Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study.

OBJECTIVE: The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica. METHODS: A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'. RESULTS: Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU. CONCLUSIONS: This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Cohort profile: evaluation of immune response and household transmission of SARS-CoV-2 in Costa Rica: the RESPIRA study.

PURPOSE: The RESPIRA cohort aims to describe the nature, magnitude, time course and efficacy of the immune response to SARS-CoV-2 infection and vaccination, population prevalence, and household transmission of COVID-19. PARTICIPANTS: From November 2020, we selected age-stratified random samples of COVID-19 cases from Costa Rica confirmed by PCR. For each case, two population-based controls, matched on age, sex and census tract were recruited, supplemented with hospitalised cases and household contacts. Participants were interviewed and blood and saliva collected for antibodies and PCR tests. Participants will be followed for 2 years to assess antibody response and infection incidence. FINDINGS TO DATE: Recruitment included 3860 individuals: 1150 COVID-19 cases, 1999 population controls and 719 household contacts from 304 index cases. The age and regional distribution of cases was as planned, including four age strata, 30% rural and 70% urban. The control cohort had similar sex, age and regional distribution as the cases according to the study design. Among the 1999 controls recruited, 6.8% reported at enrolment having had COVID-19 and an additional 12.5% had antibodies against SARS-CoV-2. Compliance with visits and specimens has been close to 70% during the first 18 months of follow-up. During the study, national vaccination was implemented and nearly 90% of our cohort participants were vaccinated during follow-up. FUTURE PLANS: RESPIRA will enable multiple analyses, including population prevalence of infection, clinical, behavioural, immunological and genetic risk factors for SARS-CoV-2 acquisition and severity, and determinants of household transmission. We are conducting retrospective and prospective assessment of antibody levels, their determinants and their protective efficacy after infection and vaccination, the impact of long-COVID and a series of ancillary studies. Follow-up continues with bimonthly saliva collection for PCR testing and biannual blood collection for immune response analyses. Follow-up will be completed in early 2024. TRIAL REGISTRATION NUMBER: NCT04537338.

Terminal efficiency, Lag and dropout in cohorts from 2007 to 2014 of dental students at the University of Costa Rica / Eficiencia terminal, rezago y abandono en las cohortes del 2007 al 2014 de estudiantes de Odontología de la Universidad de Costa Rica

Abstract Determine the terminal efficiency, lag and dropout in the cohorts of students who entered the dentistry career at the Faculty of Dentistry at University of Costa Rica in the lapse 2007 to 2014. Data from 736 files were collected. The variables considered were sex, admission age, nationality, marital status, children, admission note, domicile and high school. The data was collected from the Student Application System, the physical files, and the data base from the Supreme Court of Elections of Costa Rica. Descriptive statistics, bivariate and multivariate analysis were made, which were implemented from two logistic regression models. 98% of the students were Costa Rican, 68% women, 79% entered according to the admission note, 43% entered with an age of 18 years or less, 50% came from a public school, 77% resided in the Greater Metropolitan Area and 95% were single and remained without children. The average terminal efficiency was 6%; 46% of students have graduated with lag, 16% are still enrolled and 32% dropped out. Sex, age, admission note, and motherhood are sociodemographic variables that are associated with terminal efficiency and dropout. The average terminal efficiency in the cohorts from 2007 to 2014 in the courses at the Faculty of Dentistry University of Costa Rica was very low, almost half of the students graduated with lag and about a third dropped out the studies. The grade from the admission note seems to be a predictor of students'academic behavior, higher grade had more chances of graduating and less likely to dropout.

Resumen Determinar la eficiencia terminal, el rezago y el abandono en las cohortes de los estudiantes que ingresaron a la carrera de Odontología de la Facultad de Odontología UCR en el período 2007 al 2014. Se recopilaron los datos de 736 expedientes. Las variables consideradas fueron: sexo, edad de ingreso, nacionalidad, estado civil, hijos, lugar y colegio de procedencia, y nota de examen de admisión. Los datos se recopilaron del Sistema de Aplicaciones Estudiantiles, los expedientes físicos y del Tribunal Supremo de Elecciones de Costa Rica. Se realizó estadística descriptiva, análisis bivariado y multivariado que se implementó a partir de dos modelos de regresión logística. El 98% de los estudiantes fueron costarricenses, el 68% mujeres, el 79% ingresó según la nota de admisión, el 43% ingresó con una edad de 18 años o menos, el 50% provenía de un colegio público, el 77% residía en la gran área Metropolitana y el 95% eran solteros y permanecieron sin hijos. La eficiencia terminal en promedio fue de 6%; el 46% de los estudiantes se han graduado con rezago, el 16% continúan matriculados y el 32% hizo abandono de los estudios. El sexo, la edad, la nota del examen de admisión y la maternidad son variables sociodemográficas que se asocian con la eficiencia terminal y el abandono. El promedio de la eficiencia terminal en las cohortes del 2007 al 2014 en la carrera de Odontología de la Facultad de Odontología UCR fue muy bajo, casi la mitad de los estudiantes se han graduado con rezago y cerca de un tercio hizo abandono de los estudios. La nota del examen de admisión parece ser un predictor en el comportamiento académico de los estudiantes: a mayor nota más posibilidades de graduarse y menos de abandonar la carrera.

