguay (Eastern Region, 2008), and Bolivia (department of La Paz, 2011).1
  • Central America. Interruption of vector–borne transmission of T. cruzi by Rhodnius prolixus in Guatemala (2008), Belize (2010), El Salvador (2010), Honduras (2010), and Nicaragua (2010).
  • Andean region. Interruption of vector–borne transmission of T. cruzi by T. infestans in Peru (departments of Tacna, 2009, and Moquegua, 2010).
  • Amazon region. Surveillance network and prevention activities in Amazon regions of French Guiana (2004), Brazil (2005), Peru (2008), Ecuador (2009), and Colombia (2009). Attention to Chagas' disease as a foodborne disease.
  • Mexico. Elimination of the vector Rhodnius prolixus certified in the states of Chiapas and Oaxaca.

Source: Pan American Health Organization. Annual reports on subregional Chagas' disease initiatives, 1997–2011.

1 Brazil and Bolivia are part of the Southern Cone Initiative to Control and Eliminate Chagas' Disease and for purposes of technical cooperation on Chagas' disease are included among the countries of the Southern Cone.

These subregional initiatives have contributed to some major advances in the control of the disease, including interruption of vector–borne transmission in several countries (Figure 4.10), establishment of universal screening for T. cruzi in donated blood (44), reduction of the prevalence of infection among children, reduction of morbidity and mortality from Chagas' disease, expansion of the coverage of diagnostic and treatment services, and improvement in the quality of diagnosis, care, and treatment for affected people. Nevertheless, an estimated 100 million people continue to live in areas at risk for Chagas' disease (45). The disease has caused around 12,000 deaths per year over the last decade, a notable reduction in comparison with the average of 45,000 annually in the 1980s (46).

Figure 11

Despite the substantial progress made, not all countries have succeeded in meeting the targets established in 1998 (47), and meanwhile new challenges have arisen. Resolution A63.17 of the Sixty–third World Health Assembly (48) and Resolution CD50.R17 of the Directing Council of PAHO (49), both adopted in 2010, set out the current framework for action on the issue. The latter resolution endorsed and launched the current Strategy and Plan of Action for Chagas Disease Prevention, Control, and Care (50).

Leishmaniasis

Leishmaniasis is directly linked to poverty, although other social factors-as well as environmental and climatic ones-also directly influence its epidemiology. According to the World Health Organization's report Control of the leishmaniases (51), the global burden of this parasitic disease is 2.35 million disability–adjusted life years lost, with the Americas accounting for 2.3%. In the last 10 years, leishmaniasis has spread geographically in the Region, with a consequent increase in the number of people affected by the various forms of the disease. Cases have been reported from the southern United States to northern Argentina. Bolivia, Brazil, Colombia, Peru, and Nicaragua are currently part of the group of countries that account for 90% of all cases of cutaneous leishmaniasis in the world (51).

This disease has complex epidemiological characteristics, with specific variations in transmission cycles resulting from the circulation of several species of Leishmania and the existence of various reservoirs and vectors involved in its transmission. It also has different clinical manifestations, which require different therapeutic responses (51). In the New World, leishmaniasis is considered a zoonosis with three main transmission cycles: sylvatic, rural–domestic, and urban–domestic (51).

Cutaneous and mucosal leishmaniasis. Between 2006 and 2010, 296,005 cases of cutaneous and mucosal leishmaniasis were recorded in the Americas, 145,248 (49.1%) of which occurred in countries of the Andean subregion, 110,959 (37.5%) in Southern Cone countries, and 39,798 (13.4%) in Central American countries. The annual average number of reported cases was 61,932, with three countries accounting for 73%: Brazil (21,687), Colombia (14,166), and Peru (9,375). Nicaragua reported an annual average of 3,896 cases; Panama, 2,593; Venezuela, 2,305; and Bolivia, 2,234. Costa Rica, Honduras, and Ecuador reported 1,533, 1,420, and 969 cases per year, respectively. Other countries report fewer than 700 cases of cutaneous leishmaniasis a year, including Mexico (671), Guatemala (408), Paraguay (339), Argentina (182), French Guiana (83), Suriname (56), Guyana (10), and El Salvador (5).

The mucosal form merits special attention, as it can cause disfiguration and disability. In the Region, this form of the disease accounts for 3.1% of all reported cases, but a study conducted in the Andean subregion in 2000 indicated that the proportion is higher in Bolivia (12.0%), Ecuador (7.7%), Brazil (5.7%), and Peru (5.3%) (52).

Visceral leishmaniasis. In the Americas, visceral leishmaniasis is caused by the species Leishmania infantum and its principal vector is the sandfly of the species Lutzomyia longipalpis. In urban environments, dogs are the principal reservoir of this serious zoonosis, while foxes (Cerdocyon thous and Lycalopex vetulus) and opossums (Didelphis spp.) play a prominent role in the sylvatic transmission cycle (53).

From 2006 to 2010 a total of 19,383 cases of visceral leishmaniasis were reported in the Region, making the annual average 3,877 cases. Brazil (3,703 cases), Paraguay (85 cases), and Colombia (56 cases) accounted for more than 99% of that annual average; the remaining cases were reported in Argentina, Bolivia, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Venezuela. The case–fatality rate for visceral leishmaniasis is 7.0% in Paraguay and 5.6% in Brazil. Stratification of the data by age group reveals that case fatality is even higher (24%) among people over the age of 50 years, owing to the concomitant presence of other diseases, which increases the risk of death from visceral leishmaniasis, according to the Ministry of Health of Brazil (51, 54).

High case fatality and extensive geographic distribution, coupled with urbanization of the disease, make visceral leishmaniasis a serious public health problem in the Americas. Epidemiological studies have highlighted the importance of the vector L. longipalpis, which has shown the capacity to adapt to changing environments and feed on whatever animals are present in them, thereby contributing to maintaining the rural cycle and spreading the disease into urban areas (51).

Vaccine–preventable Diseases

Since its creation in 1977, the Expanded Program on Immunization (EPI) has significantly contributed toward reducing infant morbidity and mortality in the Americas. The regular immunization program may prevent some 174,000 child deaths in the Region each year. According to PAHO and WHO, the use of new vaccines-rotavirus vaccine, pneumococcal conjugate vaccine (PCV), and human papillomavirus (HPV) vaccine-also will prevent thousands of additional cases and deaths, thus playing a significant role in reaching the Millennium Development Goals (MDGs) (55).

This section presents the main achievements and challenges in immunization in the Americas.

Maintaining Immunization Achievements

The main immunization achievements include polio eradication; measles, rubella, and neonatal tetanus (NNT) elimination; and the control of other vaccine–preventable diseases (VPDs) such as pertussis, diphtheria, hepatitis B, and invasive diseases caused by Haemophilus influenzae type b (Hib). More than 20 years have passed since the last case of poliomyelitis caused by a wild poliovirus occurred in the Americas, in Peru in 1991. Worldwide, significant progress has been made towards eradicating polio, and the circulation of wild poliovirus type 2 seems to have been interrupted. As of 2011, endemic circulation has not been interrupted in four countries (Afghanistan, India, Nigeria, and Pakistan), however, and circulation has been reestablished in other, previously polio–free countries (56). Vaccine-derived poliovirus outbreaks continue to occur in areas or pockets of low coverage worldwide (57), highlighting the risk of this type of outbreak and of wild polio importations. Looking towards polio eradication, the Americas completed phase 1 of the poliovirus laboratory containment plan in 2010 (58).

Since the interruption of the endemic transmission of measles in the Americas in November 2002, the occurrence of measles cases in the Region has been limited to importations and cases related to importations in selected countries. However, the occurrence of large outbreaks in Africa and, mainly, in Europe has resulted in a great increase in the number of cases reported in the Americas in 2011 (Figure 4.11). Since 2003, every genotype identified from outbreaks in the Americas has been non–indigenous to the Region. Although the Americas is the only region in the world to have interrupted the endemic circulation of the measles virus, an estimated 60% reduction in mortality from measles was achieved worldwide between 1999 and 2005 (59).

Figure 12

Following the success in measles elimination, the burden of rubella became more apparent. In 2003, the countries of the Americas embarked on a new regional challenge: to eliminate rubella and congenital rubella syndrome (CRS) by 2010. After outbreaks in Brazil in 2007–2008 and in Argentina in 2008–2009, no indigenous rubella cases have been reported since February 2009. These outbreaks resulted in a total of 27 CRS cases reported in 2009: 13 in Argentina and 14 in Brazil. No CRS cases were reported in 2010. All countries of the Americas include measles and rubella (MR)–containing vaccines in their routine immunization schedules, are using MR vaccine for their follow–up campaigns, and have integrated MR surveillance, with the laboratory testing of rash–fever cases for both antigens. The implementation of "speed–up" campaigns in the 2000s vaccinated about 450 million adolescents and adults, allowed for the interruption of rubella virus transmission, and enhanced measles immunity. To maintain MR elimination, special groups such as those in the tourism industry and who live and work in areas frequently visited by foreigners have been targeted, surveillance has been strengthened to involve the private sector, and countries have enhanced their preparedness to rapidly respond to cases or outbreaks. International mechanisms related to the 2005 International Health Regulations (10) have been instrumental in coordinating case investigation and contact tracing between countries. Moreover, epidemiological surveillance has been strengthened around major international events that involve large movements of people, such as large sports and cultural events (60). In 2007, Member States adopted a resolution to document and verify the elimination of measles, rubella, and CRS in the Americas (61). A progress report will be presented to the Pan American Sanitary Conference in 2012.

All countries, with the exception of Haiti, have eliminated neonatal tetanus (NNT) as a public health problem.2The elimination of neonatal tetanus (NNT) is defined as the occurrence of less than one case per 1,000 live births in each municipality. Between 2006 and 2010 the annual average has been <50 cases. Up to 2008, Haiti reported about half of all NNT cases in the Region; however, deterioration in surveillance resulted in no NNT reports from Haiti for 2009 or 2010.

Pertussis cases increased at the onset of the 21st century, reaching 34,654 cases in 2005; cases have started to decrease since then, to a low of 17,248 cases in 2010. Over two–thirds of the cases were in the United States, where adolescents and adults accounted for an increasing proportion of cases. The United States now recommends a pertussis booster for these age groups, with the administration of tetanus–diphtheria–acellular pertussis (Tdap) vaccine. In Latin America and the Caribbean, efforts are under way to improve pertussis surveillance, diagnostics, and outbreak investigation.

Following a relatively large diphtheria outbreak in the Dominican Republic and Haiti in 2004–2005 (453 cases), the occurrence of diphtheria in the Region has decreased to <100 cases per year. In Haiti, diphtheria continues to be endemic, however, with occasional outbreaks associated with high case–fatality rates (>50%). One of the main challenges for the Region's countries in responding to diphtheria is the global shortage of diphtheria antitoxin (62). Hib vaccination has resulted in a dramatic reduction in the number of cases and hospitalizations from this cause, as shown in countries with surveillance.

The Region's countries are working to strengthen measures to assess vaccine impact. Much progress has been made in the prevention of morbidity and mortality related to hepatitis B worldwide, for example, and WHO has encouraged countries to establish control goals. In the Americas, infant coverage with three doses exceeds 90%. Cuba and the United States have adopted elimination strategies. In Cuba, as of 2010, most persons born since the 1980s have been protected due to high coverage with hepB vaccines. But clear global or regional definitions of elimination have yet to be developed. Since 2009, WHO recommends a hepatitis B dose administered within 24 hours of birth in all countries (63). In the Region, 13 countries included this dose in their routine schedules in 2010, though implementation and coverage varies widely from country to country. PAHO also recommends vaccinating health workers, but information is insufficient to assess the use of hepB vaccine in this group.

Tackling the Unfinished Immunization Agenda

Routine coverage levels for traditional childhood vaccines in the Americas continue to be >90%, among the highest in the world (Figure 4.12), but inequities persist between and within countries. In 2010, 11 countries reported national coverage of the third dose of diphtheria, tetanus, and pertussis–containing vaccines of <90%, while 42% of the more than 15,000 municipalities in Latin America and the Caribbean reported coverage of <95%. Countries are implementing plans of action tailored to their own circumstances in order to raise coverage in these municipalities. Against this background of inequities in immunization, Vaccination Week in the Americas (VWA) (64) was born in 2003 as an initiative to advance access to vaccination. VWA represents an opportunity to vaccinate (integrated with other health interventions) vulnerable or hard–to–reach populations and promote cross–border coordination, while keeping vaccination on the countries' political and social agenda. Since its inception, more than 350 million persons of all ages have been vaccinated during activities conducted under the framework of VWA. The success of VWA has come to serve as a model for the implementation of simultaneous sister initiatives in other WHO Regions, inspiring a growing movement towards a World Vaccination Week.

Figure 13

Given Haiti's fragile situation, especially following the 2010 earthquake and cholera outbreak, the country is at a particular risk for the reintroduction or reemergence of vaccine–preventable diseases. Haiti's Ministry of Public Health and Population, with support from partners, has developed a plan to address the country's unfinished immunization agenda, strengthen its vaccination program, and introduce Hib, hepatitis B, rotavirus, and pneumococcal conjugate (PCV) vaccines. The use of cholera vaccines is being considered as a complementary tool to fight cholera.

