Mirta Roses Periago

The Neglected Tropical Diseases of Latin America and the Caribbean: A Review of Disease Burden and Distribution and a Roadmap for Control and Elimination

The neglected tropical diseases (NTDs) represent some of the most common infections of the poorest people living in the Latin American and Caribbean region (LAC). Because they primarily afflict the disenfranchised poor as well as selected indigenous populations and people of African descent, the NTDs in LAC are largely forgotten diseases even though their collective disease burden may exceed better known conditions such as of HIV/AIDS, tuberculosis, or malaria. Based on their prevalence and healthy life years lost from disability, hookworm infection, other soil-transmitted helminth infections, and Chagas disease are the most important NTDs in LAC, followed by dengue, schistosomiasis, leishmaniasis, trachoma, leprosy, and lymphatic filariasis. On the other hand, for some important NTDs, such as leptospirosis and cysticercosis, complete disease burden estimates are not available. The NTDs in LAC geographically concentrate in 11 different sub-regions, each with a distinctive human and environmental ecology. In the coming years, schistosomiasis could be eliminated in the Caribbean and transmission of lymphatic filariasis and onchocerciasis could be eliminated in Latin America. However, the highest disease burden NTDs, such as Chagas disease, soil-transmitted helminth infections, and hookworm and schistosomiasis co-infections, may first require scale-up of existing resources or the development of new control tools in order to achieve control or elimination. Ultimately, the roadmap for the control and elimination of the more widespread NTDs will require an inter-sectoral approach that bridges public health, social services, and environmental interventions.

Elimination of rubella and congenital rubella syndrome in the Americas: another opportunity to address inequities in health

in the Revista Panamericana de Salud Pública/Pan American Journal of Public Health—on the global situation, in the November 2003 issue (1), and on Haiti, in this months issue (2)— are extremely timely in terms of rubella control efforts now under way in the Region of the Americas. These two articles come on the heels of a resolution that the Directing Council of the Pan American Health Organization (PAHO) passed in September of 2003, calling for the elimination of rubella and CRS from the Americas by the year 2010 (3). Adopted by the ministers of health of all the PAHO Member States, the Directing Council resolution was ultimately based on those countries’ own experiences in controlling rubella and CRS. Therefore, the initiative to eliminate rubella and CRS from the Western Hemisphere is clearly a by-product of field-based experience and the extraordinary groundswell of country-based political commitment. In their Revista/Journal article on the global situation, Robertson et al. (1) indicate that the disease burden in many developing countries remains significant and that the introduction of rubella vaccine is clearly cost-effective and cost-beneficial in reducing the incidence of rubella and CRS. However, 42% of the countries around the world that report to the World Health Organization (WHO) still have not introduced rubella vaccine into their national immunization programs (1). Of the PAHO Member States, to date only Haiti and the Dominican Republic have not officially introduced rubella vaccine into their national immunization programs. The Dominican Republic will launch its rubella vaccine program efforts in April 2004, the same month in which all the countries in the Western Hemisphere will be participating in the Vaccination Week in the Americas. Haiti will not be able to introduce the vaccine in 2004 because of its recent civil strife, but hopefully the vaccine will be introduced there in 2005, particularly if routine immunization coverage levels have improved. Reducing inequities in health services has long been a driving force in PAHO’s approach to providing immunization technical cooperation to the PAHO Member States. The PAHO Revolving Fund for Vaccine Procurement strives to do exactly that on behalf of all the countries of the Americas. The Fund provides countries with a reimbursement mechanism for the purchase of vaccines, syringes, needles, and cold chain equipment at affordable prices. Since the Fund was established in 1979, PAHO has allowed countries to participate in the benefits of the Revolving Fund only if they meet several requirements: (1) allocating a national budget line item for the cost of vaccines and syringes; (2) formulating a comprehensive and realistic national plan of action that covers multiple years of operations and that is consistent with PAHO policy; and (3) appointing a national program manager who has the authority to develop and implement the national plan of action (4). So, in addition to facilitating equitable prices through bulk purchases, the Fund helps to ensure that countries develop sustainable programs, ultimately benefiting underserved populations that most need immunization services. PAHO assists countries in reducing inequities by supporting efforts to target underserved communities with low immunization coverage. Improving coverage in all municipalities will protect the progress made in eliminating measles in the Americas, facilitate the acceleration of rubella elimination, and strengthen health system capacity to improve routine services and to introduce vaccines currently available for children in economically developed countries but not in less-developed ones. Reducing inequities in health will continue to be a top priority in PAHO’s future technical cooperation with its Member States, faithful to the commitments taken on to support those countries in achieving Health for All and the Millennium Development Goals, particularly those concerning improving maternal health and reducing child mortality. The tools to eliminate the devastating consequences of CRS exist and are readily available (5). The vaccine is safe, effective, and relatively inexpensive. The strategies for controlling and ultimately eliminating rubella and CRS include: (1) achieving high coverEditorial

Elimination of Neglected Diseases in Latin America and the Caribbean: A Mapping of Selected Diseases