Estimating the cumulative incidence of SARS-CoV-2 infection in Costa Rica: modelling seroprevalence data in a population-based cohort.

Background: The true incidence of SARS-CoV-2 infection in Costa Rica was likely much higher than officially reported, because infection is often associated with mild symptoms and testing was limited by official guidelines and socio-economic factors. Methods: Using serology to define natural infection, we developed a statistical model to estimate the true cumulative incidence of SARS-CoV-2 in Costa Rica early in the pandemic. We estimated seroprevalence from 2223 blood samples collected from November 2020 to October 2021 from 1976 population-based controls from the RESPIRA study. Samples were tested for antibodies against SARS-CoV-2 nucleocapsid and the receptor-binding-domain of the spike proteins. Using a generalized linear model, we estimated the ratio of true infections to officially reported cases. Applying these ratios to officially reported totals by age, sex, and geographic area, we estimated the true number of infections in the study area, where 70% of Costa Ricans reside. We adjusted the seroprevalence estimates for antibody decay over time, estimated from 1562 blood samples from 996 PCR-confirmed COVID-19 cases. Findings: The estimated total proportion infected (ETPI) was 4.0 times higher than the officially reported total proportion infected (OTPI). By December 16th, 2021, the ETPI was 47% [42-52] while the OTPI was 12%. In children and adolescents, the ETPI was 11.0 times higher than the OTPI. Interpretation: Our findings suggest that nearly half the population had been infected by the end of 2021. By the end of 2022, it is likely that a large majority of the population had been infected. Funding: This work was sponsored and funded by the National Institute of Allergy and Infectious Diseases through the National Cancer Institute, the Science, Innovation, Technology and Telecommunications Ministry of Costa Rica, and Costa Rican Biomedical Research Agency-Fundacion INCIENSA (grant N/A).

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study.

OBJECTIVE: To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country. METHODS: The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10. RESULTS: After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women. CONCLUSIONS: The study's findings were consistent, but not fully similar, to the international literature.

Excess mortality from COVID 19 in Costa Rica: a registry based study using Poisson regression.

Background: Official death toll related to COVID-19 has been considerably underestimated in reports from some Latin American countries. This study aimed to analyze the mortality associated with the COVID-19 pandemic in Costa Rica between March 2020 and December 2021. Methods: A registry based study based on 2017-2021 data from the National Institute of Statistics and Census was designed (N = 128,106). Excess deaths were defined by the WHO as "the difference in the total number of deaths in a crisis compared to those expected under normal conditions"; and were estimated using a Poisson regression, and mortality and years of potential life lost (YPLL) rates were calculated. Findings: The COVID-19 pandemic represented 15% of the deaths in Costa Rica between March 2020 and December 2021. The mortality rate related to COVID-19 was 83 per 100,000 person-years. Between March and July 2020 (low-incidence period), observed number of deaths was 9%-lower than expected, whereas it was 15% and 24% higher than expected between July 2020 and March 2021 (high incidence period - no vaccination), and between March 2021 and December 2021 (high incidence period - progressive vaccination) respectively. Between July 2020 and December 2021, excess deaths observed and COVID-19 deaths reported were comparable (7461 and 7620 respectively). Nevertheless, there were more deaths than expected for conditions that predispose to COVID-19 deaths. YPLL and mortality rates increased with age, but significant excess deaths were observed in all age-groups older than 30-39 years. No large differences were noted by districts' socioeconomic characteristics although excess death rate was lower in rural compared to urban areas. Interpretation: Reporting of deaths was only slightly underestimated. In the pre-vaccination period, mortality rate and YPLL rates increased with age, being highest in people aged 60 years or older and justifying the decision to initially prioritize vaccination of older individuals. Funding: The study was supported by the University of Costa Rica and the Agencia Costarricense de Investigaciones Biomédicas - Fundación Inciensa.

Health inequalities in cause-specific mortality in Costa Rica: a population-based cohort study

ABSTRACT OBJECTIVE To analyze health inequalities in cause-specific mortality in Costa Rica from 2010 to 2018, observing the main causes for inequality in the country. METHODS The National Electoral Rolls were used to follow-up all Costa Rican adults aged 20 years or older from 2010 to 2018 (n = 2,739,733) in an ecological study. A parametric survival model based on the Gompertz distribution was performed and the event death was classified according to the ICD-10. RESULTS After adjustment for urbanicity, the poorest districts had a higher mortality than the wealthier districts for most causes of death except neoplasms, mental and behavioral disorders, and diseases of the nervous system. Urban districts showed significantly higher mortality than mixed and rural districts after adjustment for wealth for most causes except mental and behavioral disorders, diseases of the nervous system, and diseases of the respiratory system. Differences according to wealth were more frequent in women than men, whereas differences according to urbanicity were more frequent in men than in women. CONCLUSIONS The study's findings were consistent, but not fully similar, to the international literature.

