Health in the Americas 2022

Health overview

Agentes de salud en una comunidad

In the Americas, the COVID-19 pandemic broke out in a context of high social inequality, generating negative synergies with other pre-existing epidemics. Several studies carried out in different countries of the Region have documented higher lethality among people residing in areas with a higher concentration of poverty, as well as among indigenous and Afro-descendant people (). The pandemic resulted in loss of human life, reductions in life expectancy, and simultaneous and synchronized impacts on physical, mental, and social health. This was especially severe in social groups in conditions of vulnerability.

Epidemiology

Between the appearance of the first cases of COVID-19 in the Region and 31 August 2022, five epidemic waves have been recorded (Figures 3.1 and 3.2). All have been characterized by differences in the virulence and lethality of the disease. The latest wave has been contained thanks to COVID-19 vaccination coverage, which has contributed to a significant reduction in mortality (,).

The Region of the Americas, with 13% of the world's population, has been one of the regions most affected by the pandemic, with 29% of confirmed cases and 44% of deaths, globally. As of 31 August 2022, there were 175 771 144 cases of COVID-19 in the Region (52%, women; 48%, men). North America recorded 55% of all cases in the Region of the Americas, but 62% of all deaths occurred in Latin America and the Caribbean (Figures 4 and 5).

Figure 3.1. Confirmed COVID-19 cases and COVID-19 deaths in the Region of the Americas, by subregion and week of notification

This figure shows the number of confirmed COVID-19 cases and deaths in the Region of the Americas from 1 January 2020 until 31 August 2022. Click the button options to view cases and deaths by week or cumulatively. The figure can be viewed in linear or log scale The yellow button allows you to view cases and deaths by subregions.

Figure 3.2. COVID-19 deaths per million population vs. cases per million population, in the context of income groups

Considering population size, burden of disease and mortality, and country wealth, this animated figure illustrates the changes in COVID-19 cases per million population for countries, since 1 January 2020 until the fully completed day the figure is viewed, graphed against cumulative deaths per million. The countries are shown according to World Bank income groups – high income (green), upper middle income (yellow), and lower middle income groups (red). Click on the “play” button at the left of the vertical (y) axis to see the change the number of cases and deaths by month. Note that you can individually select a country to illustrate the change over the period and view more information about each country.

Figure 3.3. Weekly confirmed COVID-19 deaths in the different WHO regions

This figure shows the number of COVID-19 deaths by the six WHO Regions. The first view shows the deaths for all six regions stacked. Click the "Comparison Chart" button on the left to view the deaths for each region, separately.

Figure 4. COVID-19 cases reported in the Region of the Americas, by subregion (number and percentage), as of 31 August 2022

Graph
Source: Pan American Health Organization. COVID-19 trends. Washington, DC: PAHO; 2022. Available from: https://shiny.pahobra.org/wdc/.

Figure 5. COVID-19 deaths reported in the Region of the Americas, by subregion (number and percentage), as of 31 August 2022

Graph
Source: Pan American Health Organization. COVID-19 trends. Washington, DC: PAHO; 2022. Available from: https://shiny.pahobra.org/wdc/.

The North American subregion has reported the highest number of cases per 100 000 population throughout the pandemic (25 951.50 cases per 100 000 population), followed by the Southern Cone (21 212.17) and the non-Latin Caribbean (11 418.30) (Figure 6). This result possibly reflects better management of the information generated and more timely surveillance, detection, and diagnostic systems.

Figure 6. COVID-19 case rate per 100 000 population in the Region of the Americas, by subregion

Graph
Source: Pan American Health Organization. COVID-19 trends. Washington, DC: PAHO; 2022. Available from: https://shiny.pahobra.org/wdc/.

The North American subregion also accounted for the highest proportion of deaths reported during the pandemic (Figure 7), with a total of 1 079 383 cumulative deaths reported as of 31 August 2022. However, when comparing the cumulative mortality rate per million population, the highest rate was recorded in Brazil (3191), followed by the Andean zone (2938) and the Southern Cone (2900).

Figure 7. COVID-19 mortality rate in the Region of the Americas, by subregion, per million population

Graph
Source: Pan American Health Organization. COVID-19 trends. Washington, DC: PAHO; 2022. Available from: https://shiny.pahobra.org/wdc/.

According to the World Health Organization (WHO), global data disaggregated by sex show that the number of confirmed cases is higher for women than for men (Figure 8). However, the opposite is true for deaths: men represent 58% of total deaths, compared to 42% for women (,).

Figure 8. Distribution of COVID-19 cases and deaths in the Region of the Americas, by sex (%)

GraphSource: WHO COVID Surveillance Detailed Dashboard, 2022. Available from: https://app.powerbi.com.

According to the recent WHO report on excess deaths due to COVID-19, it is estimated that there were 3.23 million deaths in the Region of the Americas, or 430,000 more deaths than were reported (). Five countries (Brazil, Colombia, Mexico, Peru, and the United States of America) accounted for 83.5% of excess mortality. Due to its high mortality rate, COVID-19 was among the leading causes of death in 2020 and 2021.

Globally available data disaggregated by age groups show that total cases are disproportionately concentrated in the population aged 20 to 50 years. In the Americas, it is estimated that the population over 70 accounts for 9.1% of cumulative cases, with 51% of cumulative deaths in this age group, as shown in Figure 9. Likewise, in the countries of the Region of the Americas, COVID-19 mortality increases exponentially with age. Vaccination has certainly reduced the risk of death overall, although the risk remains higher among older adults.

Figure 9. Proportional distribution of COVID-19 cases and deaths in the Americas by 5-year age groups for 2020, 2021, and 2022

There are two different options to view the information. The first view shows the age-adjusted rate of COVID-19 cases and deaths per million population group.

The second option presents the data in a chart.

Regarding socioeconomic inequalities, studies in several countries of the Region have documented higher COVID-19 mortality in populations in conditions of vulnerability, including people residing in areas with higher concentrations of poverty and indigenous populations.