In Latin America and the Caribbean, around 195 million people live in poverty, a situation that increases the burden of some infectious diseases. Neglected diseases, in particular, are often restricted to poor, marginalized sections of the population. Tools exist to combat these diseases, making it imperative to work towards their elimination. In 2009, the Pan American Health Organization (PAHO) received a mandate to support the countries in the Region in eliminating neglected diseases and other poverty-related infections. The objective of this study is to analyze the presence of selected diseases using geo-processing techniques. Five diseases with information available at the first sub-national level (states) were mapped, showing the presence of the disease (“hotspots”) and overlap of diseases (“major hotspots”). In the 45 countries/territories (approximately 570 states) of the Region, there is: lymphatic filariasis in four countries (29 states), onchocerciasis in six countries (25 states), schistosomiasis in four countries (39 states), trachoma in three countries (29 states), and human rabies transmitted by dogs in ten countries (20 states). Of the 108 states with one or more of the selected diseases, 36 states present the diseases in overlapping areas (“major hotspots”). Additional information about soil-transmitted helminths was included. The analysis suggests a majority of the selected diseases are not widespread and can be considered part of an unfinished agenda with elimination as a goal. Integrated plans and a comprehensive approach, ensuring access to existing diagnostic and treatment methods, and establishing a multi-sectoral agenda that addresses social determinants, including access to adequate water and sanitation, are required. Future studies can include additional diseases, socio-economic and environmental variables.

Dengue y dengue hemorrágico en las Américas

A pesar de que el dengue se conoce como entidad clinica desde hace mas de dossiglos y del conocimiento acumulado en el transcurso de los ultimos anos, estaarbovirosis continua siendo hoy uno de los principales problemas de salud mun-dial y constituye uno de los mayores retos de salud publica en el milenio actual.La infeccion, causada por cualquiera de los cuatro serotipos del virusdel dengue y transmitida al hombre por la picada del mosquito

Regional immunization programs as a model for strengthening cooperation among nations

Dos funciones esenciales de los programas de vacunacion regionales aplicados en varios paises simultaneamente consisten en controlar en todo un territorio, franqueando fronteras, las enfermedades que se pueden prevenir mediante la vacunacion y en reducir las faltas de equidad en materia de salud. Los buenos resultados de los programas de vacunacion regionales dependen del esfuerzo coordinado que hagan los paises y sus socios por alcanzar una meta regional en comun. Con el fin de explorar las lecciones derivadas de la experiencia, en este articulo se echa un vistazo al Programa Ampliado de Inmunizacion original de la Organizacion Panamericana de la Salud (OPS), al Fondo Rotatorio de la OPS para la adquisicion de vacunas y jeringas para los programas nacionales de vacunacion, y a la erradicacion de la poliomielitis del territorio americano. Se resaltan estas lecciones para ayudar a los formuladores de politicas en los niveles mundial, regional y subregional a coordinar eficazmente las intervenciones de salud realizadas por varios paises en conjunto. Para ser provechosos, los programas de salud regionales tienen que verse respaldados por un genuino compromiso con la cooperacion entre paises como valor fundamental; la capacidad para averiguar que problemas existen e idear buenas soluciones; la capacidad para llevar a cabo intervenciones de manera sustentable; el firme compromiso de los ministros de salud y otros jefes de gobierno; la gestion eficaz de los programas; los planes de salud nacionales; la buena supervision tecnica y la coordinacion de alianzas; una cooperacion tecnica mas intensa con los paises mas pobres, donde hay que redoblar los esfuerzos por conseguir mas recursos y apoyo; la cooperacion entre paises; y la capacidad para responder a circunstancias insolitas.

Elimination of cholera transmission in Haiti and the Dominican Republic.

One of the largest recent cholera epidemics to aff ect a single country began in Haiti in October, 2010, just 10 months after a devastating earthquake had struck the nation’s capital. Within a month, cholera had spread throughout Haiti and cases were being reported by its shared island neighbour, the Dominican Republic. In Dec, 2011, 522 335 cholera cases and 7001 deaths had been reported in Haiti, with an additional 21 432 cases and 363 deaths reported in the Dominican Republic. The 2-year anniversary of the earthquake is an opportune time to refocus national and international eff orts on the elimination of cholera transmission in Hispaniola. In the past year, the international community has supported cholera prevention and control strategies for Haiti and the Dominican Republic. These strategies include: improving access to safe drinking water by increasing chlorination of public and household water supplies, increasing water quality monitoring, tracking disease spread and response through surveillance, promoting safe hygiene, encouraging safe food handling practices and policies, and ensuring quality clinical care and treatment at health facility and community levels. If the evidence supports the introduction of oral cholera vaccine in this setting, another tool may be available in the fi ght against this disease. These life-saving interventions must be strengthened and sustained. Despite these eff orts, however, there are more than 200 new cholera cases daily in Haiti during the dry season, with more than 1000 cases arising each day in the rainy season. Cholera elimination will require renewed eff orts to ensure that safe water and sanitation are provided to every resident. Haiti is the most underserved country in the western hemisphere in terms of water and sanitation infrastructure. In 2008, 63% of Haitians had access to improved drinking water and 17% had access to improved sanitation, such as fl ush toilets, septic tanks, ventilated improved pit latrines, and composting toilets. This low fi gure for access to sanitation had decreased from 26% in 1990, making Haiti one of the few countries where overall sanitation coverage has declined for reasons other than population growth. By contrast, in 2008, 86% of Dominicans and 93% of people living in the Latin American and Caribbean region had access to improved drinking water, and 83% and 80% had access to improved sanitation, respectively. Millennium Development Goal (MDG) 7 encompasses a commitment to halving the proportion of the world’s population without access to improved water and sanitation by 2015. Failure to attain MDG targets in Haiti for access to improved water (74%) and sanitation (63%) will facilitate continued cholera transmission on the island, placing the entire region at risk. During the Latin America epidemic of the 1990s, cholera spread to more than 20 countries in 2 years. With support from the international community, investments in water and sanitation infrastructure contributed to the virtual elimination of epidemic cholera from Central and South America within 8 years. These interventions also led to well documented decreases in other waterborne diseases, such as typhoid fever and hepatitis A, and to reductions in infant and child mortality. The control of epidemic cholera in Latin America in the 1990s underlines the current need for investment in safe water and sanitation infrastructure in Haiti. In March, 2010, the international community pledged billions to assist Haiti. There has already been major investment by some partners. The USA has committed more than

