Revista Panamericana De Salud Publica-pan American Journal of Public Health最新文献

Objective: To analyze the risk of Trypanosma cruzi transfusion and transplantation transmission in endemic countries in the Region of the Americas.

Methods: A descriptive and comparative study on the prevention of iatrogenic transmission of T. cruzi was conducted in 21 endemic countries in the Americas (2012-2023) using sources from the Pan American Health Organization, national reports, and scientific databases. The prevalence of antibodies in donors, the proportion of voluntary donors, screening coverage, and transmission events were analyzed. Trends were evaluated with the Mann-Kendall test, and differences between groups by voluntary donors with the Wilcoxon test, using Stata 14.0 and p<0.05.

Results: The median overall prevalence of T. cruzi in blood donors steadily declined between 2012 (0.45%) and 2023 (0.16%). There is an association between a higher percentage of voluntary donation and a lower prevalence of infection. Screening coverage between 2021 and 2023 is complete. Seventy-seven percent of countries that screen for T. cruzi have programs for external evaluation of local performance. The risk of infection in polytransfused patients ranged from 1.8% to 1.3% when screening was incomplete. In relation to transplantation, the prevalence of T. cruzi infection in organ and tissue donors was 0.9% in Argentina and 0.54% in organ donors in Colombia. Although the frequency of infected donors is low, the risk of parasite transmission through organ transplantation (with the exception of the heart) ranges from 18% to 23%. Early detection in recipients through PCR is essential for beginning treatment in a timely manner and preventing complications.

Conclusions: Increasing voluntary blood donations and implementing surveillance systems are the greatest challenges to eliminating Chagas disease in the Region by 2030.

Objective: To assess compliance with smokefree regulations at hospitality venues in two cities 8 months after implementation of national regulations establishing 100% smokefree areas in all indoor workplaces, public places, and public transportation.

Methods: A cross-sectional observational field study was conducted in the capital cities of the states of Puebla and Aguascalientes from October 6 to 21, 2023. Data was collected from a convenience sample of hospitality venues across six areas defined by income. A survey was conducted by trained data collectors to document compliance with smokefree indicators in all public areas of each venue 8 months after the national policy went into effect on January 14, 2023.

Results: The analysis included 410 venues (199 restaurants, 141 cafés, and 70 bars), among which nearly 80% were completely free of smoking and/or electronic device use; however, bars showed significantly lower levels of compliance. Cigarette butts and/or ashtrays were observed in fewer than 10% of venues, and "designated smoking area" signage was present in only 1.2%. No venues fully complied with the no smoking signage. Restaurants had the highest compliance for no smoking/e-cigarette use (87.9%), while bars had the lowest (47.1%). Puebla showed a higher level of compliance for all indicators compared with Aguascalientes. Middle-income areas had the highest level of compliance, while high-income areas had the lowest. The proportion of people who were observed smoking or using electronic devices differed significantly by venue area (indoor versus semi-outdoor).

Conclusions: The findings of this cross-sectional study suggest that hospitality venues, except for bars, are largely in compliance with national smokefree regulations, despite confusion caused by litigation and misinformation from the tobacco companies and their allies. Given this, efforts to assess compliance with the smokefree regulations should be repeated once the litigation is resolved.

Objective: Tobacco use is a major modifiable risk factor for the four main noncommunicable diseases (NCDs) globally-cardiovascular diseases, chronic respiratory conditions, cancer, and diabetes. Addressing tobacco use through cessation interventions is therefore a cornerstone of comprehensive NCD prevention and control efforts. In this context, strengthening cessation support within primary health care has emerged as a high-impact and cost-effective strategy to accelerate progress toward NCD targets.

Methods: Despite advances in tobacco control, cessation support remains insufficiently implemented across much of the Region of the Americas. This article examines progress made between 2007 and 2024 in implementing the World Health Organization (WHO)-recommended tobacco cessation measures, with a focus on the availability, cost coverage, and integration of services within health systems.

