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Background: Rickettsiae are obligate intracellular Gram-negative bacteria that are the causative agent of rickettsioses and are spread to vertebrate hosts by arthropods. There are no previous reports of isolation of Rickettsia amblyommatis for Colombia. Methods: A convenience sampling was executed in three departments in Colombia for direct collection of adult ticks on domestic animals or over vegetation. Ticks were screened for the presence of Rickettsia spp. by real-time polymerase chain reaction (qPCR) amplifying the citrate synthase gene (gltA), and the positive sample was processed for isolation and further molecular characterization by conventional PCR. The absolute and relative frequencies were calculated for several tick species variables. All products from conventional PCR were further purified and sequenced by the Sanger technique. Representative sequences of 18 Rickettsia species were downloaded from GenBank. Consensus phylogenetic trees were constructed for the gltA, ompB, ompA, and htrA genes with 1000 replicates, calculating bootstrap values through the maximum likelihood method and the generalized time reversible substitution model in the MEGA 7.0 software program. Results: One female Amblyomma mixtum collected on vegetation was amplified by qPCR (gltA), indicating a frequency of 1.6% (1/61) for Rickettsia spp. infection. Sequence analysis of a rickettsial isolate from this tick in BLASTn showed 100% identity with gltA (340 base pairs [bp]), 99.87% for ompB (782 bp), 98.99% for htrA (497 bp), and 100% for ompA (488 bp) to R. amblyommatis. Concatenated phylogenetic analysis confirmed these findings indicating that the isolate is grouped with other sequences of Amblyomma cajennense complex from Panama and Brazil within the R. amblyommatis clade. Conclusions: This paper describes the isolation and early molecular identification of a R. amblyommatis strain from A. mixtum in Colombia. [ABSTRACT FROM AUTHOR]

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Background: Cervical cancer patients in Colombia have a lower likelihood of survival compared to breast cancer patients. In 1993, Colombia enrolled citizens in one of two health insurance regimes (contributory-private insurance and subsidized- public insurance) with fewer benefits in the subsidized regime. In 2008, the Constitutional Court required the Colombian government to unify services of both regimes by 2012. This study evaluated the impact of this insurance change on cervical cancer mortality before and after 2012. Methods: We accessed 24,491 cervical cancer mortality records for 2006–2020 from the vital statistics of Colombia's National Administrative Department of Statistics (DANE). We calculated crude mortality rates by health insurance type and departments (geopolitical division). Changes by department were analyzed by rate differences between 2006 and 2012 and 2013–2020, for each health insurance type. We analyzed trends using join-point regressions by health insurance and the two time-periods. Results: The contributory regime (private insurance) exhibited a significant decline in cervical cancer mortality from 2006 to 2012, characterized by a noteworthy average annual percentage change (AAPC) of -3.27% (P = 0.02; 95% CI [-5.81, -0.65]), followed by a marginal non-significant increase from 2013 to 2020 (AAPC 0.08%; P = 0.92; 95% CI [-1.63, 1.82]). In the subsidized regime (public insurance), there is a non-significant decrease in mortality between 2006 and 2012 (AAPC − 0.29%; P = 0.76; 95% CI [-2.17, 1.62]), followed by a significant increase from 2013 to 2020 (AAPC of 2.28%; P < 0.001; 95% CI [1.21, 3.36]). Examining departments from 2013 to 2020 versus 2006 to 2012, the subsidized regime showed fewer cervical cancer-related deaths in 5 out of 32 departments, while 6 departments had higher mortality. In 21 departments, mortality rates remained similar between both regimes. Conclusion: Improvement of health benefits of the subsidized regime did not show a positive impact on cervical cancer mortality in women enrolled in this health insurance scheme, possibly due to unresolved administrative and socioeconomic barriers that hinder access to quality cancer screening and treatment. [ABSTRACT FROM AUTHOR]