Diferencias de mortalidad y sus causas: un estudio comparativo entre las zonas indígenas y no indígenas de Costa Rica

Introducción: En la mayoría de los países de los continentes americanos y oceánicos, las personas indígenas tienen peores indicadores de salud que el resto de la población. El objetivo de este estudio es analizar las diferencias de mortalidad y de causas de muerte entre las zonas indígenas y el resto de Costa Rica, en el periodo de 2010 a 2018. Metodología: La población de estudio se conformó a partir del padrón electoral de las elecciones presidenciales de 2010 y las causas de muerte (ICD-10) se extrajeron del registro del Instituto Nacional de Estadísticas y Censos (INEC); fueron incluidas 2 747 616 personas para 23 985 602 personas-año de seguimiento. Resultados: No se observaron diferencias de mortalidad entre los hombres de ambas poblaciones. En cambio, la mortalidad fue ligeramente superior en las mujeres indígenas. En las zonas indígenas, por un lado, la mortalidad fue más alta en quienes tenían menos de 50 años al inicio del seguimiento, en particular, por enfermedades del sistema digestivo y causas externas de morbilidad y mortalidad; por otro, fue inferior en mayores de 70 años y se debió a tumores y enfermedades del sistema circulatorio. Conclusiones: Los resultados obtenidos no confirman la hipótesis de una mortalidad sistemáticamente mayor en las poblaciones que viven en las zonas indígenas.

Introduction: In most countries of the American and Oceanic continents, indigenous people have worse health indicators than the rest of the population. The objective of this study is to analyze the differences in mortality and causes of death between people living in indigenous areas, and people living in the rest of Costa Rica, between 2010 and 2018. Methods: . The study population is based on the 2010 National Electoral Rolls. The Registry of the National Institute of Statistics and Censuses (INEC) allowed knowing the cause of death (ICD-10). 2,747,616 people for 23,985,602 person-years of follow-up were included. Results: No differences in mortality in men were observed between both populations. In women, mortality was slightly higher in indigenous areas. In indigenous areas, mortality was higher in people who were under 50 years of age at the beginning of the follow-up, compared to the rest of the population, in particular mortality due to Diseases of the digestive system and External causes of morbidity and mortality. Mortality was lower in indigenous areas in people over 70 years of age, particularly mortality due to Tumors and Diseases of the circulatory system. Conclusion: The results of this study do not confirm the hypothesis of systematically higher mortality in populations living in indigenous areas.

Estimating vaccine effectiveness against SARS-CoV-2 infection, hospitalization and death from ecologic data in Costa Rica.

BACKGROUND: Clinical trials and individual-level observational data in Israel demonstrated approximately 95% effectiveness of mRNA-based vaccines against symptomatic SARS-CoV-2 infection. Individual-level data are not available in many countries, particularly low- and middle- income countries. Using a novel Poisson regression model, we analyzed ecologic data in Costa Rica to estimate vaccine effectiveness and assess the usefulness of this approach. METHODS: We used national data from December 1, 2020 to May 13, 2021 to ascertain incidence, hospitalizations and deaths within ecologic units defined by 14 age groups, gender, 105 geographic areas, and day of the epidemic. Within each unit we used the proportions of the population with one and with two vaccinations, primarily tozinameran. Using a non-standard Poisson regression model that included an ecologic-unit-specific rate factor to describe rates without vaccination and a factor that depended on vaccine effectiveness parameters and proportions vaccinated, we estimated vaccine effectiveness. RESULTS: In 3.621 million persons aged 20 or older, there were 125,031 incident cases, 7716 hospitalizations, and 1929 deaths following SARS-CoV-2 diagnosis; 73% of those aged ≥ 75 years received two doses. For one dose, estimated effectiveness was 59% (95% confidence interval 53% to 64%) for SARS-CoV-2 incidence, 76% (68% to 85%) for hospitalizations, and 63% (47% to 80%) for deaths. For two doses, the respective estimates of effectiveness were 93% (90% to 96%), 100% (97% to 100%), and 100% (97% to 100%). CONCLUSIONS: These effectiveness estimates agree well with findings from clinical trials and individual-level observational studies and indicate high effectiveness in the general population of Costa Rica. This novel statistical approach is promising for countries where ecologic, but not individual-level, data are available. The method could also be adapted to monitor vaccine effectiveness over calendar time.

Conocimiento acerca del manejo inmediato del trauma dental en un grupo de docentes de preescolar y primaria en Costa Rica / Immediate management dental trauma knowledge of preschool and primary school teachers in Costa Rica

Objetivo. Determinar el grado de conocimiento en el manejo inmediato del trauma dental en los profesores de preescolar y primaria en la provincia de Cartago en Costa Rica. Métodos. Se realizó un estudio observacional de corte transversal en el que se aplicó una encuesta enviada vía correo electrónico a un grupo de docentes. Se incluyeron variables sociodemográficas y de conocimiento referente a la atención del trauma dental en niños/as. El total de instituciones participantes fue de 11 (6 públicas y 5 privadas). La encuesta fue respondida por 60 docentes de instituciones públicas y 141 de centros privados. Se creó un puntaje de conocimiento, asignando 1 punto para las respuestas correctas y 0 puntos para las respuestas incorrectas. Las puntuaciones mayores a 4 fueron consideradas como "conocimiento adecuado" acerca del trauma dental y su manejo. Se realizó una estadística descriptiva de las variables y la prueba de chi cuadrado para determinar si existía diferencia en el grado de conocimiento de los docentes respecto a la atención inmediata del trauma dental según las variables sociodemográficas. Resultados. Solo un 24% de los docentes obtuvo una puntuación superior a 4. Además, se encontró una relación estadísticamente significativa entre algunas variables: a mayor edad, mayor experiencia docente y haber sido testigo de situaciones de trauma dental, mayor es el conocimiento de los docentes en esta área. Conclusiones. Los docentes de preescolar y primaria del Circuito 1 de la provincia de Cartago poseen, en su mayoría, un bajo conocimiento para la atención inmediata del trauma dental