Life expectancy in the Region

Life expectancy in Latin America and the Caribbean decreased from 75.1 years in 2019 to 72.2 in 2021 (2.9 years less); and in North America it decreased from 79.5 years in 2019 to 77.7 in 2021 (1.8 years less) (), . This was mainly due to the impact of COVID-19, with the greatest loss of life expectancy in Latin America and the Caribbean. Life expectancy in 2021 for Latin America and the Caribbean and for North America is comparable to the figure for 2004. During this period, in both Latin America and the Caribbean and in North America, life expectancy decreased more for men than for women (Table 1)

Table 1. Life expectancy in the Region of the Americas, by subregion and sex, 2004, 2019, and 2021, in years
Subregion Life expectancy
2004 2019 2021 Years lost between 2019 and 2021
North America 77,8 79,5 77,7 1,8
Men 75,2 76,9 74,9 2,0
Women 80,3 81,9 80,7 1,2
Latin America and the Caribbean 72,3 75,1 72,2 2,9
Men 69,5 71,9 68,8 3,1
Women 75,9 78,3 75,8 2,5

Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects 2022. New York: United Nations; 2022. Available from: https://population.un.org/wpp/

Health Systems and Services

With exceptions, health systems in the Americas have been characterized by underfunding, segmentation, and fragmentation. Despite ongoing processes to reform and strengthen the health sector in the countries of the Region, the progress made has failed to protect countries from the pressures of the pandemic. Public expenditure on health is low, averaging 3.8% of gross domestic product, far from the established target of 6%. This is reflected in deficits in infrastructure and human resources available for health.

The level of out-of-pocket expenditure on health in the Region is high, increasing the risk of impoverishing households. It is also one of the main sources of inequity in access to health services, because it implies a lack of financial protection for people who are in situations of greatest vulnerability and who are most exposed to catastrophic expenses in case of illness.

The enormous pressure of the pandemic on health systems in the countries of the Region has exposed, once again, the long-standing gaps in universal health that exacerbate inequalities in access to effective and comprehensive health services (,). Health services have faced unprecedented increases in demand in a scenario of limited available resources to address a new and severe situation that quickly escalated into a global public health, social, and economic crisis.

The pandemic also highlighted the challenges faced by health systems in ensuring universal access to health and universal health coverage. Adapting and retrofitting services to increase care capacity allowed for greater attention to people with the new disease, but also weakened the delivery of other services, particularly in peri-urban, rural, and indigenous areas.

Strengthening of the first level of care was uneven across countries. One of the most important actions recommended as part of the COVID-19 response in the health service delivery area was to reorganize and strengthen the capacity of the first level of care to participate in containing the spread of the disease, early detection of SARS-CoV-2, initial case monitoring and treatment , and prioritization of services in all areas, while maintaining essential services ().

The degree of effectiveness of these actions depended largely on pre-existing public health capacities in the countries. In many cases, capacity gaps limited a comprehensive and integrated response, leading to delayed response measures, disruptions in the continuity of essential services, exacerbation of access barriers, and low COVID-19 vaccination rates. By May 2020, nearly 20 countries had incorporated primary care services into the COVID-19 response, although they were not operating at full capacity. Mental health, communicable diseases, and sexual, reproductive, maternal, neonatal, child, and adolescent health services were the most affected (Table 2).

Table 2. Countries in the Region of the Americas with disruptions in health services, by area of care (%)
Health service area Countries with service disruptions (%)
First level of care 70
Vaccination 69
Care for older people 67
Nutrition 64
Neglected tropical diseases 53
Mental health, neurological, and substance use disorders 47
Communicable diseases 38
Sexual, reproductive, maternal, neonatal, infant, child, and adolescent health 32

Source: Pan American Health Organization. Third round of the National Survey on the Continuity of Essential Health Services during the COVID-19 Pandemic: November-December 2021. Interim report for the Region of the Americas, January 2022. Washington, DC: PAHO; 2022. Available from: https://iris.paho.org/handle/10665.2/56128.

By the end of 2021, 93% of countries reported disruptions in the provision of essential health services in all modalities, with 26% reporting 75-100% disruptions in services, and 55% reporting average disruptions in the 66 services analyzed; 70% of countries reported disruptions in primary care, palliative care, and rehabilitation services.

Reductions were observed in all services, which have been reflected in declines in health indicators. For example, there has been a widely unmet need for modern contraceptive methods in the Region (14.5-17.7%), resulting in an estimated 1.7 million unplanned pregnancies, nearly 800 000 abortions, 2900 maternal deaths, and nearly 39 000 infant deaths, representing a setback equivalent to 20-30 years of progress in this field ().

According to the Organization for Economic Co-operation and Development (OECD), the average number of hospital beds in Latin America and the Caribbean was 2.1 per 1000 population in 2020, less than half the average figure for OECD countries (4.7) (). In addition, the biggest bottleneck for the treatment of severe COVID-19 was the limited capacity of intensive care beds due to high occupancy rates, which in many countries of the Region exceeded 70%, becoming an emergency in itself (). As a result, one of the first actions health services took in order to provide care to COVID-19 patients was to retrofit hospital beds for patients with severe infection, supported by emergency medical teams, establish mobile hospitals and alternative sites, and provide oxygen in hospitals, first-level care centers, and homes.

An analysis of information from ministries of health official communication sites conducted in 16 countries between March 2020 and September 2021 shows that the number of intensive care beds went from 61 406 to 122 501, for a 99% increase in installed capacity (61 095 new beds). In other words, the services doubled the number of beds in just 18 months.

Human resources for health

The response to the COVID-19 pandemic has once again highlighted the chronic deficit and poor distribution of human resources for health in the Region. There is also evidence of a lack of policies, strategic planning processes, and investment in the development of a fit-for-purpose health workforce in many countries.

Globally, the majority of health workers are women (nearly seven out of 10). In the Region, 56% of human resources for health are nursing staff, 89% of them women. In addition to their work responsibilities, women are also the primary family caregivers and, in many cases, the main breadwinners. Expectations of women have increased significantly during the pandemic, which has caused them added stress and affected their mental health and well-being. Studies among health personnel in the Region show high levels of mental disorders in Argentina, Chile, Mexico, Trinidad and Tobago, and the United States.