Background: This study explores the impacts of attacks perpetrated in the context of armed conflict, to female health workers in three Colombian territories. Methods: We conducted a document review of the reports and databases of the Colombian Truth Commission, 17 in-depth semi-structured interviews with experts on the national and regional armed conflict and the medical mission, and 26 female health workers who were victims of attacks. Results: Experts and female health workers reported attacks to health activities, facilities, equipment, and personnel, including attacks to traditional doctors belonging to indigenous communities. The most frequent attacks were threats and retention of health personnel; theft of supplies and medicines; damage and use of infrastructure and means of transport for purposes other than health care; and hinderance of health service provision. The attacks occurred in a framework of structural violence that intersects with poverty, racism, and gender bias. The impacts of these attacks include gender-based violence, significant disruption of the lives of health workers, and physical, emotional, psychological, social, and economic effects on the victims and their families. The government response to protect victims and populations has been absent or insufficient. Conclusions: Attacks to health care were reported in all the studied territories obstructing adequate health care. Impacts of these attacks affect negatively the professional and personal life of the workers and are aggravated by structural violence and absent or little institutional response. [ABSTRACT FROM AUTHOR]

Background: Conflict and violence can impact on the mental health of children and young people, who are in a crucial stage of their personal growth. Not much is known about the provision of mental health care to young people in conflict-affected areas. Community-based care can be essential, as state-led services are often scarce in conflict contexts, like Colombia's Pacific region where this research was conducted. According to the WHO, such care is ideally provided in the form of a network of interconnected services, offered by different actors beyond the formal health sector. This article describes the relationship between the formal and community mental health systems in Colombia's Pacific region, and identifies ways of improving their interaction. Methods: Qualitative data were collected through 98 semi-structured interviews with community organisations, schools, international organisations and state institutions. These interviews aimed to identify the strategies used to promote young people's mental health and the interactions between the different providers. Boundary spanning theory was used to analyse how different actors and forms of mental health care provision could coordinate better. Results: Community organisations and schools use a wide array of strategies to attend to the mental health of children and young people, often of a collective and psychosocial nature. State institutions offer more clinically focused strategies, which are however limited in terms of accessibility and continuity. International organisations aim to strengthen state capacity, but often struggle due to high staff turnover. Although mental health care pathways exist, their effectiveness is limited due to ineffective coordination between actors. Conclusions: To make sure that the variety of strategies to improve young people's mental health effectively reach their beneficiaries, better coordination is needed between the different actors. Mental health care pathways should therefore integrate community organisations, while community connectors can help to manage the coordination between different actors and forms of clinical and psychosocial support. [ABSTRACT FROM AUTHOR]

Colombia has one of the longest running internal armed conflicts, which has significantly impacted the mental health of the population. This article is the first to present a national level mapping of the provision of mental health services to young people living in Colombia, through detailed review of documentation, interviews with key stakeholders and quantitative analysis of existing data on mental health and suicide. It explores the existing public mental health provision in the country, focussing on where mental health resources are concentrated and how these are implemented. We use this mapping to understand how the current mental health system in Colombia fits with international approaches to youth mental health. We show that whilst mental health policy is variously framed (biomedical, biosocial, psychologically or through human rights), Colombian policy clearly focusses on a differential approach. This differential approach shapes service provision to target support at those in need, consequently neglecting whole population level mental health support. This means that not all stakeholders were clearly articulated or included in policy and that key institutional stakeholders, such as the education sector, were not linked to implementation plans or activity. Policy approaches were also over-centralised with little cross-institutional collaboration. Youth were specifically missing from services, as was explicit understanding of the intergenerational effects and impact of conflict. This was exacerbated by unequal distribution of mental health care services concentrated in populous, urban areas away from conflict-affected regions. Suicide is the second most prevalent cause of death with 10% of population who were recorded as dying by violence, dying from completed suicide. Triangulation implies a strong relationship between suicide and poorer access to professional support in conflict-affected areas and suggests that international frameworks and policy approaches to supporting youth mental health have been insufficiently adapted for conflict and post conflict contexts. [ABSTRACT FROM AUTHOR]

