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Introducción: las interrelaciones positivas y negativas entre el hombre y el medioambiente impactan en la salud general de la población, por esto, la gestión del conocimiento y la transformación social, orientadas a la prevención de la exposición a factores de riesgo ambiental y a la creación de ambientes propicios, deben realizarse a través de acciones multidisciplinares intersectoriales, como el trabajo colaborativo de redes del conocimiento. Objetivo: describir las interacciones entre los actores de la Red de Conocimiento de Salud Ambiental del Observatorio Nacional de Salud de Colombia (ONS), con el fin de promover, mejorar y fortalecer la colaboración, intercambio de información y planificación conjunta de acciones. Metodología: estudio descriptivo transversal de análisis de redes sociales mediante herramientas de minería de texto del lenguaje de programación R. Se analizaron las categorías de agua y saneamiento, clima, calidad del aire, radiaciones electromagnéticas e intoxicaciones químicas de un corpus documental de 99 textos de los actores de la red general de conocimiento en salud pública del ONS. Se calcularon medidas de centralidad y prestigio y se graficaron redes dirigidas multicapa con Power BI. Resultados: los actores con mayor centralidad en la red fueron: Ministerio de Salud y Protección Social, Superintendencia de Salud, Profamilia, universidades de Antioquia y La Salle, ONS, Observatorio de Salud Ambiental de Bogotá, Organización Panamericana de la Salud y Organización Mundial de la Salud. Las cinco categorías analizadas presentaron bajas centralidades de grado, y las categorías de agua y clima mostraron mayor participación de los actores (más nodos e interacciones). Conclusiones: el análisis de redes sociales permitió identificar temas relevantes de salud ambiental entre los actores de la red del ONS, además de actores clave para desarrollar espacios de interacción y gestión del conocimiento. Acorde con las limitaciones del análisis, se sugiere la inclusión de aproximaciones bibliométricas para la actualización de las interacciones de la red.

ObjectiveThe impact of the COVID-19 pandemic goes beyond morbidity and mortality from that disease. Increases in maternal mortality have also been described but have not been extensively studied to date. This study aimed to examine changes in maternal mortality and identify correlates and predictors of excess maternal mortality in Colombia during the pandemic.SettingAnalysis of data from the national epidemiological surveillance databases of Colombia (Sivigila).ParticipantsDeaths among 6342 Colombian pregnant women who experienced complications associated with pregnancy, childbirth or the perperium during 2008–2020 were included in this study. For inequalities analysis, a subsample of 1055 women from this group who died in 2019 or 2020 years were analysed.MethodsWe collected data from the national surveillance system (Sivigila) on maternal mortality. Analysis was carried out in two stages, starting with a time series modelling using the Box-Jenkins approach. Data from Sivigila for 2008–2019 were used to establish a baseline of expected mortality levels. Both simple and complex inequality metrics, with the maternal mortality ratios (MMRs), were then calculated using the Multidimensional Poverty Index as a socioeconomic proxy.ResultsMaternal deaths in 2020 were 12.6% (95% CI −21.4% to 95.7%) higher than expected. These excess deaths were statistically significant in elevation for the months of July (97.4%, 95% CI 35.1% to 250.0%) and August (87.8%, 95% CI 30.5% to 220.8%). The MMR was nearly three times higher in the poorest municipalities compared with the most affluent communities in 2020.ConclusionsThe COVID-19 pandemic had considerable impact on maternal health, not only by leading to increased deaths, but also by increasing social health inequity. Barriers to access and usage of essential health services are a challenge to achieving health-related Sustainable Development Goals.

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.

Introducción: Los análisis de redes sociales (ARS) son útiles para identificar la proximidad entre actores y el grado de conocimiento entre ellos. El objetivo de este estudio fue realizar un ARS de la red de conocimiento en salud pública (RCSP) del Observatorio Nacional de Salud. Materiales y métodos: Se recolectaron 78 documentos técnicos de los actores de la red durante el periodo 2015-2019, los cuales fueron analizados empleando técnicas de minería de texto mediante el lenguaje de programación R, a partir de redes dirigidas y analizando indicadores de densidad, diámetro, distancia, centralidad de grado y centralidad de grado de entrada (CGE). Resultados: El análisis de interacciones indicó que los actores que conformaban la RCSP mostraron mayor interés en la evaluación de políticas públicas (82 nodos) y enfermedades no transmisibles (79 nodos). En estas categorías se presentaron densidades bajas, indicando que hay una baja conectividad entre actores. Las CGE de la Organización Mundial de la Salud (OMS) y la Organización Panamericana de la Salud (OPS) fueron superiores a los actores nacionales. Conclusiones: el ARS a partir de la minería de texto de producciones documentales, permitió identificar interacciones entre los actores en todas las categorías analizadas, mostrando mayor interacción en cuanto a evaluación e implementación de política y dimensiones del Plan Decenal de Salud Pública (PDSP) asociadas a una alta mortalidad.