Objective. To determine the degree of knowledge in the immediate management of dental trauma in preschool and primary school teachers in the province of Cartago in Costa Rica. Methods. A cross-sectional observational study was performed. An electronic survey was sent via email to a group of teachers. Sociodemographic and knowledge variables regarding dental trauma care in children were included. Eleven schools participated in the study (6 public and 5 private). The survey was answered by 60 teachers from public institutions and 141 from private schools. A knowledge of score was created, assigning 1 point for correct answers and 0 points for incorrect answers Scores greater than 4 were considered as "adequate knowledge" about dental trauma and its management. Descriptive statistics of the variables and the chi-square tests were performed to determine if there was a difference in the degree of knowledge of the teachers regarding the immediate care of dental trauma according to the sociodemographic variables. Results. Only 24% of the teachers obtained a score higher than 4. In addition, a statistically significant relationship was found between some variables: the older they are, the more experienced they are in teaching, and having witnessed situations of dental trauma, the greater the knowledge of the teachers in this area. Conclusions. Preschool and primary teachers of Circuit 1 of the province of Cartago have, mostly, little knowledge for the immediate care of dental trauma.

Identificación de las zonas con dificultades geográficas de acceso a los servicios públicos de salud en Costa Rica: una propuesta metodológica / Identification of areas with geographical access difficulties to public health services in Costa Rica: a methodological proposal

Objetivo: el propósito de este estudio es presentar y aplicar una herramienta metodológica para identificar las zonas en las cuales el acceso a los servicios de salud pudiera resultar difícil para la población debido a la barrera geográfica, tanto por su distancia al centro médico, como por su capacidad de desplazamiento, específicamente en los cantones de Curridabat, Escazú y Desamparados. Métodos: a partir de la división geográfica del país en unidades geoestadísticas mínimas realizada por el Instituto Nacional de Estadísticas y Censos, se calculó, por cada unidad, la distancia en minutos que se tardaría en recorrer caminando, por la ruta real más rápida, desde la unidad geoestadística mínima hasta la sede de su equipo básico de atención en salud asignado. Resultados: el 3,4% de la población estudiada vivía en una unidad geoestadística mínima clasificada como con dificultad importante de acceso a los servicios de salud, pues presentaba tanto la barrera física de la distancia, como poco desplazamiento en automotores y baja condición socioeconómica. Se identificaron 65 unidades geoestadísticas mínimas (sobre 2014 incluidas en el estudio) que se encontraban a más de 20 minutos caminando de la sede de su equipo básico de atención en salud y cuya población contaba con baja capacidad de desplazamiento y baja condición socioeconómica; la mayoría de ellas en el Área de Salud de Desamparados. Conclusión: este estudio presenta una herramienta metodológica para aplicar en la identificación de zonas a cuya población le pudiera resultar difícil el acceso geográfico a los servicios de salud, tanto por su distancia a un centro médico, como por su capacidad de desplazamiento, específicamente en los cantones de Curridabat, Escazú y Desamparados.

Aim: The objective of this study is to present and apply a methodological tool to identify the areas in which the inhabitants could have geographic access difficulties as a barrier to access to health services, both because of its distance from the health center and its mobility capacity, specifically in the cantons of Curridabat, Escazú and Desamparados. Methods: Based on the geographical division of the country into minimum geostatistical units carried out by the Instituto Nacional de Estadísticas y Censos, the distance in minutes that it would take to walk it was calculated for each unit, based on the actual fastest route between the minimum geostatistical unit and the headquarters of its assigned basic health care team. Results: An 3.4% of the studied population lived in a minimum geostatistical unit classified as having significant difficulty accessing health services since they accumulated both the physical barrier of distance and little mobility in automobiles. 65 minimum geostatistical units were identified (out of 2014 included in the study) as being at more than 20 minutes walking from the basic health care team, with a population with low mobility capacity, and consequently low socioeconomic status. Most of these were found in the Desamparados Health Area. Conclusion: This study presents and applies a methodological tool to identify the areas in which the inhabitants could have geographic access difficulties as a barrier to access to health services, both due to their distance from the health center and their mobility capacity, in Curridabat, Escazú and Desamparados.

Social inequality in incidence and mortality of malignant neoplasms of lip, oral cavity and pharynx: Is Costa Rica an international paradox?

