Los grandes retos del desarrollo a la Salud Publica

en el Siglo XXI y las oportunidades con la Vacunación

Julio 26, 2018

Carlos Espinal Tejada, M.D. Director, Global Health Consortium

Robert Stempel College of Public Health and Social Work Florida International University

Miami, Florida

AGENDA La salud y los paradigmas del progreso, el cambio demográfico y

el perfil de la enfermedad

Los retos de la vacunación

Visión global de las amenazas. Las epidemias del Siglo 21

Las inequidades y desigualdades

Conclusiones

AGENDA

3 http://www.worldometers.info/world-population/latin-america-and-the-caribbean-population/

Distribución de la población por sexo y grupo de edad en América Latina

De una población piramidal a una rectangular

1950 1980 2010 2040

Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 Revision. (Medium variant)

https://populationpyramid.net/latin-america-and-the-caribbean/2050/

El Cambio demográfico

y la llegada del tsunami de plata

United Nations DESA / Population Division

4 http://www.worldometers.info/world-population/latin-america-and-the-caribbean-population/

LOS CAMBIOS DEMOGRAFICOS

5

CARGA DE ENFERMEDAD AMERICA LATINA Y EL CARIBE

• CARGA DE Mortality by Leading Causes of Death

Results for the Region overall for 2010–2013 indicated among the 10–24 year age group 1. Homicide, rate of 20.4 per 100,000 2. Land transport accidents, rate 13.4 per 100,000 3. Suicide, rate of 5.7 per 100,000 25–64 year age group 1. Ischemic heart diseases, rate 35.9 deaths per 100,000 2. Diabetes mellitus, rate 19.1 per 100,000 3. Homicides were on par with cirrhosis and other liver diseases, with a rate of 18.3 per 100,000. 5. Land transport accidents, rate of 17.0 per 100,000 65 years old and older 1. Ischemic heart diseases, rate 620.6 deaths per 100,000 2. Cerebrovascular disease deaths, rate 327.5 per 100,000 3. Dementia and Alzheimer’s disease, rate 292.8 per 100,000

6

FINANCIAMIENTO DE LA SALUD

Total health expenditure is increasing both in absolute terms and as % of GNP

References: WB, 2016.

Health Expenditure - Total (% Of GDP) In Latin America And Caribbean

7

Health expenditure (as a percentage of GDP) and composition (public-private, as a percentage of total expenditure), 2014

https://www.paho.org/salud-en-las-americas-2017/?p=178

Public health expenditure and its weight in total expenditure Considering the universal health strategy’s public health expenditure benchmark of at least 6% of GDP • Only 5 of the 34 countries are above that threshold: Canada, Costa Rica, Cuba, the

United States, and Uruguay. • The countries below the threshold include three with public health expenditure

above 5% of GDP: Colombia (5.4%), Nicaragua (5.1%), and Panama (5.9%).

• At 17%, total health expenditure in relation to GDP in the United States is known to be the highest in the world, without proportionally better health outcomes

• This indicates the need not only for more resources but greater efficiency in their use.

• At the opposite extreme, countries with lower public health expenditure are also those in which the composition of total health expenditure is more skewed toward the private component: Guatemala (private expenditure of 62%), Haiti (79%), Saint Kitts and Nevis (58%), and Venezuela (71%).

FINANCIAMIENTO DE LA SALUD

8

Per capita health expenditure in the Americas

https://www.paho.org/salud-en-las-americas-2017/?p=178

Per capita expenditure and equity in expenditure

• Total per capita health expenditure in the Region averages 1,320 international dollars (Intl$) per year.

• Ranges from Intl$ 160 in Haiti to Intl$ 9,145 in the United States. • This absolute level of expenditure can be compared with the

average for the OECD countries (Organisation for Economic Cooperation and Development) which is triple that of the Region.