Regarding underutilized vaccines, progress continues to be made in the introduction of seasonal influenza vaccine in the Region. As of 2010, 39 countries or territories3No data from the French Departments in the Americas. were using the vaccine in the public sector, almost double the number that were doing so in 2004. This includes 36 countries and territories that vaccinate the elderly, 34 that vaccinate health care workers, 29 that vaccinate children, 26 that vaccinate persons with chronic diseases, and 17 that vaccinate pregnant women. Despite the vaccine's widespread use, data on coverage of target populations continue to be limited (60).

In regards to yellow fever, all countries with enzootic areas include yellow fever vaccine in their childhood vaccination schedule. Countries conducting national preemptive mass vaccination campaigns have seen yellow fever greatly reduced: Bolivia, for example, has only reported four cases since its 2007 campaign. In 2008, Paraguay reported a yellow fever outbreak with 28 cases and 11 deaths; 9 cases occurred in urban areas (the first urban outbreak of the disease in the Americas since 1954) (65). About 3.6 million yellow fever vaccines were quickly mobilized to deal with this outbreak. Since 2010, yellow fever vaccination has been compromised by a drop in vaccine supply.

Mumps incidence reached its peak at 5.2 cases per 100,000 population in 2007. Recent outbreaks in Uruguay (2005–2007), the United States (2006), Cuba (2006), Canada (2007–2008), and Venezuela (2007) have highlighted the need to improve surveillance, as a way to better understand the epidemiology of mumps in the Americas and to guide control policies (60). All countries except Haiti include mumps vaccines in their routine vaccination schedules.

Facing New Immunization Challenges

The sustainable introduction of new, more expensive vaccines continues to represent a challenge for immunization programs throughout the Region. PAHO's ProVac Initiative (66) has been strengthening the countries' capabilities to make evidence–based decisions regarding new vaccine introduction. To this end, the initiative has strengthened the countries' infrastructure for decision–making; advocated for evidence–based decisions; developed tools for economic analyses and provided training to national multidisciplinary teams on their use; supported country–level efforts to collect and analyze data; and supported effective planning for introduction when the evidence supports it (67).

New rotavirus vaccines4The first rotavirus vaccine licensed in the United States in 1998 was withdrawn from the market in 1999, due to an increased risk of intussusception. became available in 2006, and WHO recommended that all children receive this vaccine as part of the regular schedule in 2009. As of May 2011, 16 countries and territories of the Americas had introduced the vaccine. However, reported coverage levels for rotavirus vaccine are lower than those for other EPI vaccines recommended at the same age (Figure 4.12). In Latin America and the Caribbean, 15 countries are part of PAHO's rotavirus surveillance network; 12 of them are using the vaccine. Effectiveness studies in that region have shown that the rotavirus vaccine has had a significant impact on the reduction of hospitalizations and deaths due to severe diarrhea in children under 5 years old (68). After the pneumococcal conjugate vaccines (PCVs) were introduced in the United States (2001) and Canada (2002), uptake of the vaccine began to pick up in Latin America and the Caribbean in 2007. Three vaccines, with different serotype numbers, are currently available: PCV7, PCV10, and PCV13. As of May 2011, 17 countries and three territories of the Americas had introduced the PCV to their national immunization programs. The price of the vaccine was one of the main deterrents for an earlier PCV introduction in Latin America and the Caribbean. As of this writing, the epidemiological surveillance network of bacterial pneumonia and meningitis in children under 5 years old in sentinel hospitals in Latin America and the Caribbean includes 10 countries that report epidemiological surveillance data for bacterial pneumonias and meningitis to PAHO (60). This network will function as an important platform to determine PCV effectiveness, the vaccine's impact on hospitalization and mortality trends, and other related studies.

Human papillomavirus (HPV) vaccine uptake in the Region has been slower than that of rotavirus or PCV, even though these vaccines, coupled with new screening methods for HPV infections, can boost cervical cancer prevention. This is especially true in Latin America and the Caribbean, where cervical cancer mortality rates are six times higher than they are in Canada and the United States (age–standardized rates of 10.8 and 1.7 per 100,000 women, respectively). As of July 2011, five countries had incorporated HPV vaccination into their national or subnational programs. Vaccination in the private sector and publicly funded HPV vaccination also occurs throughout the Region, but the number of localities where this happens is unknown. Demonstration projects with vaccine donations also have been conducted in selected countries. Overall, these experiences have shown programmatic and communication problems in reaching and vaccinating adolescents (60).

The influenza H1N1 pandemic posed particular challenges for the Region's immunization programs in 2009–2010. Pandemic vaccination plans of action had to be quickly drafted to target individuals with chronic disease, pregnant women, and health care workers, among others, while simultaneously dealing with uncertainties regarding the H1N1 vaccine supply and availability. Some 350 million vaccine doses were acquired in the Region, but the timing of vaccine use varied by source-Canada and the United States, which acquired the vaccine through direct purchase from manufacturers, received the vaccine first, in October 2009; Brazil and Mexico, with influenza vaccine–technology transfer agreements under way, and Argentina, with a public–private agreement, received vaccines between December 2009 and April 2010; the 24 countries that procured vaccine exclusively from PAHO's Revolving Fund for vaccine procurement received vaccine between January and May 2010; and countries receiving a WHO donation began to receive vaccine between March and June 2010. An estimated total of 144 million doses were administered in Latin America and the Caribbean, representing 98% of the goal. The lowest coverage was among pregnant women (67% coverage of the pre–established goal; median, 46%), despite their increased risk of complications and mortality (Table 4.8). Vaccination campaign implementation and vaccine safety were closely monitored. Communicating risk was an important aspect of this effort, as rumors regarding vaccine safety were circulating widely on the Internet (69).

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In the coming years, immunization programs will face many challenges. As new vaccines get developed (a dengue vaccine is expected in 2014), immunization programs will necessarily face new challenges and opportunities. Responsible management of immunization programs; the development and execution of annual and multi–year plans; local–level planning and monitoring of coverage and surveillance data; the promotion of coordination among partners through national interagency committees; the training of health workers; effective supervision; and regular and sustained program evaluation will be important in moving forward. As countries begin to take advantage of current information and communication technologies (ICTs), they will be able to move beyond a mere tallying of the number of vaccines administered to setting up computerized nominal immunization registries that allow for individualized follow–up of vaccination schedules; this, in turn, may result in increased coverage rates. Legislation and innovative financing mechanisms are increasingly needed to ensure the sustainability of immunization programs that turn more complex each day (60). PAHO's Revolving Fund for Vaccine Procurement continues to ensure that the countries have an uninterrupted supply of quality vaccines at affordable prices (70). Over time, the Revolving Fund has increased the number of biologicals it offers and its expenditures. Finally, immunization programs increasingly will need to rely on traditional and new communication channels, such as Web 2.0, to raise awareness about the importance of immunization to newer generations of parents who may never have seen vaccine–preventable diseases.

Zoonoses

Zoonoses are diseases transmitted between humans and animals, with or without an intermediary vector (71). Social, economic, and environmental factors contribute to maintain these diseases, which are more likely to affect vulnerable populations (72). Veterinary public health takes an integrated approach to the human–animal–environment interface (73) in dealing with both neglected zoonoses (74) and potential public health emergencies (75) and events of international concern (76). The Inter–American Meeting, at the Ministerial Level, on Health and Agriculture-politically, the highest–level health forum in the Region-brings together senior government officials to discuss issues of mutual interest and establish joint commitments relating to the human–animal interface (77).

Rabies

Data from the SIEPI Epidemiological Information System on rabies in the Americas (78) show that since the Program for the Elimination of Rabies in the Americas was launched in 1983, the incidence of human rabies in the countries of the Region has shown a steady downward trend. Cases of rabies in humans and dogs have fallen by over 90% (Figure 4.13). Between 2006 and 2010, 79 cases of human rabies transmitted by dogs were recorded (an average of 16 per year), of which 21 occurred in Haiti; 15 in Bolivia; 10 in Brazil; 8 in Guatemala; 6 in the Dominican Republic; and the remaining 19 in several other countries, each of which reported fewer than 6 cases. Dog–transmitted human rabies occurs most often in low–income peripheral areas surrounding large cities. Between 2008 and 2011, 28 of 560 first–level political/administrative units (states, departments, or provinces) in 11 of 21 Latin American countries reported human cases. A steady yearly decline has been observed, both in the number of cases and in the number of areas affected, reflecting epidemiological progress towards the attainment of the goal of rabies elimination in the Region (75).

Figure 14

Some countries continue to experience outbreaks of human rabies transmitted by wildlife, mainly hematophagous ("vampire") bats, especially in the Amazon region (79). Since 2004, with the exception of 2006 and 2008, human deaths from bat–transmitted rabies have outnumbered human cases of dog–transmitted rabies. Between 2005 and 2010, a total of 81 deaths from bat–transmitted rabies were reported to the Regional Information System for Epidemiological Surveillance of Rabies in the Americas (SIRVERA/SIEPI), 57 (70.4%) of them in Peru, in the departments of Amazonas, Junín, and Loreto, among indigenous communities and informal–sector workers engaged in panning for gold along the Madre de Dios and Puno rivers (78). Of the remaining 24 deaths, 13 (16.0%) occurred in Mexico, 5 (6.2%) in Brazil, 5 (6.2%) in Colombia, and 1 (1.2%) in Venezuela. Activities and progress in rabies control in the Region are evaluated every two years at the Regional Meeting of Directors of National Rabies Control Programs in Latin America (80).

Leptospirosis

Leptospirosis is a zoonosis caused by bacteria of the genus Leptospira, which is found worldwide. Infection in humans is the result of exposure to infected urine from mammal carriers, either directly or through contact with contaminated soil or water (71). Leptospirosis is endemic throughout the Region and has epidemic potential. Several outbreaks occurred in the Americas between 2005 and 2010, including one in Nicaragua in 2007 (81), in which the average number of cases was somewhat more than 1 per week, but as many as 100 cases were reported in the two weeks following a flood. Guyana experienced an outbreak in 2005 that caused six deaths and more than 40 probable cases in the first three days of a period of flooding (82), and in 2008 Brazil confirmed 3,493 cases following intense rains and flooding in the state of Santa Catarina (54). The burden of disease has not yet been precisely estimated (83), owing in part to lack of epidemiological surveillance and to the fact that the disease is often not diagnosed correctly, especially among vulnerable populations. Studies have shown that males contract the disease more frequently than females, probably because of greater occupational exposure. Effective prevention and control of outbreaks requires strong multidisciplinary action, which in turn calls for coordinated intersectoral effort among the entities responsible for public health, animal health, and the environment.

Plague

Plague is a disease caused by the bacterium Yersinia pestis, which is transmitted by rat fleas (Xenopsylla cheops). In the Americas, foci of the disease are found in parts of Bolivia, Brazil, Ecuador, and Peru (71). Plague mainly affects populations living in extreme poverty (75) and in dwellings prone to infestation by rodents and their fleas (84). In Peru, the country with the largest number of plague cases in the Americas, the infectious agent continues to circulate in the rural areas of the northern macro–region (85). Between 2006 and 2010, Peru reported 50 cases and 7 deaths, for a case–fatality rate of 14%. Of the total number of cases, 12 were reported in 2006 and 14 in 2010; the case–fatality rates in those years were 8% and 36%, respectively. In 2009 and 2010, after 12 years of "epidemiological silence," the disease reappeared with epidemic characteristics in the department of La Libertad, mainly among families engaged in temporary farm work involving corn and sugarcane harvesting.

Neglected Diseases and Other Poverty–related Infectious Diseases

The neglected diseases are a group of infectious and parasitic diseases that affect mainly the poorest and most vulnerable populations. Since they share social and environmental determinants, these diseases frequently overlap geographically, as is evident from their epidemiological profiles (86). In 2009, the Directing Council of PAHO adopted Resolution CD49.R19 on the elimination of neglected diseases and other poverty–related infections; this resolution guides region–wide work aimed at achieving control and elimination goals for these diseases (75).

Leprosy

There has been a steady decline in new cases of leprosy in the Region, with the number reported falling from 47,612 in 2006 to 37,782 in 2010; consequently, the reported prevalence decreased from 0.71 per 10,000 population in 2006 to 0.38 per 10,000 population in 2010. Except for Brazil, all of the Region's countries have reached the goal of elimination (<1 case per 10,000 population). In 2010, of the 11 countries that reported more than 100 new cases, the proportion of multibacillary cases exceeded 60% in seven of them. Such cases pose a greater risk of transmission of the mycobacterium to contacts and persons living in the patient's household. It is interesting to note that although Brazil reported more than 92% of all new cases in the Region, it had one of the lowest proportions of multibacillary cases (Table 4.9). The number of cases in children under 15 remained stable, as did that of new cases with grade–2 disability (except in the United States of America). These data indicate that active transmission continues and that diagnosis does not occur until a late stage in some countries.

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Schistosomiasis

Schistosomiasis transmission exists in Brazil, Saint Lucia, Suriname, and Venezuela. Twenty–five million people remain at risk for the disease, most of whom live in Brazil, where schistosomiasis is present in 19 of the country's 27 states. Average prevalence in the endemic states is 5.6%, according to data for 2007. A national study conducted among schoolchildren in Suriname in 2010 found seroprevalence of 8.3%. Although prevalence data for Saint Lucia are not yet available, reported incidence in 2007 was six per 100,000 population. Schistosomiasis transmission is believed to have been interrupted in the Dominican Republic, but confirming studies are needed. Brazil reports that more than 80% of cases detected every year receive treatment (87).

