Neurodevelopmental assessment of normocephalic children born to Zika virus exposed and unexposed pregnant people.

BACKGROUND: Studies examining the association between in utero Zika virus (ZIKV) exposure and child neurodevelopmental outcomes have produced varied results. METHODS: We aimed to assess neurodevelopmental outcomes among normocephalic children born from pregnant people enrolled in the Zika in Pregnancy in Honduras (ZIPH) cohort study, July-December 2016. Enrollment occurred during the first prenatal visit. Exposure was defined as prenatal ZIKV IgM and/or ZIKV RNA result at enrollment. Normocephalic children, >6 months old, were selected for longitudinal follow-up using the Bayley Scales of Infant and Toddler Development (BSID-III) and the Ages & Stages Questionnaires: Social-Emotional (ASQ:SE-2). RESULTS: One hundred fifty-two children were assessed; after exclusion, 60 were exposed and 72 were unexposed to ZIKV during pregnancy. Twenty children in the exposed group and 21 children in the unexposed group had a composite score <85 in any of the BSID-III domains. Although exposed children had lower cognitive and language scores, differences were not statistically significant. For ASQ:SE-2 assessment, there were not statistically significant differences between groups. CONCLUSIONS: This study found no statistically significant differences in the neurodevelopment of normocephalic children between in utero ZIKV exposed and unexposed. Nevertheless, long-term monitoring of children with in utero ZIKV exposure is warranted. IMPACT: This study found no statistically significant differences in the neurodevelopment in normocephalic children with in utero Zika virus exposure compared to unexposed children, although the exposed group showed lower cognitive and language scores that persisted after adjustment by maternal age and education and after excluding children born preterm and low birth weight from the analysis. Children with prenatal Zika virus exposure, including those normocephalic and have no evidence of abnormalities at birth, should be monitored for neurodevelopmental delays. Follow-up is important to be able to detect developmental abnormalities that might not be detected earlier in life.

Assessment of Community Awareness and Screening of Chagas Disease in the Latin American Community of Greater New Orleans.

Chagas disease is a public health problem in the Americas, from the southern United States (USA) to Argentina. In the USA, less than 1% of domestic cases have been identified and less than 0.3% of total cases have received treatment. Little is known about affected immigrant Latin American communities. A prospective study was conducted to assess knowledge about Chagas disease among the Latin American community living in the Greater New Orleans area. Participants answered a baseline questionnaire, viewed a short educational video presentation, completed a post-presentation questionnaire, and were screened with an FDA-approved blood rapid diagnostic test (RDT). A total of 154 participants from 18 Latin American countries (n = 138) and the USA (n = 16) were enrolled and screened for Trypanosoma cruzi infection. At baseline, 57% of the participants knew that Chagas disease is transmitted through an insect vector, and 26% recognized images of the vector. Following the administration of an educational intervention, the participants' knowledge regarding vector transmission increased to 91% and 35% of participants were able to successfully identify images of the vector. Five participants screened positive for T. cruzi infection, indicating a 3.24% [95%CI: 1.1-7.5%] prevalence of Trypanosoma cruzi infection within the Latin American community of the New Orleans area. Results highlight the urgent need for improving access to education and diagnostics of Chagas disease.

Comparative effectiveness and duration of protection of ChAdOx1, CoronaVac, BNT162b2, mRNA-1273, and Ad26.COV2.S COVID-19 vaccines for symptomatic and hospitalized Mu, Delta, and Omicron: A test-negative case-control study.

OBJECTIVE: We carried out a study to estimate the vaccine effectiveness (VE) of homologous vaccination schedules against COVID-19, using data from mandatory information systems from Bogota, Colombia. METHODS: A test-negative case-control study in adults from Bogota (Colombia), between March 1st of 2021 and February 25th of 2022. We assess VE among symptomatic COVID-19 cases during the Mul, Delta, and Omicron predominance periods in Bogota, with controls matched by sex, age (±5 years), and date of testing (±7 days), using a case:control ratio of 1:1. We selected homologous vaccination schedules with ChAdOx1, CoronaVac, BNT162b2, mRNA-1273, and Ad26.COV2.S. VE was reported as one minus the odds ratio in adjusted conditional logistic regressions, with their 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant. RESULTS: 52,913 cases were matched to controls, 16,722 for Mu, 14,094 for Delta, and 22,097 for Omicron. VE was high against COVID-19 during Mu weeks with full vaccination using the monovalent BNT162b2 (VE: 69; 95% CI, 65 to 72) vaccine and ChAdOx1 (VE: 64; 95% CI, 31 to 81) and significantly lower with CoronaVac (P < 0.001) and Ad26.COV2.S (P = 0.005). During Delta, VE against COVID-19 was higher with BNT162b2 (VE: 55; 95% CI, 51 to 58). The VE for COVID-19 cases during Omicron was higher with a booster dose of monovalent BNT162b2 (VE: 45; 95% CI, 34 to 54). The VE of primary series and booster for ChAdOx1, Ad26.COV2.S, and CoronaVac did not show protection for Omicron. CONCLUSION: Our study provides further evidence on the protective effect of mRNA vaccines for Omicron, and warrant that the duration of protection against symptomatic infection may last for only a few months.