FINANCIAMIENTO DE LA SALUD

Newborn

Children under 5 years

Adolescents Adults

Senior Citizens

Pregnant Women

BCG Hep B

Pentavalent, Rotavirus,

PCV, IPV/OPV,

MMR, YF, influenza,

varicella

HPV, Meningococcal, Td, YF, Booster doses

Influenza, MR, Tdap , YF, Hep B

Influenza, Pneumococcal

Influenza, Td/Tdap

PAHO’s Regional Vaccination Program: Across the Life Course

“El Valor de la vacunación en Salud Publica”

Tetanos

Pertussis

Difteria

Polio

Fiebre amarilla

Sarampión

2.5

millones de

muertes

evitadas

Las Vacunas salvan millones de niños anualmente

RETORNO DE LA

INVERSION

POR CADA

USD$ 1

INVERTIDO EN:

MORTALIDAD POR EPV EN ADULTOS

Adultos

Niños

99% de las muertes anuales por EPV se observan en adultos

90% de las muertes ocurren en ancianos

Influenza y enf. neumocóccica principales causas de muerte por EPV

Muertes anuales por EPV – USA 07

Fuente: CDC, IOM

La mortalidad por EPV en adultos es 200 veces mayor que en niños

99%

1%

“El Valor de la vacunación en Salud Publica”

2017 CAN=45 USA=120 ARG=3 VEN=727 Total=895

Distribution of confirmed measles cases by countries. The Americas 2017-2018*.

2018 ARG=3 ATG=1 BRA=115 CAN=11 COL=24 ECU=7 GTM=1 MEX=4 PER=2 USA=63 VEN=904 Total=1.135

Sources: Surveillance country reports sent to the Immunization Unit of PAHO/WHO and by the Ministry of Popular Power of

Venezuela. *Data as of May 11, 2018

76 81

85 86 86 86

87 88 88 88

89 89

90 90 90 90

91 92 92

93 93 93

94 95 95 95 95 95 95

96 96 96

97 97

98 100 100 100 100 100 100 100 100 100

0 10 20 30 40 50 60 70 80 90 100

HaitiCuraçao

Dominican RepublicTrinidad and Tobago

GuatemalaEcuador

BermudaVenezuela

PeruAntigua and Barbuda

Cayman IslandsBahamas

Sint MaartenEl Salvador

CanadaArgentinaParaguay

United States of AmericaBarbados

Costa RicaColombia

ChileBolivia

UruguayJamaica

GrenadaBrazilBelizeAruba

Turks and Caicos IslandsDominica

AnguillaSuriname

MexicoSt Kitts and Nevis

Virgin Islands (UK)St Vincent & the Grenadines

St LuciaPanama

NicaraguaMontserrat

HondurasGuyana

Cuba

95%

MMR1 vaccination coverage in children 1 year of age The Americas, 2016

MMR1 coverage (%)

Source: Country reports through the PAHO-WHO/UNICEF Joint Reporting Forms (JRF), 2017.

26 43

48 53

64 65

66 68

72 74

75 76

77 83

84 85 85

86 86

87 87 87 87 87 87

88 88

89 92 92 92

94 95

96 96

100 100 100 100

0 10 20 30 40 50 60 70 80 90 100

HaitiSuriname

BoliviaVenezuela

EcuadorGuatemala

PeruAntigua and Barbuda

BermudaBahamasParaguay

Trinidad and TobagoBrazil

ArubaSint Maarten

JamaicaGrenada

CanadaAnguilla

Virgin Islands (UK)El SalvadorCosta RicaColombia

ChileBarbados

St LuciaArgentina

Turks and Caicos IslandsUruguay

DominicaCuraçaoGuyanaMexico

St Kitts and NevisBelize

St Vincent & the GrenadinesPanama

MontserratCuba

95%

MMR2 vaccination coverage in children The Americas, 2016

MMR2 coverage (%)

Source: Country reports through the PAHO-WHO/UNICEF Joint Reporting Forms (JRF), 2017.

