Objetivos de desarrollo del milenio directamente relacionados con la salud 4, 5a y 6revisión del estado de la cuestión. Perspectivas a partir de 2015

Resumen

EXECUTIVE SUMMARY 1. INTRODUCTION: Our work focuses in health related Millennium Development Goals: MDG 4 (To reduce in 2/3 Underfive Mortality Rate from 1990 to 2015); MDG 5 A (To reduce in 3/4 Maternal Mortality Ratio from 1990 to 2015); MDG 6 (To stop the advancement and to reduce morbidity and mortality associated with tuberculosis, malaria, HIV, as well as other infectious diseases). 2. OBJECTIVES: To evaluate the degree of achievement of the health related MDGs. Explore accelerations or decelerations in progress. Elaborate univariable and multivariable models for each MDG Develop spatial analysis of progress for each MDG from 1990 to 2015. 3. MATERIAL AND METHODS: 1- Bibliographic exhaustive review in relation with health related MDGs until December 2016 (Pubmed, Scielo, Lilacs, Cochrane Plus Library, Web of Knowledge). 2 - Access to United Nations databases about MDGs. (WHO, WB, UNPD, UNICEF) 3 - Ecological descriptive and analytical study, geographical and of temporal series, from 1990 to 2015. Stratification by WHO Region and WB Income Group was applied. 4 - We explored as main indicators related with studied MDGs: underfive mortality rate, maternal mortality ratio, tuberculosis prevalence, and HIV prevalence in adults from 15 to 49 years. 5 - Description of the evolution of indicators selected from 1990 to 2015. Spatial analysis about the goals related to each MDG. Join Point lineal regression to look for significant trend variations was applied. 6.- Univariable and multivariable analysis for each indicator was developed. For underfive mortality and maternal mortality we chose lineal regression analysis (with ecological relative risk calculation), and for tuberculosis prevalence and HIV prevalence in adults from 15 to 49 years we chose mixed models of negative binomial regression.   4. RESULTS: - Underfive mortality rate declined from 90 to 43 deaths per 1000 live births from 1990 to 2015 (52,2%, versus 66,7% of MDG 4). Consequently, despite the considerable global progress, MDG has not been achieved. Measles vaccination coverage passed from 73% in 1990 to 85 % in 2014, avoiding million of deaths during that period. In our analysis we found an inverse correlation between underfive mortality rate and World Bank Income Group. We did not find any Join Point in lineal regression analysis. In the multivariable lineal regression model selected we included the following variables: World Bank Income Group, Quartile of Human Development Index, Adolescent fertility rate, Measles vaccination coverage, Primary education female net enrolment rate, Access to improved sources of drinking water, Access to improved sanitation, and Year. - Maternal Mortality Ratio has diminished globally 43,9%, (from 385 per 100000 live births in 1990 to 216 per 100000 live births in 2015) with an acceleration during the period 2000-2015. Nevertheless, it has not been sufficient to reach the objective (75% of reduction was the goal). The mean global annual decline rate between 2000 and 2010 was 2,9%. In absolute numbers, the greatest decline was experienced by Sub-Saharan Africa. More than 71% of births were attended by skilled health personnel in 2015, versus 59% in 1990. In Southern Africa, the proportion of pregnant women receiving at least 4 antenatal visits increased from 50% in 1990 to 89% in 2014. An inversely proportional relation was found between income level and maternal mortality ratio. In our study, we did not find any significant Join Point in lineal regression for maternal mortality ratio. We carried out univariable and multivariable lineal regression analysis, with exploration of ecological relative risk. In the multivariable lineal regression model selected we included: Income group according to World Bank classification, measles vaccination coverage, global fertility rate, human development index, female primary education net enrolment rate, incidence of tuberculosis, prevalence of HIV infection among adults aged 15 to 49, neonatal mortality net rate, access to improved drinking-water sources, access to improved sanitation facilities. - From 2000 to 2013 37 million lives were saved through preventive interventions, diagnosis and treatment of tuberculosis. Tuberculosis mortality rate declined 45% and prevalence of tuberculosis experienced a 41% reduction during that period. Tuberculosis mortality rate declined 2,8% annually from 1990 to 2000, and 3,7% annually from 2000 to 2013. Incidence of tuberculosis decreased mainly after 2000, especially in the South East Asian Region. In our analysis we found one significant Join Point in lineal regression for Tuberculosis Prevalence from 1990 to 2013. We carried out univariable and multivariable mixed models with negative binomial regression analysis. In the multivariable negative binomial regression mixed model selected we included: income group according to World Bank classification, maternal mortality ratio, deaths by tuberculosis in HIV negative people, Human Development Index, Tuberculosis detection rate (%), Tuberculosis Incidence, Neonatal Mortality Rate, Population access to improved sanitation (%), Gross Domestic Product per capita in thousands of US $. - HIV incidence had a peak in 1997, and mortality due to HIV experienced another peak in 2005, with a substantial global decline in both parameters after these peaks.New HIV infections decreased 40% from 2000 (3,5 million) to 2013 (2,1 million). In June 2014 13,6 million people received anti-retroviral therapy (ART), versus 800000 in 2003. Sub-Saharan Africa has the greater proportion of people living with HIV and it has experienced also the greatest increase in number of people receiving ART, though