OBJECTIVES: Low socioeconomic position (SEP) has been associated with higher incidences and mortality of lip, oral cavity and pharynx (LOP) cancers in the vast majority of countries with available data. The origins of health inequalities in cancer are socioeconomic, although they vary by time and country. Evidence from Low-and Middle-income Countries (LMICs) remains scarce. This study aims to identify and describe socioeconomic inequalities in LOP cancers incidence and mortality in Costa Rica. The hypothesis tested is that people leaving in low-SEP districts in Costa Rica have greater incidence and mortality rates of lip, oral cavity and pharynx cancers. METHODS: The 10th revision of the International Classification of Diseases (ICD-10) was used to define cancer sites. Data come from a national population-based Cancer Registry with 100% completeness to study incidence. Incidence rate included all new cases of LOP cancer diagnosed from January 1, 2011, and December 31, 2015, for a total of 2 798 517 individuals, 13 832 524 years of follow-up and 601 LOP cases. Mortality rate was extracted from the National Death Index, including 2 739 733 individuals, 23 950 240 person-years of follow-up and 586 LOP cancer deaths, from January 1, 2010, to December 31, 2018. The 2011 Census (with 94% of Costa Rican inhabitants) was used to characterize the urbanicity and wealth of 477 districts. Survival models were performed for both incidence and mortality, allowing to consider existing competitive risks. Cox models were used for incidence, and parametric survival models based on a Gompertz distribution for mortality. RESULTS: The study found that people who lived in the most socioeconomically disadvantaged areas had lower probabilities of developing LOP cancers than people in the richest districts. The same pattern for mortality, however, was not significant. CONCLUSIONS: The hypothesis that incidence and mortality of LOP cancers will show a positive social gradient was not confirmed in this study, contradicting the existing literature. This could be explained by the social distribution of risky health behaviours, more frequent in socially advantaged populations.

Are traditional screening tools adequate for monitoring the nutrition risk of in-hospital patients? An analysis of the nutritionDay database.

BACKGROUND: Monitoring of adequate food intake is not a priority in hospital patients' care. The present study aimed to examine selective data from the nutritionDay survey to determine the impact of food intake during hospitalization on outcomes according to the nutrition risk status. METHODS: We conducted a descriptive analysis of selected data from 7 consecutive, annual, and cross-sectional nutritionDay samples from 2009 to 2015. The impact of food intake on outcomes was assessed by univariate and multivariate Cox models controlling for PANDORA scores. RESULTS: A total of 7994 adult patients from Colombia, 7243 patients from 9 Latin American countries, and 155,524 patients worldwid were included. Less than half of the patients worldwide consumed their entire meal on nutritionDay (41%). The number of reduced eaters is larger in the "no nutrition risk group" than in the "nutrition risk group" (30% vs 25%). Reduced eating is associated with higher mortality and delayed discharge in patients, regardless of the nutrition risk status. Patients without nutrition risk at the screening who ate "nothing, but were allowed to eat" had 6 times more risk of mortality (hazard ratio, 6.48; 95% CI, 3.5311.87). CONCLUSIONS: This is the first large-scale study evaluating the relationship of food intake on clinical outcomes showing an increase of in-hospital mortality rates and a reduction in the probability of being discharged home regardless of the nutrition risk status. Traditional screening tools may not identify a group of patients who will become at risk because of reduced intake while in the hospital.

Complex social gradient in life expectancy in Costa Rica: an ecological study with 24-Million person-years follow-up / Complejo gradiente socioeconómico en esperanza de vida en Costa Rica: un estudio ecológico con seguimiento de 24 millones de personas-año

ABSTRACT: The knowledge of Costa Rica's situation regarding the social gradient in mortality is still incomplete. National Electoral Rolls, which included all adult Costa Rican citizens were used. The event was death between 2010 and 2018. The exhaustive final sample included 2,747,616 people for 23,985,602 person-years of follow-up. An ecological study at the electoral district level was performed. A negative social gradient was observed in men and in women, in particular in urban area. A protective effect of rural areas compared to urban areas was revealed in men, but not in women. As a result, in men, the poorest districts of mixed/rural areas had similar life expectancy than the richest districts in urban areas. These results partially contradicted the international literature on socioeconomic inequalities. It demonstrates the importance of studying contexts other than high-income countries to better understand the social inequalities in health worldwide.

RESUMEN: El conocimiento sobre la distribución del gradiente social de la mortalidad en Costa Rica aún no ha sido totalmente comprendido y nuevos estudios pueden confirmar o refutar lo que anteriormente se ha observado. Se utilizaron las listas electorales nacionales, que incluían a todos los ciudadanos costarricenses adultos. El evento fue la muerte entre 2010 y 2018. Siendo la muestra exhaustiva final de 2.747.616 personas para 23.985.602 personas-año de seguimiento. Se realizó un estudio ecológico a nivel de distrito electoral, para caracterizar la situación socioeconómica de cada uno. Se observó un gradiente social negativo en hombres y mujeres, en particular en el área urbana. Se observó un efecto protector de las áreas rurales en comparación con las áreas urbanas en los hombres, pero no en las mujeres. Como resultado, en los hombres, los distritos más pobres de las áreas mixtas/rurales tenían una esperanza de vida similar a la de los distritos más ricos de las áreas urbanas. Estos resultados contradicen parcialmente la literatura internacional sobre las inequidades socioeconómicas en mortalidad. Demuestra la importancia de estudiar contextos distintos a los de los países de ingresos altos para comprender mejor las desigualdades sociales en salud en todo el mundo.