To ensure the functioning of the health system, changes have been required in strategic planning and regulation for health personnel, and in support and capacity-building for these workers. Many countries have also faced pre-existing health workforce challenges, including shortages (estimated at 15 million workers globally in 2020, and 10 million by 2030, mainly in low- and lower-middle-income countries), poor distribution, and misalignment with respect to needs and skills.

In the period between the confirmation of the first cases of COVID-19 in the Americas and 29 November 2021, at least 2 397 174 cases have been reported among health personnel, including 13 081 deaths, according to information available from 41 countries and territories of the Americas (Table 3) (). The cases represent 16% of all health personnel, estimated at 15 million in the Region (). Moreover, recent WHO-led studies have estimated more than 115 000 COVID-19 deaths among health workers globally (including some 60 000 in the Americas) ().

Table 3. Number of confirmed COVID-19 cases and cumulative deaths among health personnel in the Region of the Americas, by country and territory, January 2020 to 30 November 2021
Country/Territory Confirmed cases of COVID-19 Deaths
Anguilla 13 0
Antigua and Barbuda 44 2
Argentina 240 261 1273
Aruba 301 0
Bahamasa 955 14
Belize 542 4
Bermuda 59 0
Bolivia (Plurinational State of)a 28 418 456
Bonaire 123 1
Brazil 655 105 903
Canadaa 113 105 64
Chilea 64 681 134
Colombia 68 230 337
Costa Rica 8969 57
Curaçao 138 0
Dominicaa 1 0
Ecuador 13 332 156
El Salvadora 7643 79
United States 761 378 2810
Grenadaa 14 0
Guatemalaa 8642 65
Haitia 781 3
Hondurasa 13 668 115
Cayman Islands 36 0
Falkland Islandsa 12 0
Turks and Caicos Islands 110 0
Virgin Island (British)a 141 0
Jamaicaa 861 4
Mexicob 286 285 4572
Panama 9078 115
Paraguay 17 839 183
Peru 76 099 1475
Dominican Republic 1645 23
Saint Kitts and Nevisa 34 0
Saint Eustatius 8 0
Saint Vincent and the Grenadinesa 31 0
Saint Lucia 246 0
Sint Maarten (Netherlands) 73 0
Suriname 1722 3
Uruguay 9745 28
Venezuela (Bolivarian Republic of)a 6806 205
Total 2 397 174 13 081

Notes: a Latest available data is from 30 October 2021.
b The information corresponds to the 'occupation' variable of the Epidemiological Surveillance System for Viral Respiratory Disease (SIS VER). The analysis reflects the cases reported as performing a health-related occupation. The information collected in SIS VER does not make it possible to identify whether infection occurred in the workplace, at home, or in the community; nor does it indicate whether health workers are currently part of a medical care unit.
Source: Pan American Health Organization. Epidemiological Update: Coronavirus disease (COVID-19) -: 2 December 2021. Washington, DC: PAHO; 2021. Available from: https://www.paho.org/en/documents/epidemiological-update-coronavirus-disease-covid-19-2-december-2021.

The countries of the Region developed various strategies aimed at optimizing the availability of human resources while guaranteeing their safety and working conditions, including the provision of personal protective equipment (PPE) and instructions for its use, safety guidelines for staff, economic incentives for those working in direct care of COVID-19 patients, recognition of COVID-19 as an occupational disease, life insurance coverage for staff, and interventions to address their mental health issues.

Routine immunization program

Over the past decade, routine childhood vaccination programs have significantly contributed to reducing vaccine-preventable diseases and saving millions of lives. Despite the progress made, the impact of the pandemic was also associated with disruptions to vaccination activities.

Administered doses as well as subsequent vaccination coverage have declined in the Region since 2020 (Table 4). The subregions that have experienced significant reductions in supplied doses are North America, followed by the Southern Cone and the Andean Area for DTP-1 (diphtheria, tetanus, and pertussis), DTP-3, and MMR-1 (measles, mumps, and rubella). Declines in coverage range from 3.7% for the DTP-3 vaccine to 10.3% for MMR-2 (Table 5). In this context, PAHO is working with countries and partners to improve vaccination coverage and reduce the risk of outbreaks of vaccine-preventable diseases in the effort to leave no one behind.

Table 4. Relative difference in doses of different vaccines administered in the Region of the Americas, by subregion, comparison between 2021 and 2019
Subregion DTP-1 (%) DTP-3 (%) MMR-1 (%)
North America –51,2 –38,5 –50,4
Brazil –22,4 –12,4 –35,9
Latin Caribbean –9,5 –10,5 –11,6
Non-Latin Caribbean –12,8 –12,7 12,8
Central America –24,8 –24,6 –24,8
Southern Cone –42,8 –44,8 –45,3
Andean Area –42,8 –36,5 –31,3

Source: Pan American Health Organization. Impact of COVID-19 on the coverage of the systematic vaccination program 2019-2021. Washington, DC: PAHO. Unpublished.

Table 5. Vaccination coverage in the Region of the Americas, 2019–2021
Vaccine 2019 (%) 2020 (%) 2021 (%) Decrease (2019-2021*)a
DTP-1 89 88,6 86 3,5
DTP-3 84 85 81 3,7
PCV (last dose) 86,8 81,7 80 8,5
Polio3 87 82 79 9,8
MMR-1 87 87 85 2,4
MMR-2 75 65 68 10,3

Notes: a Estimate by the Pan American Health Organization.
DTP: diphtheria, tetanus and pertussis; PCV: pneumococcal conjugate vaccine; Polio3: poliomyelitis. MMR: measles, mumps, and rubella.
Source: Pan American Health Organization. Immunization Reported Coverage. Washington, DC: PAHO; 2022. Available from: https://ais.paho.org/imm/IM_JRF_COVERAGE.asp.

Information systems and digital transformation

Having health information systems that are functional, interconnected, and interoperable has proven to be a strategic tool for decision-making related to the pandemic response. Developments and innovations in information systems and epidemiological surveillance have made it possible to anticipate the path of the pandemic using digital tools such as chatbots, platforms, and applications (for example, artificial intelligence, robotics, telehealth, blockchains, and the internet of things), as well as artificial intelligence to control the infodemic, processing and analysis of available data, and development of simulation models, among others.