Results: Only 7 of the 35 countries in the Americas achieved the highest level of cessation support, which combines national free quit lines, the availability of nicotine replacement therapy (NRT), and the provision of cessation services with partial or full cost coverage. Although these countries represent over 70% of the population, disparities persist-particularly in the Caribbean and in lower-middle-income countries. Findings show that NRT and other pharmacological treatments are inconsistently available, treatment costs are often not covered, and quit lines operate in only 40% of countries. These gaps underscore the urgent need for stronger policies, sustainable financing, and improved health system coordination.

Conclusion: Tobacco cessation must be prioritized as an essential health service, integrated into national NCD strategies, and supported by legal and institutional frameworks guaranteeing equitable access. Strengthening cessation is essential to reducing tobacco use and its health and economic burden across the Americas.

Objective: To assess patient-reported experiences of access to services along the Cardio-Cerebrovascular and Metabolic Comprehensive Healthcare Pathways (CVD-RIAS) among patients with hypertension and/or diabetes in two primary health care networks in Bogotá, highlighting achievements and identifying remaining challenges to integrated care.

Methods: Cross-sectional descriptive analysis using baseline data from patients with confirmed hypertension and/or type 2 diabetes enrolled in CVD-RIAS. In-person surveys and linked clinical records were used to examine access experiences across consultations, tests, prescriptions, and medication delivery. Results were stratified by age, education, income, and Charlson Comorbidity Index.

Results: Of 1 258 patients, 85.5% reported no access issues for hypertension or diabetes care. Most (80%) rated contact frequency positively; most contacted were general physicians and pharmacies. Most patients contacted at least one professional (99.6%), received diagnostic tests (88%,) and obtained some or all prescribed medications (97.3%). Sixty percent accessed specialists, mostly through the assigned network. Median specialist wait was two months, longer for high-risk and higher-income patients. Perceptions were split: 45% found wait times reasonable, 45% did not. Ratings of contact frequency, wait times, and access to referred services varied by sociodemographic characteristics. Overall, patient care pathways were aligned with milestones defined in CVD-RIAS.

Conclusions: The CVD-RIAS model is achieving goals of expanding access to services, aligning care delivery with clinical risk, and fostering positive patient experiences. These findings reflect progress toward risk-based, integrated service delivery. Remaining gaps - incomplete medication supply and difficulties accessing referred services - underscore the need for efforts to enhance coordination and equity.

Objective: Maternity waiting homes (MWHs) are residential facilities where pregnant women live during the last few weeks of their gestation and can easily be transported to a hospital equipped to provide obstetric emergency care or skilled birth attendance. The expansion of MWHs has been associated with the prevention of obstetric complications. This paper examines how MWHs have been implemented across Latin America, analyzing their evolution, the specific needs they address in different countries, and their impact on maternal and neonatal health outcomes throughout the region.

Methods: The methodology of this study was based on a comprehensive narrative review of the literature available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Latin American region and country names, and on discussions with key informants in Cuba.

Results: The findings show that, in Latin America, MWHs were first implemented in Cuba in 1962, followed years later by Chile, Nicaragua, Guatemala, Honduras, Peru, Brazil, Panama, Paraguay, Mexico, and Colombia. In all these countries, MWHs were established as a strategy to reduce maternal mortality, albeit through various funding models and with varying levels of quality and consistency of services. Community engagement, cultural responsiveness, funding sustainability, women's autonomy, breadth and quality of services, and the evolution of MWHs beyond their original purpose are among the emergent themes in our findings. While countries such as Chile, Panama, and Peru have modified MWH designs and operations to incorporate indigenous traditional birthing practices and cultural preferences, countries such as Brazil, Cuba, and Paraguay have focused on practices that prioritize numerical outcomes over women's experiences and autonomy.