Prevalence of Dental Caries Among Costa Rican Male Students Aged 12-22 Years Using ICDAS-II / Prevalencia de caries en varones costarricenses escolarizados de 12 a 22 años utilizando ICDAS-II

ABSTRACT: Objective: Dental decay is a public health challenge in Low- and Middle- Income Countries, particularly for young people, often confronted to healthcare access barriers. The aim of this study was to determine the prevalence and severity of dental caries among young male students in Costa Rica. Study design: A cross-sectional study was performed in 428 Costa Rican male students aged 12-22 years, who attended a nonprofit social welfare boarding school in 2019. A clinical examination was ran by three calibrated examiners following the International Caries Detection and Assessment System (ICDAS-II). Results: Caries prevalence was estimated at 83%, 15% have lost a tooth due to dental decay, 61% have at least one filled tooth, 36% have at least one filled and decayed tooth. The most frequent caries lesions were codes 2-Inactive (46.7%) and code 1-Inactive (23.8%). DMFT indicated a mean index using ICDAS-II 1-6>0 codes of 7.89. Using ICDAS-II 3-6>0 as threshold, the index decreases to 3.94. Finally, the lower and upper first permanent molars were found to be the most affected teeth. Conclusions: Dental caries experience represents a significant public health burden in young people, requiring better access to public dental healthcare.

RESUMEN: Objetivo: La caries dental continúa siendo uno de los grandes desafíos de salud pública en los países de ingresos bajos y medios, en particular para los jóvenes, que a menudo se enfrentan a barreras de acceso a la atención médica y odontológica. El objetivo de este estudio es determinar la prevalencia y severidad de la caries dental entre jóvenes estudiantes varones en Costa Rica. Diseño del estudio: se realizó un estudio transversal con 428 estudiantes varones costarricenses de entre 12 y 22 años, que asistieron a un internado de asistencia social sin fines de lucro llamado Ciudad de los Niños en 2019. Tres examinadores calibrados realizaron un examen clínico siguiendo el Sistema Internacional de Detección y Evaluación de Caries. (ICDAS-II). Resultados: La prevalencia de caries se estimó en 83%, el 15% ha perdido un diente debido a caries dental, el 61% tiene al menos un diente obturado, el 36% tiene al menos un diente obturado y con caries. Las lesiones de caries más frecuentes fueron los códigos 2-Inactivo (46,7%) y el código 1-Inactivo (23,8%). CPOD indicó un índice medio utilizando códigos ICDAS-II 1-6>0 de 7,89. Usando ICDAS-II 3-6>0 como umbral, el índice disminuye a 3,94. Finalmente, los primeros molares permanentes inferiores y superiores resultaron ser los dientes más afectados. Conclusiones: La experiencia de la caries dental representa una carga de salud pública significativa en los jóvenes, que requiere un mejor acceso a la atención médica dental pública.

[COVID-19 deaths: Distribution by age and universal medical coverage in 22 countriesMortes por COVID-19: distribuição por idade e universalidade da cobertura médica em 22 países]. / Defunciones por COVID-19: distribución por edad y universalidad de la cobertura médica en 22 países.

OBJECTIVE: Relate standardized age distribution of COVID-19 deaths in 22 countries in the Americas and Europe to different indicators of population characteristics and health systems. METHODS: Distributions of COVID-19 deaths by age group in 22 countries of the Americas and Europe were standardized based on the age pyramid of the world's population. Correlations were calculated between the standardized proportion of people aged <60 years among the deceased and each of six indicators. RESULTS: Standardization based on the world age pyramid revealed considerable differences in age distribution among countries; the proportion of people aged <60 years was higher in Latin America and the United States than in Canada or Western Europe. The standardized proportion of people aged <60 years among persons who died of COVID-19 is strongly correlated to the existence of universal quality medical coverage (r=-0.92, p<0.01). This relationship remained significant after being adjusted for the other indicators. CONCLUSION: We propose that weaknesses in medical coverage of the population may have created higher case-fatality in populations aged <60 years in Latin America and the United States.

OBJETIVO: Correlacionar a distribuição etária padronizada de mortes por COVID-19 em 22 países das Américas e da Europa com diversos indicadores das características das populações e dos sistemas de saúde. MÉTODOS: As distribuições das mortes por COVID-19 por faixa etária em 22 países das Américas e da Europa foram padronizadas pela pirâmide etária da população mundial. Foram calculadas correlações entre a proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram e cada um dos seis indicadores. RESULTADOS: Foram evidenciadas diferenças importantes de distribuição etária entre os países estudados após a padronização pela pirâmide etária da população mundial, sendo maior a proporção de mortes de pessoas com menos de 60 anos na América Latina e nos Estados Unidos que no Canadá ou na Europa ocidental. A proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram por COVID-19 está fortemente correlacionada com a universalidade de cobertura médica de qualidade (r=­0,92, p<0,01). Esta correlação se manteve significativa após o ajuste para outros indicadores analisados. CONCLUSÃO: O nosso estudo sugere que falhas na cobertura médica da população podem ter provocado maior letalidade nas pessoas com menos de 60 anos na América Latina e nos Estados Unidos.

Relationship between childhood obesity and socio-economic status among primary school children in Costa Rica.

