RESUMO Objetivo. Examinar vários aspectos relacionados aos mercados e fornecedores de produtos farmacêuticos da CARICOM, incluindo a localização da sede do laboratório fabricante, histórico regulatório e tipo de produtos (inovadores versus genéricos); proporção de medicamentos adquiridos que constam da relação de medicamentos essenciais da Organização Mundial da Saúde (OMS); e medicamentos mais caros comprados. Métodos. Foi realizada uma análise de informação sobre compras feitas por compradores selecionados da CARICOM. Quatro listas de compras do setor público foram obtidas com informação de acesso público ou compartilhada pelos compradores. As análises foram feitas com base em parâmetros disponíveis ou inferidos a partir dos dados. Resultados. A maioria dos produtos farmacêuticos é proveniente de laboratórios com sedes na América do Norte e Europa (63%–67%). Do total, 60%–87% dos medicamentos adquiridos são de laboratórios de produtos genéricos e 25%–50% constam da relação de medicamentos essenciais da OMS. Existe uma ampla variação nos preços dos medicamentos mais caros comprados. Conclusões. Foram identificadas fragilidades e oportunidades na situação de compras dos países da CARICOM, em particular relacionadas à qualidade dos produtos e ao uso racional dos medicamentos. Esta análise serve de referência a ser usada futuramente pelos governos e outras partes interessadas.

ABSTRACT Objective. To examine multiple aspects of the medicines in CARICOM procurement markets, including manufacturer headquarters location, regulatory history, and type (innovator versus generic); the proportion of World Health Organization (WHO) essential medicines; and the most expensive medicines procured. Methods. An analysis of procurement information from selected CARICOM procurers. Four public sector procurement lists were obtained based on public availability or sharing of data from public sector procurers. Analyses were based on parameters available or deduced from these data. Results. The majority of products come from manufacturers headquartered in North America and Europe (63%–67%). The percentage of medicines procured from generic companies is 60%–87%; and 25%–50% of medicines procured are on the WHO Essential Medicines List. Wide price variations exist in the most expensive medicines purchased. Conclusions. The analysis identifies vulnerabilities and opportunities in the procurement situation of CARICOM states, particularly related to quality and rational use of medicines. This analysis represents a baseline that governments and other stakeholders can use in the future.

RESUMEN Objetivo. Revisar los múltiples aspectos de los medicamentos en los mercados de compras y los proveedores de CARICOM, como la ubicación de la sede del fabricante, el historial de regulación, el tipo (patentado versus genérico); la proporción de medicamentos esenciales de la Organización Mundial de la Salud (OMS); y los medicamentos comprados más caros. Métodos. Se analizó información sobre la compra por parte de determinados organismos de CARICOM. La información procedía de cuatro listas de organismos del sector público que realizan las compras, que se consiguieron en función de su disponibilidad pública o de los datos distribuidos por los organismos del sector público que realizan las compras. Los análisis estaban basados en los parámetros disponibles o derivados de estos datos. Resultados. La mayoría de los productos proviene de fabricantes radicados en América del Norte y Europa (entre 63% y 67%). El porcentaje de medicamentos que se compra de empresas genéricas oscila entre 60% y 87%; y de 25% a 50% de los medicamentos que se compran están en la Lista de Medicamentos Esenciales de la OMS. Hay una gran divergencia de precios entre los medicamentos comprados más caros. Conclusiones. En el análisis se han encontrado vulnerabilidades y oportunidades con respecto a la situación de las compras de medicamentos de los Estados de CARICOM, especialmente en cuanto a la calidad y al uso racional de los medicamentos. Este análisis representa una línea de base que los gobiernos u otros interesados directos pueden utilizar en el futuro.

Environmental water requirement (EWR) assessment methods, for ascertaining how much water should be retained in rivers to sustain ecological functioning and desired levels of biodiversity, have mostly been developed for perennial rivers. Despite non-perennial rivers comprising about 30-50% of the world's freshwater systems, data on their hydrology, biota and ecological functioning are sparse. Current EWR assessments require hydrological and other data that may not be available for such rivers and some adaptation in the methods used seems necessary. DRIFT is an EWR method for perennial (or near-perennial) rivers that has been developed in South Africa over the past two decades and is now widely applied nationally and internationally. When applied to the semi-permanent Mokolo River, challenges particular to, or accentuated by, non-perennial rivers included the reliable simulation of hydrological data, the extent of acceptable extrapolation of data, difficulties in predicting surface-water connectivity along the river, and the location and resilience of pools, as well as whether it was possible to identify a reference (natural) condition. DRIFT-ARID, reported on here, is an adaptation of the DRIFT approach to begin addressing these and other issues. It consists of 11 phases containing 9 activities.