Conclusions: The findings suggest a critical gap between the theoretical design of MWH programs and their practical implementation. The evolution of MWHs suggests that they address a spectrum of needs beyond their original purposes, such as providing culturally responsive maternal support and psychosocial and early childhood support. MWHs may be effective in reducing maternal and neonatal mortality when incorporated as part of wider maternal health strategies. Countries with persistently high maternal mortality, especially those with significant geographical barriers to care, could benefit from incorporating MWHs. Remarkably, we did not find MWHs in any of the countries with the highest maternal mortality ratios in the region: Haiti, Venezuela, Bolivia, Jamaica, and the Dominican Republic.

Objective: To explore healthcare stakeholders' experiences of care coordination during cancer diagnosis in Chile, Colombia, and Ecuador, including how these experiences are influenced by factors related to the countries' public subsystems.

Methods: A qualitative study was conducted based on 115 semi-structured interviews with healthcare professionals and administrative personnel in both primary care (n = 40) and secondary/tertiary care (n = 46) as well as managers and policymakers (n = 29). Thematic analysis, guided by a care coordination framework, was performed first per country and then across countries.

Results: The analysis points to limited transfer of clinical information causing repeated tests as well as poor clinical management coordination in terms of delayed referrals from primary care and restricted access to specialized care, altogether contributing to diagnostic delays. Self-reinforcing loops of barriers for care coordination included fragmented clinical information systems, poor skills and training among healthcare professionals, as well as insufficient diagnostic equipment in all three study countries, scarcity of specialized healthcare professionals and functioning of the prioritization system for certain cancers in Chile, and working conditions and insurance companies' management of care in Colombia. Informal communication strategies and personal networks emerged as adaptive responses to these challenges, facilitating coordination in some cases but also risking data security and consistency in care.

Conclusions: The study highlights the urgent need for political prioritization of cancer care coordination, including investments in unified clinical record systems, training of healthcare professionals, and diagnostic infrastructure. It also emphasizes the importance of recognizing healthcare stakeholders' responses to barriers.

Objective: Using real-world parameters, to estimate the number of procedures associated with cervical cancer to be incorporated with the implementation of organized screening with HPV-DNA testing, and to project these estimates within Brazil's Unified Health System (SUS).

Methods: This is a descriptive study using data from the PREVENTIVO program in Indaiatuba, a municipality in the state of São Paulo (2017-2023), which used HPV-DNA testing to screen women aged 25 to 64 years. Based on data regarding test performance, reflex cytology, colposcopy, biopsy, cervical excisions, and referral to high-complexity care, the annual need for these procedures was estimated considering national guidelines and coverage by the supplementary private health system. These estimates were compared with the number of procedures performed nationwide in 2024 in the context of opportunistic screening with cytology (Pap smear).

Results: HPV-DNA test positivity was 12.7% (3.4% for HPV16/18 and 9.3% for other high-risk HPV types). The estimated number of annual procedures to implement the program in Brazil in 2025 included: 8.2 million HPV DNA tests, 759,000 reflex cytology tests, 506,000 colposcopies, 355,000 biopsies, and 127,000 excisional procedures. Considering the current supply, there were shortfalls in all states and regions, especially for colposcopy, biopsy, and excision, with differences of up to -96.5% relative to estimated demand.

Conclusion: The transition to screening with HPV DNA testing requires restructuring the supply of procedures in the SUS. The parameters presented here support regionalized planning, promoting efficient resource allocation and reducing inequities in access.

Objectives: This study sought to analyze the current state of the training for and practice of family medicine and family and community medicine to identify gaps and opportunities to implement strategic actions to strengthen the health workforce.

Methods: This paper reports the results of an observational, analytical, cross-sectional study carried out in countries in the World Health Organization's Region of the Americas in 2024. A 22-item survey was administered to members of professional associations of family medicine and family and community medicine practitioners, and a 12-item survey was administered to specialists in this field. Nineteen professional associations and 291 specialists took part in the study. The data were analyzed using descriptive statistics and content analysis.

