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Cardiovascular disease in Guatemala Epidemiology, control, and prevention
Joaquin Barnoya, MD, MPH Cardiovascular Unit of Guatemala and
Department of Surgery Division of Public Health Sciences
Department of Surgery Division of Public Health Sciences
The world
Department of Surgery Division of Public Health Sciences
Infant mortality
Department of Surgery Division of Public Health Sciences
Infectious diseases
Department of Surgery Division of Public Health Sciences
All non-communicable diseases
Department of Surgery Division of Public Health Sciences
Infant mortality
Department of Surgery Division of Public Health Sciences
Epidemiologic transition in Guatemala
Moscoso et. al. Retrato de muertes evitables. 2008
Department of Surgery Division of Public Health Sciences
Acute myocardial infarction frequency
Moscoso et. al. Retrato de muertes evitables. 2008
Department of Surgery Division of Public Health Sciences
CVD mortality by region, 1986-2005
Moscoso et. al. Retrato de muertes evitables. 2008
Department of Surgery Division of Public Health Sciences
Diabetes frequency
Moscoso et. al. Retrato de muertes evitables. 2008
Department of Surgery Division of Public Health Sciences
Cardiovascular Unit of Guatemala
Year 2007 2008 2009 2010 2011
Total Patients 12,235 14,258 13,782 13,802 13,608
Heart Surgery 394 334 394 370 342
Coronary Bypass 153 107 * * 117
Cath lab
Interventional 682 756 827 * 771
Diagnostic * 91 33 * *
Stents 148 144 155 * 134
Department of Surgery Division of Public Health Sciences
Strengthening evidence-informed decision-making
PULL
Decision makers
trained and
supported to use
and demand
research and
synthesis
PUSH
Researchers trained
and supported
to supply research
and syntheses and
to disseminate
results
Increasing linkage and exchange
Strengthening EIDM
Department of Surgery Division of Public Health Sciences
Scientific production
Department of Surgery Division of Public Health Sciences
Epidemologic publication rates per million inhabitants by country
Number of articles per million inhabitants
Country
1990
1995
2000
2005
2010
Growth rate (%)
Argentina 1.20 1.29 3.11 3.61 5.14 428
Brazil 1.20 1.50 2.84 5.30 6.33 524
Chile 8.19 3.75 4.86 2.09 7.78 95
Cuba 4.44 5.41 5.77 5.81 5.09 115
Guatemala 0.90 2.20 1.07 2.12 2.35 262
Costa Rica 5.20 3.74 3.82 8.09 6.99 134
Barreto SM, et. al. Int. J of Epidemiol 2012
Department of Surgery Division of Public Health Sciences
Coffee production
Department of Surgery Division of Public Health Sciences
Strategic Plan for NCD Control 2010-2015
• National Program for NCD Control
• General Objective • Stop increase and reduce by 5% morbility and mortality from
NCD
• Specific Objectives • Epidemiologic profile
• Strengthen local healthcare system capacity
• Intervene on the determinant risk factors to promote a healthy lifestyle.
• Support NCD research
• Develop NCD treatment and prevention guidelines
• No budget or funding provided for the plan.
Ministerio de Salud Publica. Guatemala, 2011
Department of Surgery Division of Public Health Sciences
CVD prevention
• Framework Convention on Tobacco Control • Signed and ratified
• No national smoking prevalence survey • No longitudinal data
• Scant progress in implementation
• Only country with no taxes on tobacco
Department of Surgery Division of Public Health Sciences
Chronic Disease Control Research Fellowship Program - UNICAR
• Tobacco - #1 risk factor
• Establish, through mentorship, a new generation of young researchers
• Mentorship Capacity building • Mentorship culture multiplier effect
• Individuals, organizations, institutions, and networks
• Funded – International Development Research Centre
Department of Surgery Division of Public Health Sciences
USPSTF Grade A, B Preventive Services
Corral et. al. 2011 In review
Department of Surgery Division of Public Health Sciences
USPSTF Grade D, I Preventive Services
Corral et. al. 2011 In review
Department of Surgery Division of Public Health Sciences
Perceived barriers
46.4 % Lack of time
31.3 % Inadequate patients’ resources
23.5 % Lack of patient’s interest
13.8 % Low self-confidence
11.3 % Mistrust on services’ effectiveness
10.1 % Forgetfulness
Corral et. al. 2011 In review
Department of Surgery Division of Public Health Sciences
Tobacco Use
• Have ever smoked: • 456 (44.66%) have tried at least once.
• 295 (64.69%) continued smoking.
• Start smoking: • Mean: 17 years (± 4.5 SD).
• Prevalence: • Men: 22.7%
• Women: 0.68%
Department of Surgery Division of Public Health Sciences
Smoking prevalence. Rural Guatemala. 2009
Religion Smokers Non Smokers p
Catholic 172 (33.66%) 339 (66.34%) 0.001
Protestant 33 (8.4%) 360 (91.6%)
Others 82 (20.6%) 316 (79.4%)
Education
Does not read or write.