Access to data, information, and multimedia content has been simplified thanks to the massive use of the internet, social networks, and mobile technologies. However, these same mechanisms generate an information overload that is very difficult to manage in rapid decision-making processes, while facilitating the circulation of false or distorted information; this is part of the infodemic that has led to a reluctance to be vaccinated, resistance to following preventive measures and, in many cases, incorrect self-medication or abandonment of treatment, among other effects.

At the same time, the incorporation of digital applications in the fields of health and public health has helped to improve patient monitoring (for COVID-19 and other conditions), management of medical health records, responsible self-care, teleconsultations, tele-education, automatic capture of critical data, and issuance of digital vaccination certificates and mobility passes, among others. All this has made it possible to maintain access to health services, reducing the cost of care and bringing health care closer to areas and populations in situations of vulnerability.

Also, the use of artificial intelligence has played a prominent role in the area of procurement during the pandemic and has been essential in more efficiently solving complex problems such as automating tasks, designing more effective distribution routes, automatically capturing new data sources, and above all, ensuring that the management of relationships with international suppliers is based to a greater extent on transparent and quality data. Nevertheless, significant digital gaps in connectivity and bandwidth for appropriate internet access persist in the Americas; if not addressed with timely public policies, these gaps could exacerbate existing inequities.

Communicable diseases and COVID-19

In the past ten years, several countries have reached milestones in the elimination of diseases such as malaria, rabies transmitted by dogs, onchocerciasis, foot-and-mouth disease, Chagas disease, and trachoma, as well as in mother-to-child transmission of the human immunodeficiency virus (HIV) and syphilis. However, the COVID-19 pandemic brought with it significant challenges. Factors that have hampered health program operations include the service disruptions due to quarantines and restrictions on the movement of people imposed by several countries; a lack of resources and critical supplies for patient care and the continuation of prevention and control services; reorientation and redistribution of human and financial resources to respond to the pandemic; and problems in international and domestic supply chains for medicines and other inputs.

Reversing progress toward the Sustainable Development Goals (SDGs) targets for tuberculosis, HIV, and malaria is a major setback on the road to achieving SDG 3 and closing inequality gaps in vulnerable populations. The Results Report 2021 of the Global Fund to Fight AIDS, Tuberculosis and Malaria presents a devastating scenario with respect to achieving the targets for HIV, tuberculosis, and malaria following COVID-19 (). The pandemic caused multiple disruptions in all established interventions for the management, control and elimination of communicable diseases, including their diagnosis and treatment (Table 6).

Table 6. Percentage of countries in the Region of the Americas that reported disruption of services and programs for the control and prevention of communicable diseases
Disruptions Countries (%)
Diagnosis and treatment of tuberculosis 65
Access to diagnostic tests for human immunodeficiency virus (HIV) 50
Diagnosis and treatment of malaria 50
Diagnosis and treatment of viral hepatitis 43
Prevention services 59

Source: Pan American Health Organization. Third round of the National Survey on the Continuity of Essential Health Services during the COVID-19 Pandemic: November-December 2021. Interim report for the Region of the Americas, January 2022. Washington, DC: PAHO; 2022. Available from: https://iris.paho.org/handle/10665.2/56128.

In addition, nearly half of the countries experienced disruptions in care services for neglected infectious diseases and other communicable diseases, including regular vector control activities, mass delivery of medicines, and screening of populations at risk of infection. Due to the reallocation of resources in response to the pandemic, it continues to be complicated to resume actions in various services, putting at risk the fulfillment of the commitments made to eliminate these diseases by 2030. In addition, health supply chains, which are essential in providing diagnosis and treatment of these diseases, suffered disruptions in 40% of countries.

The global antimicrobial resistance crisis has been aggravated by the emergence of new and more complex resistance mechanisms. This relates to the increased use of antimicrobials to treat COVID-19 patients, as well as gaps in infection prevention and control practices in overburdened health systems.

Addressing inequalities related to HIV, tuberculosis, and malaria is a complex issue that has been exacerbated by the COVID-19 pandemic. To respond to these challenges, it is necessary to strengthen people-centered primary health care, universal health, and multisectoral actions with a focus on the social determinants of health.

Human immunodeficiency virus

In 2020, most countries in the world did not reach the 90-90-90 targets of the Joint United Nations Programme on HIV/AIDS (UNAIDS). The same year, based on UNAIDS Spectrum estimates, in Latin America and the Caribbean there was an 8.7% increase in the coverage of antiretroviral therapy, despite COVID-19.

Based on data reported by 20 countries to UNAIDS, in 2020 there was a 34% decrease in the number of people tested for HIV compared to 2019, and a 27% decrease in the number of people with a new positive HIV diagnosis. The reduction in the number of people tested and diagnosed as HIV-positive did not fully reverse in 2021. It is also important to note that in 2020 there were 34 526 people on HIV pre-exposure prophylaxis (PrEP) compared to 19 783 in 2019 (32, 33). (,).

Tuberculosis

COVID-19 has replaced tuberculosis as the world's leading deadly infectious disease; however, tuberculosis remains a leading infectious disease, second only to COVID-19. In the Americas, estimated TB deaths increased from 24 000 in 2019 to 27 000 in 2020, a trend that is projected to continue in 2021 and 2022.

In 2020 there was a 17% increase in people diagnosed with tuberculosis, compared to 2019. In the same period, there was a 19% reduction in people in treatment for drug-resistant tuberculosis, along with a 20% decrease in HIV/TB patients on antiretroviral therapy during tuberculosis treatment. Also, there was a 27% decrease in the child population under 5 years of age in contact with tuberculosis patients who received preventive therapy ().

Malaria

COVID-19 has been associated with a reduction in the total number of malaria cases at the regional level. The results were uneven within countries, with sharp reductions in some countries and increases in others. The pandemic had a general impact on malaria surveillance, with a decrease in case detection, active surveillance, and deployment and coverage of vector control actions.