Nelson J Alvis-Zakzuk,1,2 Diana Díaz-Jiménez,1 Pablo Chaparro-Narváez,1 Juan C Gutiérrez-Clavijo,1 Liliana Castillo-Rodríguez,1 Francisco Edna-Estrada,3 Carlos Castañeda-Orjuela,1 Fernando De La Hoz-Restrepo4 1Observatorio Nacional de Salud, Instituto Nacional de Salud, Bogotá, D.C., Colombia; 2Departamento de Ciencias de la Salud, Universidad de la Costa-CUC, Barranquilla, Colombia; 3Federación Colombiana de Obstetricia y Ginecología, Cartagena, Bolívar, Colombia; 4Grupo de Evaluación en Epidemiología y Salud Pública, Universidad Nacional de Colombia, Bogotá, D.C., ColombiaCorrespondence: Nelson J Alvis-ZakzukDepartamento de Ciencias de la Salud, Universidad de la Costa-CUC, Cl. 58 #55 - 66, Barranquilla, ColombiaEmail nalvis1@cuc.edu.coObjective: We aimed to estimate out-of-pocket (OOP) health expenditures and the indirect costs related to prenatal check-ups in pregnant women seen in a maternity hospital in the Colombian Caribbean region.Methods: We described the economic costs of pregnant women, with no age limits, who attended prenatal check-ups in a maternity hospital. To estimate OOP and indirect costs owing to prenatal check-ups in pregnant women, a survey was constructed, where the woman was asked about some sociodemographic variables, to characterize those attending the prenatal check-ups. Absolute and relative frequencies, averages and confidence intervals were used to characterize the population and estimate OOP and indirect costs in pregnant women. The latter were estimated from the percentile method. A bootstrapping was performed to reduce the bias within the analysis.Results: In total, 56 pregnant women were surveyed, with an average age of 25.9 years (± 6.2). All women surveyed had OOP associated to the prenatal check-up in at least one cost-item, and the OOP ranged between

Background Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen–drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen–drug combinations in 204 countries and territories in 2019. We obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years. We used predictive statistical modelling to produce estimates of AMR burden for all locations, including for locations with no data. Our approach can be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drug-resistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. We present final estimates aggregated to the global and regional level. Findings On the basis of our predictive statistical models, there were an estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9–35·3), and lowest in Australasia, at 6·5 deaths (4·3–9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000–1 270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019. One pathogen–drug combination, meticillin-resistant S aureus, caused more than 100 000 deaths attributable to AMR in 2019, while six more each caused 50 000–100 000 deaths: multidrug-resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporin-resistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae, and third-generation cephalosporin-resistant K pneumoniae. Interpretation To our knowledge, this study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

Objectives This study aimed to estimate the direct medical costs due to hospitalizations by COVID-19 in Colombia and to identify their cost drivers in Colombia. Methods This is a retrospective cost-of-illness study of COVID-19 in Colombia. We estimated direct medical costs using data from patients insured to a Benefit Plan Administrator Company, between March 15, 2020 and May 29, 2020. Absolute and relative frequencies, averages, medians, and interquartile ranges (IQRs) were used to characterize the population and estimate the costs of hospitalized patients with COVID-19. We stratified the cost analysis by sex, age groups, comorbidities, and type of hospitalization (general ward and intensive care unit [ICU]). Cost drivers were calculated from a generalized linear model. Results We studied 113 confirmed patients, 51.3% men. On average, the hospital length of stay was 7.3 (± 6.2) days. A person hospitalized with COVID-19 reported median costs of $1688 (IQR 788-2523). In women, this cost was $1328 (IQR 463-2098); in men, this was 1.4 times greater. The median cost for ICU was $4118 (IQR 2069-5455), 3 times higher than those hospitalized only in the general ward. Admission to the ICU, having 1 comorbidity, length of stay, high blood pressure, having 5 comorbidities, and being treated in the city of Cartagena were statistically significant with direct medical costs. Conclusions Our study provides an idea of the magnitude of costs needed to hospitalize a COVID-19 case in Colombia. Other studies in Colombia have assessed the costs of hospitalization for infectious diseases such as influenza, costs significantly lower than those described here.