Similarity network fusion to identify phenotypes of small-for-gestational-age fetuses.

Fetal growth restriction (FGR) affects 5-10% of pregnancies, is the largest contributor to fetal death, and can have long-term consequences for the child. Implementation of a standard clinical classification system is hampered by the multiphenotypic spectrum of small fetuses with substantial differences in perinatal risks. Machine learning and multiomics data can potentially revolutionize clinical decision-making in FGR by identifying new phenotypes. Herein, we describe a cluster analysis of FGR based on an unbiased machine-learning method. Our results confirm the existence of two subtypes of human FGR with distinct molecular and clinical features based on multiomic analysis. In addition, we demonstrated that clusters generated by machine learning significantly outperform single data subtype analysis and biologically support the current clinical classification in predicting adverse maternal and neonatal outcomes. Our approach can aid in the refinement of clinical classification systems for FGR supported by molecular and clinical signatures.

Reductions in Childhood Pneumonia Mortality After Vaccination in the United States.

BACKGROUND: We aim to estimate the magnitude of the reduction in pneumococcal pneumonia and meningitis mortality after the mass introduction of pneumococcal conjugate vaccine (PCV)7 and PCV13 in children in the United States. METHODS: We assessed the trends in mortality rates from pneumococcal pneumonia and meningitis, in the United States between 1994 and 2017. We fitted an interrupted time-series negative binomial regression model (adjusted by trend, seasonality, PCV7/PCV13 coverage, and H. influenzae type b vaccine coverage) to estimate the counterfactual rates without vaccination. We reported a percent reduction in mortality estimates relative to the projected no-vaccination scenario, using the formula 1 minus the incidence risk ratio, with 95% confidence intervals (CIs). RESULTS: Between 1994 and 1999 (the prevaccination period), the all-cause pneumonia mortality rate for 0-1-month-old children was 2.55 per 100,00 pop., whereas for 2-11 months-old children, this rate was 0.82 deaths per 100,000 pop. During the PCV7-period in 0-59-month-old children in the United States, the adjusted reduction of all-cause pneumonia was 13% (95% CI: 4-21) and 19% (95% CI: 0-33) of all-cause meningitis For PCV13, the reductions in this age group were 21% (95% CI: 4-35) for all-cause pneumonia mortality and 22% (95% CI: -19 to 48) for all-cause meningitis mortality. PCV13 had greater reductions of all-cause pneumonia than PCV13 in 6-11-month-old infants. CONCLUSIONS: The universal introduction of PCV7, and later PCV13, for children 0-59 months old in the United States was associated with decreases in mortality due to all-cause pneumonia.

Performance of the INTERGROWTH-21st and World Health Organization fetal growth charts for the detection of small-for-gestational age neonates in Latin America.

OBJECTIVE: To evaluate the performance of INTERGROWTH-21st (IG-21st ) and World Health Organization (WHO) fetal growth charts to identify small-for-gestational-age (SGA) and fetal growth restriction (FGR) neonates, as well as their specific risks for adverse neonatal outcomes. METHODS: Multicenter cross-sectional study including 67 968 live births from 10 maternity units across four Latin American countries. According to each standard, neonates were classified as SGA and FGR (birth weight <10th and less than third centiles, respectively). The relative risk (RR) and diagnostic performance for a low APGAR score and low ponderal index were calculated for each standard. RESULTS: WHO charts identified more neonates as SGA than IG-21st (13.9% vs 7%, respectively). Neonates classified as having FGR by both standards had the highest RR for a low APGAR (RR, 5.57 [95% confidence interval (CI), 3.99-7.78]), followed by those who were SGA by both curves (RR, 3.27 [95% CI, 2.52-4.24]), while neonates with SGA identified by WHO alone did not have an additional risk (RR, 0.87 [95% CI, 0.55-1.39]). Furthermore, the diagnostic odds ratio for a low APGAR was higher when IG-21st was used. CONCLUSION: In a population from Latin America, the WHO charts seem to identify more SGA neonates, but the diagnostic performance of the IG-21st charts for low APGAR score and low ponderal index is better.