In the 2019-2020 period, the number of mosquito nets distributed to protect families from malaria decreased by 20.6%. In the same period, there was a 28% reduction in the number of people tested for malaria, and a 46% reduction in the population protected with indoor residual spraying (,).

Noncommunicable diseases and COVID-19

Comorbidity

Before the pandemic, noncommunicable diseases accounted for 81% of deaths in the Americas, led by cardiovascular diseases, chronic respiratory diseases, diabetes mellitus, cancer, and Alzheimer's disease, and other dementias. In the Region, 24% of people had at least one underlying condition, although this value varies by subregion: Latin America accounts for 22% and the non-Latin Caribbean for 29% (). This pattern coincides with the comorbidities presented by persons with COVID-19 and is associated with a greater risk of serious illness ().

Different analyses have shown an increased risk of death from COVID-19 in people with pre-existing noncommunicable diseases, particularly diabetes, hypertension, and obesity (). Of the total reported cases of COVID-19, 1 509 786 had at least one comorbidity. The number of cases with at least one comorbidity increases with age, and the over-70 age group accounted for 28% of reported cases (Figure 10).

Figure 10. Number of patients with at least one reported comorbidity in the Region of the Americas, by age group, from 1 January 2019 to 8 September 2022

Graph
Source: Pan American Health Organization. COVID-19 Data reported by countries and territories in the Region of the Americas. Washington, DC: PAHO, 2022. Available from: https://ais.paho.org/phip/viz/COVID-19EpiDashboard.asp.

As for COVID-19 patients admitted to an intensive care unit or who required ventilatory support, there is only one example ( not necessarily representative) in which 24.6% and 23.4% of total cases, respectively, had at least one reported comorbidity. Of the 371 789 patients admitted to an intensive care unit, cardiovascular disease was recorded in 60% of cases (182 846), followed by diabetes in 30% of cases (90 902). Of the 352 537 patients on a ventilator, 50% (177 556) reported cardiovascular disease, followed by diabetes in 23% of cases (80 727).

Mental health

The magnitude of mental health disorders in the population during the COVID-19 pandemic has not yet been fully documented. However it is clear that interpersonal relationships, in particular, have been negatively affected, with increases in reported cases of domestic violence and in calls for help to mental health services.

The different mitigation measures implemented in the countries to control the spread of the pandemic (quarantines, restrictions on mobility, and physical distancing) increased anxiety, depression, and consumption of addictive substances in large sectors of the population (,). Anxiety associated with the pandemic has led to the description of a COVID-19-related stress syndrome (). Canada and the United States have reported that 38% of adults experienced some degree of distress, and 16% experienced elevated levels of anxiety, further burdening the demand for mental health services ().

The prevalence of depression and anxiety due to the COVID-19 pandemic increased until January 2021, if analyzed in terms of both reported daily SARS-CoV-2 infections and changes in mobility. These conditions were observed particularly in young people, women, people in situations of socioeconomic vulnerability, and people with pre-existing mental disorders (). These increases represent 53.2 million additional cases of major depression and 76.2 million additional cases of anxiety disorders—increases of 27.6% and 25.7%, respectively, compared to pre-pandemic levels ().

Studies have shown that the pandemic has amplified risk factors associated with suicide, such as loss of employment and financial loss, trauma and abuse, mental health disorders, and barriers to accessing health care. A study in the Region by the United Nations Children's Fund (UNICEF) indicates that 27% of adolescents and young people reported symptoms of anxiety and 15% reported symptoms of depression, while a third of them identified the economic situation as the main trigger of these states (). Furthermore, 43% of women and 31% of men said they felt pessimistic about the future (). Among health personnel, studies in the Region show high levels of mental disorders in Argentina, Chile, Mexico, Trinidad and Tobago, and the United States.

Mental health should be permanently positioned on the same level as physical health. Countries should guarantee access to mental health services, prioritize vulnerable populations, and develop strategies and initiatives in conjunction with the education and labor sectors for early identification of mental health conditions that require care.

Pregnancy

A comparative study conducted by the Centers for Disease Control and Prevention found that pregnant women are 5.4 times more likely to be hospitalized than non-pregnant women of the same ethnicity and age. Their risk of being hospitalized in an intensive care unit is also higher, and the risk of needing mechanical ventilation is 1.7 times higher ().

While the overall risk of severe illness and death for pregnant people remained low globally, the effects of the pandemic on this population group in the Region of the Americas were especially severe. According to data from 24 countries in 2021, there was an increase in both the number of cases and deaths among SARS-CoV-2-positive pregnant people compared to 2020 (Table 7). Most countries reported a higher maternal mortality ratio in 2021.

Table 7. Selected indicators for COVID-19 in pregnant people, Region of the Americas, 2020 and January-November 2021
Country Number of SARS-CoV-2-positive pregnant people Number of deaths in SARS-CoV-2-positive pregnant people MMRb (per 100 000 live births) Number of SARS-CoV-2-positive pregnant people Number of deaths in SARS-CoV-2-positive pregnant people MMRb (per 100 000 live births)
2020 2021 (January to November)
Argentina 9001 41 5,5 13 483 174 23,2
Belize 181 2 28,4 445 8 150,6
Bolivia (Plurinational State of) 963 31 12,5 2442 20 8,1
Brazil 5489 256 9 9871 1046 37
Canada 2925 1 0,3 5627 2 0,5
Chile 6610 2 0,9 9220 14 6,2
Colombia 7994 56 7,7 10 765 137 22,4
Costa Rica 335 3 0,4 1048 9 0,1
Cuba 180 0 0 5769 95 87,3
Ecuador 1589 29 8,6 1255 28 8,3
El Salvador 272 10 9 292 5 4,5
United States 68 459 80 2 79 057 160 4
Guatemala 652 8 1,9 1306 7 1,6
Haiti 79 4 5,1 27 0 0
Honduras 508 15 7,2 310 41 19,6
Mexicoa 10 568 205 9,4 20 293 431 25,5
Panamaa 1697 9 11,3 922 5 6,3
Paraguaya 599 1 0,7 1563 88 61,5
Peru 40 818 81 14,3 14 622 109 19,2
Dominican Republic 707 36 21,7 879 9 6,3
Saint Lucia 5 0 0 41 0 0
Surinamea 184 2 18,9 396 20 189,8
Uruguay 106 0 0 1659 12 25,5
Venezuela (Bolivarian Republic of) 338 9 1.5 439 7 1,1

Notas: a Includes pregnant and postpartum people.
MMR: Maternal mortality ratio based on deaths of SARS-CoV-2-positive pregnant people (and in some cases, postpartum people) per 100 000 live births. The number of newborns is obtained from estimates provided at the PAHO Core Indicators Portal. See: Pan American Health Organization. Core Indicators Portal. Core Indicators Dashboard. Washington, DC: PAHO; [c2021]. Available from: https://opendata.paho.org/en/core-indicators/core-indicators-dashboard.
Source: Data provided by national focal points for the International Health Regulations or published by ministries of health, health institutes, or other similar health entities.