espanolLas lesiones de transito son un importante problema de salud publica por la discapacidad y muerte que producen y la carga economica que generan. El objetivo del estudio fue identificar las caracteristicas y patrones de distribucion espacial y temporal de las muertes debidas a lesiones de transito en Cali. Se realizo un estudio descriptivo con base en la informacion de mortalidad que produce el Departamento Administrativo Nacional de Estadistica (DANE). Una frecuencia alta de defunciones se presento en las comunas 3, 8, 9 y 19. La mayor parte de las muertes se presentaron entre motociclistas y peatones. La tasa promedio de mortalidad para el periodo (2008-2013) fue de 13,6 fallecimientos por 100.000 habitantes. Temporal y espacialmente, la mortalidad evidencio disminucion durante el periodo estudiado y se identificaron agrupamientos en distintas comunas del municipio. Estos resultados pueden contribuir en la prevencion de las lesiones y de la mortalidad, asi como de la promocion de la seguridad vial desde distintos sectores sociales y en particular sobre los actores viales involucrados. EnglishTraffic injuries are an important public health problem due to the disability and death they cause and the economic burden they generate. The objective of the study was to identify the characteristics and patterns of spatial and temporal distribution of deaths due to traffic injuries in Cali (Colombia) during 2008 - 2013. A descriptive study was carried out based on the mortality information produced by the Colombian National Statistics Institute. A high frequency of deaths occurred in communes 3, 8, 9 and 19. Most of the deaths occurred between motorcyclists and pedestrians. The average mortality rate for the period was 13.6 deaths per 100,000 inhabitants. Temporary and spatially, the mortality showed a decrease during the period studied and groupings were identified in different communes of the municipality. These results can contribute to the prevention of injuries and mortality, as well as the promotion of road safety from different social sectors and, in particular, the road actors involved. francaisLes accidents de la circulation sont un probleme de sante publique important en raison de l’invalidite et des deces qu’ils provoquent et du fardeau economique qu’ils generent. L’objectif de l’etude etait d’identifier les caracteristiques et les modeles de distribution spatiale et temporelle des deces dus aux accidents de la circulation a Cali (Colombie) entre 2008 et 2013. Une etude descriptive a ete realisee sur la base des informations sur la mortalite produites par l’Institut national colombien de statistique. Une frequence elevee de deces s’est produite dans les communes 3, 8, 9 et 19. La plupart des deces sont survenus entre des motocyclistes et des pietons. Le taux de mortalite moyen pour la periode etait de 13,6 deces pour 100 000 habitants. Temporairement et spatialement, la mortalite a montre une baisse au cours de la periode etudiee et des regroupements ont ete identifies dans differentes communes de la commune. Ces resultats peuvent contribuer a la prevention des blessures et de la mortalite, ainsi qu’a la promotion de la securite routiere dans differents secteurs sociaux et, en particulier, les acteurs de la route impliques.