Soil–transmitted Helminthiases

In 2009 an estimated 45.4 million children (14 million preschoolers and 31.4 million school–age children) in the Americas were at high risk of infection by soil–transmitted helminths (Ascaris lumbricoides, Trichuris trichiura, and hookworms) as a result of lack of access to basic sanitation services (88). Since 2005 antihelminthic treatment coverage has increased in the Region overall. In 2009, more than five million preschool–age children received treatment (24% coverage among at–risk preschool children in the Region), more than twice as many as reported in 2008 (2.2 million). The data also indicate that more than 33 million school–age children were treated, yielding a coverage level of over 100% of the at–risk population in this age group. This excess coverage can be explained by deficiencies in record keeping (87).

Onchocerciasis

In 2008, the Directing Council of PAHO adopted Resolution CD48.R12, which set the goal of interrupting transmission of onchocerciasis in the Region by the end of 2012 (89). By the end of 2010, transmission had been eliminated from two foci in Guatemala (Escuintla and Santa Rosa) and one in Mexico (northern Chiapas) and had been interrupted in another five foci, which are in the post–treatment surveillance phase. The latter are located in Colombia, Ecuador, Guatemala (Huehuetenango), Mexico (Oaxaca), and Venezuela (north–central region). Transmission is believed to have been interrupted in two other foci, one in southern Chiapas, Mexico, and the other in central Guatemala. Transmission persists in a northeastern focus in Venezuela and in areas along the Brazilian–Venezuelan border inhabited by the Yanomami indigenous people. This focus will be the most difficult one to eliminate, as its remote location makes access difficult and the population is highly mobile. Although blindness caused by onchocerciasis has been considered eliminated in the Region since 2007, onchocerciasis–related eye disease persists in foci in the northeastern and southern parts of Venezuela and in the Amazon basin in Brazil.

Trachoma

There is evidence of trachoma transmission in Brazil, Guatemala, and Mexico, and an estimated 50 million people in those countries live in areas at risk. In Brazil nearly 50,000 cases were detected and treated in 2010. The same year clinical data were published that provided evidence of the presence of trachoma in indigenous communities in the department of Vaupés in Colombia; however, no prevalence data are available as yet (75). A survey was conducted in 2010 to evaluate historical foci of trachoma transmission in Guatemala and risk mapping and classification of states was completed in Brazil. In Mexico, interventions have been carried out in the country's sole focus, located in the state of Chiapas.

Lymphatic Filariasis

Foci of lymphatic filariasis exist in Brazil, the Dominican Republic, Guyana, and Haiti. Over nine million people remain at risk of infection, the largest proportion of them living in Haiti. Costa Rica, Suriname, and Trinidad and Tobago are in the process of documenting the interruption of transmission and are expected to be taken off the global list of endemic countries. In 2009, 3.4 million people received treatment, almost all of them (3.2 million) in Haiti (75). In the Dominican Republic the last mass treatment day was carried out in 2007, and in 2010 a national survey was launched in order to assess the status of transmission in foci targeted by interventions, determine whether transmission is in fact occurring in several possible foci, and evaluate the impact of immigration from Haiti on the occurrence of new cases and the establishment of new foci in the country.

Tuberculosis

Tuberculosis remains a serious public health problem and a significant cause of suffering and death in the Americas, especially among disadvantaged populations as it is a disease closely associated with poverty and marginalization.

According to Global Tuberculosis Control 2010 (90), the estimated incidence in the Region in 2009 was 29 per 100,000 population and the total number of cases was 272,000. An estimated 20,000 deaths occurred among non–HIV–infected persons who contracted new cases of tuberculosis that year (2.1 per 100,000 population) and there were 5,000 deaths among people with tuberculosis and HIV coinfection. Estimated incidence varied from country to country, ranging from under 2 cases per 100,000 population to over 100. The incidence of tuberculosis reported by countries in the Region in that year was 23 per 100,000 population and the number of cases, 216,000-79.4% of the WHO estimates. WHO also estimated that 53% of tuberculosis cases in the Region occurred in Brazil, Haiti, and Peru, which in fact reported only 45% of all cases. Twelve countries accounted for 84% of estimated cases and 83% of reported cases: Bolivia, Brazil, Colombia, the Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, and Peru. PAHO identified them as priority countries for tuberculosis control under the Regional Plan for Tuberculosis Control 2006-2015 (91).

PAHO introduced the directly observed treatment, short course (DOTS) strategy in 1996 (92). Subsequently, in 2006, in response to the epidemic of HIV infection and the emergence of cases of multidrug-resistant tuberculosis and extensively drug–resistant tuberculosis (93), the Region began applying the Stop TB Strategy (94) with a view to accelerating progress towards the achievement of the Millennium Development Goals and the goals of the Stop TB Partnership. The results achieved as of 2009 are shown in Table 4.10 and described in a 2009 report on tuberculosis in the Americas (Tuberculosis in the Americas: Regional Report 2009) (95). In 2009 the Region embarked upon a new phase of tuberculosis control, redoubling efforts in response to World Health Assembly Resolution WHA62.15 (96), in which Member States committed to ensuring universal access to diagnosis and treatment for all tuberculosis patients.

Figure 15

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The incidence of tuberculosis in the Americas has declined steadily since the 1990s, with reductions of up to 4% a year since the implementation of the DOTS strategy (Figure 4.14). Recent reductions in incidence have been attributed to the strengthening of control measures and to the economic growth observed in the majority of the Region's countries (95). Nevertheless, incidence rates and their trends have varied among countries, probably as a result of specific factors such as differences in the types of tuberculosis control measures applied and in poverty rates and rates of HIV infection in each country.

Figure 16

Sputum smear–positive pulmonary tuberculosis accounted for the largest share of new cases detected in 2009, of which 64% occurred in males, yielding a male:female ratio of 1.8. Incidence was higher among males in all age groups, but especially in older groups. The group aged 15 to 34 years was, in absolute numbers, the most affected group among both sexes. Of total reported cases for 2009, children accounted for 9,900 (5%), although the percentage varied from country to country, ranging from 1% to 20%. This wide range reflects differences in case–finding practices, diagnosis, and reporting among the countries of the Region.

Since the introduction of the DOTS strategy, the case detection rate-the number of cases notified divided by the number of cases estimated for that year, expressed as a percentage-has risen steadily, increasing from 69% in 1995 to 79% in 2009 for the Region as a whole. The increase in individual countries has ranged from 25% to over 100%. At the same time, the treatment success rate-defined as the percentage of smear–positive cases that were cured or in which treatment was completed-has also risen, from 58% in the 1997 cohort to 77% in that of 2008 (97). However, this increase has not been constant, owing to problems in the quality of DOTS strategy application in several countries. The unfavorable results observed in the most recent treatment cohorts have been due to high percentages of treatment dropout, unevaluated cases, and patient death. The number of deaths is significant in countries with a high prevalence of tuberculosis and HIV coinfection and in some that have low tuberculosis prevalence.

Of the 216,000 tuberculosis cases reported in 2009, the results of HIV testing were known for 90,000 (41.7%). Of those cases, 15,200 patients had tested positive, making the prevalence of HIV infection among those tested 17%. Both HIV testing rates and the prevalence of coinfection have remained stable in recent years; however, only 10 countries provided information on active tuberculosis case–finding among people with HIV infection, which raises doubt as to whether it is occurring in the other countries of the Region (90). Of people found to have tuberculosis and HIV coinfection, 73% received antiretroviral treatment, 56% of them in Brazil.

According to the WHO reports "Multidrug and extensively drug–resistant TB (M/XDR–TB): 2010 report on surveillance and response" (98) and "Towards universal access to diagnosis and treatment of multidrug–resistant and extensively drug–resistant tuberculosis by 2015: WHO progress report 2011" (99), an estimated 6,300 of the reported tuberculosis cases in 2009 were multidrug–resistant; however, countries only reported 2,900 multidrug–resistant cases (48% of the estimate). This underreporting was the result of lack of drug susceptibility testing among previously treated patients and newly diagnosed patients at high risk for drug resistance. The countries of the Region with the highest prevalence of multidrug–resistant tuberculosis (≥3% of new cases) are the Dominican Republic, Ecuador, Guatemala, and Peru, which together accounted for 68% of total multidrug–resistant cases reported, with Peru alone accounting for 54%. In 2010, 17 countries had projects approved by the Green Light Committee and made significant progress in programmatic management of multidrug–resistant tuberculosis (100). Nine countries reported cases of extensively drug–resistant tuberculosis, but the true magnitude of the problem in the Region is unknown (98, 99).

National tuberculosis control programs are integrated into primary health care and are applying innovative interprogrammatic interventions in order to strengthen their health systems, including the Practical Approach to Lung Health (PAL) (101), a syndromic approach to the management of respiratory diseases; strategies for strengthening laboratory networks; and the Public–Private Mix (PPM) initiative for engaging all health care providers. The PPM initiative and the involvement of civil society and affected persons, whether through partnerships such as Stop TB or community–based programs, facilitate patients' access to care, especially among underserved populations, such as persons deprived of their liberty, indigenous peoples, displaced persons, and poor residents of large cities.

With regard to funding for the activities of national tuberculosis control programs in 2010, only 15 countries provided information on the amount required to carry out their operational plans. Those amounts increased 38% between 2006 and 2010, but the financing gap also increased, between 3% and 12%, as a result of reductions in resources received from States, which are the principal source of funding. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, which is the second largest source of funding, contributed 15% of the total amount required in countries eligible for Global Fund support.

The Region as a whole has achieved the tuberculosis–related Millennium Development Goal targets ahead of the 2015 deadline. The incidence and prevalence of the disease began to decline in the 1990s, as did tuberculosis mortality. According to WHO estimates, prevalence fell from 97 per 100,000 population in 1990 to 38 per 100,000 in 2009, and mortality dropped over the same period from 8.0 to 2.1 per 100,000 population. Although these reductions were over 50%, the progress of individual countries has not been uniform: in 20 countries prevalence and mortality were reduced by half or less between 1990 and 2009, while in 10 countries the reductions were modest and control activities need to be stepped up in order to attain the Millennium Development Goals. Six countries saw increases in prevalence or mortality, or both, as a result of the epidemic of HIV infection or weaknesses in control activities, especially among vulnerable population groups. These six countries stand little chance of achieving Millennium Development Goal 6 by 2015 (Table 4.10).

HIV/AIDS and Other Sexually–transmitted Infections

Epidemiologic Overview

Thirty years after the first AIDS cases were reported, the Joint United Nations Programme on HIV and AIDS (UNAIDS) estimates that in 2010 close to 3.2 million persons in the Americas had HIV: 48% in North America (1.5 million), 45% in Latin America (1.4 million), and 8% in the Caribbean (240,000); of these, an estimated 57,500 persons were under 15 years old (102). The Caribbean, with an estimated 1% adult HIV prevalence, presents wide variations across countries, from a low of 0.1% in Cuba to 3.1%, 2.3%, and 1.9% in the Bahamas, Belize, and Haiti, respectively. The adult prevalence for both North America and Latin America was estimated at 0.5% for 2009, but El Salvador, Guatemala, Honduras, and Panama had higher rates (0.8%–0.9%).

Women account for approximately 50% of all infections in the Caribbean. According to the UNAIDS–WHO 2009 AIDS Epidemic Update HIV prevalence is especially high among adolescent and young women, who tend to have infection rates significantly higher than males in those ages (103). Cultural and behavioral patterns, such as early initiation of sexual activity and intergenerational relationships, influence vulnerability to HIV in this subregion. UNAIDS studies and studies conducted by other researchers show that intimate–partner violence rates (IPV) are higher among HIV–positive women than among those who are HIV–negative (102, 104).

Between 2001 and 2009, the number of new infections in Latin America and the Caribbean seems to have declined moderately, with an estimated 10,000 fewer new infections occurring in 2009 (109,000) than in 2001 (119,000). In North America, rates of annual new HIV infections have been stable for at least the past five years, and deaths due to AIDS began to decline soon after antiretroviral therapy was introduced in 1996. A downward trend in HIV–related deaths in the Caribbean started in 2005. As reported in "Patterns, trends and sex differences in HIV/AIDS reported mortality in Latin American countries: 1996–2007" (105), several Latin American countries, including Argentina, Brazil, Chile, and Costa Rica, reported significant reductions in HIV–related mortality after the introduction of antiretroviral therapy. In other countries, HIV mortality rates have remained stable or, paradoxically, have increased, such as in Ecuador and Venezuela.

Epidemic Drivers and Vulnerabilities

The majority of Latin American and Caribbean countries are home to concentrated epidemics. In Latin America, data show high HIV prevalence rates (4% to 20%) among men who have sex with men (MSM) in urban settings, and moderate to high incidence rates, especially among young MSM. According to a review of the challenges of the HIV epidemic, 20% to 30% of MSM report bisexual behavior (106); this group is an important bridge and may partially explain the increasing number of cases among women.

In the Caribbean, unprotected sexual intercourse between sex workers and their clients is a key factor in HIV transmission (102). United Nations General Assembly Special Session on HIV/AIDS (UNGASS) country reports and other published studies show that the burden of HIV among female sex workers in the Caribbean ranges from 4.8% in the Dominican Republic (107), to 9% in Jamaica (108), and to 17% in Guyana (109). Trend analysis suggests a downward trend in HIV prevalence among female sex workers in Santo Domingo, Dominican Republic. Among men who have sex with men, studies in the Dominican Republic, Jamaica, and Trinidad and Tobago found an HIV prevalence of 6%, 32%, and 20%, respectively (103).