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1. World Health Organization. WHO Coronavirus (COVID-19) Dashboard Geneva2021 [Available from: https://covid19.who.int/.

2. Pan American Health Organization. COVID-19: Dashboard Washington, D.C.: PAHO; 2022 [Available from: https://shiny.pahobra.org/covid19/.

3. Castro MC, Gurzenda S, Turra CM, Kim S, Andrasfay T, Goldman N. Reduction in life expectancy in Brazil after COVID-19. Nat Med. 2021;27(9):1629-35.

4. García-Guerrero VM, Beltrán-Sánchez H. Heterogeneity in Excess Mortality and Its Impact on Loss of Life Expectancy due to COVID-19: Evidence from Mexico. Can Stud Popul. 2021:1-36.

5. Rosero-Bixby L, Jiménez-Fontana P. Crónica de la pandemia de Covid-19 en Costa Rica. San José: Programa Estado de la Nación (PEN). 2021.

6. International Monetary Fund. World Economic Outlook: Managing Divergent Recoveries. Washington, D.C.: IMF; 2021.

7. Comisión Económica para América Latina y el Caribe. Panorama Social de América Latina, 2020. Santiago; 2021.

8. Comisión Económica para América Latina y el Caribe-Organizacion Panamericana de la Salud. The prolongation of the health crisis and its impact on health, the economy and social development,. CEPAL-OPS; 2021.

9. Economic Commission for Latin America and the Caribbean/PanAmerican Health Organization. The prolongation of the health crisis and its impact on health, the economy and social development. Washington, D.C.: The Economic Commission for Latin America and the Caribbean (ECLAC) and the Pan American Health Organization (PAHO); 2021.

10. Vélez CM. COVID19 Vaccination in Latin America and the Caribbean: Challenges, needs and opportunities. Montevideo: United Nations Educational, Scientific and Cultural Organization; 2021.

11. Comisión Económica para América Latina y el Caribe. Estudio económico de América Latina y el Caribe. Santiago: CEPAL; 2021. Contract No.: Rev. 1.

12. International Labor Organization. Working from home: from Invisibility to Decent Work. Geneva: ILO; 2021.

13. Economic Commission for Latin America and the Caribbean. Balance Preliminar de las Economías de América Latina y el Caribe, 2021. Santiago: ECLAC; 2022.

14. Maurizio R. Transitando la crisis laboral por la pandemia: hacia una recuperación del empleo centrada en las personas. Organización Internacional del Trabajo; 2021.

15. Organisation for Economic Co-operation and Development. Informalidad e inclusión social en tiempos de Covid-19, Cumbre ministerial virtual sobre inclusión social en América Latina y el Caribe.: OECD; 2020.

16. Gibbons R, Waldman M. Enriching a Theory of Wage and Promotion Dynamics inside Firms. Journal of Labor Economics. 2006;24(1):59 - 107.

17. Vélez R, Gómez-Franco L. Movilidad social en México: hallazgos y pendientes,. Centro de Estudios Espinosa Yglesia, Mexico; 2018.

18. Llamosas I, Rangel E. Efectos del primer empleo sobre las perspectivas laborales de los trabajadores en las regiones de México. Un enfoque de movilidad social, México. 2019.

19. International Monetary Fund. Fiscal Monitor; A Fair Shot. Washington, D.C.: IMF; 2021.

20. Comisión Económica para América Latina y el Caribe. Una década de acción para un cambio de época. Quinto informe sobre el progreso y los desafíos regionales de la Agenda 2030 para el Desarrollo Sostenible en América Latina y el Caribe. Santiago: CEPAL; 2022.

21. Krubiner CB, Faden RR, Karron RA, Little MO, Lyerly AD, Abramson JS, et al. Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response. Vaccine. 2021;39(1):85-120.

22. Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):769-75.

23. Zambrano LD, Ellington S, Strid P, Galang RR, Oduyebo T, Tong VT, et al. Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(44):1641-7.

24. López-Rodríguez G, Galván M, Galván Valencia O. Comorbilidades asociadas a mortalidad materna por COVID-19 en México. Gaceta médica de México. 2021;157:618-22.

25. Villar J, Ariff S, Gunier RB, Thiruvengadam R, Rauch S, Kholin A, et al. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatrics. 2021;175(8):817-26.

26. United Nations. Policy Brief: The Impact of COVID-19 on children. New York: UN; 2020 15 April 2020.

27. Doran CM, Kinchin I. A review of the economic impact of mental illness. Australian Health Review. 2019;43(1):43-8.

28. Layard R. Mental health: the new frontier for labour economics. IZA Journal of Labor Policy. 2013;2(1):2.

29. Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. The Lancet Psychiatry. 2021;8(6):535-50.

30. Zielinsk C. Infodemics and infodemiology: a short history, a long future. Rev Panam Salud Publica. 2021;45(e40).

31. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. The Lancet Psychiatry. 2021;In press.

32. Pan American Health Organization. The burden of mental disorders in the region of the Americas, 2018. Washington, D.C.: PAHO; 2018.

33. Kohn R, Ali A, Puac-Polanco V, Figueroa C, López-Soto V, Morgan K, et al. Mental health in the Americas: an overview of the treatment gap. Rev Panam Salud Publica. 2018;42:e165.