The global inter-relatedness of disease control

3 billion in humanitarian relief, recovery, Published Online January 11, 2012 DOI:10.1016/S01406736(12)60031-2

Anticipating new vaccines in the Americas

The Lancet Infectious Diseases has highlighted the crucial need to stress the global inter-relatedness of control of infectious diseases. Control of vaccine-preventable diseases across borders is a key function of the regional immunisation programme of the Pan American Health Organization (PAHO). PAHO’s regional programme is grounded in the following core values: inter-country co operation; capacity to identify problems and design appropriate solutions; capacity to sustain interventions; strong political commitment; sound programme management; national plans of action; well-functioning technical oversight and partner coordination; enhanced tech nical cooperation in high priority countries; cross-border cooperation; and the ability to respond to exceptional circumstances. The outbreak that occurred in Venezuela between September, 2001, and November, 2002, was the last instance of widespread measles virus circulation in the western hemisphere. However, sporadic cases and outbreaks associated with importations continue to occur after the disease has been eliminated (panel). These measles outbreaks associated with import ations draw attention to the tremendous challenge that PAHO and member countries have to protect and sustain the progress achieved in measles elimination in the Americas. In the post-elimination phase of measles control in the Americas, all these import-related outbreaks require an extraordinary amount of time and resources (both human and fi nancial). Re-establishment of endemic measles virus circulation in the Americas upon importation remains a distinct possibility and would undo substantial progress in reducing child mortality, one of the eight UN Millennium Development Goals. In September, 2003, the Directing Council of the PAHO adopted the resolution to eliminate rubella and congenital rubella syndrome in the Americas by the year 2010. This initiative was largely launched on the heels of the success of measles elimination. Keeping the region free of both measles and rubella will require continued actions to strengthen global cooperation of measles and rubella control, and will hopefully provide more lessons learned for an eff ective response to any pending global pandemic of infl uenza.

Calidad de vida y longevidad: un nuevo reto para la salud pública en las Américas: editorial

is extremely timelyin terms of vaccine development. The authors correctly conclude that the heavy bur-den of disease attributable to rotavirus in Latin America suggests that vaccines cur-rently being developed could have considerable impact in preventing hospitalizations,clinic visits, and deaths.The Pan American Health Organization (PAHO) is strongly committed toaddressing what the authors conclude to be the important public health priority ofreducing the deaths and hospitalizations attributable to rotavirus diarrhea (2). One of theguiding principles for immunization programs in the Americas is reducing the inequitiesin health that exist between resource-wealthy countries and resource-poor ones.Providing new and underutilized vaccines to the children and families who need themmost best exemplifies this guiding principle (3). The gap between vaccines available inresource-wealthy countries and resource-poor ones continues to expand each year. Asstated in the World Banks

Renewing primary health care in the Americas: the Pan American Health Organization proposal for the twenty-first century

More people in the Americas now live longer thanwas true at any other time in our history. Never-theless, further reducing premature deaths amongadults and older adults will require major efforts,parallel to global efforts to meet the MillenniumDevelopment Goals and to together plan a future in which everyone can enjoy good health and qual-ity of life. At the beginning of the 21st century the Re-gion of the Americas had some 2 228 900 peoplewho were 90 years of age or older, and 90 400 ofthem were centenarians. By the middle of the cen-tury, these figures will have climbed to nearly 13 903 000 and 689 000, respectively. At the begin-ning of this century nonagenarians represented apopulation group who managed to survive in spiteof high infant mortality and major epidemics of in-fectious diseases. These survivors—selected by theirgenetic characteristics and their living conditions—represent extraordinary cases of active aging to avery advanced age. One example is Elizabeth “MaPampo” Israel of Dominica, who died in 2003 at theage of 127. However, the people who will be non-agenarians between 2025 and 2050 will not havebeen