Biochemical and Hematological Markers in Workers with Chronical Exposure to Lead and Cadmium in Colombia.

The aim of the present study was to find if workers chronically exposed to lead (Pb) and cadmium (Cd) presented changes in their general health and in the clinical parameters of the population under study. We carried out a cross-sectional survey in a sample of informal workers in Cartagena, Colombia. The population under study was composed of male informal workers (≥18 years of age), with experience in their job, selected from occupational settings with potential exposure to Pb and Cd (i.e., mechanics, battery and garbage recyclers, and welders). The median age was 45 years (interquartile range (IQR), 33−53). The median blood Pb level (BLL) was 2 µg/dL (IQR, 0.76−6.22), and the median of blood Cd level (BCL) was 1.22 µg/L (IQR, 0.33−2.01). The study found that 33% of high exposure jobs with BLL > 5 µg/dL (n = 57), whereas in 'control' workers, this was 15.3% (n = 9). The highest BLLs were found in battery recyclers (82.1%; n = 23), followed by mechanics (37.3%, n = 22). In the logistic regression model adjusted by age, time on the job, smoking and elevated BCL and BLL increased 3.2 times (95% CI, 1.1−9.7) in mechanics and 29.6 times (95% CI, 7.2−145.6) in battery recyclers. This study found negative changes in the health of workers with higher chronic exposure to lead in Cartagena, Colombia.

Effectiveness of CoronaVac and BNT162b2 COVID-19 mass vaccination in Colombia: A population-based cohort study.

Background: In February 2021, Colombia began mass vaccination against COVID-19 using mainly BNT162b2 and CoronaVac vaccines. We aimed to estimate vaccine effectiveness (VE) to prevent COVID-19 symptomatic cases, hospitalization, critical care admission, and deaths in a cohort of 796,072 insured subjects older than 40 years in northern Colombia, a setting with a high SARS-CoV-2 transmission. Methods: We identified individuals vaccinated between March 1st of 2021 and August 15th of 2021. We included symptomatic cases, hospitalizations, critical care admissions, and deaths in patients with confirmed COVID-19 as main outcomes. We calculated VE for each outcome from the hazard ratio in Cox proportionally hazards regressions (adjusted by age, sex, place of residence, diabetes, human immunodeficiency virus, cancer, hypertension, tuberculosis, neurological diseases, and chronic renal disease), with 95% confidence intervals (CI). Findings: A total of 719,735 insured participants of 40 and more years were followed. We found 21,545 laboratory-confirmed symptomatic COVID-19 among unvaccinated population, along with 2874 hospitalizations, 1061 critical care admissions, and 1329 deaths, for a rate of 207.2 per million person-days, 27.1 per million person-days, 10.0 per million person-days, and 12.5 per million person-days, respectively. We found CoronaVac was not effective for any outcome in subjects above 80 years old; but for people 40-79 years of age, we found two doses of CoronaVac reduced hospitalization (33.1%; 95% CI, 14.5-47.7), critical care admission (47.2%; 95% CI, 18.5-65.8), and death (55.7%; 95% CI, 32.5-70.0). We found BNT162b2 was effective for all outcomes in the entire population of subjects above 40 years of age, significantly declining for subjects ≥80 years. Interpretation: Two doses of either CoronaVac in population between 40 and 79 years of age, or BNT162b2 among vaccinated above 40 years old significantly reduced deaths of confirmed COVID-19 in a cohort of individuals from Colombia. Vaccine effectiveness for CoronaVac and BNT162b2 declined with increasing age. Funding: UK National Institute for Health Research, the European Union's Horizon 2020 research and innovation programme, and the Bill & Melinda Gates Foundation.

Maternal mortality linked to COVID-19 in Latin America: Results from a multi-country collaborative database of 447 deaths.

Background: This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database. Methods: This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges. Findings: We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight. Interpretation: This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays. Funding: Latin American Center for Perinatology, Women and Reproductive Health.