Background: Colombia has experienced decades of conflict between the government and non-state actors. Attacks on healthcare have been a grave but regular facet of that violence. In response, the Misión Médica (MM) program was developed to support, protect, and defend healthcare. Sporadic violence continues, with many recent attacks perpetrated not by armed actors but by residents. Given the history of conflict and ongoing violence, we sought to capture the perspectives of both healthcare workers (HCWs) and community members (CMs) regarding the characteristics and impacts of attacks on health in Colombia to gain insight into how to better prevent violence and mitigate its impacts. Methods: A cross-sectional survey was conducted from January to March 2021 in seven departments in Colombia in regions that witnessed attacks on healthcare. Questionnaires were administered to HCWs and CMs via purposive sampling, probing their experiences with attacks on health with both closed and open-ended questions. The categorical responses were stratified by health worker vs. non-health worker and descriptively analyzed. Narrative responses were analyzed via a hybrid deductive/inductive thematic approach. Results: Seventy-three individuals participated in the study (36 HCWs and 37 cm). Approximately 77% of HCWs believed that attacks on healthcare impacted health outcomes while 68% of CMs did not see a direct connection between violence against healthcare and poor health outcomes. Awareness of the MM program was significantly different between HCWs (83.3%) and CMs (37.8%). The survey responses explored the characteristics of attacks on health, compounded impacts of violence on the health system, personal impacts, and perspectives on mitigation efforts. Conclusions: The study demonstrates that: (1) attacks on healthcare are context-dependent and require a local lens for mitigation and management; (2) both HCWs and CMs have critical perspectives that must be considered, (3) the impacts of violence against healthcare are complex and compounded and (4) that awareness of the legal protections of the Geneva Conventions must be combined with education on the health impacts for robust protection strategies. Critically, Both CMs and HCWs experience fear and psychosocial ramifications of these attacks, suggesting the need for stronger protections and resources to support the health workforce and the local community. [ABSTRACT FROM AUTHOR]

Background: Self-efficacy alludes to personal competence in an individual's effectiveness when facing stressful situations. This construct has been related to different domains of the health field, finding that high levels of self-efficacy benefit human functioning and enhance well-being. Methods: The present study aimed to determine the psychometric properties of the self-efficacy scale for managing chronic diseases (SEMCD-S) by assessing factorial, convergent and divergent validity, reliability, and measurement invariance. Likewise, the comparison of self-efficacy according to socio-demographic characteristics was proposed by contrasting latent factors. An instrumental, transactional, descriptive, and non-experimental design study was carried out with the participation of 325 Colombian senior citizens. Results: The findings suggest that the scale has appropriate psychometric properties. The one-factor structure exhibited a satisfactory fit, the mean-variance extracted reported acceptable figures and the correlation analysis with other constructs supported this instrument's convergent and discriminant validity. Likewise, it was invariant to the different socio-demographic aspects examined, while the internal consistency figures were high. Differences in the means of the latent factors were only detected in the academic grade. In this case, older adults with a primary school level attained higher self-efficacy values than those who had completed high school or university studies. Conclusions: It is concluded that the self-efficacy scale for chronic disease management is a valid and reliable instrument that can be used in the Colombian context to measure and compare this construct. [ABSTRACT FROM AUTHOR]