espanolLa desnutricion infantil produce danos fisicos e irreversibles en la capacidad cognitiva, trastornos del crecimiento, retrasos motores y cognitivos, disminucion de la inmunidad y un aumento de la morbilidad y mortalidad. Este estudio estimo los factores asociados a la desnutricion en menores de cinco anos en La Guajira, Colombia. Se realizo un analisis multivariado de corte transversal, a partir de la Encuesta Nacional de Salud Nutricional (ENSIN). Se estimo un modelo logit sobre los determinantes de la desnutricion global. La variable dependiente se construyo como el peso para la edad menor a dos desviaciones estandar. Se estimaron Odds Ratio (OR) ajustados por pesos muestrales para evaluar el riesgo de las variables independientes con sus valores de referencias. Entre los principales hallazgos, se estudiaron 622 ninos menores de cinco anos de La Guajira, de los cuales 52,7% fueron hombres y 55% vivian en zona rural. El 11,2% de los ninos presenta desnutricion global. Ser el sexto hijo o posterior representa un mayor riesgo de desnutricion global (OR=4,07, IC95%=1,50–10,99), mientras que habitar viviendas con servicio de alcantarillado los protege de sufrir este tipo de desnutricion (OR=0,16, IC95%=0,05–0,57). No contar con servicio de alcantarillado y pertenecer a una familia numerosa resultan siendo caracteristicas de contexto que se asocian con un mayor riesgo de desnutricion infantil en esta region. Afectar estos determinantes sociales permitira hacer mas eficiente la politica de vigilancia y control de la desnutricion en este grupo etario. EnglishUndernutrition produces physical and irreversible damage in cognitive capacity, growth disorders, motor and cognitive delays and decreased immunity. In addition, undernutrition increases morbidity and mortality in children under-five. We estimated the factors associated with undernutrition in children under-five in La Guajira, Colombia. We conducted a cross-sectional multivariate analysis, using data of the Colombian National Survey of the Nutritional Situation (ENSIN, in Spanish). We estimated a logit model on the determinants of global malnutrition. The outcome variable was undernutrition, defined as weightfor-age lesser or equal than two standard deviation. We estimated Odds Ratios (OR) adjusted by the sample design in order to assess the risk of each group compared to a reference group. We studied 622 children under-five years, of which 52.7% were men and 55% lived in rural areas. Out of the total, 11.2% of the children had global undernutrition. Being of the sixth child onwards increases the risk of global undernutrition (OR=4.07, CI95%=1.50-10.99). Also, living at homes with sewerage service provides protection against global undernutrition (OR=0.16, CI95%=0.05-0.57). In short, sewerage service and large families were associated with undernutrition in La Guajira, Colombia. To affect these social health determinants would improve the policy of surveillance and control of undernutrition in children under-five years. francaisLa denutrition entraine des dommages physiques et irreversibles de la capacite cognitive, des troubles de la croissance, des retards moteurs et cognitifs et une diminution de l’immunite. De plus, la denutrition augmente la morbidite et la mortalite chez les enfants de moins de cinq ans. Nous avons estime les facteurs associes a la denutrition chez les enfants de moins de cinq ans a La Guajira, en Colombie. Nous avons effectue une analyse multivariee transversale, en utilisant les donnees de l’Enquete nationale colombienne sur la situation nutritionnelle (ENSIN, en espagnol). Nous avons estime un modele logit sur les determinants de la malnutrition globale. La variable de resultat etait la denutrition, definie comme un rapport poids / âge inferieur ou egal a deux ecarts-types. Nous avons estime les rapports de cotes (OR) ajustes par le plan de sondage afin d’evaluer le risque de chaque groupe par rapport a un groupe de reference. Nous avons etudie 622 enfants de moins de cinq ans, dont 52,7% d’hommes et 55% vivant en milieu rural. Sur ce total, 11,2% des enfants souffraient de denutrition mondiale. Le fait d’avoir un sixieme enfant augmente le risque de denutrition globale (OR = 4,07, IC95% = 1,50-10,99). De plus, le fait de vivre dans des maisons avec un service d’assainissement offre une protection contre la denutrition mondiale (OR = 0,16, IC95% = 0,05-0,57). En bref, les services d’assainissement et les familles nombreuses etaient associes a la denutrition a La Guajira, en Colombie. Affecter ces determinants sociaux de la sante ameliorerait la politique de surveillance et de controle de la denutrition chez les enfants de moins de cinq ans.

This study aimed to critically review the decision-making (DM) processes for new vaccines introduction in Latin America's Expanded Program on Immunization (EPIs) and role of cost-effectiveness analyses (CEAs).An online survey was conducted between August and December 2019 to Latin America and the Caribbean (LAC) EPI managers, participants of the National Immunization Technical Advisory Group (NITAG). Information about criteria to introduce the most recent vaccine was asked. CEA role in that decision and technical knowledge of informants were investigated. Frequencies of categorical data were calculated. Bar plots and stacked bar plots were used to visualize the data.A total of 26 EPI managers and stakeholders participated in the survey from 14 LAC countries. Respondents worked at the Ministry of Health and the Pan American Health Organization. Most recent vaccines included were human papillomavirus (42.3%), injectable polio (26.9%), and varicella (15.4%). High burden of disease and cost-effectiveness/cost-utility were identified as the main a priori criteria used to new vaccine introduction, but not all inputs are available or good quality. Discussion about vaccine introduction was conducted at NITAG meetings, reported as independent by most countries. Nevertheless, NITAG members did not master the essential CEAs concepts.DM of vaccine introduction in LAC is reported by EPI managers as a process of discussion with participation of several actors where economic rationalities had a high role in the decision. It is necessary to strengthen the technical capacity to understand economical inputs to inform DM and advocate to include other rationalities as important in the discussion.