Antecedentes: Este estudio tuvo el objetivo de describir las características clínicas de las muertes maternas asociadas a COVID-19 registradas en una base de datos latinoamericana multipaís. Métodos: Se implementó un estudio observacional descriptivo en el que participaron ochos países Latinoamericanos desde el 1ero de marzo 2020 al 29 de noviembre 2021. La información se obtuvo del Sistema Informático Perinatal del Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva. Presentamos las variables categóricas como frecuencias y porcentajes y las variables continuas en medianas con rangos inter cuartiles. Resultados: Identificamos un total de 447 muertes. La mediana de edad materna fue de 31 años. 86·4% de las mujeres se infectaron ante del parto, siendo la mayoría de los casos detectados en el tercer trimestre del embarazo (60·3%). Los síntomas más frecuentes en la primera consulta y la admisión fueron disnea (73·0%), fiebre (69·0%), y tos (59·0%). Se reportaron disfunciones orgánicas en 90·4% de las mujeres durante la admisión. Un total de 64·8% de las mujeres fueron ingresadas a cuidados críticos por una mediana de ocho días de estadía. En la mayoría de los casos la muerte ocurrió durante el puerperio, con una media de siete días entre el parto y su ocurrencia. El parto prematuro fue la complicación perinatal más frecuente (76·9%) y 59·9% tuvo bajo peso al nacer. Interpretación: Este estudio describe las características de las muertes maternas durante la pandemia por COVID-19 a partir de una base colaborativa multipaís. Se observaron barreras para el acceso a cuidados intensivos. Los tomadores de decisión deberían trabajar en el fortalecimiento de la conciencia de gravedad, y en estrategias de referencia para evitar potenciales demoras. Financiamiento: Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva.

Cost-Effectiveness Analysis of Strategies of COVID-19 Vaccination in Colombia: Comparison of High-Risk Prioritization and No Prioritization Strategies With the Absence of a Vaccination Plan.

OBJECTIVES: Our study compares two national COVID-19 vaccination plan strategies-high-risk prioritization and no prioritization-and estimates their cost-effectiveness compared with no vaccination, to generate possible recommendations for future vaccination plans. METHODS: We developed a Markov discrete-time, compartmental, deterministic model stratified by Colombian departments, healthcare workers, comorbidities, and age groups and calibrated to seroprevalence, cases, and deaths. The model simulates three scenarios: no vaccination, no prioritization of vaccination, and prioritization of high-risk population. The study presents the perspective of the health system of Colombia, including the direct health costs financed by the government and the direct health outcomes related to the infection. We measured symptomatic cases, deaths, and costs for each of the three scenarios from the start of the vaccination rollout to February 20, 2023. RESULTS: Both for the base-case and across multiple sensitivity analyses, the high-risk prioritization proves to be the most cost-effective of the considered strategies. An increment of US$255 million results in an incremental cost-effectiveness ratio of US$3339 per disability-adjusted life-year avoided. The simulations show that prioritization of high-risk population reduces symptomatic cases by 3.4% and deaths by 20.1% compared with no vaccination. The no-prioritization strategy is still cost-effective, with an incremental cost-effectiveness ratio of US$5223.66, but the sensitivity analysis the show potential risks of losing cost-effectiveness under the cost-effectiveness threshold (one gross domestic product per averted disability-adjusted life-year). CONCLUSIONS: The high-risk prioritization strategy is consistently more cost-effective than the no-prioritization strategy across multiple scenarios. High-risk prioritization is the recommended strategy in low-resource settings to reduce the burden of disease.

Impact of mobility restrictions on the dynamics of transmission of COVID-19 in Colombian cities.

BACKGROUND: Our aim was to study the association between case rates and reductions in urban mobility in state capitals of Colombia. METHODS: We designed an ecological time-series study to correlate the Colombian incidence rate with reductions in mobility trends of retail stores. RESULTS: The meta-analysis of ß coefficients describing the association between case rates and reductions in mobility trends of retail stores resulted in a mean estimate of 0.0637 (95% confidence interval 0.027 to 0.101; p<0.001) with nearly 100% heterogeneity. CONCLUSIONS: We recommend continuing to consider mobility restrictions when the number of cases starts to climb in each local jurisdiction.

New obstetric systemic inflammatory response syndrome criteria for early identification of high-risk of sepsis in obstetric patients.