Introduction: Colombia has 50,912,429 inhabitants, but only 50–70% of the population can effectively access health care services. The emergency room (ER) is a main contributor to the in-hospital care system since up to half of the admissions come through it. Telemedicine has become a tool to facilitate effective access to health care services, improve the timeliness of care, reduce diagnostic variability, and reduce costs associated with health. The aim of this study is to describe the experience of a Distance Emergency Care Program through Telemedicine (TelEmergency) to improve specialist access for patients at the Emergency Room (ER) in low- and medium-level care hospitals in Colombia. Methods: An observational descriptive study of a cohort including 1,544 patients during the program's first two years was conducted. Descriptive statistics were used to analyze the available data. The data are presented with summarized statistics of sociodemographic, clinical, and patient-care variables. Results: The study included a total of 1,544 patients, and the majority were adults between 60 and 79 years of age (n = 491, 32%). More than half were men (n = 832, 54%), and 68% (n = 1,057) belonged to the contributory health care regime. The service was requested from 346 municipalities, 70% (n = 1,076) from intermediate and rural settings. The most common diagnoses were related to COVID-19 (n = 356, 22%), respiratory diseases (n = 217, 14%), and cardiovascular diseases (n = 162, 10%). We observed 44% (n = 681) of local admissions either under observation (n = 53, 3%) or hospitalization (n = 380, 24%), limiting the need for hospital transfers. Program operation data revealed that 50% (n = 799) of requests were answered within two hours by the medical staff. The initial diagnosis was modified in 7% (n = 119) of the patients after being evaluated by specialists at the TelEmergency program. Conclusions: This study shows the operational data collected during the first two years after the implementation of the TelEmergency program in Colombia, the first of its kind in the country. Its implementation offered specialized timely management of patients at the ER in low- and medium-level care hospitals, where there is no availability of specialized doctors. [ABSTRACT FROM AUTHOR]

Mixed methods are essential in public health research and malaria control, because they allow grasping part of the complexity and diversity of the factors that determine health-disease. This study analyzes the mixed studies on malaria in Colombia, 1980–2022, through a systematic review in 15 databases and institutional repositories. The methodological quality was assessed with Mixed Methods Appraisal Tool (MMAT), STrengthening the Reporting of OBservational studies in Epidemiology (STROBE), and Standards for Reporting Qualitative Research (SRQR). The qualitative and quantitative findings were grouped into a four-level hierarchical matrix. The epidemiological profile of malaria morbidity, from traditional epidemiology, has been sustained by environmental problems, armed conflict, individual risk behaviors, and low adherence to recommendations from health institutions. However, the qualitative component reveals deeper causes that are less studied, of greater theoretical complexity, and that reflect challenges to design and implement health interventions, such as socioeconomic and political crises, poverty, and the neoliberal orientation in the malaria control policy; the latter reflected in the change in the role of the State, the fragmentation of control actions, the predominance of insurance over social assistance, the privatization of the provision of health services, the individualistic and economistic predominance of health, and low connection with popular tradition and community initiatives. The above confirms the importance of expanding mixed studies as a source of evidence to improve malaria research and control models in Colombia, and to identify the underlying causes of the epidemiological profile. [ABSTRACT FROM AUTHOR]

Background: The Colombian armed conflict has left millions of victims and has restricted access to different services provided by the government, especially for people with disabilities. This article studies the barriers faced by the victim population with disabilities when they want to access the health system in the department of Meta, Colombia, and offers a perspective from the experiences of people with disabilities who have been victims of the armed conflict in the country. Methods: To carry out this qualitative study, focus groups were conducted to capture the experiences and feelings of this population in the context of violence and high conflict. Results: The results show the barriers encountered by the victim population with disabilities, their families, and their caregivers when they want to access medical or health services. Conclusions: Many problems affect the population with disabilities and the victim population in Colombia today. The Colombian government has not been able to establish adequate policies to eliminate or even reduce access to services such as health, education, housing, and social protection. Key message: • The population with disabilities who have been victims of the armed conflict in Colombia find more significant barriers to accessing health services than people without disabilities due to various situations of exclusion in the provision and accessibility of medical services. • In the department of Meta, the population with disabilities who have been victims of the armed conflict manifest being vulnerable and lacking protection from the Colombian government. • Colombia, to date, has not been able to fully implement national and international agreements that guarantee respect for the human rights of people with disabilities. • It is essential that both national and local governments implement policies and actions so that the victim population with disabilities can access health, education, and social protection services. [ABSTRACT FROM AUTHOR]

