Cardiovascular disease in Guatemala Epidemiology, control ...abc.org.br/IMG/pdf/doc-3382.pdf · Cardiovascular disease in Guatemala Epidemiology, control, and prevention Joaquin Barnoya,

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


The world


Infant mortality


Infectious diseases


All non-communicable diseases


Infant mortality


Epidemiologic transition in Guatemala

Moscoso et. al. Retrato de muertes evitables. 2008


Acute myocardial infarction frequency



CVD mortality by region, 1986-2005



Diabetes frequency



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


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


Scientific production


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


Coffee production


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


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


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


USPSTF Grade A, B Preventive Services

Corral et. al. 2011 In review


USPSTF Grade D, I Preventive Services



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



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%


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%)


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


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


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


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


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


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


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


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


Joaquin Barnoya, MD, MPH Research Director

Cardiovascular Unit of Guatemala [email protected]

©2010

Documents

Cardiovascular disease in Guatemala Epidemiology, control ...abc.org.br/IMG/pdf/doc-3382.pdf · Cardiovascular disease in Guatemala Epidemiology, control, and prevention Joaquin Barnoya,