Background Accurate, comprehensive, cause-specific mortality estimates are crucial for informing public health decision making worldwide. Incorrectly or vaguely assigned deaths, defined as garbage-coded deaths, mask the true cause distribution. The Global Burden of Disease (GBD) study has developed methods to create comparable, timely, cause-specific mortality estimates; an impactful data processing method is the reallocation of garbage-coded deaths to a plausible underlying cause of death. We identify the pattern of garbage-coded deaths in the world and present the methods used to determine their redistribution to generate more plausible cause of death assignments. Methods We describe the methods developed for the GBD 2019 study and subsequent iterations to redistribute garbage-coded deaths in vital registration data to plausible underlying causes. These methods include analysis of multiple cause data, negative correlation, impairment, and proportional redistribution. We classify garbage codes into classes according to the level of specificity of the reported cause of death (CoD) and capture trends in the global pattern of proportion of garbage-coded deaths, disaggregated by these classes, and the relationship between this proportion and the Socio-Demographic Index. We examine the relative importance of the top four garbage codes by age and sex and demonstrate the impact of redistribution on the annual GBD CoD rankings. Results The proportion of least-specific (class 1 and 2) garbage-coded deaths ranged from 3.7% of all vital registration deaths to 67.3% in 2015, and the age-standardized proportion had an overall negative association with the Socio-Demographic Index. When broken down by age and sex, the category for unspecified lower respiratory infections was responsible for nearly 30% of garbage-coded deaths in those under 1 year of age for both sexes, representing the largest proportion of garbage codes for that age group. We show how the cause distribution by number of deaths changes before and after redistribution for four countries: Brazil, the United States, Japan, and France, highlighting the necessity of accounting for garbage-coded deaths in the GBD. Conclusions We provide a detailed description of redistribution methods developed for CoD data in the GBD; these methods represent an overall improvement in empiricism compared to past reliance on a priori knowledge.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Funder: Instituto Nacional de Salud, Bogotá, Colombia, Salmonella Typhi (S. Typhi) is the causative agent of typhoid fever; a systemic disease affecting ~20 million people per year globally. There are little data regarding the contemporary epidemiology of typhoid in Latin America. Consequently, we aimed to describe some recent epidemiological aspects of typhoid in Colombia using cases reported to the National Public Health Surveillance System (Sivigila) between 2012 and 2015. Over the four-year reporting period there were 836 culture confirmed cases of typhoid in Colombia, with the majority (676/836; 80.1%) of reported cases originated from only seven departments. We further characterized 402 S. Typhi isolates with available corresponding data recovered from various departments of Colombia through antimicrobial susceptibility testing and molecular subtyping. The majority (235/402; 58.5%) of these typhoid cases occurred in males and were most commonly reported in those aged between 10 and 29 years (218/402; 54.2%); there were three (0.74%) reported fatalities. The overwhelming preponderance (339/402; 84.3%) of S. Typhi were susceptible to all tested antimicrobials. The most common antimicrobial to which the organisms exhibited non-susceptibility was ampicillin (30/402;7.5%), followed by nalidixic acid (23/402, 5.7%). Molecular subtyping identified substantial genetic diversity, which was well distributed across the country. Despite the diffuse pattern of S. Typhi genotypes, we identified various geographical hotspots of disease associated with local dominant genotypes. Notably, we found limited overlap of Colombian genotypes with organisms reported in other Latin American countries. Our work highlights a substantial burden of typhoid in Colombia, characterized by sustained transmission in some regions and limited epidemics in other departments. The disease is widely distributed across the country and associated with multiple antimicrobial susceptible genotypes that appear to be restricted to Colombia. This study provides a current perspective for typhoid in Latin America and highlights the importance of pathogen-specific surveillance to add insight into the limited epidemiology of typhoid in this region.