Background: Cultural safety training, whereby health professionals learn to reflect on their own culture and to respect the cultural identity of patients, could address intercultural tensions in health care. Given the context of their medical education, however, medical students might perceive such training to be dull or even unnecessary. Game jams, collaborative workshops to create and play games, are a potentially engaging learning environment for medical students today. How medical students learn while making games is poorly documented. This study describes the characteristics of educational games created by participants in a cultural safety game jam and the concepts they used to create games. Methods: As part of a trial, 268 Colombian medical students divided into 48 groups participated in an eight-hour game jam to create a prototype of an educational game on cultural safety. In this qualitative descriptive study, we reviewed the description of the games uploaded by participants, including the name, objective, game narrative, rules, rewards, penalties, and pictures. An inductive thematic analysis collated their descriptions. Results: The game descriptions illustrated the characteristics of the educational games and the aspects of the cultural safety concept that the students used to create games. Medical students situated cultural safety within a continuum with culturally unsafe actions at one end and cultural safety at the other end. Although not familiar with game design, the students designed prototypes of basic educational games including game dynamics, game scenarios, learning objectives, and pedagogical strategies. Conclusion: The findings of this study could help researchers and educators to understand how medical students learn from game design and the kind of games that game jam participants can create without previous game design skills. [ABSTRACT FROM AUTHOR]

Background: Resistance to anti-malarial drugs is associated with polymorphisms in target genes and surveillance for these molecular markers is important to detect the emergence of mutations associated with drug resistance and signal recovering sensitivity to anti-malarials previously used. Methods: The presence of polymorphisms in genes associated with Plasmodium falciparum resistance to chloroquine and sulfadoxine-pyrimethamine was evaluated by Sanger sequencing, in 85 P. falciparum day of enrollment samples from a therapeutic efficacy study of artemether–lumefantrine conducted in 2018–2019 in Quibdo, Colombia. Samples were genotyped to assess mutations in pfcrt (codons 72–76), pfdhfr (codons 51, 59, 108, and 164), and pfdhps genes (codons 436, 437, 540, and 581). Further, the genetic diversity of infections using seven neutral microsatellites (NMSs) (C2M34, C3M69, Poly α, TA1, TA109, 2490, and PfPK2) was assessed. Results: All isolates carried mutant alleles for pfcrt (K76T and N75E), and for pfdhfr (N51I and S108N), while for pfdhps, mutations were observed only for codon A437G (32/73, 43.8%). Fifty samples (58.8%) showed a complete neutral microsatellites (NMS) profile. The low mean number of alleles (2 ± 0.57) per locus and mean expected heterozygosity (0.17 ± 0.03) showed a reduced genetic diversity. NMS multilocus genotypes (MMG) were built and nine MMG were identified. Conclusions: Overall, these findings confirm the fixation of chloroquine and pyrimethamine-resistant alleles already described in the literature, implying that these drugs are not currently appropriate for use in Colombia. In contrast, mutations in the pfdhps gene were only observed at codon 437, an indication that full resistance to sulfadoxine has not been achieved in Choco. MMGs found matched the clonal lineage E variant 1 previously reported in northwestern Colombia. [ABSTRACT FROM AUTHOR]