Methods developed to determine the amount of water required (EWR) to sustain ecosystem services in non-perennial rivers need a different approach to those used in perennial rivers. Current EWR methods were mostly developed for use in perennial rivers. Non-perennial rivers differ from perennial ones in terms of variability in flow, periods of no-flow and related habitat availability. A DRIFT-ARID method (an adaptation of the Downstream Response to Imposed Flow Transformation (DRIFT) method) was developed, tested and adjusted, using the semi-permanent Mokolo River. Field data from five study sites was collected from April to May 2010 by a multidisciplinary team. The results were used in a DRIFT-ARID Decision Support System (DSS) to determine the impact of five chosen development scenarios in the Mokolo River Catchment. An integrated groundwater-surface water MIKE-SHE hydrological model was used to simulate the hydrology of the chosen scenarios. Specific non-perennial river indicators such as onset of dry phase were identified and included in the DRIFT-ARID DSS. DRIFT-ARID has the potential to be used in non-perennial rivers and, once set up, can provide results for future scenarios. The method now needs to be tested on other non-perennial river types, especially episodic rivers where data are scarce or non-existent.

The objective of the present paper was to compare accessibility and utilisation of schistosomiasis diagnostic and treatment services in a small village and the surrounding rural area in northern part of the state of Minas Gerais Brazil. The study included 1,228 individuals: 935 central village residents and 293 rural residents of São Pedro do Jequitinhonha. Schistosoma mansoni infection rates were significantly higher in the central village than in the rural area during a survey in 2007 (44.3% and 23.5%, respectively) and during the 2002 schistosomiasis case-finding campaign (33.1% and 26.5%, respectively) (p < 0.001). However, during the 2002-2006 period, only 23.7% of the villagers and 27% of the rural residents obtained tests on their own from health centres, hospitals and private clinics in various nearby towns. In 2007, 63% of the villagers and 70.5% of the rural residents reported never having received treatment for schistosomiasis. This paper reveals considerable variation in the accessibility and utilisation of schistosomiasis-related health services between the central village and the rural area. A combination of low utilisation rates between 2002-2006 and persistently high S. mansoni infection rates suggest that the schistosomiasis control program must be more rapidly incorporated into the primary health services.

Urinary schistosomiasis remains a significant burden for Africa and the Middle East. The success of population-based control programs will depend on their impact, over many years, on Schistosoma haematobium reinfection and associated disease. In a multi-year (1984-1992) control program in Kenya, we examined risk for S. haematobium reinfection and late disease during and after annual school-based treatment. In this setting, long-term risk of new infection was independently associated with location, age, hematuria, and incomplete treatment, but not with sex or frequency of water contact. Thus, very local environmental features and age-related factors played an important role in S. haematobium transmission, such that population-based control programs should optimally tailor their efforts to local conditions on a village-by-village basis. In 2001-2002, the late benefits of earlier participation in school-based antischistosomal therapy were estimated in a cohort of formerly-treated adult residents compared to never-treated adults from the same villages. Among age-matched subjects, current infection prevalence was lower among those who had received remote therapy. In addition, prevalence of bladder abnormality was lower in the treated group, who were free of severe bladder disease. Treatment of affected adults resulted in rapid resolution of infection and any detectable bladder abnormalities. We conclude that continued treatment into adulthood, as well as efforts at long-term prevention of infection (transmission control) are necessary to achieve optimal morbidity control in affected communities.

OBJECTIVE: To determine the prevalence and incidence of tuberculosis in one of Uganda's poor peri-urban areas. METHODS: Multi-stage sampling was used to select a sample of households whose members were evaluated for presence of signs and/or symptoms of active tuberculosis; history of tuberculosis treatment; and relevant demographic, socioeconomic, and household environment characteristics. Patients with suspected tuberculosis underwent standardized evaluation for active disease. FINDINGS: A sample of 263 households with 1142 individuals was evaluated. Nineteen people were classified as having had tuberculosis during the one-year reference period (May 2001-April 2002): nine (47%) cases already had been diagnosed through the health care system, while 10 cases (53%) were diagnosed through the survey. The prevalences for all forms of tuberculosis and for sputum smear-positive tuberculosis were 14.0 (95% confidence interval (CI) 7.8-20.3) and 4.4 (CI = 0.83-7.89) per thousand, respectively. The incidences for all forms of tuberculosis and for sputum smear-positive tuberculosis were 9.2 (CI = 3.97-14.4) and 3.7 (CI = 0.39-6.95) per thousand per year, respectively. CONCLUSION: The rate of tuberculosis in this peri-urban community was exceptionally high and may be underestimated by current surveillance systems. The need for interventions aimed at reducing tuberculosis transmission in this, and other similar communities with high case rates, is urgent.