OBJECTIVES: We aimed to establish new cut-off values for SIRS (Systemic Inflammatory Response Syndrome) variables in the obstetric population. METHODS: A prospective cohort study in pregnant and postpartum women admitted with systemic infections between December 2017 and January 2019. Patients were divided into three cohorts: Group A, patients with infection but without severe maternal outcomes (SMO); Group B, patients with infection and SMO or admission to the intensive care unit (ICU); and Group C, a control group. Outcome measures were ICU admission and SMO. The relationship between SIRS criteria and SMO was expressed as the area under the receiver operating characteristics curve (AUROC), selecting the best cut-off for each SIRS criterion. RESULTS: A total of 541 obstetric patients were enrolled, including 341 with infections and 200 enrolled as the reference group (Group C). The patients with infections included 313 (91.7%) in Group A and 28 (8.2%) in Group B. There were significant differences for all SIRS variables in Group B, compared with Groups A and C, but there were no significant differences between Groups A and C. The best cut-off values were the following: temperature 38.2 °C, OR 4.1 (1.8-9.0); heart rate 120 bpm, OR 2.9 (1.2-7.4); respiratory rate 22 bpm, OR 4.1 (1.6-10.1); and leukocyte count 16,100 per mcl, OR 3.5 (1.6-7.6). CONCLUSIONS: The cut-off values for SIRS variables did not differ between healthy and infected obstetric patients. However, a higher cut-off may help predict the population with a higher risk of severe maternal outcomes.

Diarrheal Deaths After the Introduction of Rotavirus Vaccination in 4 Countries.

BACKGROUND: We aim in our analysis to estimate the reduction of diarrhea-related mortality rates after introduction of a rotavirus vaccine in subregions of 4 Latin American countries. METHODS: We selected diarrhea-related deaths from individual-level data from death certificates in Brazil, Colombia, Ecuador, and Mexico. Counts were aggregated by region, year and month, and age group for each country. We ran an interrupted time-series analysis using Poisson regression to obtain seasonal and trend-adjusted estimates of impact. Results are reported as percentages (1 - mortality rate ratio). RESULTS: We found a reduction in diarrhea-related mortality in children <5 years old of 18% (95% confidence interval [CI], 15 to 20) for Mexico, 39% (95% CI, 35 to 44) for Colombia, 19 (95% CI, 17 to 22) for Brazil, and -26% (95% CI, -40 to -14) for Ecuador. Using wavelet analyses, we found a reduction of 6- and 12-month seasonality in Brazil, Colombia, and Mexico. We also found that the increased reduction of diarrhea-related deaths was larger with greater prevaccine burden of diarrhea in infants. CONCLUSIONS: Our findings and available evidence support the recommendation from the World Health Organization for the monovalent and/or pentavalent rotavirus vaccine in countries worldwide. We found an increased benefit in those settings with a higher burden of infant diarrhea-related deaths.

The impact of maternal anemia and labor on the obstetric Shock Index in women in a developing country.

BACKGROUND: The Shock Index is a clinical tool to evaluate the hemodynamic status during hemorrhage. The impact of labor and pre-existing anaemia is unknown. The objective was to describe and discuss its clinical utility in this context. METHODS: This was a prospective cross-sectional study. The Shock Index (ratio between heart rate and systolic blood pressure) was measured in pregnant women at term, before or during labor. They were stratified according to the presence of anemia. RESULTS: The median Shock Index was significantly lower in women in labor than in those not in labor (0.72 (IQR: 0.64-0.83) vs. 0.85 (IQR: 0.80-0.94); p < 0.001). In women in labor, the Shock Index was not significantly different if anemia was present (0.72 (0.63-0.83) vs. 0.73 (0.65-0.82); p = 0.67). CONCLUSIONS: Values of the Shock Index are affected by labor, which may hinder its utility in identifying hemorrhage during this period. However, the values were not altered by maternal anaemia. Therefore, an abnormal postpartum Shock Index should not be attributed to an abnormal antepartum Shock Index due to mild/moderate anemia.

Underreporting of Fatal Congenital Zika Syndrome, Mexico, 2016-2017.

To determine completeness of fatal congenital Zika syndrome reporting in Mexico, we examined data from the Mexican National Institute of Statistics and Geography. We found that an estimated 50% more infants died from microcephaly attributable to congenital Zika syndrome during 2016-2017 than were reported by the existing surveillance system.