Background: There is scarce information about ischemic stroke in young patients in Colombia. To get insights about this phenomenon, this study describes the etiologies and risk factors of ischemic stroke in young patients in a third level complexity referral hospital in Medellin, Colombia.Methods: A retrospective observational cross-sectional study was carried out reviewing the medical records of patients between 18 to 49 years old admitted for the first time for ischemic stroke, from January 2009 to December 2019. The sociodemographic characteristics, risk factors, and etiological classification of ischemic stroke according to the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) were described.Results: Two hundred thirty-seven cases were found. The most frequent risk factors were arterial hypertension (31.7%), smoking (29.5%) and alcohol intake (23.2%). There was a greater number of traditional cardiovascular risk factors at older ages. The TOAST classification was large-artery atherosclerosis (6.8%), cardioembolism (17.7%), small-vessel disease (7.6%), other determined etiology (25.7%) and undetermined (42.2%). Within cardioembolism, the most common high-risk source was valve replacement, and the most common moderate-risk source was patent foramen ovale. Craniocervical arterial dissection (11.4%) and substance abuse (2.9%) were the two most frequent sources within other determined etiologies. The most common compromised vascular territory was the anterior (55.7%).Conclusions: The high frequency of traditional risk factors in young patients highlights the need to optimize primary and secondary prevention plans. This study provides new insights about the relevance of illicit substance abuse in Colombia as a cause of stroke in young patients, unlike the previous one conducted in Bogotá. Infectious causes were other peculiarities found. It is necessary to investigate the reasons for the high proportion of undetermined causes. [ABSTRACT FROM AUTHOR]

Background: Cultural safety training is not yet standard in Colombian medical education. If incorporated, it could address currently adversarial interactions between health professionals and the 40% of people who use traditional medicine practices. In 2019, a randomised controlled trial tested the impact of cultural safety training for medical students using participatory serious game design. The quantitative evaluation showed improved cultural safety intentions of Colombian medical trainees. We report here a qualitative evaluation of the most significant change perceived by trial participants. Methods: This qualitative descriptive study used the most significant change technique. We invited the trial participants engaged in clinical settings to describe stories of change in their supervised clinical practice that they attributed to the intervention. Using a deductive thematic analysis based on a modified theory of planned behaviour, two independent reviewers coded the stories and, by consensus, created themes and sub-themes. Results: From 27 stories of change, we identified seven themes and 15 subthemes: (a) Conscious knowledge: benefits of cultural safety training, consequences of culturally unsafe behaviour, cultural diversity and cultural practices; (b) Attitudes: respect and appreciation for cultural diversity, openness, and self-awareness; (c) Subjective norms: positive perception of cultural practices and less ethnocentrism; (d) Intention to Change; (e) Agency to accept cultural diversity and to prevent culturally unsafe actions; (f) Discussion; and (g) Action: better communication and relationship with patients and peers, improved outcomes for patients, physicians, and society, investigation about cultural health practices, and efforts to integrate modern medicine and cultural health practices. Conclusion: The narratives illustrated the transformative impact of cultural safety training on a results chain from conscious knowledge through to action. Our results encourage medical educators to report other cultural safety training experiences, ideally using patient-related outcomes or direct observation of medical trainees in clinical practice. Trial registration: Registered on ISRCTN registry on 18/07/2019. Registration number: ISRCTN14261595. [ABSTRACT FROM AUTHOR]

Background: In Colombia, a person caught in possession of an illicit substance is not judicially sanctioned as long as the quantity does not exceed the maximum allowable amounts. Given that the public is divided on the appropriateness of this policy, an examination of the various public positions was undertaken.Method: A convenience sample of 302 adults were presented with 48 vignettes depicting a situation of everyday life easily recognizable by all in Colombia; that of a male person who is apprehended in the street by the police because he is suspected of illicit trafficking. These vignettes were created by orthogonal variation of four factors: Type of substance, amount of substance, type of charge against the offender, and offender's age.Results: Through cluster analysis, six qualitatively different positions were found. These positions corresponded to three distinct, classical philosophies (a) a libertarian, free-market philosophy - punishment should never be extremely severe because the trade in psychotropic substances is a trade like any other (6%), (b) a moralistic, conservative philosophy - punishment should always be extremely severe except perhaps in certain cases (52%), and (c) a progressive, human rights-inspired philosophy - punishment should always be proportional to the seriousness of the facts (42%).Conclusion: Half of Colombian people supported a control policy according to which the use of psychotropic substances is considered profoundly immoral. Most of the other segment of the population express views similar to those of international organizations. It is therefore desirable that legislators rely on progressive international legislation to support domestic policies that are not strictly moralistic and conservative. [ABSTRACT FROM AUTHOR]