Reports from Argentina (110) and Peru (111) show transgender populations bearing a high burden of HIV (34% and 30%, respectively) that is coupled with high–risk behaviors for HIV, the presence of other STIs, violence, and stigmatization. Stigma and discrimination, as well as legislative barriers, continue to impact prevention efforts on most at–risk populations. Injecting drug users have also been recognized as a high–burden group, especially in Argentina, Brazil, Paraguay, Uruguay, and the United States–Mexico border. Regional estimates indicate that 29% of injecting drug users in Latin America are infected with HIV (112). Evidence shows that non–injecting drug use, such as of crack cocaine, is increasingly becoming a risk factor for HIV transmission in Latin America and the Caribbean.

Some mobile populations, including migrants, may be at higher risk of HIV infection because of social exclusion, violence, and lack of access to health services. Prevalence of HIV among prisoners has been reported at 6% in São Paulo, Brazil, and at 5% in Belize (102) and Guyana (109). Ethnic groups also are particularly vulnerable and shoulder a high burden: the Gariífuna in Honduras, for example, have high prevalence rates (4.5%), and indigenous peoples in Canada, although they represent only 3.3% of Canada's total population, comprise 5%–8% of persons living with HIV.

Sexually–transmitted Infections

A WHO progress report on scaling up priority HIV/AIDS interventions in the health sector estimates an annual incidence of 89 million sexually–transmitted infections among the population aged 15 to 49 years in the Americas (113). According to WHO country reports, the prevalence of syphilis among pregnant women appears highest in Haiti and Paraguay (3%–5%) (113). High rates (4.5%) have also been reported in Cochabamba, Bolivia (114). Genital infection of young people by Chlamydia trachomatis bacteria is one of the most common sexually transmitted diseases, and the few studies conducted in Latin America and the Caribbean indicate its incidence has been on the rise. Studies of adolescent females in Central Brazil (115) and female university students in Honduras (116) showed a high prevalence of Chlamydia trachomatis infections (19.6% and 6%, respectively).

Progress in the Health Sector's Response to HIV

Studies in Argentina (117), Brazil (118), and the United States (119) suggest that between 21% and 50% of persons with HIV in the Americas don't know their infection status. Among those in need of antiretroviral therapy in 2009, WHO estimates that 475,000 persons in Latin America and the Caribbean were receiving it (90), a 128% increase from 2003, when the Treat 3 Million by 2005 Initiative stated that approximately 210,000 people were on antiretroviral therapy (120). This was the highest regional coverage worldwide, at 50% (113) among low– and middle–income countries. The number of new infections still outpaces the number of persons placed on treatment, however. Among low– and middle–income Latin American and Caribbean countries in 2009, only Cuba and Guyana achieved an antiretroviral therapy (ART) coverage >80%, while seven other countries achieved rates of 50%–80% (Argentina, Brazil, Chile, Costa Rica, El Salvador, Mexico, and Suriname). Antiretroviral treatment among children was reported at 58% in 2009, with differences between Latin America (68%) and the Caribbean (29%). Antoretroviral use in Latin America and the Caribbean differs from that in other regions; approximately 16% of individuals are receiving second– or third–line regimen drugs, as opposed to 2.5% in other low– and middle–income countries. Difficulties in access to prequalified low price generic formulations persist, reinforcing the need to support treatment optimization and cost reduction as proposed by the WHO–UNAIDS initiative "Treatment 2.0" (121). Resistance studies increasingly report intermediate levels (5%–15%) of transmitted resistance in newly diagnosed individuals in Honduras (7%), Brazil (8.1%), Argentina (8.4%), and Venezuela (11%) (122, 123).

Based on WHO's 2010 report, Global Tuberculosis Control, tuberculosis continues to be a significant contributor to HIV–associated morbidity and mortality (90). In Latin America and the Caribbean, prevalence of HIV among tuberculosis patients is high (17%); in 2009, 14,700 cases of tuberculosis in HIV patients were reported, although underregistration is probable, given that only 41% of tuberculosis patients know their HIV–infection status. The expansion of soniazid programs is limited, which implies that fewer than 5,000 HIV cases are provided with isoniazid prophylactic treatment out of 45,000 HIV patients screened annually for tuberculosis in Latin America and the Caribbean (90).

The goal of eliminating mother–to–child transmission of HIV and congenital syphilis by 2015 was endorsed by the countries of the Americas in 2010 (124). Although the quality of available data varies widely in Latin America and the Caribbean, estimated trends in the provision of antiretroviral therapy to pregnant women for the prevention of mother–to–child transmission have shown a significant increase since 2004, with levels holding at 54% in 2009 (113). In the United States, in 2008, data from enhanced perinatal surveillance in 15 areas showed antiretroviral therapy coverage during pregnancy was 88%; 37% of infants had missing information on HIV status, and the mother–to–child transmission rate in those with information was 2.6% (125). The main barrier to further reduce mother–to–child transmission of HIV is a low rate of HIV testing among pregnant women, which despite increases from the 29% rate seen in 2005, still only reached 57% in Latin America and the Caribbean in 2009 (113). The persistence of vertical approaches in HIV service delivery models and difficulties in integrating HIV in primary health care continue to hinder the countries' capacity to close the gaps in access to essential services.

Prevention of Sexual Transmission of HIV

Despite some progress, the percentage of sex workers reached by HIV prevention programs remains low, ranging from under 30% to 60%. In the Caribbean, country reports show that 32% to 73% of sex workers received an HIV test in the last 12 months, comprehensive HIV knowledge appears low to average (6% to 79%), and consistent condom use ranged from 68% to 96%. In Latin America, consistent condom use among men who have sex with men and among sex workers is low to moderate; for example, in Nicaragua it is 19% and 60%, respectively (126). In 2008, the countries of the Americas issued the Mexico City Declaration, "Educating to Prevent," which underscored the importance of education in the effort to prevent HIV. Nonetheless, comprehensive knowledge on HIV prevention among young persons remains low to moderate in the Caribbean (median of 50% and 43% among males and females, respectively) and in Latin America (28% and 30% in males and females, respectively) (127).

Financing the HIV Response

Funding for the global HIV response accelerated rapidly in 2002–2003, driven largely by the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and the United States President's Emergency Plan for AIDS Relief (PEPFAR). From 2001 to 2010, the World Bank executed HIV projects in Latin America and the Caribbean in the amount of US$ 347 million; PEPFAR executed US$ 600 million for HIV projects in 2004–2008. Latin American and Caribbean countries also have received more than US$ 1 billion for HIV from GFATM since 2003, plus US$ 25 million in approved grants starting in 2010–2011 (128). Nevertheless, government expenditure is estimated to have accounted for the majority of the overall investments in HIV in Latin America and the Caribbean (average of 92%, interquartile range of 45%–97% for 2007–2009). Given the current financial scenarios, it is critical for countries to close gaps in external funding through domestic allocations, in order to maintain achievements and cover remaining gaps. Recent changes in GFATM eligibility criteria will significantly reduce the number of qualifying countries in the Region, and some will qualify exclusively for most–at–risk–population funding, meaning that core program expenses, such as antiretroviral therapy, will no longer be eligible costs in their proposals.

Maternal and Congenital Syphilis

During the 50th Directing Council of PAHO, all governments of the Americas approved the Strategy and Plan of Action for the Elimination of Mother–to–Child Transmission of HIV and Congenital Syphilis (129).

To date, two of the Region's countries have eliminated congenital syphilis as a public health problem: Chile, which reports a prevalence of under 0.5 cases per 1,000 live births, and Cuba, which has not reported any cases in the last three years. In 2004 a national study conducted in Brazil revealed the prevalence of maternal syphilis to be 1.6%, and it is estimated, on the basis of that figure, that 12,000 congenitally infected children are being born in that country every year. Research conducted in seven regions of Paraguay in 2008, using data from the Perinatal Information System, found that the prevalence of maternal syphilis ranged from 1.2% to 6.9%. Uruguay's perinatal information system reported a maternal syphilis rate of 1.3%; that country has introduced rapid syphilis detection tests for use in universal screening of pregnant women (130). In Bolivia an evaluation of 1,594 postpartum women found a syphilis prevalence of 7.2% (131). In El Salvador, a study conducted with data from the Perinatal Information System found that of 72,562 women registered in 28 hospitals, 46,215 (63.7%) were screened for syphilis (VDRL test) and 127 (0.3%) tested positive (132).

While the elimination of syphilis might seem at hand, the disease's persistence demonstrates that elimination will only be possible when the quality of primary care for pregnant women is ensured, which in turn will require the humanization of care, the integration of the services, and constant monitoring.

CHRONIC, NONCOMMUNICABLE DISEASES

Hypertension and Cardiovascular Diseases

Hypertension

More than 80% of cardiovascular diseases are associated with hypertension, hypercholesterolemia, and smoking. Of these disorders, hypertension is the most important cardiovascular risk factor and is linked to 62% of strokes and 49% of cases of ischemic heart disease (133). Hypertension is the leading cause of death and the second leading cause of disability worldwide (134).

In 2000, there were one billion people with hypertension in the world, and the number is expected to rise to 1.4 billion by 2025 (135). The prevalence of hypertension is high in the Americas among both males and females, exceeding 30% in all countries of the Region. In some, it is as high as 48% (136).

Improving the hypertension5The hypertension control rate is the proportion of people with hypertension (blood pressure ≥ 140/90 mm Hg or currently taking antihypertensive medication) whose blood pressure is below 140/90 mm Hg. control rate in the population is a complex undertaking. Although current data are still insufficient, a recent study of seven Latin American cities found control rates ranging from 12% in Lima, Peru, to 41% in Mexico City, Mexico (137). In the United States, the control rate improved from 27% in 1988–1994 to 50% in 2007–2008. The rates were lower among young adults and the population of Latin American descent (138).

The magnitude of hypertension as a health problem is the result of a breakdown in health and social systems at the population level, and in order to address it health interventions are needed that seek not only to avoid the harm done by hypertension, but also to modify its determinants. Excessive intake of sodium in the form of salt and spiraling rates of obesity are two examples of determinants that are particularly serious and visible among socially vulnerable and older population groups. Hypertension is a chronic illness that requires continuous integrated care, and this does not occur in the health services of many countries, where care is fragmented and episodic. Hypertension management should be part of a health system based on primary care, in which scientific advances in prevention can be brought to bear to redesign health services and render them more effective (139).

Population aging, tobacco use, unhealthy diet, and lack of physical activity, particularly in the context of globalization and unplanned urban growth, help to explain the high prevalence of hypertension, hypercholesterolemia, diabetes, and obesity and the consequent high prevalence of cardiovascular diseases.

Cardiovascular Diseases

According to information from the PAHO mortality information system, in 2007 1,746,767 deaths in the Americas were caused by diseases classified under ICD-10 (5) as diseases of the circulatory system (ICD–10: I00–I99). That figure amounts to 30.5% of total deaths in the Region. Of those deaths, 85% were due to four causes: ischemic heart disease (ICD 10: I20–I25), cerebrovascular diseases (ICD 10: I60–I69), heart failure (ICD 10: I50), and hypertensive diseases (ICD 10: I10–I15).

In 2007, ischemic heart disease was the leading cause of death in the Americas, among both males and females, accounting for 742,028 deaths (406,004 males and 336,024 females), or 13% of total deaths in the Region. It was also the leading or second leading cause of death in 30 countries, with rates markedly higher among males than females. Major differences were observed between countries, with age– and sex–adjusted mortality rates ranging from 34 per 100,000 population to 129 per 100,000. The highest rates among males were seen in Trinidad and Tobago, Venezuela, and Colombia (195, 154, and 131 per 100,000 males, respectively), while the highest rates among females were in Saint Vincent and the Grenadines, Venezuela, and Nicaragua (109, 97, and 92 per 100,000 females, respectively).

A high proportion of deaths from ischemic heart disease in Latin America and the Caribbean can be classified as premature. Such premature deaths are much more frequent among males than females and they tend to occur during the most productive years of life, making their economic and social impact even greater. For example, in 2007 reported mortality from ischemic heart disease among people under 70 years of age in Canada was 32 per 100,000 males and 9 per 100,000 females, while in Trinidad and Tobago and Venezuela the rates were 2.2 to 3.7 times higher than in Canada (Figure 4.15).

Figure 17

In 2007, cerebrovascular diseases caused 387,913 deaths (175,551 males and 212,362 females) and represented the second leading cause of death among both sexes. These diseases accounted for nearly 7% of total deaths in the Region and figured among the three leading causes of death in at least 12 countries. According to data from the PAHO mortality information system, the countries with the highest mortality (per 100,000 population) from cerebrovascular diseases were Suriname (99), Paraguay (87), Trinidad and Tobago (78), Brazil (74), and Venezuela (65). Canada had the lowest rate of death from this cause in the Region: 21 per 100,000 population. In the majority of countries in the Region, mortality from cerebrovascular diseases is higher among males; however, in Canada, Costa Rica, and El Salvador rates among males and females are similar.

The 2009 edition of PAHO's basic indicators series was devoted to the subject of premature mortality from cerebrovascular diseases (140). That analysis revealed a nonlinear inverse relationship between premature mortality from cerebrovascular disease (as a proportion of the total number of deaths from this cause) and per capita gross national income, adjusted for purchasing power parity. The data show that the higher the national income, the lower the proportional premature mortality from this cause (Figure 4.16).