OBJECTIVE: This article analyses the relationship between socio-economic status and the prevalence of overweight and obesity in the primary school population in Costa Rica. DESIGN: A National School Weight/Height Census was disseminated across Costa Rica in 2016. The percentage of children who were overweight or obese was calculated by sex, age and socio-economic indicators (type of institution: private, public, mix; type of geographic location: rural, urban and the level of development of the district of residence: quartiles). A mixed-effects multinomial logistic regression model and mixed-effects logistic regression model were used to analyse the association between the prevalence of being overweight or obese and district socio-economic status. SETTING: The survey was carried out in public and private primary schools across Costa Rica in 2016. PARTICIPANTS: In total, 347 366 students from 6 to 12 years were enrolled in public and private primary schools. RESULTS: The prevalence of overweight and obesity among children was 34·0 %. Children in private schools were more likely to be overweight or obese than students in public schools (OR = 1·10 [1·07, 1·13]). Additionally, children were less likely to be overweight or obese if attending a school in a district of the lowest socio-economic quartile compared with the highest socio-economic quartile (OR = 0·79 [0·75, 0·83]) and in a rural area compared with the urban area (OR = 0·92 [0·87, 0·97]). CONCLUSIONS: Childhood obesity in Costa Rica continues to be a public health problem. Prevalence of overweight and obesity in children was associated with indicators of higher socio-economic status.

Defunciones por COVID-19: distribución por edad y universalidad de la cobertura médica en 22 países

[RESUMEN]. Objetivo. Relacionar la distribución etaria estandarizada de las defunciones por COVID-19 en 22 países americanos y europeos, con diferentes indicadores de las características de las poblaciones y de los sistemas de salud. Métodos. Las distribuciones de las defunciones por COVID-19 por grupo etario en 22 países americanos y europeos fueron estandarizadas sobre la pirámide de edades de la población mundial. Se calcularon las correlaciones entre la proporción estandarizada de personas de menos de 60 años dentro de las personas fallecidas y cada uno de los seis indicadores. Resultados. Se evidenció la existencia de diferencias importantes de distribución por grupo etario entre los países después de haber estandarizado sobre la pirámide de edades a nivel mundial, siendo la proporción de personas de menos de 60 años superior en América Latina y Estado Unidos que en Canadá o Europa occidental. La proporción estandarizada de personas de menos de 60 años dentro de las personas fallecidas por COVID-19 está fuertemente correlacionada con la universalidad de una cobertura médica de calidad (r=-0,92, p<0,01). Esta relación se mantuvo significativa después de haber ajustado sobre los otros indicadores analizados. Conclusión. Se propone que las debilidades de la cobertura médica de la población podrían haber creado una mayor letalidad en las poblaciones de menos de 60 años en América Latina y en los Estados Unidos.

[ABSTRACT]. Objective. Relate standardized age distribution of COVID-19 deaths in 22 countries in the Americas and Europe to different indicators of population characteristics and health systems. Methods. Distributions of COVID-19 deaths by age group in 22 countries of the Americas and Europe were standardized based on the age pyramid of the world's population. Correlations were calculated between the standardized proportion of people aged <60 years among the deceased and each of six indicators. Results. Standardization based on the world age pyramid revealed considerable differences in age distribution among countries; the proportion of people aged <60 years was higher in Latin America and the United States than in Canada or Western Europe. The standardized proportion of people aged <60 years among persons who died of COVID-19 is strongly correlated to the existence of universal quality medical coverage (r=-0.92, p<0.01). This relationship remained significant after being adjusted for the other indicators. Conclusion. We propose that weaknesses in medical coverage of the population may have created higher case-fatality in populations aged <60 years in Latin America and the United States.

[RESUMO]. Objetivo. Correlacionar a distribuição etária padronizada de mortes por COVID-19 em 22 países das Américas e da Europa com diversos indicadores das características das populações e dos sistemas de saúde. Métodos. As distribuições das mortes por COVID-19 por faixa etária em 22 países das Américas e da Europa foram padronizadas pela pirâmide etária da população mundial. Foram calculadas correlações entre a proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram e cada um dos seis indicadores. Resultados. Foram evidenciadas diferenças importantes de distribuição etária entre os países estudados após a padronização pela pirâmide etária da população mundial, sendo maior a proporção de mortes de pessoas com menos de 60 anos na América Latina e nos Estados Unidos que no Canadá ou na Europa ocidental. A proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram por COVID-19 está fortemente correlacionada com a universalidade de cobertura médica de qualidade (r=–0,92, p<0,01). Esta correlação se manteve significativa após o ajuste para outros indicadores analisados. Conclusão. O nosso estudo sugere que falhas na cobertura médica da população podem ter provocado maior letalidade nas pessoas com menos de 60 anos na América Latina e nos Estados Unidos.