To estimate the cost-effectiveness of available diagnosis alternatives for Mucosal Leishmaniasis (ML) in Colombian suspected patients. A simulation model of the disease's natural history was built with a decision tree and Markov models. The model´s parameters were identified by systematic review and validated by expert consensus. A bottom-up cost analysis to estimate the costs of diagnostic strategies and treatment per case was performed by reviewing 48 clinical records of patients diagnosed with ML. The diagnostic strategies compared were as follows: 1) no diagnosis; 2) parasite culture, biopsy, indirect immunofluorescence assay (IFA), and Montenegro skin test (MST) combined ; 3) parasite culture, biopsy, and IFA combined; 4) PCR-miniexon; and 5) PCR-kDNA. Three scenarios were modeled in patients with ML clinical suspicion, according to ML prevalence scenarios: high, medium and low. Adjusted sensitivity and specificity parameters of a combination of diagnostic tests were estimated with a discrete event simulation (DES) model. For each alternative, the costs and health outcomes were estimated. The time horizon was life expectancy, considering the average age at diagnosis of 31 years. Incremental cost-effectiveness ratios (ICERs) were calculated per Disability Life Year (DALY) avoided, and deterministic and probabilistic sensitivity analyses were performed. A threshold of willingness to pay (WTP) of three-time gross domestic product per capita (GDPpc) (US$ 15,795) and a discount rate of 3% was considered. The analysis perspective was the third payer (Health System). All costs were reported in American dollars as of 2015. PCR- kDNA was the cost-effective alternative in clinical suspicion levels: low, medium and high with ICERs of US$ 7,909.39, US$ 5,559.33 and US$ 4,458.92 per DALY avoided, respectively. ML diagnostic tests based on PCR are cost-effective strategies, regardless of the level of clinical suspicion. PCR-kDNA was the most cost-effective strategy in the competitive scenario with the parameters included in the present model.

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. Resumen 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.

Introduction: Inequalities in the health field are caused by the differences in the social and economic conditions, that influence the disease risk and the measures taken to treat the disease. Objective: We aimed to estimate the social inequalities in health in Colombia, according to the type of affiliation to the health system as a proxy of socioeconomic status. Materials and methods: We conducted a retrospective descriptive analysis calculating incidence rates age and sex adjusted for all mandatory reporting events using the affiliation regime (subsidized and contributory) as a socioeconomic proxy. Estimates were made at departmental level for 2015. Social inequalities were calculated in terms of absolute and relative gaps. Results: We found social inequalities in the occurrence of mandatory reporting events in population affiliated to the Colombian subsidized regime (poor population). In this population, 82.31 cases of Plasmodium falciparum malaria per 100,000 affiliates were reported more than those reported in the contributory regime. Regarding the relative gap, belonging to the subsidized regime increased by 31.74 times the risk of dying from malnutrition in children under 5 years of age. Other events such as those related to sexual and reproductive health (maternal mortality, gestational syphilis and congenital syphilis); neglected diseases and communicable diseases related to poverty (leprosy and tuberculosis), also showed profound inequalities. Conclusion: In Colombia there are inequalities by regime of affiliation to the health system. Measured socioeconomic status was a predictor of increased morbidity and premature mortality.Introducción. Las desigualdades en salud se generan por diferencias en las condiciones sociales y económicas, lo cual influye en el riesgo de enfermar y la forma de enfrentar la enfermedad. Objetivo. Evaluar las desigualdades sociales en salud en Colombia, utilizando el tipo de afiliación al sistema de salud como un parámetro representativo (proxy) de la condición socioeconómica. Materiales y métodos. Se trata de un análisis descriptivo y retrospectivo en el que se calcularon las tasas específicas de incidencia, ajustadas por edad y sexo, para eventos de notificación obligatoria, utilizando el régimen de afiliación (subsidiado o contributivo) como variable representativa del nivel socioeconómico. Las estimaciones se hicieron a nivel departamental para el 2015. Las desigualdades sociales se calcularon en términos de brechas absolutas y relativas. Resultados. Se evidencian desigualdades sociales en la ocurrencia de eventos de notificación obligatoria, las cuales desfavorecen a la población afiliada al régimen subsidiado. En esta población, se reportaron 82,31 casos más de malaria Plasmodium falciparum por 100.000 afiliados, que los notificados en el régimen contributivo. Respecto a la brecha relativa, el pertenecer al régimen subsidiado se asocia con un aumento de 31,74 veces del riesgo de morir por desnutrición en menores de cinco años. Otros eventos también presentaron profundas desigualdades, como los relacionados con la salud sexual y reproductiva (mortalidad materna, sífilis gestacional y sífilis congénita), las enfermedades infecciosas y las enfermedades transmisibles relacionadas con la pobreza (lepra y tuberculosis). Conclusión. El tipo de afiliación al Sistema General de Seguridad Social en Salud en Colombia es un buen indicador del nivel socioeconómico, y es un factor predictor de mayor morbilidad y mortalidad prematura asociada con los factores determinantes sociales de la salud.