Background: The negative association between income inequality and health has been known in the literature as the Income Inequality Hypothesis (IIH). Despite the multiple studies examining the validity of this hypothesis, evidence is still inconclusive, and the debate remains unsolved. In addition, relatively few studies have focused their attention on developing or emerging economies, where levels of inequality tend to be the highest in the world. This work examines the statistical association between income inequality and self-rated health status in Colombia, a highly unequal Latin American country. Methods: To explore whether this association is present in the general population or whether it is only confined to the bottom of the income distribution, we use data from the 2011–2019 National Quality of Life Survey. Multiple probit estimations are considered for testing the robustness of the IIH. Results: Evidence favouring the IIH was found, even after controlling for individual income levels, average regional income, and socioeconomic characteristics. The link between income inequality and the probability of reporting poor health seems to be present across all income quintiles. However, the magnitude of such association is considerably smaller when using inequality measures with relatively greater sensitivity to income differences among the rich. Conclusions: The association between regional income inequality and individual's self-rated health status in Colombia is not only confined to low-income individuals but extends across all socioeconomic strata. This association is robust to the income inequality measure implemented, the income-unit of analysis, and changes in the sample. It is suggested that reducing income disparities can potentially contribute to improving individual's health. [ABSTRACT FROM AUTHOR]

Since the COVID-19 outbreak, millions of people have been infected with SARS-CoV-2 around the world. An area of epidemiological relevance is Latin America, tropical regions, due to the distribution of endemic diseases such as chikungunya, dengue (DENV), malaria, Zika virus, where febrile disease abounds. The early signs and symptoms of DENV and COVID-19 could be similar, making it a risk that patients may be wrongly diagnosed early during the disease. The problem increases since COVID-19 infection can lead to false positives in DENV screening tests. We present two cases of acute undifferentiated febrile syndrome that were diagnosed with SARS-CoV-2 and DENV co-infection, confirmed by ELISA and RT-PCR for both viral pathogens. The occurrence of simultaneous or overlapped infections can alter the usual clinical course, severity, or outcome of each infection. Therefore, epidemiological surveillance and intensified preparation for those scenarios must be considered, as well as further studies should be done to address cases of co-infection promptly to avoid major complications and fatal outcomes during the current pandemic. Other endemic tropical diseases should not be neglected. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial stewardship programs (ASPs) have become a fundamental pillar in optimizing antimicrobial usage, improving patient care, and reducing antimicrobial resistance (AMR). Herein we evaluated the impact of an ASP on antimicrobial consumption and AMR in Colombia.Methods: We designed a retrospective observational study and measured trends in antibiotic consumption and AMR before and after the implementation of an ASP using interrupted time series analysis over a 4-year period (24 months before and 24 months after ASP implementation).Results: ASPs were implemented according to the available resources in each of the institutions. Before ASP implementation, there was a trend toward an increase in the antibiotic consumption of all measured antimicrobials selected. Afterward, an overall decrease in antibiotic consumption was observed. The use of ertapenem and meropenem decreased in hospital wards, while a decrease in the use of ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, and vancomycin was observed in intensive care units. After ASP implementation, the trend toward an increase of oxacillin-resistant Staphylococcus aureus, ceftriaxone-resistant Escherichia coli, and meropenem-resistant Pseudomonas aeruginosa was reversed.Conclusions: In our study, we showed that ASPs are a key strategy in tackling the emerging threat of AMR and have a positive impact on antibiotic consumption and resistance. [ABSTRACT FROM AUTHOR]