Conocimientos sobre tabaco y sus riesgos a la salud en Costa Rica: un análisis estructural / Knowledge about tobacco and its health risks in Costa Rica: structural analysis

Resumen Objetivo: Identificar factores asociados al conocimiento sobre el tabaco y los riesgos de su consumo basados en la "Encuesta global de tabaquismo en adultos" realizada en Costa Rica durante el 2015. Métodos: Estudio epidemiológico, observacional de tipo transversal con representación nacional (n = 8 607). Con la base de datos de la "Encuesta global de tabaquismo en adultos", se diseñó un modelo de ecuaciones estructurales y se construyó la variable latente: conocimientos. Como determinantes del conocimiento se usaron las variables: sociodemográficas, económicas, fumado, cesación, exposición a la publicidad y a la información sobre los peligros de fumar incluidas en la encuesta. Resultados: El conocimiento sobre el tabaco y los riesgos del consumo aumentó con la edad, fue superior en hombres y en zonas urbanas. Los fumadores tuvieron menos conocimientos sobre el fumado pasivo y más sobre enfermedades. Conclusiones: La Encuesta global de tabaquismo en adultos permitió medir el nivel de conocimiento sobre los riesgos asociados al tabaco y estudiar sus determinantes socioeconómicos.

Abstract Objective: To identify tobacco knowledge and consumption risk determinants based on the Global Adult Tobacco Survey carried out in Costa Rica in 2015. Methods: Cross-sectional study using a multi-stage cluster sample, nationally representative of Costa Rica (n = 8 607). A structural equation model was conducted. A latent endogenous (dependent) variable called knowledge was constructed. Exogenous (independent) observed variables were: sociodemographic factors, household wealth, prior smoking, cessation attempt, exposure to advertising and to information on the dangers of smoking included in Global Adult Tobacco Survey. Results: Knowledge about tobacco and the risks of consumption increased with age, it was higher in men and in urban areas. Smokers had less knowledge about passive smoking and more about diseases. Conclusions: Global Adult Tobacco Survey allowed to measure the level of knowledge about the risks associated with tobacco and study its socioeconomic determinants.

Defunciones por COVID-19: distribución por edad y universalidad de la cobertura médica en 22 países / COVID-19 deaths: Distribution by age and universal medical coverage in 22 countries / Mortes por COVID-19: distribuição por idade e universalidade da cobertura médica em 22 países

RESUMEN Objetivo. Relacionar la distribución etaria estandarizada de las defunciones por COVID-19 en 22 países americanos y europeos, con diferentes indicadores de las características de las poblaciones y de los sistemas de salud. Métodos. Las distribuciones de las defunciones por COVID-19 por grupo etario en 22 países americanos y europeos fueron estandarizadas sobre la pirámide de edades de la población mundial. Se calcularon las correlaciones entre la proporción estandarizada de personas de menos de 60 años dentro de las personas fallecidas y cada uno de los seis indicadores. Resultados. Se evidenció la existencia de diferencias importantes de distribución por grupo etario entre los países después de haber estandarizado sobre la pirámide de edades a nivel mundial, siendo la proporción de personas de menos de 60 años superior en América Latina y Estado Unidos que en Canadá o Europa occidental. La proporción estandarizada de personas de menos de 60 años dentro de las personas fallecidas por COVID-19 está fuertemente correlacionada con la universalidad de una cobertura médica de calidad (r=-0,92, p<0,01). Esta relación se mantuvo significativa después de haber ajustado sobre los otros indicadores analizados. Conclusión. Se propone que las debilidades de la cobertura médica de la población podrían haber creado una mayor letalidad en las poblaciones de menos de 60 años en América Latina y en los Estados Unidos.

ABSTRACT Objective. Relate standardized age distribution of COVID-19 deaths in 22 countries in the Americas and Europe to different indicators of population characteristics and health systems. Methods. Distributions of COVID-19 deaths by age group in 22 countries of the Americas and Europe were standardized based on the age pyramid of the world's population. Correlations were calculated between the standardized proportion of people aged <60 years among the deceased and each of six indicators. Results. Standardization based on the world age pyramid revealed considerable differences in age distribution among countries; the proportion of people aged <60 years was higher in Latin America and the United States than in Canada or Western Europe. The standardized proportion of people aged <60 years among persons who died of COVID-19 is strongly correlated to the existence of universal quality medical coverage (r=-0.92, p<0.01). This relationship remained significant after being adjusted for the other indicators. Conclusion. We propose that weaknesses in medical coverage of the population may have created higher case-fatality in populations aged <60 years in Latin America and the United States.

RESUMO Objetivo. Correlacionar a distribuição etária padronizada de mortes por COVID-19 em 22 países das Américas e da Europa com diversos indicadores das características das populações e dos sistemas de saúde. Métodos. As distribuições das mortes por COVID-19 por faixa etária em 22 países das Américas e da Europa foram padronizadas pela pirâmide etária da população mundial. Foram calculadas correlações entre a proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram e cada um dos seis indicadores. Resultados. Foram evidenciadas diferenças importantes de distribuição etária entre os países estudados após a padronização pela pirâmide etária da população mundial, sendo maior a proporção de mortes de pessoas com menos de 60 anos na América Latina e nos Estados Unidos que no Canadá ou na Europa ocidental. A proporção padronizada de pessoas com menos de 60 anos entre as pessoas que morreram por COVID-19 está fortemente correlacionada com a universalidade de cobertura médica de qualidade (r=-0,92, p<0,01). Esta correlação se manteve significativa após o ajuste para outros indicadores analisados. Conclusão. O nosso estudo sugere que falhas na cobertura médica da população podem ter provocado maior letalidade nas pessoas com menos de 60 anos na América Latina e nos Estados Unidos.