34. Tausch A, e Souza RO, Viciana CM, Cayetano C, Barbosa J, Hennis AJM. Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations. The Lancet Regional Health - Americas. 2022;5:100118.

35. Mascayano F, Alvarado R, Martínez-Viciana C, Irarázaval M, Durand-Arias S, Freytes M, et al. 30 years from the Caracas Declaration: the situation of psychiatric hospitals in Latin America and the Caribbean prior, during and after the COVID-19 pandemic. Social Psychiatry and Psychiatric Epidemiology. 2021;56(8):1325-7.

36. Campion J, Javed A, Sartorius N, Marmot M. Addressing the public mental health challenge of COVID-19. The Lancet Psychiatry. 2020;7(8):657-9.

37. Kumar A, Nayar KR. COVID 19 and its mental health consequences. Journal of Mental Health. 2021;30(1):1-2.

38. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. New England Journal of Medicine. 2020;383(6):510-2.

39. Vigo D, Patten S, Pajer K, Krausz M, Taylor S, Rush B, et al. Mental Health of Communities during the COVID-19 Pandemic. The Canadian Journal of Psychiatry. 2020;65(10):681-7.

40. Parlapani E, Holeva V, Nikopoulou VA, Sereslis K, Athanasiadou M, Godosidis A, et al. Intolerance of Uncertainty and Loneliness in Older Adults During the COVID-19 Pandemic. Frontiers in Psychiatry. 2020;11(842).

41. Scholten H, Quezada-Scholz VE, Salas G, Barria-Asenjo NA, Molina R, García JE, et al. Psychological Approach to COVID-19: A Narrative Review of the Latin American Experience. Revista Interamericana de Psicología/Interamerican Journal of Psychology. 2020;54(1):e1287.

42. Taylor S, Landry CA, Paluszek MM, Fergus TA, McKay D, Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates. Depression and Anxiety. 2020;37(8):706-14.

43. Santomauro DF, Mantilla Herrera AM, Shadid J, Zheng P, Ashbaugh C, Pigott DM, et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet. 2021;398(10312):1700-12.

44. Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatrics. 2021;175(11):1142-50.

45. Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, et al. Epidemiology of mental health problems in COVID-19: a review. F1000Res. 2020;9:636-.

46. Ma Z, Zhao J, Li Y, Chen D, Wang T, Zhang Z, et al. Mental health problems and correlates among 746 217 college students during the coronavirus disease 2019 outbreak in China. Epidemiol Psychiatr Sci. 2020;29:e181.

47. Wathelet M, Duhem S, Vaiva G, Baubet T, Habran E, Veerapa E, et al. Factors Associated With Mental Health Disorders Among University Students in France Confined During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(10):e2025591.

48. O'Connor RC, Wetherall K, Cleare S, McClelland H, Melson AJ, Niedzwiedz CL, et al. Mental health and well-being during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study. The British Journal of Psychiatry. 2021;218(6):326-33.

49. Creswell C, Shum A, Pearcey S, Skripkauskaite S, Patalay P, Waite P. Young people's mental health during the COVID-19 pandemic. The Lancet Child & Adolescent Health. 2021;5(8):535-7.

50. Panchal U, Salazar de Pablo G, Franco M, Moreno C, Parellada M, Arango C, et al. The impact of COVID-19 lockdown on child and adolescent mental health: systematic review. European Child & Adolescent Psychiatry. 2021.

51. Näslund-Hadley E, Hernandez-Agramonte JM, Montaño K, Namen O, Alpizar G, Luna U, et al. Educación inicial remota y salud mental durante la pandemia COVID-19. Washington, D.C.: División de Educación, Sector Social, Banco Interamericano de Desarrollo; 2020.

52. UNICEF. La reapertura y continuidad de los servicios de cuidado infantil y aprendizaje temprano son una prioridad en la región 2021 [Available from: https://www.unicef.org/lac/media/22861/file.

53. Li Y, Wang A, Wu Y, Han N, Huang H. Impact of the COVID-19 Pandemic on the Mental Health of College Students: A Systematic Review and Meta-Analysis. Front Psychol. 2021;12:669119.

54. Panchal U, Salazar de Pablo G, Franco M, Moreno C, Parellada M, Arango C, et al. The impact of COVID-19 lockdown on child and adolescent mental health: systematic review. Eur Child Adolesc Psychiatry. 2021:1-27.

55. Jones EAK, Mitra AK, Bhuiyan AR. Impact of COVID-19 on Mental Health in Adolescents: A Systematic Review. Int J Environ Res Public Health. 2021;18(5).

56. Samji H, Wu J, Ladak A, Vossen C, Stewart E, Dove N, et al. Review: Mental health impacts of the COVID-19 pandemic on children and youth - a systematic review. Child Adolesc Ment Health. 2021.

57. National Scientific Council on the Developing Child. Excessive Stress Disrupts the Architecture of the Developing Brain. Harvard: Center on the Developing Child, Havard University; 2014.

58. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42.

59. Lee BP, Dodge JL, Leventhal A, Terrault NA. Retail Alcohol and Tobacco Sales During COVID-19. Annals of Internal Medicine. 2021;174(7):1027-9.

60. MacKillop J, Cooper A, Costello J. National Retail Sales of Alcohol and Cannabis During the COVID-19 Pandemic in Canada. JAMA Network Open. 2021;4(11):e2133076-e.

61. Myran DT, Smith BT, Cantor N, Li L, Saha S, Paradis C, et al. Changes in the dollar value of per capita alcohol, essential, and non-essential retail sales in Canada during COVID-19. BMC Public Health. 2021;21(1):2162.

62. Roberts A, Rogers J, Mason R, Siriwardena AN, Hogue T, Whitley GA, et al. Alcohol and other substance use during the COVID-19 pandemic: A systematic review. Drug and Alcohol Dependence. 2021;229:109150.

63. Taylor S, Paluszek MM, Rachor GS, McKay D, Asmundson GJG. Substance use and abuse, COVID-19-related distress, and disregard for social distancing: A network analysis. Addictive Behaviors. 2021;114:106754.