Background: In the Americas, endemic countries for Aedes-borne diseases such as dengue, chikungunya, and Zika face great challenges particularly since the recent outbreaks of CHIKV and ZIKV, all transmitted by the same insect vectors Aedes aegypti and Ae. albopictus. The Special Program for Research and Training in Tropical Diseases (TDR-WHO) has developed together with partners an Early Warning and Response System (EWARS) for dengue outbreaks based on a variety of alarm signals with a high sensitivity and positive predictive value (PPV). The question is if this tool can also be used for the prediction of Zika and chikungunya outbreaks.Methodology: We conducted in nine districts of Mexico and one large city in Colombia a retrospective analysis of epidemiological data (for the outbreak definition) and of climate and entomological data (as potential alarm indicators) produced by the national surveillance systems for dengue, chikungunya and Zika outbreak prediction covering the following outbreak years: for dengue 2012-2016, for Zika 2015-2017, for chikungunya 2014-2016. This period was divided into a "run in period" (to establish the "historical" pattern of the disease) and an "analysis period" (to identify sensitivity and PPV of outbreak prediction).Results: In Mexico, the sensitivity of alarm signals for correctly predicting an outbreak was 100% for dengue, and 97% for Zika (chikungunya data could not be obtained in Mexico); the PPV was 83% for dengue and 100% for Zika. The time period between alarm and start of the outbreak (i.e. the time available for early response activities) was for Zika 4-5 weeks. In Colombia the sensitivity of the outbreak prediction was 92% for dengue, 93% for chikungunya and 100% for Zika; the PPV was 68% for dengue, 92% for chikungunya and 54% for Zika; the prediction distance was for dengue 3-5 weeks, for chikungunya 10-13 weeks and for Zika 6-10 weeks.Conclusion: EWARS demonstrated promising capability of timely disease outbreak prediction with an operational design likely to improve the coordination among stakeholders. However, the prediction validity varied substantially across different types of diseases and appeared less optimal in low endemic settings. [ABSTRACT FROM AUTHOR]

Background: Cancer patients' end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals. Methods: Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient's death. Results: Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids. Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied. Conclusions: Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients' wishes, and availability of palliative care should be further investigated. [ABSTRACT FROM AUTHOR]

Background: The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016. Methods: The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method. Results: The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability. Conclusions: Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups. [ABSTRACT FROM AUTHOR]

Background: Dengue, Zika and chikungunya are arboviruses of significant public health importance that are transmitted by Aedes aegypti and Aedes albopictus mosquitoes. In Colombia, where dengue is hyperendemic, and where chikungunya and Zika were introduced in the last decade, more than half of the population lives in areas at risk. The objective of this study was to characterize Aedes spp. vectors and study their natural infection with dengue, Zika and chikungunya in Ibagué, a Colombian city and capital of the department of Tolima, with case reports of simultaneous circulation of these three arboviruses. Methods: Mosquito collections were carried out monthly between June 2018 and May 2019 in neighborhoods with different levels of socioeconomic status. We used the non-parametric Friedman, Mann–Whitney and Kruskal–Wallis tests to compare mosquito density distributions. We applied logistic regression analyses to identify associations between mosquito density and absence/presence of breeding sites, and the Spearman correlation coefficient to analyze the possible relationship between climatic variables and mosquito density. Results: We collected Ae. aegypti in all sampled neighborhoods and found for the first time Ae. albopictus in the city of Ibagué. A greater abundance of mosquitoes was collected in neighborhoods displaying low compared to high socioeconomic status as well as in the intradomicile compared to the peridomestic space. Female mosquitoes predominated over males, and most of the test females had fed on human blood. In total, four Ae. aegypti pools (3%) were positive for dengue virus (serotype 1) and one pool for chikungunya virus (0.8%). Interestingly, infected females were only collected in neighborhoods of low socioeconomic status, and mostly in the intradomicile space. Conclusions: We confirmed the co-circulation of dengue (serotype 1) and chikungunya viruses in the Ae. aegypti population in Ibagué. However, Zika virus was not detected in any mosquito sample, 3 years after its introduction into the country. The positivity for dengue and chikungunya viruses, predominance of mosquitoes in the intradomicile space and the high proportion of females fed on humans highlight the high risk for arbovirus transmission in Ibagué, but may also provide an opportunity for establishing effective control strategies. [ABSTRACT FROM AUTHOR]