Results: Training in family medicine and family and community medicine is primarily conducted through specialization (68.4%, 13/19) and residency programs (63.2%, 12/19), and a competency exam is required in 63.2% (12/19) of the 23 countries included in the study, represented by 19 professional associations. Training programs cover topics relevant to professional practice, but progress needs to be made, especially in addressing emerging topics. There are few opportunities for continuing education, as reported by 53.7% (29/54) of specialists in Central America, the Latin Caribbean and Mexico, and 35.0% (79/226) in South America. There is a gap in actions aimed at improving working conditions, with policies for well-being and retention implemented in only 36.8% (7/19) of the countries. In addition, responses to open-ended questions indicated that many professionals had a heavy workload, and that their jobs were insecure and precarious, as well as that remuneration was incompatible with their functions, that infrastructure was inadequate, and there was a lack of resources for practice. Despite sampling limitations related to the non-probabilistic design of the study and the unequal participation among countries, it nonetheless provides valuable evidence about training and practice in family and community medicine in the Region of the Americas.

Conclusions: Although the practice of family medicine and family and community medicine has been established for more than three decades in the Region, the field faces significant implementation challenges. Strategic investments are needed to strengthen the recognition and perceived value of family and community medicine as a specialty, ensure adequate working conditions and improve the quality of education. Strengthening family and community medicine by undertaking coordinated actions across multiple stakeholders is crucial for building resilient health systems grounded in primary health care.

Objective: To evaluate the post-pandemic regulatory preparedness of countries of the Region of the Americas for emergency authorization of vaccines as of August 2024 and propose recommendations for future public health emergencies.

Methods: Special report describing the mechanisms for emergency use authorization of vaccines established in the regulatory frameworks of Latin American and English-speaking Caribbean countries.

Results: Most of the countries (64%) included in this analysis did not make any changes in their regulations for emergency situations following the COVID-19 pandemic. Special import permits constitute the most common established mechanism for emergency authorization (82%). Regulatory reliance-based mechanisms were found in a minority of countries (32%), as were emergency use authorization, provisional marketing authorization, or fast-track registration mechanisms (23%). Only reliance-based mechanisms were found to use risk criteria based on the source from which vaccines were obtained.

Conclusions: This analysis reflects the need to strengthen the Region's regulatory systems to address future public health emergencies and facilitate access to necessary vaccines. Furthermore, regulatory systems should adopt a regulatory approach based on risk criteria, with distinct procedures and requirements, as well as strengthen cooperation with other National Regulatory Authorities (NRAs) at the regional and global levels, to achieve greater regulatory efficiency.

As part of a regional initiative to improve care for noncommunicable diseases (NCD) in vulnerable territories, a specific module of the Essential Conditions Evaluation (ECE) tool of the Pan American Health Organization (PAHO) was developed and implemented in 15 health facilities in Camiri and the Guaraní Kereimba Iyaambae Indigenous Autonomous Government (GAIGKI) in the Bolivian Chaco region between February and May 2024. The objective was to detect gaps, document strengths, and generate useful evidence for territorial planning.The instrument included 50 variables grouped into 10 key dimensions, in line with the technical frameworks of the World Health Organization (WHO) and PAHO. It was implemented through a participatory methodology, led by PAHO and previously trained local teams. The analysis made it possible to tailor the assessment to the priorities of the territory, focusing on hypertension, diabetes, cancer, and mental disorders.The results revealed gaps in governance, financing, human resources, and information systems in both municipalities. Camiri stood out for its basic equipment and clinical follow-up; GAIGKI, for local planning and the availability of specialized personnel. Both municipalities showed progress in basic tests, essential medicines, and the continuity of care.The experience demonstrated the technical feasibility of the module, its cultural relevance, and its potential for integration into national surveillance systems. With technical and financial support from PAHO, intersectoral coordination and community participation were promoted, generating key input to improve the integrated management of NCDs in primary health care in rural and Indigenous contexts.