Figure 18

Although cardiovascular diseases represent a complex problem, there is reason to believe that the situation may be improving. For example, while diseases of the circulatory system are the leading cause of death in the Americas, mortality from these causes has not increased. In fact, a recent analysis of the situation that included the Region's most populous countries with stable mortality records showed a clear decline in the risk of death between 2000 and 2007 (or in the latest year for which data were available) in the 43 countries studied. The average annual reduction for the group of countries as a whole was 3.2% among males and 3.4% among females. In Canada and the United States, the reductions were greater than 3.2% per year, among both males and females, whereas in Chile and Costa Rica the annual decline was over 2.5%, also among both sexes.

In 2010, PAHO initiated a regional consultation process aimed at setting priorities for cardiovascular health in the Americas, based on the best available scientific evidence and criteria of cost–effectiveness, social value, and equity (141). The priorities identified include three highly cost–effective interventions: (1) reduce tobacco use, (2) reduce salt intake, and (3) use a multidrug combination (aspirin, two types of antihypertensive drugs, and a statin) to treat people identified in primary care services as being at high risk of cardiovascular disease, especially if they suffer from hypertension and diabetes. It is estimated that together the first two interventions could prevent 13.8 million deaths within a period of 10 years (142). The third intervention could avert 18 million deaths from cardiovascular disease at a yearly cost of US$ 1.08 per person in 23 low– and middle–income countries with a high burden of these diseases (143).

One of the key messages to emerge from the regional consultation was that since cardiovascular diseases are the leading cause of death and premature death in most countries of the Region, and since they share determinants, risk factors, and care needs with other chronic diseases, prioritizing cardiovascular health activities would yield direct benefits for the prevention and control of diabetes, chronic respiratory diseases, cancer, and obesity. This approach is consistent with the Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases, adopted by the countries of the Americas in 2006 (144).

Malignant Neoplasms

The analysis that appears below is based entirely on mortality data supplied by PAHO Member States.

Malignant neoplasms together constitute the second leading cause of death in the countries of the Americas. In 2007 this group of causes accounted for 1,130,882 deaths in the Region, 583,711 of males and 547,171 of females. The standardized mortality rate for all types of cancer was 118.1 per 100,000 population for both sexes, 137.1 per 100,000 for males, and 104.2 per 100,000 for females. In most countries of the Region, and consequently in most subregions, mortality from all types of cancer has decreased slightly since 2000 among both males and females, as shown in Figure 4.17.

Figure 19

For the Region as a whole, the most important cancers among males, in terms of frequency, absolute number of deaths, and mortality rate, were lung cancer (137,303 deaths), prostate cancer (69,736 deaths), and colorectal cancer (38,382 deaths). Among females, they were lung cancer (100,357), breast cancer (81,209), and colorectal cancer (40,490 deaths). Figure 4.18 shows mortality rates for the most frequent cancer types among females and males.

Figure 20

Analysis by subregion reveals that among males in North America6Not including Mexico. and the countries of the English–speaking Caribbean, the rates were slightly higher than in Latin America (142.9 and 152.4 per 100,000 males for North America and the English–speaking Caribbean, respectively, versus 128.4 per 100,000 for Latin America). Within Latin America, the Southern Cone and the countries of the English–speaking Caribbean had higher rates than the countries of the Andean subregion and Central America. In Central America, mortality from all types of malignant neoplasms was markedly lower than in other subregions of the Americas. Male mortality showed major variations across countries. For example, Uruguay, whose most recent mortality data are for 2004, reported the highest cancer mortality rate among males (223.6 per 100,000), while Guyana and Mexico (data for 2007) had the lowest (64.8 and 60.7 per 100,000, respectively).

Among females, the highest cancer mortality rates were observed in North America and Latin America (104.9 and 100.8 per 100,000 females, respectively), while in the countries of the English–speaking Caribbean they were slightly below the mean (92.5 per 100,000 females). Within Latin America, mortality from malignant neoplasms was higher in the Andean subregion than in the other subregions (Figure 4.18).

The highest cancer mortality rates per 100,000 females in the Region were reported by Peru (134.1) and Uruguay (121.0, data from 2004). In 2007, the lowest rates per 100,000 were found in Puerto Rico (64.9) and Mexico (73.1).

In general, mortality is higher among males than females, except in Ecuador, El Salvador, Guatemala, Guyana, Nicaragua, and Paraguay, where rates are higher among females. This phenomenon may be attributable to high mortality from cervical cancer in those countries, which have rates that are much higher than the mean for the Region. In Mexico, Peru, and Venezuela, cancer mortality rates among males and females are very similar (ratio close to 1). In most countries of the Region, cancer mortality has declined slightly among both males and females since 2000. However, in Cuba, Ecuador, and Peru, mortality from all types of cancer has continued to rise by an average of 1% per year.

Lung cancer, one of the most frequent malignant neoplasms in the Region, accounted for the largest number of deaths in 2007, among both males (137,303 deaths) and females (100,357 deaths). Those figures represent 23.7% and 18.4% of total deaths from malignant neoplasms, respectively. Mortality from lung cancer in the Region was 32.7 per 100,000 males and 19.1 per 100,000 females. Since 2000, most countries in Latin America have seen a decline in annual mortality from this cause among males, but the trend has been somewhat different among females. In Argentina, Brazil, Chile, El Salvador, Nicaragua, and Uruguay annual lung cancer mortality among females has risen steadily by between 1.4% and 4.4%, depending on the country and year.

Breast cancer ranks second, after lung cancer, as a cause of death from malignant neoplasms among females in the Region. In 2007, a total of 81,209 women died from this type of cancer (16 per 100,000 women). Breast cancer mortality does not show any clear geographic pattern in the Americas. The only area that has noticeably higher mortality from this cause is the non–Latin Caribbean, where the rate is 23.9 per 100,000 women. In North America and Latin America, the rates are similar (16.7 and 14.8 per 100,000 females, respectively). Fortunately, as has been the case in Europe and North America, breast cancer mortality has shown a downward trend in several countries of the Southern Cone, including Argentina, Chile, and Uruguay, thanks to early detection and to advances in treatment. However, in Colombia, Costa Rica, Cuba, Ecuador, Mexico, Paraguay, and Venezuela, mortality has been rising yearly since 2000 by between 0.4% and 1.8%.

Cervical cancer is the most important malignant neoplasm among women the world over in terms of frequency and associated mortality. In 2007 the countries of the Region reported a total of 24,143 deaths from this type of cancer, making the mortality rate 5.2 per 100,000. This value masks major differences among the various subregions, however. While in North America the mortality rate is 1.9 per 100,000 women, in Latin America it is 8.3 per 100,000 and in the non–Latin Caribbean, 15 per 100,000. The trend of cervical cancer mortality could change in the future as a result of early detection programs and the incorporation of the human papillomavirus vaccine into immunization programs. In fact, deaths from cervical cancer declined between 0.5% and 7% a year from 2000 to 2007 in most countries of Latin America, except for Cuba, Ecuador, Paraguay, and Peru, where mortality from this cause is still increasing by 0.4% to 1% a year.

Analysis of cervical cancer and breast cancer mortality trends by country reveals that in middle– and high–income countries, such as Canada, the United States of America, and some Southern Cone countries, including Argentina, Chile, and Uruguay, mortality from breast cancer is higher than mortality from cervical cancer and that both have declined over time, thanks to early detection and improved treatment. In some countries of the Region, including Colombia, Mexico, and Panama, mortality from breast cancer has risen steadily, while mortality from cervical cancer has fallen significantly. In other countries, such as El Salvador and Nicaragua, cervical cancer mortality is much higher than breast cancer mortality.

Prostate cancer ranks second, after lung cancer, as a cause of death among males. In 2007, there were 69,736 deaths from this cancer in the Americas, with an age–standardized rate of 15.9 per 100,000 men. The geographical distribution of deaths from prostate cancer shows a very irregular pattern, with mortality extremely high in the countries of the non–Latin Caribbean, where the rate in 2007 was as high as 63.5 per 100,000 men, four times higher than the mean for the Region. In the same year, the mortality rate for prostate cancer was 12.8 per 100,000 men in North America and 19.7 per 100,000 men in Latin America. The etiology and the agents that promote progression to clinical cancer are unknown, but a variety of risk factors come into play, including certain hormonal patterns, family history, and diet.

Colon and rectum cancer ranks third as a cause of cancer death in the Americas, after lung and prostate cancer in males and lung and breast cancer in females. In 2007 a total of 38,382 men and 40,490 women died from colorectal cancer; mean mortality for the Region was 9.0 deaths per 100,000 males and 7.2 per 100,000 females. There are no marked differences among subregions, although mortality from this cause is relatively low in the countries of Central America (approximately 3.7 deaths per 100,000 among both males and females).

By country, the highest mortality rates in the Region among males are found in Uruguay (17.1 deaths per 100,000), while the lowest are in Belize, El Salvador, Guatemala, Guyana, and Mexico, all of which have rates below 4.0 deaths per 100,000 males. Among females, the highest rates are reported in Cuba and Uruguay (more than 12 deaths per 100,000) and the lowest in Belize, Guatemala, Guyana, and Mexico (fewer than 3.5 deaths per 100,000).

The most noteworthy trend with respect to colorectal cancer in the Region is the considerable increase in mortality in many countries of Latin America, especially among males, which contrasts with the decline in mortality from this cause among females. Examples of this are found in Chile, Costa Rica, El Salvador, and Nicaragua, which have seen annual increases in mortality of between 1% and 4% among males since 2000, whereas mortality among females has declined during the same period.

More information may be found on the PAHO/WHO cancer program website (145).

Diabetes Mellitus

Diabetes mellitus is a metabolic disease characterized by chronic hyperglycemia, which is caused by a defect in either the production or the action of insulin, or both. The number of people with diabetes in the Americas is projected to increase from 62.8 million in 2011 to 91.1 million in 2030 (146). There are three types of diabetes: type 1 diabetes, which affects mainly children and young people; type 2 diabetes, which appears most frequently in adults and is related to a high–calorie diet, physical inactivity, and obesity; and gestational diabetes.

Prevalence studies of diabetes mellitus relate to total cases of the disease, generally in adults, including a large group of people with type 2 diabetes mellitus (which may account for up to 90%–95% of cases) and a small group of people with type 1 diabetes. The findings of prevalence studies depend largely on the diagnostic criteria used, sampling methods, and the way in which the data are analyzed. Many of the prevalence studies conducted in Latin America and the Caribbean date back several years and have not been repeated. In the United States, on the other hand, surveillance of both diagnosed and undiagnosed diabetes mellitus is carried out through the Behavioral Risk Factor Surveillance System (BRFSS) (147) and the National Health and Nutrition Examination Survey (NHANES) (148). BFRSS uses telephone surveys that explore various health issues, such as the prevalence of diabetes mellitus and hypertension. NHANES uses in–person surveys in which participants answer questionnaires and undergo laboratory tests and a physical examination. Some countries, such as Chile and Mexico, have conducted more than one national population survey on diabetes. Brazil has a national telephone–based risk factor surveillance system, known as Vigitel, which covers diagnosed diabetes and other chronic diseases. Costa Rica has recently launched a national health–center–based surveillance system that periodically studies the prevalence of diagnosed and undiagnosed diabetes and tracks blood glucose levels among people suffering from the disease.

In the Americas, diabetes mellitus is most prevalent among adults in the countries of the English–speaking Caribbean; the second highest prevalence is found among populations along the border between Mexico and the United States of America. In Mexico and the majority of the countries of Central America, South America, and the Latin Caribbean, the prevalence is between 8% and 10%. The lowest prevalence reported was in Tegucigalpa, Honduras (6.1%), in 2004 (149, 150, 151).

Certain groups within a single population have been found to be at higher risk for diabetes. Examples include African Americans and persons of Mexican descent in the United States of America, among whom the prevalence of diabetes is higher than among the country's Caucasian population. These ethnic differences are linked to both genetic and environmental factors, including poor diet and lack of exercise. In the Americas, the highest prevalence of type 2 diabetes mellitus has been found in the United States of America among the Pima indigenous group in the state of Arizona, among whom almost all adults develop the disease (152).

Recent data from population–based national surveys indicate that the total prevalence of diabetes mellitus, including both diagnosed and undiagnosed cases, increased from 6.3% to 9.4% in Chile between 2003 and 2010 (153). In Argentina, the prevalence of diagnosed diabetes rose from 8.4% in 2005 to 9.6% in 2009 (154).

Managing patients with diabetes is difficult for health services. People with diabetes need to receive comprehensive care that considers the central role that patients must play with respect to their own health. At the same time, professionals from various areas need to collaborate in order to provide the care prescribed in evidence–based guides and protocols. Most people with diabetes seen in health services are not maintaining good blood glucose control. Recent data indicate that the proportion of people with uncontrolled diabetes was 66% in Chile (153) in 2009; 70% in Veracruz, Mexico, in 2005 (155); 63% among the Hispanic population on the Mexican side of the Mexico–United States border in 2001–2002 and 58% among the population on the United States side during the same period (156); and 54% in Costa Rica in 2010 (157).

Diabetes mortality statistics do not always reflect the true magnitude of the disease as a cause of death. This is because many deaths are classified according to the final disease or condition that results in death-which is frequently a chronic complication of diabetes, such as some form of cardiovascular disease-rather than diabetes itself. One of the most significant aspects of mortality from chronic diseases, especially diabetes, is shortening of the life expectancy of those suffering from such diseases. Figure 4.19 shows premature mortality from diabetes mellitus among males and females under 70 years of age. The highest rates in this age group for both sexes and for males, respectively, were 58.9 and 68.8 per 100,000 population, reported in Trinidad and Tobago; among females, the highest rate was 50.9 per 100,000, reported in Belize. The lowest rates were in Canada, both overall (4.7 per 100,000) and among males (6.2 per 100,000) and females (3.2 per 100,000) (see also the mortality section of this chapter).