Inequalities on mortality due to acute respiratory infection in children: A Colombian analysis / Desigualdades en la mortalidad debidas a la infección respiratoria aguda en niños: análisis de la situación en Colombia

Introduction: Acute respiratory infections (ARI) are a leading public health issue worldwide. Objective: To explore the inequalities in ARI mortality rates in under-5, according to socioeconomic characteristics. Materials and methods: We conducted an ecological analysis to study inequalities at municipal level due to ARI mortality in children under 5 years. The data were obtained from official death records of the Departamento Administrativo Nacional de Estadística. The analysis of inequalities in the under-5 mortality rate (U5MR) included: 1) Classification of the population in different socio-economic strata, and 2) measurement of the degree of inequality. We used the ARI-U5MR as an outcome measurement. The mortality rates were estimated at national and municipal levels for the years 2000, 2005, 2010, and 2013. Rate ratios, rates differences, and concentration curves were calculated to observe the inequalities. Results: A total of 18,012 children under 5 years died by ARI in Colombia from 2000 to 2013. ARIU5MR was greater in boys than in girls. During this period, an increase in the infant mortality relative gap in both boys and girls was observed. In 2013, the U5MR evidenced that for boys from municipalities with the highest poverty had a 1.6-fold risk to die than those in municipalities with the lowest poverty (low tercile). In girls, the ARI-U5MR for 2005 and 2013 in the poorest tercile was 1.5 and 2 times greater than in the first tercile, respectively. Conclusion: Colombian inequalities in the ARI mortality rate among the poorest municipalities compared to the richest ones continue to be a major challenge in public health.

Introducción. Las infecciones respiratorias agudas (IRA) son un importante problema de salud pública a nivel mundial. Objetivo. Explorar las desigualdades de la tasa de mortalidad debida a IRA en niños menores de 5 años según las variables socioeconómicas. Materiales y métodos. Se hizo un análisis ecológico para estudiar las desigualdades a nivel municipal de las tasas de mortalidad por IRA en menores de 5 años. Los datos se obtuvieron a partir de los registros de muertes del Departamento Administrativo Nacional de Estadística. El análisis de desigualdades incluyó la clasificación de la población por estatus socioeconómico y la medición del grado de desigualdad. Como resultado en salud se utilizó la tasa de mortalidad por IRA en menores de 5 años. Se estimaron tasas a nivel nacional y municipal para 2000, 2005, 2010 y 2013. Se calcularon razones y diferencias de tasas y curvas de concentración para observar las desigualdades. Resultados. Entre 2000 y 2013 murieron por IRA en Colombia 18.012 menores de 5 años. La tasa de mortalidad por ARI fue mayor en niños que en niñas. En el periodo, se observó un incremento en la brecha de mortalidad infantil en ambos sexos. En el 2013, la tasa de niños que murieron en municipios con mayor pobreza fue 1,6 veces mayor que la de niños en aquellos con menos pobreza. En niñas, en el 2005 y el 2013, la tasa en el tercil más pobre fue 1,5 y 2 veces mayor que la del primer tercil, respectivamente. Conclusión. Las desigualdades en la tasa de mortalidad por IRA de los municipios más pobres en comparación con la de los más ricos, continúan siendo un reto importante en salud pública.

Heterogeneity Between States in the Health and Economic Impact of Measles Immunization in the United States.

BACKGROUND: Vaccines have been used successfully for disease elimination programs in many countries. Evidence on the impact of vaccination programs can support decision-making among medical practitioners and policy makers to improve immunization rates. We estimated the health and economic impact of measles vaccination for each of the 48 contiguous states and the District of Columbia since 1964. METHODS: For each state, we fitted multiple time-series models to prevaccination data and used the best-fitting model to predict counterfactual cases that would have occurred in the absence of vaccination. We then subtracted observed from counterfactual measles cases, deaths, and related costs to estimate the impact of vaccination. RESULTS: We estimated that 149 million children were vaccinated against measles in the United States between 1964 and 2014, at a cost of $12.2 billion, and that vaccination prevented 29.8 million cases, 32 000 deaths, and $25.8 billion in societal costs. The impact exceeded the national average in 70% of Western and Northeastern states, compared with only 24% of Southern and Midwestern states. CONCLUSIONS: The significant health and economic benefit of measles vaccination in the United States should encourage continued investments to sustain and expand vaccination programs globally.