Introduction: Suicide is a serious social and public health problem that affects the population in most countries in the world. Differences in suicide rates in rural and urban areas have been previously described. Objective: To study the trend of mortality rates by suicide in Colombia, in rural and urban areas by gender, age group, and suicide method during the years 1979-2014. Materials and methods: We conducted a temporal trend ecologic study using death certificates from the Departamento Administrativo Nacional de Estadística, DANE. Specific and adjusted by age and gender mortality rates were calculated. We estimated negative binomial and inflection point regression models to study the trends in mortality rates stratified by gender, age group, and suicide method. Results: A total of 56,448 suicides was reported in Colombia between 1979 and 2014. The risk of suicide was higher in urban areas for men, individuals between 25 and 44 years, and 65 and over; and for those who used hanging as the suicide method. Also, the risk of suicide was higher in the rural area for men between 45 and 64 years old, and those who used firearms, sharp weapons, hanging, and others as suicide methods. The trend of suicide rates in urban areas showed its maximum peak in 1999 and in the rural ones in 2000. Then, in the two areas, there was a gradual decrease. Hanging in both areas presented a tendency to rise in men. Conclusions: Suicide has shown a tendency toward reduction after the year 2000, with differences between urban and rural areas.Introducción. El suicidio es un grave problema social y de salud pública que afecta a la población de la mayoría de los países del mundo. Se han descrito diferencias en las tasas de suicidio entre las áreas rurales y las urbanas. Objetivo. Estudiar la tendencia de las tasas de mortalidad por suicidio en Colombia en las áreas de defunción rural y urbana y según sexo, grupo de edad y método de suicidio para el periodo 1979-2014. Materiales y métodos. Se realizó un estudio ecológico de tendencia temporal a partir de la información de mortalidad del Departamento Administrativo Nacional de Estadística. Se calcularon las tasas de mortalidad específica y ajustada por edad y sexo. Las tendencias de las tasas por área para el periodo de estudio, y tanto por sexo y grupo de edad como por método de suicidio, se estudiaron mediante modelos negativos de regresión binomial y regresión de puntos de inflexión. Resultados. Un total de 56.448 suicidios se registró en Colombia entre 1979 y 2014. El riesgo de suicidio fue más alto en el área urbana en hombres, en los grupos etarios de 25 a 44 años y de 65 y más años, y en quienes emplearon el ahorcamiento. El riesgo de suicidio fue mayor en el área rural para los hombres entre los 45 y los 64 años, y para aquellos que recurrieron al disparo de armas de fuego, armas cortantes, ahorcamiento y otros. La tendencia de las tasas en el área urbana mostró su máximo pico en 1999 y, en la rural, en el 2000; posteriormente, en ambas áreas se produjo un descenso paulatino. El ahorcamiento presentó una tendencia al ascenso en hombres en las dos áreas. Conclusión. El suicidio ha mostrado una tendencia hacia la reducción después del año 2000, con diferencias entre las áreas urbanas y las rurales.

Objective The aim of the present study was to estimate the economic impact of chikungunya virus (CHIKV) infection in Colombia from a societal perspective. Methods We conducted a retrospective, bottom-up cost-of-illness study in clinically confirmed cases during the first chikungunya (CHIK) outbreak in Colombia in 2014. Direct and indirect costs were estimated per patient. Economic costs were calculated by the addition of direct costs (direct medical costs and out-of-pocket heath expenditures) and indirect cost as a result of loss of productivity. Results A total of 126 patients (67 children and 59 adults) with CHIK were included. The median of the direct medical cost in children was US$257.9 (interquartile range [IQR] 121.7–563.8), and US$66.6 (IQR 26.5–317.3) for adults. The productivity loss median expenditures reached US$81.3 (IQR 72.2–203.2) per adult patient. The median economic cost in adults as a result of CHIK was US$152.9 (IQR 101.0–539.6), of which 53.2% was a result of indirect costs. Out-of-pocket expenditures comprised 3.3% of all economic costs. Conclusions Our study can help health decision makers to properly assess the burden of disease caused by CHIK in Colombia, an endemic tropical country. We recommend to strength the health information systems and to continue investing in public health measures to prevent CHIK.