there is still room for improvement. In our analysis we found 2 Join Points for HIV Prevalence from 1990 to 2013: 1997 and 2001. In our multivariable negative binomial regression mixed model we included the following variables: WHO Region, Public Expenditure in Education as a percentage of GDP, Physicians per 1000 inhabitants, Incidence of Tuberculosis. As well as these variables, in the univariable analysis we found other variables with a significant association with the HIV Prevalence in people aged 15 to 49 years: Human Development Index, access to improved sanitation and adult literacy rate. We did not find significant association with proportion of population receiving ART, though it is a key variable according to WHO and GBD estimations. - With respect to malaria, 98 endemic countries have reversed the trends in incidence in 2015 in comparison with year 2000. The African Region, though representing the greatest burden of disease by malaria (88% cases and 90% deaths). Nevertheless, malaria keeps representing a major health problem with 214 million cases and 472.000 deaths globally in 2015, with 3.300 million people in risk. Global incidence of malaria decreased 37% and mortality due to malaria experienced a 58% decline globally. More than 900 million of insecticide treated nets (ITN) were distributed from 2004 to 2014 in Sub-Saharan Africa. Both cases and deaths due to malaria grew quickly from 1990 to 2003 (232 million cases peak) and 2004 (1,2 million deaths peak). From 2004, child deaths due to malaria in Sub-Saharan Africa declined a 31.45%. From 2000 it has been evidenced an acceleration in progress regarding MDG 6 with respect to malaria. Data about cases and deaths due to malaria have a much greater uncertainty than for tuberculosis and HIV. There is a great under-reporting of malaria cases. As well as, in many countries with a greater mortality due to malaria they do not have vital registration systems. In 2015, 91% of world population had access to an improved drinking water source, versus 76% in 1990. Furthermore 68% of the world had access to improved sanitation in 2015, versus 54% in 1990. There was an inversely proportional relation between income level and degree of achievement of the goals of MDG 7. 5. DISCUSSION: Regarding MDG 4: WHO Regions with a lower degree of fulfilment of the objective were the African Region (98,7 deaths per 1000 live births in 2015), and the South East Asian Region (52,5 deaths per 1000 live births in 2015). Two thirds of deaths in underfive children are due to infectious diseases (mainly pneumonia, diarrhea, and malaria). Most of these deaths are preventable. Despite improvements in nutrition, prevention and treatment of malaria, and measles inmunization, there is still work to do, since antibiotic treatment in respiratory illnesses, or oral rehydration therapy for diarrhea remain insufficient. The main limitation of the work with underfive mortality rate was the poor quality of data: only 60 countries have reliable civil registration systems. In the rest of nations, mortality estimations are subject to significant sources of bias. The next goals are marked by the Sustainable Development Goals (SDG): to get all countries reach an underfive mortality rate under 25 per 1000 live births in 2030. Sub-Saharan African countries would need to accelerate their progress in order to achieve such a goal. Regarding MDG 5A: The WHO Regions closer to the MDG 5A are European Region, American Region, and South East Asian Region. Regions further from reaching the Objective are the African Region, Eastern Mediterranean Region, and Western Pacific Region. Maternal mortality represents the objective which remains further from the goal. While South East Asian Region diminished its maternal mortality ratio in 75%, the African Region only got a 44,88% reduction from 1990 to 2015. Maternal mortality represents the health indicator showing greater gaps between richest and poorest countries. (It is 25 times higher in developing countries with respect to developed nations). The health indicators influencing maternal mortality ratio selected by WHO as key ones are the proportions of births attended by skilled health personnel, and antenatal visits coverage (at least one visit, at least 4 visits). The proportion of births attended by skilled health personnel has increased globally. Antenatal care might potentially improve. Alkema et al, 2016, from United Nations, developed a lineal regression multivariable model which included three co-variables: general fertility rate, GDP (gross domestic product) per capita, and proportion of births attended by skilled health personnel. We did include in our model also the global fertility rate. The PIB of Alkema’s model could be included in the Human Development Index from our model (since this is a complex indicator including educational level, GDP per capita, and life expectancy). The proportion of births attended by skilled health personnel was significant in our univariable analysis (protection factor), but it was not significant in the multivariable one. These authors also developed projections for the period 2016 to 2030, (Sustainable Development Goals) with the goal of a maternal mortality ratio under 70 deaths per 100000 live births in 2030, with no country with more than 140 deaths per 100000 live births. In order to reach the goal countries should reduce their MMR (maternal mortality ratio) with an annual decline rate of 7,5%. This would require clinical interventions, social and political commitment. Also stronger information systems to monitor progress would be needed. Regarding MDG 6: Tuberculosis Prevalence declined at a higher annual rate than tuberculosis incidence, mainly due to short and early therapies (DOTs). Since tuberculosis incidence and mortality due to tuberculosis usually