Las Epidemias del siglo 21

Chotani, GIDSAS-JHU, 2006

GIDSAS Current Pandemic Concerns

GLOBAL HEALTH CONSORTIUM GHC

Global air traffic map

El impacto de la urbanización

Deficiente planeación urbana e insufuciente

infraestructura

Estacion Pantitlan, Ciudad Mexico Source: Ciudadanos en Red

Aerial photograph of the municipality of Iztapalapa in Mexico City ® Andreas Gursky en Pinterest

UN MUNDO DE INEQUIDADES Y DESIGUALDADES

Refugiados y Desplazados

IMPORTANT EPIDEMICS OR PANDEMICS DUE TO EMERGENT OR RE-EMERGING DISEASES (2002-2015)

Sands P, Mundaca-Shah C, Dzau VJ. The Neglected Dimension of Global Security — A Framework for Countering Infectious-Disease Crises. New England Journal of Medicine, January 13,2016

- 609 deaths since 2012

Millions of cases since 20116; Microcephaly 3.5 billion USD

774 deathss 50 billion USD

Millions of cases since 2013.

643 deaths (2012- 2015); 26 countries

11,300 deaths; 2.2 billion USD

Pandemic Flu

>23,000 cases; >400 deaths

GLOBAL HEALTH CONSORTIUM GHC

Mycobacterium tuberculosis o bacilo de Koch,

LAS EPIDEMIAS DEL SIGLO 21

24

Número de casos de dengue y países/territorios reportando dengue en las Américas, 1980 – 2018*

*Fuente: Información de países enviada a OPS/OMS Semana epidemiológica #19

1.54 millones

2.95 millones

6.78 millones

12.94 millones

25

Theories of Origin • The virus originated in China in a rare genetic shift of the influenza virus.

• It came from the far East

• The virus jumped from birds to humans

• The virus started in Tibet, spread to Europe and was spread to troops

coming back to the U.S

• The flu was thought to have come from Spain because the most reliable

news coverage came from that area, thus the image Spain was most

affected.

SPANISH FLU PANDEMIC

The big pandemic of 1918

LAS EPIDEMIAS DEL SIGLO 21

Alzheimer

28

LAS EPIDEMIAS DEL SIGLO 21

Alzheimer

La epidemia de los analgesicos opiaceos US

La "epidemia" de heroína y opiáceos en EEUU ya deja un muerto cada 19 minutos

Medicamentos recetados para el dolor -como el oxycodone e hydrocodone- y la

heroína.

Primera causa de muerte en menores de 50 a.

Increases in HCV Incidence - United States

• ~33,900 new HCV infections in 2015 • 1:1 male: female ratio, predominantly white • Highest incidence- 20-29 years, non-urban areas

Suryaprasad, CID 2014, Zibbell MMWR 2015, CDC unpublished data

-

0.2

0.4

0.6

0.8

1.0

1.2

1.4

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Rat

e P

er

10

0,0

00

Year of Report

Metropolitan

Nonmetropolitan

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Rep

ort

ed c

ases

/10

0,0

00

p

op

ula

tio

n

Year

Male

Female

The Diabetes Epidemic/Pandemic

Diabetes case study

Diabetes in the Context of Universal Health Care

46%-60%

undiagnosed

LOS GRANDES RETOS LA RESISTENCIA MICROBIANA

RESISTENCIA A LOS ANTIBIOTICOS

AMR Undermines 8 Sustainable Development Goals

X

X

X X

X

X X

X 36

UN MUNDO DE INEQUIDADES Y DESIGUALDADES

COLOMBIA

TRABAJO INFANTIL DANE 2016

Niñez y Adolescencia

• Tasa de Trabajo Infantil (TTI) 7,8% : 869,000

• Tasa de Trabajo Ampliada para Oficios de Hogar: 12,5%: 527,000

Victimas de trabajo infantil: 1,396.000 niños y niñas

La Salud y el Ambiente

TODOS

UNIDOS?