To prioritize diseases, population and methods of analysis in public health according to the preferences of the stakeholders of the knowledge network of the National Health Observatory.The conjoint analysis methodology (AC) was used; it consists on the construction of a complete factorial model taking a random sample of subjects that must identify the preferences of the attributes of a given construct according to a pre-established order of importance. The stakeholders of the knowledge network who participated were professionals from public universities, members of health promotion entities, health provision services, health departments, non-profit health organizations, specialized research centers, mayor's offices, and corporations.The groups of priority diseases were mental and behavioral disorders (13.8%), cardiovascular and circulatory diseases (13%), neoplasms (10%), diarrhea, respiratory infections, meningitis and other common infectious diseases (6.7%), and nutritional deficiencies (6.3 %). The preferred prioritization criteria were the burden of disease and high-impact epidemiological dynamics. The analysis of priority information was the analysis of social determinants. The most preferred population was the general population.Participants perceive both chronic and infectious diseases as a priority, which is consistent with the epidemiological transition of the country. The priority for the Colombian health system is to strengthen the capacity of human resources and the surveillance system in different areas to have a better decision-making process in relation to public health.Priorizar los grupos de enfermedades, población y métodos de análisis en salud pública según las preferencias de los actores de la red de conocimiento del Observatorio Nacional de Salud.Se utilizó el método de análisis conjunto (AC), que consiste en la construcción de un modelo factorial completo tomando una muestra aleatoria de sujetos que deben, según un orden de importancia pre-establecido, identificar las preferencias de los atributos de determinado constructo. Los actores de la red de conocimiento que participaron fueron profesionales de universidades públicas, miembros de EPS, IPS, secretarias de salud departamental, organizaciones sin ánimo de lucro enfocadas en salud, centros de investigación especializados, de alcaldías, y corporaciones.Los grupos de enfermedades prioritarios fueron: trastornos mentales y del comportamiento (13,8%), enfermedades cardiovasculares y circulatorias (13%), neoplasmas (10%) Diarrea, infecciones respiratorias, meningitis y otras enfermedades infecciosas comunes (6,7%) y deficiencias nutricionales (6,3%). Los criterios de priorización preferidos fueron la carga de enfermedad derivada y la dinámica epidemiológica del alto impacto. La información prioritaria de análisis fue la de determinantes sociales. El grupo poblacional de mayor preferencia fue la población general.Se evidenció que los participantes perciben como prioritarias tanto las enfermedades crónicas como infecciosas concordante con la transición epidemiológica del país. La prioridad más sentida del sistema sanitario colombiano es la construcción de capacidad del recurso humano y el fortalecimiento del sistema de vigilancia en las regiones para la toma de decisiones en salud pública.

Poisoning due to pesticides is an important public health problem worldwide due its morbidity and mortality. In Colombia, there are no exact data on mortality due to pesticide poisoning.To estimate the trend of mortality rate due to pesticide poisoning in Colombia between 1998 and 2011.We carried out a descriptive analysis with the database reports of death as unintentional poisoning, self-inflicted intentional poisoning, aggression with pesticides, and poisoning with non-identified intentionality, population projections between 1998 and 2011, and rurality indexes. Crude and age-adjusted mortality rates were estimated and trends and Spearman coefficients were evaluated.A total of 4,835 deaths were registered (age-adjusted mortality rate of 2.38 deaths per 100,000 people). Mortality rates were higher in rural areas, for self-inflicted intentional poisoning, in men and in age groups between 15 and 39 years old. The trend has been decreasing since 2002. Municipality mortality rates due to unintentional poisoning and aggression correlated significantly with the rurality index in less rural municipalities.Mortality rates due to pesticide poisoning presented a mild decrease between 1998 and 2011. It is necessary to adjust and reinforce the measures conducive to reducing pesticide exposure in order to avoid poisoning and reduce mortality.