Figure 21

Poorly controlled diabetes increases the risk of cardiovascular diseases, nephropathy, neuropathy, amputation, and blindness. People with diabetes are also at higher risk for tuberculosis, as was demonstrated by a recent study conducted in Mexico, which found that diabetes was associated with 20% of tuberculosis cases (158).

Diabetes mellitus continues to be one of the greatest threats to health in the 21st century, and the trend of the disease will continue to rise unless prevention improves, the obesity epidemic is halted, and better results are obtained in the management of people who already have the disease.

Chronic Respiratory Diseases

This section reports on the following chronic respiratory diseases: asthma, chronic obstructive pulmonary disease, emphysema, and chronic bronchitis, encompassing ICD–10 codes J40 to J47 (5).

In 2007, these diseases caused 10% of all deaths from noncommunicable diseases in Latin America and the Caribbean. The proportion of total deaths attributed to these causes increased from 3.0% in 2001 to 4.3% in 2007. According to data from the PAHO mortality information system for 2007 (updated in 2011), mortality rates (adjusted) for chronic respiratory diseases in the Region range from 3 to 40.7 per 100,000 population and are consistently higher among males than among females.

The highest mortality from these diseases among people under 70 years of age was found in Brazil (10.3 per 100,000 population), the United States of America (8.5 per 100,000), and Uruguay (7.9 per 100,000), and the lowest, in Ecuador (2.4 per 100,000), the Bahamas (2.7 per 100,000), and Barbados (2.9 per 100,000). Like overall mortality from these causes, rates for individual countries were consistently higher among males (159).

The publication Noncommunicable Diseases in the Americas-Basic Indicators 2011 (159) contains an analysis of years of life lost (YLL) and reduction in life expectancy as a result of chronic respiratory disease, which shows that in 2007 a total of 1,322 years of life were lost in the Region, with YLL values per 10,000 population ranging from 9.2 in Brazil and 7.8 in Colombia to 2.2 in Ecuador. The effect of chronic respiratory diseases in terms of years of life expectancy lost ranges from almost a year (0.9) in Costa Rica to 0.2 years in Argentina, Guatemala, Paraguay, and Peru.

EXTERNAL CAUSES: ACCIDENTS AND VIOLENCE

Analysis of morbidity and mortality from external causes is hindered by problems relating to insufficient and poor quality data, which, in turn, have legal implications for individuals and information systems. Although mortality may be the best indicator with respect to these causes, the possibility of misclassification of causes of death should be borne in mind. The main distinction to make in analyzing mortality from these causes is that of intent-i.e., whether death was the result of self–inflicted injury or injury caused intentionally by others or of injuries that were not intentional and that are attributable to unsafe behavior or conditions.

Injury and Violence

Between 2000 and 2007, there were 4.4 million deaths from external causes in the Region, for an average of 551,000 deaths a year.

Deaths from external causes occur primarily among people 15–44 years old. However, there are almost as many deaths from external causes among people over the age of 80 as there are among young people aged 15 to 19, a fact that may indicate a lack of attention to the safety and care of the elderly (Figure 4.20).

Figure 22

Analysis of the data by sex shows that mortality from external causes among males increased 3.8% in the Region between 2000 and 2007 (rising from 229.1 to 237.8 per 100,000 males). Among females the rates are much lower, although they also increased, from 63.2 to 69.9 per 100,000 females, between 2000 and 2007.

In general, women have a higher probability of being killed by someone close to them. Between 30% and 70% of murders of women in such varied countries as the United States of America, Israel, and South Africa are perpetrated by the victims' partners (160, 161, 162). Figure 4.21 shows the male:female ratio of mortality from external causes, which ranges from 1.8 in Cuba to 6.4 in Colombia, pointing to the need to address the problem from a gender perspective.

Figure 23

Mortality from homicide and events of undetermined intent among males aged 20 to 39 has increased in some countries of the Americas over the period of analysis, while in others it has declined (Table 4.11). The risk of dying from violent acts (homicide) in Latin America varies from country to country (Table 4.5).

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When analyzing mortality from violence, it should be borne in mind that the relationship between level of urbanization and level and distribution of wealth in a country as risk factors for violence has still not been clearly established (163); income and urbanization levels are not always associated with higher mortality from homicide. That said, in several of the countries where the gaps in income distribution are the widest (Brazil, Colombia, Ecuador, El Salvador, and Guatemala), mortality from homicide tends to be higher (Table 4.12).

1-health conditions and trends-e-t12.jpg

Exposure to the risk of violence differs by sex. When the United Nations Development Program gender inequality index (164) is analyzed, Canada, the United States, and Cuba have relatively low indices (0.29, 0.4, and 0.47, respectively) and also have a lower male:female ratio of mortality from external causes. On the other hand, intermediate gender inequality indices-such as those of Argentina (0.53), Chile (0.51), Costa Rica (0.50), and Mexico (0.58)-and other, relatively higher indices-such as those of Brazil (0.63), Colombia (0.66), and Guatemala (0.71)-are associated with higher male:female ratios of mortality from external causes.

As Figure 4.22 shows, the trend of crude death rates per 100,000 population from external causes in the Region is relatively stable, except in Suriname, Trinidad and Tobago, and Venezuela, where the trend is upward.

Figure 24

Figure 4.6 reveals that the proportion of deaths due to the various external causes of mortality has remained relatively constant. Motor vehicle accidents are more frequent among young people, as are homicides, while falls-analyzed in the section on mortality from external causes-are more frequent among the elderly, as are suicides. When the information is disaggregated by sex, it is clear that death from assault is more frequent among males, while external injuries and events of undetermined intent are more frequent among females.

Poverty relief programs have shown a positive effect on violence reduction. For example, in Mexico, a study on the relationship between intimate partner violence against women living in extremely poor urban areas and those women's participation in a human development program called Oportunidades (Opportunities) found a significantly lower number of acts of violence against program participants than non–participants (34.5% and 40.4%, respectively) (165).

To address the problem, in March 2008 Mexico's Secretariat of Health and PAHO hosted the first Ministerial Meeting of the Americas on Violence and Injury Prevention, held in Mexico. The meeting adopted the Ministerial Declaration on Violence and Injury Prevention in the Americas, which emphasizes the need to step up efforts to solve this public health and development problem (CD48.20, Annex A). Subsequently, on the basis of World Health Assembly Resolution WHA56.24, "Implementation of the recommendations of the World report on violence and health" (166), adopted in 2003, the 48th Directing Council of PAHO adopted Resolution CD48.R11, which urges Member States to promote and spearhead processes and promote partnerships with other sectors to help prevent violence and injuries and promote safety, given the multicausal nature of externally caused injuries (167). That resolution constitutes the current frame of reference for the Region with regard to violence and injuries. The Directing Council of PAHO subsequently adopted the Plan of Action on Road Safety, through Resolution CD51.R6, which sets out the basis for its implementation in the coming years (168).

Occupational Accidents and Diseases

Based on figures recorded on the population covered by some type of occupational injury insurance in 16 countries of the Region, it is estimated that in 2007 there were at least 7.6 million occupational accidents, which amounts to 20,825 such accidents each day (Figure 4.23). When analyzing trends, however, it is important to take into account that the data only cover formal–sector workers, that the information comes from various sources, and that the data are not always of good quality.

Figure 25

The ability to compare official occupational accident rates in the Region's countries (Figure 4.24) is hindered by underreporting of events and because the information refers only to one segment of the working population-insured workers. Depending on the country, occupational insurance coverage ranges from a low of 12% to a high of 87% of the active work force in the formal sector, depending on the country. Furthermore, most countries lack statistics on occupational accidents that are disaggregated by sex.

Figure 26

Records for workers covered by some type of occupational injury insurance indicate that in 2009 there were 11,343 fatal occupational accidents in the Region, 5,236 of them (3.5 per 100,000 workers) in Latin America and the Caribbean and 6,107 (8.9 per 100,000 workers) in Canada and the United States of America. According to data published in Morbidity and Mortality (201), the highest rate of fatal occupational accidents in the United States of America occurs among workers of Latin American origin. The foregoing figures, however, do not fairly represent the situation in the Region as a whole. For example, according to a report on the Registry of Fatal Occupational Accidents in Nicaragua in 2005, such accidents were underreported by 226% (202)</url>. In Brazil the level of underreporting in 2005 ranged from 39.0% to 90.4%, depending on the state in question (203).

Based on information from nine countries in the Region, it is estimated that at least 281,389 cases of occupational disease occurred in 2009, which is 770 new cases per day (Figure 4.25). The increase in rates of occupational disease observed in Argentina between 2000 and 2008 and in Colombia between 2000 and 2009 can be attributed to a deterioration in working conditions and/or improvement in detection and reporting of such diseases. The reduction in rates in other countries might be the result of inadequacies in surveillance systems and in detection of occupational diseases rather than of improvements in employment and working conditions. The fact that countries acknowledge the deficiencies in their surveillance systems, case detection, and occupational disease reporting systems lends support to this hypothesis.

Figure 27

Several studies show that occupational injuries and diseases are being underreported in the Region (204, 205). In the United States, for example, workers' compensation systems underreport more than 180,000 occupational accidents, while some 340,000 such accidents go unreported in that country's Bureau of Labor Statistics' annual Survey of Occupational Injuries and Illnesses (206). In Chile, on the basis of data from the First National Survey of Employment, Equity, Work, and Health (ENETS), it was estimated that up to 38% of occupational injuries are not reported, which amounts to 376,078 unreported cases in 2009 (207). In 2004, according to a study using data from the Mexican Social Security Institute, the average rate of underreporting was estimated at 26.3% for the country as a whole, with values of up to 68% in some states (208). In Brazil, underreporting in the state of São Paulo in 2005 was estimated at 79.5% (209). This situation is related in part to the fact that records do not include self–employed persons or informal–sector workers; moreover, workers are not encouraged to report occupational injuries and diseases and those who do are subjected to intimidation and harassment (210). There are reports indicating that many employers dismiss workers who report cases of occupational injury and illness (211).

RISKS

Tobacco Use

According to the WHO Report on the Global Tobacco Epidemic, 2009 (212), tobacco use causes almost six million deaths each year worldwide, 600,000 of them due to exposure to second–hand smoke-430,000 are deaths of adults and 170,000, of children (213). Tobacco use is a risk factor for six of the eight leading causes of death in the world and is the second preventable cause of death after hypertension. According to the Global status report on noncommunicable diseases 2010 (136), if the current trend continues, by 2020 tobacco use will kill more than 7.5 million people a year throughout the world. Of those deaths, 80% will occur in low– and medium–income countries, where the poorest population groups will be most affected. Evidence presented in Equity, social determinants, and public health programmes, 2010 (214) shows that tobacco use reflects social inequalities, since the prevalence of smoking is greater among lower–income population groups with lower education levels.

According to the WHO Report on the Global Tobacco Epidemic, 2011 (215) and the monograph Gender, women, and the tobacco epidemic (216) there are nearly 1.2 billion smokers in the world and 145 million of them live in the Region of the Americas. The prevalence of smoking among adults in the Region is 22%, very close to the global average (24%) and fourth among WHO's six regions. A country–by–country analysis of the data reveals that tobacco–use rates vary widely, ranging from over 25% in Bolivia, Chile, the United States of America, and Uruguay to below 10% in Barbados, Dominica, and Saint Kitts and Nevis. The principal feature of smoking in the Americas-distinguishing it from the rest of the world's regions-is that among adults it is ceasing to be a problem predominantly of males. The consumption gap between males and females is also narrowing among young people, and in some countries of the Region the male:female ratio has reversed in the youngest age groups (13 to 15 years) (Figures 4.26 and 4.27).

Figure 28

Between 2006 and 2010, significant headway was made with regard to ratification and implementation of the WHO Framework Convention on Tobacco Control (FCTC) (217). Globally, more than 170 countries have ratified the Convention, including 28 of the 35 Member States of PAHO (as of December 2010). Some 20 countries in the Region have enacted national tobacco control legislation in accordance with at least one of the mandates established under the Convention, including the following: (1) 9 countries have passed national laws (or subnational laws encompassing more than 90% of the population) that unconditionally prohibit smoking in all enclosed spaces, in both public buildings and workplaces; (2) 15 countries have adopted regulations on packaging and labeling of tobacco products consistent with the Convention, although two do not include pictorial warnings; (3) 2 countries have totally banned tobacco advertising, promotion, and sponsorship; and (4) several countries have increased tobacco taxes, although only two have achieved the benchmark of taxes equivalent to 75% of the retail price. In the majority of countries, according to the WHO Report on the Global Tobacco Epidemic, 2011 (215), the price of a 20–cigarette pack of the most sold brand remains relatively low, averaging under PPP$ 3.64 (purchasing power parity–adjusted dollars, or international dollars) globally.

Progress in implementing the FCTC mandates is already leading to reductions in tobacco use and improvements in health. In Uruguay, for example, a report on a survey of smoking among adults in the country (218) showed a decline of 24% in the prevalence of tobacco use between 2006 and 2009.

Despite progress in some countries, however, the tobacco epidemic will continue to grow in the Region unless national laws implementing the FCTC mandates are enacted at a faster pace. One of the main obstacles to further progress is interference by the tobacco industry, which in recent years has ramped up its efforts to undermine tobacco control policies. In fact, the industry has instituted legal proceedings in several countries of the Region (Colombia, Guatemala, Peru, and Uruguay, among others) that range from domestic lawsuits challenging the constitutionality of legislation to international actions alleging that tobacco packaging and labeling regulations violate trade agreements.