happen at a higher mean age, aging of population will drive to an increase in tuberculosis cases and deaths. The burden of disease is greater in South East Asia and in India, as well as in the South of Africa. The graphic of our multivariable model was quite similar to WHO estimations in the evolution of tuberculosis prevalence for the period 1990-2015. Some groups have fixed ambitious goals after 2015 such as the "zero" incidence of tuberculosis or "zero" deaths due to tuberculosis. Summarizing we may consider as fulfilled the goal of MDG 6 for tuberculosis. Around 7,6 million deaths due to HIV have been avoided from 1995 to 2013 thanks to this therapy (ART). If this is added to the prevention of mother-child transmission, around 19,1 million lives would have been saved from 1990 to 2013, 70,3% in developing countries. There is a wide uncertainty for prevalence, incidence and mortality due to HIV. HIV prevalence is declining globally at an annual rate of 5-8% in the last five years, thanks to ART, with a greater impact in the group of HIV of sexual transmission. Nevertheless, national data about results achieved by ART are inconsistent... and estimations, both of UNAIDS and of the group of GBD are based upon cohort studies and other publications. Monitoring ART results should be a priority in the future, given its impact in prevalence and mortality due to HIV. Summarizing, we could affirm that the objective relating HIV infection has been achieved. In 2015, 57 out of 106 countries affected by malaria in 2000 have reduced incidence in at least 75%, and other 18 countries did it in 50-75%. The European Region has reported zero cases of autochthonous malaria in 2015. From 2000, malaria mortality decreased 72% in the American Region, 63% in Western Pacific Region, and 64% in Eastern Mediterranean Region. The African Region, has also experienced considerable progress: 66% decline in mortality in general (71% in underfive children). More than 6,2 million of deaths have been avoided from 2000 to 2015, mainly in underfive children in Sub-Saharan Africa. In 2015, 55% of population sleeps under ITN, versus a 2% in 2000. In Murray's multivariable model (GBD study) for malaria they found as independent variables first line anti-malarial drugs' resistance, and population coverage (%) of ITN (insecticide treated nets). Both variables must be combined to understand changes in underfive mortality due to malaria in last years. Achievements in the last 15 years have been possible thanks to a 10 times increase in international financing fighting malaria from year 2000, with investment in: ITN, fumigation with residual insecticides, rapid diagnostic tests for fever cases (from 36% in 2005 to 65% in 2014) and artemisinin combination therapies (highly effective against P.falciparum). Incidence estimation would improve with rapid diagnosis tests and monitoring its variation depending on resistance to first line anti-malarial drugs. Summarizing, we may consider that the MDG for malaria has been achieved. World Health Assembly established in 2015 the World Technical Strategy against Malaria 2016-2030, with a set of goals for 2030, among them, to reduce global incidence and mortality due to malaria in at least 90%. A long term political commitment, with 3 times greater inversion to control malaria would be needed.   Regarding MDG 7: In 2015, 147 countries achieved the goal of drinking water, 95 the one of sanitation, and 77 countries, both. All countries where less than 50% people uses improved sources of drinking water belong to Sub-Saharan Africa and Oceania. Also, in general, we could conclude that MDG 7 relating drinking water and sanitation access has been accomplished. Actually, the international community, through WHO and others UN institutions, has already established the agenda post-2015, and the work initiated with MDG in relation with health issues, is being continued in the SDG (2016-2030) with even more ambitious goals.   6. CONCLUSIONS: - Underfive mortality rate declined a 52,2 % (the goal of MDG 4 was 66,67%). Consequently, despite the progress made, this MDG has not been globally achieved. - Maternal mortality ratio experienced a global decline of 43,9 % (the goal of MDG 5A was 75%). This is the objective which remains further from being achieved globally. - Tuberculosis mortality rate declined 47% and prevalence of tuberculosis experienced a 41% reduction during that period. Incidence of tuberculosis decreased mainly after 2000. Tuberculosis Prevalence declined at a higher annual rate than tuberculosis incidence, mainly due to short and early therapies (DOTs). The MDG 6 relating tuberculosis has been fulfilled. - HIV incidence had a peak in 1997, and mortality due to HIV experienced another peak in 2005, with a substantial global decline in both parameters after these peaks. New HIV infections decreased 40% from 2000 (3,5 million) to 2013 (2,1 million). Around 19,1 million deaths due to HIV have been avoided from 1995 to 2013 thanks to anti-retroviral therapy (ART) and the prevention mother-to-child transmission of HIV. The MDG 6 relating HIV has been globally achieved. - With respect to malaria, 98 endemic countries have reversed the trends in incidence in 2015 in comparison with year 2000. According to Malaria World Report 2015 57 from 106 countries affected by malaria in 2000 have reduced incidence in at least 75%, and other 18 countries did it in 50-75%. From 2000, malaria mortality decreased globally. We could consider MDG 6 relating malaria has been achieved. - In 2015, 91% of world population had access to an improved drinking water source, versus 76% in 1990. In 2015 68% of world population had access to improved sanitation, versus 54% in 1990. Therefore147 countries fulfilled the goal of drinking water, 95 the one of sanitation, and 77 countries, both.