OBJETIVO: Determinar la prevalencia y la incidencia de tuberculosis en una de las áreas periurbanas pobres de Uganda. MÉTODOS: Se realizó un muestreo polietápico para seleccionar una muestra de hogares a cuyos miembros se evaluó para determinar la presencia de signos y/o síntomas de tuberculosis activa; los antecedentes de tratamiento antituberculoso, y las características demográficas, socioeconómicas y del entorno doméstico pertinentes. Los pacientes con presunta tuberculosis fueron sometidos a una evaluación estandarizada para determinar si padecían la forma activa de la enfermedad. RESULTADOS: Se evaluó una muestra de 263 hogares con un total de 1142 personas. Se determinó que 19 de ellas habían tenido tuberculosis durante el periodo de referencia de un año (mayo de 2001 - abril de 2002): nueve casos (47%) ya habían sido diagnosticados a través del sistema de atención de salud, y 10 casos (53%) se diagnosticaron en el curso de la encuesta. La prevalencia de todas las formas de tuberculosis y de los casos con esputo positivo fue de 14,0 (intervalo de confianza (IC) del 95%=7,8-20,3) y 4,4 (IC95% = 0,83-7,89) por mil, respectivamente. La incidencia de todas las formas de tuberculosis y de los casos con esputo positivo fue de 9,2 (IC95% = 3,97-14,4) y 3,7 (IC95% = 0,39-6,95) por mil al año, respectivamente. CONCLUSIÓN: La tasa de tuberculosis en esta comunidad periurbana era excepcionalmente alta, y posiblemente los actuales sistemas de vigilancia subestiman esa cifra. Urge implementar intervenciones encaminadas a reducir la transmisión de tuberculosis en estas y otras comunidades similares con altas tasas de casos.

OBJECTIF: Déterminer la prévalence et l'incidence de la tuberculose dans l'une des zones péri-urbaines défavorisées de Kampala. MÉTHODES: Echantillonnage à plusieurs degrés pour sélectionner des foyers où l'on a recherché des symptômes de tuberculose évolutive, étudié les antécédents de traitement antituberculeux, de même que les caractéristiques démographiques, socio-économiques et l'environnement de chacun de ces foyers. En cas de suspicion de tuberculose, on a procédé à une évaluation standardisée des patients. RÉSULTATS: L'étude a porté sur un échantillon de 263 foyers rassemblant 1 142 personnes et a classé dix-neuf d'entre elles dans la catégorie des sujets atteints de tuberculose pendant les 12 mois de référence (mai 2001 - avril 2002). Le système de santé avait déjà posé le diagnostic pour neuf des cas (47 %) et l'étude a permis de diagnostiquer les 10 autres (53 %). La prévalence était de 14,0 (intervalle de confiance (IC) à 95 % : 7,8 - 20,3) pour la tuberculose en général, toutes formes confondues, et de 4,4 (IC : 0,83-7,89) pour 1 000 pour la tuberculose à frottis positif. Pour l'incidence, les chiffres correspondants sont de 9,2 (IC : 3,97-14,4) et de 3,7 (IC : 0,39-6,95) pour 1 000 et par an. CONCLUSION: Dans cette communauté péri-urbaine, la fréquence de la tuberculose est exceptionnellement élevée et elle est peut-être sous-estimée par les systèmes de surveillance actuels. Il est donc urgent d'intervenir afin de lutter contre la transmission dans cette communauté et dans toutes celles où les taux de tuberculose sont très élevés.

A major advance in our understanding of the natural history of Schistosoma haematobium-related morbidity has come through the introduction of the portable ultrasound machines for non-invasive examination of the kidneys and bladder. With the use of generators or battery packs to supply power in non-clinical field settings, and with the use of instant photography or miniaturized thermal printers to record permanent images, it is possible to examine scores of individuals in endemic communities every day. Broad-based ultrasound screening has allowed better definition of age-specific disease risks in urinary schistosomiasis. Results indicate that urinary tract abnormalities are common (18% overall prevalence) in S. haematobium transmission areas, with a 2-4% risk of either severe bladder abnormality or advanced ureteral obstruction. In longitudinal surveys, ultrasound studies have shown that praziquantel and metrifonate therapy are rapidly effective in reversing urinary tract abnormalities among children. The benefits of treating adults are less well known, but research in progress should help to define this issue. Similarly, the prognosis of specific ultrasound findings needs to be clarified, and the ease of sonographic examination will make such long-term follow-up studies feasible. In summary, the painless, quick, and reproducible ultrasound examination has become an essential tool in the study of urinary schistosomiasis.

Severity of urinary tract morbidity increases with intensity and duration of Schistosoma haematobium infection. We assessed the ability of yearly drug therapy to control infection intensity and reduce S. haematobium-associated disease in children 5-21 years old in an endemic area of Kenya. In year I, therapy resulted in reduced prevalence (66% to 22%, P < 0.001) and intensity of S. haematobium infection (20 to 2 eggs/10 mL, urine), with corresponding reductions in the prevalence of hematuria (52% to 19%, P < 0.001). There was not, however, a significant first-year effect on prevalence of urinary tract abnormalities detected by ultrasound. Repeat therapy in years 2 and 3 resulted in significant regression of hydronephrosis and bladder abnormalities (41% to 6% prevalence, P< 0.001), and further reductions in proteinuria. Repeat age-targeted therapy was associated with decreased prevalence of infection among young children (< 5yr) entering into the target age group. Two years after discontinuation of therapy, intensity of S. haematobium infection and ultrasound abnormalities remained suppressed, but hematuria prevalence began to increase (to 33% in 1989). Reinstitution of annual therapy in 1989 and 1990 reversed this trends. We conclude that annual oral therapy provides an effective strategy for control of morbidity due to S. haematobium on population basis, both through regression of disease in treated individuals, and prevention of infection in untreated subjects.