Alcohol Use

Worldwide, alcohol consumption is the third leading risk factor for disease and disability; in the Americas, it ranks first (Figure 4.28). According to WHO's report, Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks (219), 9.1% of all disability–adjusted life years (DALYs) in the Region in 2004 (14.2% among males and 3.4% among females) were attributable to alcohol consumption; the relative burden is higher in Central American and South American countries. Harmful alcohol use is estimated to have caused at least 347,224 deaths that year in the Region (1.3% of all deaths). Injuries and violence, and neuropsychiatric conditions, account for most early mortality and morbidity due to alcohol (Figure 4.29).

Figure 29

Per capita alcohol consumption and abstinence rates in men and women vary widely from subregion to subregion, but WHO's Global Status Report on Alcohol (220) put the average consumption in the Americas (weighed by the population over 15 years of age) at 8.67 liters of pure alcohol per year-well above the global average of 6.13 liters per year. Beer is the most consumed alcoholic beverage in most countries in the Region (54.7% of total consumption), with spirits ranking second (32.9%), and wine coming in a distant third (12%) (Table 4.13).

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Harmful use of alcohol affects mostly men (85% of alcohol–related deaths are among men) and is the leading risk factor for death in men aged 15–59, mainly due to injuries, violence, and cardiovascular diseases. According to WHO, in 2005, about 17.9% of men and 4.5% of women in the Region drank heavily (defined as consuming five or more standard drinks among men and four or more standard drinks among women in a single occasion) on a weekly basis in the 12 months prior to being surveyed. Men also outnumber women in engaging in weekly episodes of heavy drinking, a practice that is closely linked to premature death and disability. And men have lower rates of abstinence than women. Lower socioeconomic and educational attainment status result in a greater risk of alcohol–related death, disease, and injury-a social determinant (221) that is greater for men than women. On the other hand, women are biologically more vulnerable than men to alcohol's effects at the same level of consumption. Women also suffer more severe violence, abuse, and dependence on intimate partners who drink heavily (222).

Results from the Global School-based Student Health Survey (223) in selected countries in the Region indicate a high prevalence of drinking to intoxication among 13–15–year–olds in the 30 days prior to the survey. This is particularly worrisome, given that research has shown how even low alcohol consumption can harm the developing brain and has linked early initiation of drinking with later alcohol dependence.

Several of the Region's countries are major producers of alcoholic beverages, and taxes on the sale of alcohol represent a significant source of revenue for their national economies. Alcohol consumption generates important profits for producers, distributors, and advertisers, as well as for the hospitality industry. Alcohol is also a global commodity produced within networks of transnational corporations. Marketing plays a critical role in making alcohol an integral part of the lifestyle of the target user and creating an intimate relationship between the consumer and the product. In this regard, alcohol marketing is targeting new markets and consumers as a way to expand profits and influence. In developing countries, where drinking is less frequent, women and adolescents are particularly targeted with new products and marketing strategies, associating drinking with culture, sports, independence, and a "modern" way of life. Studies demonstrate that the marketing of alcohol can influence early initiation of drinking and drinking to excess. Both practices are harmful to young people, particularly to women (224).

There are a number of effective and cost–effective interventions in many different countries around the world, as reviewed in "Alcohol: no ordinary commodity" (225). However, alcohol policies are weak and not enforced in most countries of the Region (226). At the same time, there is hope in reversing the current situation given the approval of the WHO global strategy to reduce the harmful use of alcohol (227), at the World Health Assembly, as well as the Regional Plan of Action to Reduce Harmful Use of Alcohol, adopted at the 51st Directing Council of PAHO in 2011 (228).

Psychoactive Substance Use

Psychoactive substances include both legal and illegal drugs that affect brain function. Alcohol is the legal drug that causes the most harm to individuals and society, more than all other illicit drugs combined (see the alcohol use section in this chapter) and even tobacco. According to the United Nations Office on Drugs and Crime's World Drug Report (229), the most widely used illicit drugs are cannabis, cocaine, and volatile solvents. The non–medical use of psychotropic substances also is on the rise. Survey data compiled by PAHO (230) indicate that lifetime prevalence of drug use in Latin America varies widely from country to country and by level of development. Lifetime prevalence of drug use among adolescents aged 13–15 years ranges from 3% to 22% in the school population. The rates are universally higher among boys than girls (average lifetime prevalence during early adolescence is 13.5% for boys and 8.1% for girls).

The use of drugs for intoxication may increase the risk of accidents, injuries, and interpersonal problems. Frequent and regular use is reported by an estimated 20% of the population across different countries of the world and in the Region, with associated risks with serious consequences for public health. While drug dependence is a chronic, relapsing mental health disorder, various treatment approaches have been shown to be effective, which are recommended by WHO (231).

According to PAHO's Strategy on Substance Use and Public Health (232) and Plan of Action on Psychoactive Substance Use and Public Health (233), drug use, a public health priority in the Region, contributes to disease burden in two ways-it causes premature death and produces significant health consequences, some directly attributable to drug use, and others, to the mode of drug administration (e.g., intravenous injection). Possible health consequences include HIV/AIDS, hepatitis B and C, other infections, drug dependence, lethal and non–lethal overdose, suicide, and injuries (234). Drug use problems among males ranked ninth among the top 10 risk factors that contributed to disability–adjusted life years (DALYs) in the Americas in 2004 (Figure 4.28).

Comprehensive drug control policies involve both controlling drug supply and reducing demand. According to a scholarly review of drug policies, the lack of systematic research on the most common policy options for controlling drug supply (e.g., enforcement, interdiction, incarceration) hinders the effective application of these measures (235). In terms of demand–reduction strategies, evidence suggests that there are various prevention, treatment, screening, and early intervention options that can address harmful substance use and substance dependence. It has been shown that a substantial investment in evidence–based, early intervention efforts within primary health care (236), as well as in other non–specialized settings and treatment services, can reduce drug–related problems, provided that these services are accessible, affordable, and available to all those in need (231, 237). Such services are also effective in reducing drug–related crime and the spread of HIV infection. Needle–exchange programs are effective because they prevent HIV and other blood–borne infections, such as hepatitis B and C (235). Such programs engage injecting drug users in treatment and other health services (238), such as voluntary HIV counseling and testing, and sexual and reproductive health services.

Sexual Behavior

Early sexual–activity initiation, having multiple sexual partners, and sexual violence are factors that contribute to acquiring HIV and other sexually transmitted infections and that erode sexual health. In the Region, in surveys conducted from 2005 to 2008, between 9% and 25% of women and men aged 15–24 years had had sexual intercourse before the age of 15 (239, 240). According to a report from the Population Council, an international non–profit non–governmental organization conducting biomedical, social science, and public health research in more than 50 countries around the world, such early sexual initiation is not always voluntary. In fact, between 15% and 48% of this early sexual initiation occurs in a context of coercion or violence (241). In studies conducted in Barbados, Jamaica, and Trinidad and Tobago, between 52% and 73% of women reported having experienced sexual violence by partners (242). As shown in the publication ¡Ni una más! El derecho a vivir una vida libre de violencia en América Latina y el Caribe (243), school–based sampling surveys in various Latin American and Caribbean countries found that between 5% and 40% of adolescents had been sexually abused at some point in their lives. The proportion of persons aged 15–49 years old who had had sexual intercourse with more than one partner in the last 12 months, according to country reports, varies significantly, ranging from 85% in Trinidad and Tobago, to 23% in Cuba, and 8% in Belize. The figures also differ dramatically between men and women: for example, a study conducted in Jamaica shows that 61.5% of males, but only 16.5% of females, reported multiple partners (244). Dynamics around sexual attraction and sexual orientation also influence sexual health and wellness and access to sexual health services, but persisting stigma and discrimination often keep these issues hidden. In nine studies conducted in Latin America, an average of 19% of young men who have sex with men self–identified as heterosexual. Meta–analyses of studies among men who have sex with men conducted in 2006 and 2008 estimated that in the Caribbean, 1% to 3% of men will have had male–to–male sex in their lifetimes; the figure for Latin America is 10%. The study also estimated that about 1% of men who have sex with men in Latin America and the Caribbean are married (245). The conditions in which sexual behavior occurs also contribute to vulnerability and risk, particularly in the context of transactional and paid–for sex. The estimated percentage of females engaged in sex work in seven countries ranged from 0.2% to 7.4% (246). Existing laws, policies, and practices drive sex work underground, making it difficult to reach sex workers and their clients with HIV services.

OTHER CAUSES OF MORBIDITY

Mental Health

Mental and neurological disorders account for 22% of the total burden of disease in Latin America and the Caribbean, and depression and disorders due to alcohol use are the largest contributors to that burden. Analysis of the prevalence of such disorders and of the treatment gap (proportion of people with mental disorders who do not receive care) by leading diagnostic categories, based on a compilation of 17 epidemiological studies on mental illness in Latin America and the Caribbean, revealed that the treatment gap is very wide. Moreover, the gap may be underestimated because concomitant morbidity is generally not taken into account, nor is the quality and efficacy of treatment (247, 248) (Table 4.14).

1-health conditions and trends-e-t14.jpg

Suicide, which accounts for some 63,000 deaths a year (adjusted mortality of 7.4 per 100,000 population), constitutes a severe public health problem in the Americas. The suicide death rate for Latin America and the Caribbean was 5.8 per 100,000 population (9.4 among males and 2.5 among females). In the Region as a whole, suicide ranks 27th as a cause of death, but it is the third leading cause among the population aged 10 to 24 years. It also makes up 12% of deaths from external causes, according a report on mortality from suicide in the Americas (249).

Epilepsy affects some five million people in the Americas and is one of the most frequent chronic neurological disorders in the Region. However, it is estimated that in Latin America and the Caribbean more than 50% of persons with epilepsy do not receive medical care (250). The disease accounts for 0.7% of the burden of disease in the Region, with no appreciable differences by sex. In Canada and the United States of America, the epilepsy burden is smaller (0.4%) than in the rest of the Region (0.9%). The prevalence of epilepsy and mortality from the disease vary, depending on several factors. According to a compilation of 32 community–based studies, lifetime epilepsy prevalence in Latin America and the Caribbean averages 17.8 per 1,000 population and ranges from a low of 6.0 to a high of 43.2. From 1999 to 2007, there were an average of 7,179 deaths per year from epilepsy (as the primary cause) in the Region, with a mortality rate of 0.8 per 100,000 population. In Latin America and the Caribbean, the epilepsy mortality rate is 1.1 per 100,000 population, higher than it is in Canada and the United States (0.4 per 100,000). A report on epilepsy in Latin America (250) and the Strategy and Plan of Action on Epilepsy, adopted by the Directing Council of PAHO by means of Resolution CD 51.R8 (251), present the available information on the subject.

Program and Service Response

PAHO assessments of mental health systems in Latin American and Caribbean countries reveal that, despite the significant burden that mental disorders represent, the response capacity of health services remains insufficient. On average, the percentage of the health budget allocated to mental health in the countries assessed is lower than 2%, and 67% of that allocation goes to psychiatric hospitals. For example, in six Central American countries and the Dominican Republic it was found that only 1.6% of the health budget was allocated to mental health, and 75% of that amount was allocated to psychiatric hospitals. This illustrates the need not only to increase funding for mental health, but also to find a way to redirect resources towards outpatient and community–based systems. The WHO Assessment Instrument for Mental Health Systems (AIMS) subregional and country reports provide more information on the subject (252).

Of all the countries in the Region, 65.6% have national mental health plans, 71% of which were formulated or updated after 2004. In addition, 56.3% of the countries reported that they had legislation on mental health, although in many cases the laws need to be updated and adapted to new technical and human rights standards. With regard to policies, plans, and laws, the current challenge is to achieve their real, effective application. Information from countries indicates that 38% have mental health training programs for primary care physicians and a similar proportion have guides or protocols for the care of patients with mental disorders at the primary care level. The median number of psychiatric beds per 10,000 population is 2.6. Those beds are distributed among psychiatric hospitals (45%), general hospitals (22%), and residential or other facilities (33%).

At least one association of users of mental health services exists in 52% of the Region's countries and an association of family members of persons with mental disorders exists in 60%. Such associations are an important means of promoting social participation and achieving greater involvement of users and their families in the formulation and implementation of mental health plans. The WHO Mental Health Atlas 2011 contains information on this subject (253).

Mental Health Prospects

If the situation in Latin America and the Caribbean is assessed in the light of the Caracas Declaration (1990) as a historical point of reference, it is evident that despite existing limitations, deficiencies, and challenges, great progress has been achieved in the majority of countries with regard to the reform of services and protection of the human rights of people with mental disorders. Almost all the countries of the Region have better laws, national plans, and a vision of a community–based model of mental health care linked to primary care and integrated into the health services system. Moreover, there is greater awareness on the part of governments and society about the challenges posed by mental disorders, the treatment gap, and the stigma that still surrounds people with such disorders.

In 2009, the 49th Directing Council of PAHO adopted the Strategy and Plan of Action on Mental Health, which sets out a roadmap for the next 10 years (254). Subsequently, the Regional Conference on Mental Health: 20 Years after the Declaration of Caracas, held in Panama in October 2010, issued a final declaration that clearly established the goal of ensuring a transition to community–based care and the elimination of insane asylums by 2020.