78 (27.46%) 206 (72.54%) 0.001
of 6 years 78 (15.79%) 416 (84.21%)
of 6 years 40 (10.87%) 328 (89.13%)
Occupation
Field Workers 219 (34.33%) 419 (65.67%) 0.001
Non Field Workers 36 (14.63%) 210 (85.37%)
Others type of work 40 (9.26%) 392 (90.74%)
Department of Surgery Division of Public Health Sciences
Smoking among physicians
• Costa Rica 19%
• Guatemala 18%
• Ecuador 32%
• Colombia 26%
• Chile 30.5%
• Argentina 30.3%
• Mexico 22%
• USA 3.3%
Grossman Bull. WHO. 1999
Barnoya CC&C 2002
Sanchez Rev. Pan S.P. 2003
Rosselli Prev Med 2001
Bello et al. Rev Med Chile 2004
Department of Surgery Division of Public Health Sciences
Meta-analysis of the effect of smoke-free legislation on acute coronary events.
Mackay D F et al. Heart 2010;96:1525-1530 ©2010 by BMJ Publishing Group Ltd and British Cardiovascular Society
• 2010 IOM Report
• Causality
• Europe and US
• 17 studies (35 estimates)
• 1 yr – 10 % (6%-14%)
• 3 yrs – 30%
• Length of follow-up
• Only predictor of magnitude of effect
Department of Surgery Division of Public Health Sciences
Ambient air nicotine in Guatemala. 2005
-3.00877
.947689
nico_log
0 1 2 3 4 5 6Hospital School Gov’t bldg
Airport University Bars Restaurant
0.001
0.01
1.00
10.00
μg/m3
Barnoya et al. Cancer Epi Biomark & Prev. 2007
Department of Surgery Division of Public Health Sciences
Restaurant nicotine levels. Before and after study. Guatemala
.0037
4.1
872
Pre indicates data colected in 2007 and post indicates data collected in 2009 six months after the smoke-free law.
Restaurant nicotine levels in Guatemala
Rest Pre Rest Post
Barnoya et. al. Cancer Causes & Control. 2010
Department of Surgery Division of Public Health Sciences
Bar air nicotine levels. Before and after study. Guatemala
86% decrease
02
46
8
Pre indicates data colected in 2007 and post indicates data collected in 2009 six months after the smoke-free law.
Bar nicotine levels in Guatemala
Bar Pre Bar Post
Barnoya et. al. Cancer Causes & Control. 2010
Department of Surgery Division of Public Health Sciences
Availability of smoking cessation medications and cigarettes by pharmacy type and city.
Cessation Medications Cigarettes
n (%) p n (%) p
Total (n=505) 115 (22.8) 29 (5.7)
Type
Chain (n=173) 81 (46.8) <0.001 20 (11.6) 0.003
Independent (n=229) 34 (14.9) 9 (3.9)
City
Guatemala City (n=463) 97 (21.0) 0.001 27 (5.8) 0.8
Antigua (n=42) 18 (42.9) 2 (4.8)
Viteri et. al. Tobacco Control 2011
Department of Surgery Division of Public Health Sciences
Smoking cessation medications availability and cost (US$).
Availability (%) Median Cost (IQR*) Daily Median
(n=115) Cost (IQR)†
Nicotine patch (7 patch package) 93 (80.9) 16.50 (14.44 - 20.63) 2.36 (2.06 - 2.95)
Nicotine gum (30 gum package) 91 (79.1) 13.00 (12.24 - 15.75) 4.33 (4.08 - 5.25)
Varenicline (1mg x 28) 63 (54.8) 69.26 (68.06 - 70.51) 4.95 (4.86 - 5.04)
Bupropion (150mg x 30) 13 (11.3) 59.00 (56.60 - 59.00) 3.93 (3.77 - 3.93)
Least expensive medication available
15.27 (12.25 - 20.00)
20 cigarettes = one pack (US$) 1.70 (1.63 - 1.77)
Minimum wage in Guatemala (US$): 7.00/day.
*IQR = Interquartile Range. †Based on information from The Regents of the University of California.
Viteri et. al. Tobacco Control 2011
Department of Surgery Division of Public Health Sciences
Conclusion
• Guatemala • “Double-burden” of disease
• Lack of political will to address the NCD epidemic • Undocumented (lack of epidemiologic data)
• Unfunded (rely on international funds)
• Research capacity • Fundamental to address the NCD epidemic
• Urgent need to strengthen in Guatemala
• Turning research into policy
Department of Surgery Division of Public Health Sciences
Joaquin Barnoya, MD, MPH Research Director
Cardiovascular Unit of Guatemala barnoyaj@wudosis.wustl.edu
©2010
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