Oral Diseases and Conditions

Oral diseases affect a person's overall health and represent a burden to communities and countries. Moreover, some diseases such as HIV and diabetes manifest themselves in the oral cavity, and certain drug or radiation treatments may increase the risk of oral diseases (255).

Dental caries is by far the most prevalent disease in the mouth. In most industrialized countries, 60%–90% of school–aged children have experienced dental caries (256); in fact, dental caries is more common than chronic asthma in children (255). Dental caries is a multicausal disease that has important socioeconomic and cultural factors (257). Early detection of carious lesions and use of fluoride products have been used effectively to prevent disease in children and adults (258, 259). Figure 4.30 shows the mean number of decayed, missing, and filled teeth in children aged 12 years for the Region's countries, based on two or more surveys conducted since 1980. The data show dramatic improvement and an overall decrease in dental caries since the 1980s. In the 2000s, some of the Region's less developed countries reached or surpassed the levels of more developed countries. The main factors that may have contributed to such improvement are the regional efforts for implementation and consolidation of salt and water fluoridation programs during the 1990s and the focus on alternative approaches to increase access to oral health services with cost–effective interventions supported in the late 1990s and 2000s.

Figure 30

Ocular Health

Various studies have shown that blindness and visual impairment remain public health problems related to poverty and marginalization and that up to 88% of blindness cases found in rural areas are curable (260). Measures aimed at reducing the incidence of blindness should be strengthened in order to avoid an increase in its prevalence.

According to data published between 2006 and 2008, the prevalence of low vision (visual acuity of less than 6/18–3/60) among people over 50 years of age ranged from 5.9% in Buenos Aires, Argentina (260, 261), to 12.5% in rural areas of Guatemala (262). Unoperated cataract remains the leading cause of blindness and visual impairment, in part because service coverage is very inadequate in poor areas and the quality of surgery is not optimal (263, 264). Although refractive errors are not a major cause of blindness, they do impair vision.

Considerable progress has been made on the priorities established under the Plan of Action for the Prevention of Avoidable Blindness and Visual Impairment (265), adopted by the 49th Directing Council of PAHO in 2009: the cataract surgery rate per one million population has increased by more than 100% in several countries, including Costa Rica, Nicaragua, and Venezuela, and by more than 80% in others, such as Peru and Uruguay. Between 2005 and 2008, the average rate for the Latin American countries increased 18% (266). The coverage of programs for detection and treatment of retinopathy of prematurity has also expanded in Latin America (267). However, although treatment for diabetic retinopathy has been shown to be effective, greater knowledge of how to increase retinopathy screening rates among the diabetic population is needed, both globally and in the Region (268). Also needed is more evidence to demonstrate the benefits of programs for detection and treatment of visual impairment among schoolchildren (269).

Onchocerciasis, which is on the verge of being eradicated in Latin America (270), and trachoma, on which significant progress has been made (271), are discussed in the section of this chapter on neglected diseases.

In the coming years, it will be necessary to improve access to and the quality of cataract surgery, continue to expand the coverage of retinopathy of prematurity and low vision programs, and standardize programs dealing with refractive error, diabetic retinopathy, and glaucoma.

Reproductive Health

Lack of access to contraceptive methods leads to unwanted pregnancies, and simply reducing the number of such pregnancies could prevent approximately one fourth of maternal deaths.

Although contraceptive use by women of childbearing age (15 to 49 years old) is high on average in most Latin American and Caribbean countries, when the data are analyzed by level of education it becomes apparent that there are significant differences within countries (272) (Table 4.15).

1-health conditions and trends-e-t15.jpg

Unmet need for family planning is an indicator of access to reproductive health services that is most consistent with a human rights approach, since it takes into account women's reproductive preferences and intentions.

Most of the Region's countries have reduced the percentage of unmet family planning needs. However, work remains to be done in order to completely close the gap between demand for and supply of contraceptive methods, particularly modern contraceptives, especially in marginalized and adolescent populations.

Fertility among adolescent women in the Region has decreased, particularly among middle– and high–income groups, but the decline has been slower than among adult women, which means that adolescent women's share of total fertility has increased. According to 2009 data from the United Nations Population Division (273), in half of the Region's countries the specific fertility rate among adolescents is over 71 per 1,000 women 15 to 19 years of age. However, the rate varies among countries, ranging from 12 per 1,000 in Canada to 111 per 1,000 in Nicaragua (Figure 4.31).

Figure 31

An average of 1.2 million unplanned pregnancies occur in the Region each year, with unmarried adolescent women accounting for 49% of them (275).

The dual protection afforded by condom use is key to preventing reproductive health disorders. However, while in Canada 75% of adolescents reported using a condom during their last sexual encounter (276), in Latin America and the Caribbean only 47% to 52% of sexually active young people use contraceptive methods. One in 20 adolescents contracts a sexually–transmitted infection every year, the most frequent being chlamydial infection, gonorrhea, syphilis, and trichomoniasis. It is estimated that some 250,000 young people aged 15 to 24 are living with HIV infection (277).

Maternal mortality can be considered a summary measure of reproductive health and, as such, it reveals the great inequities that exist with regard to health (also see the section on mortality in this chapter). This means that not only should maternal deaths be taken into account, but also the high incidence of maternal morbidity associated with the reproductive process. Indeed, it is estimated that for each maternal death there are 20 cases of extremely severe illness (278).

The number of women receiving four or five prenatal care visits is relatively high in Latin America and the Caribbean. However, the proportion of scheduled visits with standardized, high–quality content is low. In the Dominican Republic, for example, prenatal care coverage is 95%, but the maternal mortality rate remains high (133.5 per 100,000 live births), which points up the need to consider the content of prenatal care in order to assess its quality (279).

Maternal mortality in Latin America and the Caribbean declined between 1990 and 2010 by more than 5,000 deaths-deaths that would have occurred had the conditions prevailing in 1990 remained unchanged (Figure 4.32). However, progress towards Millennium Development Goal 5 cannot be considered satisfactory, since a reduction of only 35% has been achieved at the regional level and a further reduction of 40% in three years' time would be needed in order to reach that goal. Moreover, the maternal mortality ratio varies considerably among countries, ranging from 7.6 per 100,000 live births in Canada in 2006 to 630 per 100,000 live births in Haiti in the same year. If countries are grouped into two categories on the basis of maternal mortality ratio and coverage of contraception, prenatal care, and delivery care services, it is clear that maternal mortality is below 50 per 100,000 live births where service coverage is high (Argentina, Chile, Costa Rica, Cuba, Puerto Rico, and Uruguay), but where coverage is lower, maternal mortality is 60 per 100,000 live births or more (279).

Figure 32

More than half of maternal deaths in Latin America and the Caribbean are due to direct obstetric causes, notably hypertensive disease (26%); hemorrhage of pregnancy, labor, or the puerperium (21%); abortion (13%); sepsis and other puerperal infections (8%); obstructed labor (12%); and other direct causes (15%) (284).

One of the factors most closely and consistently associated with the reduction of maternal morbidity and mortality is skilled attendance at delivery. Analyzing this indicator can identify situations and countries requiring substantial improvement. Of 45 countries, 33 reported having reached the benchmark of skilled attendance at 90% of births (279). However, as occurs with prenatal care, there are countries that report high coverage of skilled attendance, but in practice do not adhere to the international definition of "skilled attendance." Among women who reside in rural areas, the proportion of deliveries attended by skilled personnel is clearly lower. This contrast can be seen in Haiti, where skilled care during delivery is approximately four times more frequent in urban areas than in rural ones. Socioeconomic status is also an important determinant of the type of care received during childbirth (Figure 4.33). Bolivia provides an extreme example: the percentage of women receiving skilled care at delivery in the highest–income quintile is more than double that of the lowest–income quintile (98% and 45%, respectively).

Figure 33

The availability of emergency obstetric services is limited in rural and indigenous populations in the Region. Ten years ago, countries such as El Salvador and Honduras did not have obstetric care centers capable of providing the basic services recommended by the United Nations, and in Bolivia the level of care was only 11% of the recommended level (286). Unfortunately, there are no recent studies showing the evolution of the situation or the current state of affairs.

In order to improve maternal health it is essential to attain educational and socioeconomic levels that will ensure gender equality with the participation of the whole of society. It is also essential to improve the quality of pre–pregnancy, prenatal, delivery, and postpartum care and, especially, emergency obstetric care. Enhancing vital statistics is also important in order to provide data that will enable effective monitoring of the level and trend of maternal mortality.

Aging

In 2006, the population aged 60 or older in Latin America and the Caribbean numbered approximately 56 million, and the figure is expected to rise to 100 million by 2025 and to 200 million by 2050. Life expectancy at 60 years of age is currently 21 years, which means that 81% of today's newborns will live 60 years and 42% will live more than 80 years. Hence, in 2025 there will be 15 million people aged 80 or older (287). Although population aging is occurring everywhere in the Region, in Latin America and the Caribbean it is happening at an unprecedented pace, and many countries lack the economic resources needed to cope with the situation. Population aging generates concrete needs that have to be addressed by both families and by health and social services systems. Nearly half of the older persons interviewed for a PAHO–sponsored study of health, well–being, and aging (known by its Spanish acronym, SABE) said that they did not have sufficient economic means to meet their daily needs, and one third did not have retirement benefits, pension payments, or a paid job (288).

Poor health is not unavoidable in old age. Indeed, in the United States of America 77% of people over the age of 65 years report that they are in good health (289), but in Latin America and the Caribbean the proportion is under 50% (290). Various studies in Canada and the United States have shown a reduction in the prevalence of disability in this age group; however, in Latin America and the Caribbean, 20% of people over the age of 65 have limited basic functional capacity and require long–term care at home or in institutions (291).

Although population aging has clear consequences for social security and public health systems, a holistic view of the health of older persons is still lacking in the Region. Knowledge of the specific health and health care needs of people in this age group is not even from country to country, and the majority of health systems do not have indicators for monitoring and assessing the impact of health measures on older persons. Care coverage and continuity are inadequate, as are geographic, physical, economic, and cultural access to health services without discrimination. Moreover, even persons who do have access do not always receive services that meet their needs. Only partial information is available about the situation in cities, as is shown by some of the data obtained through the SABE study: 40% of people with hypertension had not seen a primary care provider in the 12 months preceding the survey, only 27% of the women interviewed had undergone mammography in the two preceding years, and 80% of respondents indicated that they had unmet dental care needs (289, 290).

In Latin America and the Caribbean, family members provide most of the care for older persons, with women providing the vast majority (90%), although their capacity to continue doing so is changing. Some 60% of family caregivers report that providing such care is "too much" for them, and more than 80% say they are having trouble covering the cost of caring for an older adult. The rapid demographic transition has affected the availability of family resources to support the elderly, as declining birth and fertility rates have reduced the potential availability of adult children who can care for older adults. These factors, coupled with other social phenomena-such as changing family structure, women's entry into the labor market, migration, and urbanization-make it reasonable to assume that more and more older adults will fail to receive the care they need.

Unless the prevalence of disability decreases and the living conditions of older adults improve, demand for various types of home or institutional care, especially long–term care, will continue to grow as life expectancy continues to rise. At the same time, the availability and the allocation of human resources equipped to deal with the problem are unequal. Even in countries with high percentages of older adults, the curricula of health sciences training programs rarely include a holistic approach to health care for this age group.

In 2009, the 49th Directing Council of PAHO approved the Plan of Action on the Health of Older Persons, Including Active and Healthy Aging (290), which identifies four interdependent strategic areas that link together commitments, values, resources, capacities, and opportunities having to do with older adults:

  • Health of older persons in public policy
  • Suitability of health systems to meet the challenges of an aging population
  • Training of human resources necessary to meet this challenge
  • Development of the capacity to generate the information needed to undertake and evaluate action to improve the health of the older population

Disability

Everyone is susceptible to disability at some point in life; in fact, the number of persons with disabilities is growing. That growth has been influenced by multiple factors, including population growth, population aging, and the global increase in chronic health conditions associated with disability. Environmental and other factors-such as accidents of all types, disasters, armed conflicts and other violent acts, eating habits, and psychoactive substance abuse-have also contributed to the rise in disability.

The global prevalence of disability in the general population (persons aged 15 years and older), estimated on the basis of the global population, is 15%. Of that percentage, approximately 2.2% are people with severe functional difficulties (291). The WHO global burden of disease report (292) estimated that 19.4% of the general population lives with some degree of disability, and of that group, 3.8% have a severe disability. It is estimated that children (boys and girls) make up 5.1% of all persons with disabilities and that 0.7% have serious disabilities. Based on those figures, it is estimated that some 140 to 180 million people in the Americas live with a disability (279, 292).

Between 2006 and 2011, the Region's countries worked to align their policies, plans, and programs on disability and rehabilitation with the recommendations contained in resolutions WHA58.23 of the World Health Assembly (293) and CD47.R1 of the Directing Council of PAHO (294), and also with the Convention on the Rights of Persons with Disabilities (295), the Program of Action for the Decade of the Americas for the Rights and Dignity of Persons With Disabilities (296), and the World report on disability (291). Considerable progress has been made in revising national laws and national development plans on disability in order to establish standards for the delivery of rehabilitation services, the prevention of disability, and the provision of assistive devices to persons with disabilities (Table 4.16).

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At the subregional level, the countries that are part of the Hipólito Unanue Agreement have identified strategic directions for an Andean health policy on disability. Its objective is to generate synergies through joint effort in order to meet the demand for care of persons with disabilities and improve their quality of life (297, 298, 299, 300, 301).

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