64. McKnight-Eily LR, Okoro CA, Strine TW, Verlenden J, Hollis ND, Njai R, et al. Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic - United States, April and May 2020. MMWR Morb Mortal Wkly Rep. 2021;70(5):162-6.

65. Ward RM, Riordan BC, Merrill JE, Raubenheimer J. Describing the impact of the COVID-19 pandemic on alcohol-induced blackout tweets. Drug and Alcohol Review. 2021;40(2):192-5.

66. Garcia-Cerde R, Valente JY, Sohi I, Falade R, Sancehz ZM, Monteiro MG. Alcohol use during the COVID-19 pandemic in Latin America and the Caribbean. Rev Panam Salud Publica. 2021;45:e52.

67. Jalili M, Niroomand M, Hadavand F, Zeinali K, Fotouhi A. Burnout among healthcare professionals during COVID-19 pandemic: a cross-sectional study. International Archives of Occupational and Environmental Health. 2021;94(6):1345-52.

68. Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, McAlister RP, Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. PLoS One. 2020;15(8):e0237301.

69. Ghahramani S, Lankarani KB, Yousefi M, Heydari K, Shahabi S, Azmand S. A Systematic Review and Meta-Analysis of Burnout Among Healthcare Workers During COVID-19. Front Psychiatry. 2021;12:758849.

70. Morgantini LA, Naha U, Wang H, Francavilla S, Acar Ö, Flores JM, et al. Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey. PLoS One. 2020;15(9):e0238217.

71. Juárez-García A, Camacho-Ávila A, García-Rivas J, Gutiérrez-Ramos O. Psychosocial factors and mental health in Mexican healthcare workers during the COVID-19 pandemic. Salud Mental. 2021;44(5):229-40.

72. Wu T, Jia X, Shi H, Niu J, Yin X, Xie J, et al. Prevalence of mental health problems during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of Affective Disorders. 2021;281:91-8.

73. Abeldaño Zuñiga RA, Juanillo-Maluenda H, Sánchez-Bandala MA, Burgos GV, Müller SA, Rodríguez López JR. Mental Health Burden of the COVID-19 Pandemic in Healthcare Workers in Four Latin American Countries. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2021;58:00469580211061059.

74. Uutela A. Economic crisis and mental health. Current Opinion in Psychiatry. 2010;23(2).

75. Giovanella L VR, Tejerina-Silva H, Acosta-Ramírez N, Parada-Lezcano M, Ríos G, et al. ¿A atenção primária à saúde integral é parte da resposta à pandemia de Covid-19 na América Latina?? . Trabalho, Educação e Saúde. 2021;19(e00310142).

76. Pan American Health Organization. Nota Técnica. La adaptación del Primer Nivel de Artención en el contexto de la pandemia COVID-19: intervenciones, modalidades y ámbitos. Washington, D.C.: PAHO; 2020.

77. Organisation for Economic Co-operation and Development. Strengthening the frontline: How primary health care helpshealth systems adapt during the COVID-19 pandemic. Paris: OECD; 2021.

78. Pan American Health Organization. Respuesta de la Organización Panamericana de la Salud a la COVID-19 en la región de las Américas 17 de enero a 31 de mayo de 2020. Washington, D.C.: PAHO; 2020.

79. Pan American Health Organization. Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas. Washington, D.C.: PAHO; 2020.

80. World Health Organization. Tracking Continuity of Essential Health Services during the COVID-19 Pandemic. An interactive dashboard Geneva: WHO; 2022 [Available from: https://www.who.int/teams/integrated-health-services/monitoring-health-services/national-pulse-survey-on-continuity-of-essential-health-services-during-the-covid-19-pandemic/dashboard.

81. Pan American Health Organization. Análisis de género y salud: COVID-19 en las Américas (OPS/EGC/COVID-19/21-0006). Washington, D.C.: PAHO; 2021.

82. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region. UNFPA; 2020.

83. World Health Organization. Governments push for Universal Health Coverage as COVID-19 continues to devastate communities and economies. 2021 [Available from: https://www.who.int/news-room/feature-stories/detail/governments-push-for-universal-health-coverage-as-covid-19-continues-to-devastate-communities-and-economies.

84. Lal A, Erondu N, Heymann D, Gitahi G, Yates R. Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. The Lancet. 2021;397(10268):61-7.

85. Sen-Crowe B, Sutherland M, McKenney M, Elkbuli A. A Closer Look Into Global Hospital Beds Capacity and Resource Shortages During the COVID-19 Pandemic. Journal of Surgical Research. 2021;260:56-63.

86. Organisation for Economic Co-operation and Development. Intensive care beds capacity Paris: OECD; 2022

87. Organisation for Economic Co-operation and Development. Development Co-operation Report 2020: Learning from Crises, Building Resilience. Paris: OECD; 2020.

88. Pan American Health Organization. COVID-19 has impacted the operation of health services for noncommunicable diseases in the Americas Washington, D.C.: PAHO; 2020 [Available from: https://www.paho.org/en/news/17-6-2020-covid-19-has-impacted-operation-health-services-noncommunicable-diseases-americas.

89. Shet A, Carr K, Danovaro-Holliday MC, Sodha SV, Prosperi C, Wunderlich J, et al. Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories. Lancet Glob Health. 2022;10(2):e186-e94.

90. Pan American Health Organization. Annual Report of the Director of the Pan American Sanitary Bureau 2021. Working through the COVID-19 Pandemic. (Official Document: 364). Washington, D.C.: PAHO; 2021.

91. Economic Commission for Latin America and the Caribbean. Latin America and the Caribbean and the COVID-19 pandemic Economic and social effects. 2020 [Available from: https://repositorio.cepal.org/bitstream/handle/11362/45351/S2000263_en.pdf?sequence=6&isAllowed=y.

92. Organisation for Economic Co-operation and Development. Policy Responses to Coronavirus (COVID-19) COVID-19 in Latin America and the Caribbean: An overview of government responses to the crisis. Paris: OECD; 2020 [Available from: https://www.oecd.org/coronavirus/policy-responses/covid-19-in-latin-america-and-the-caribbean-an-overview-of-government-responses-to-the-crisis-0a2dee41/.

93. The World Bank. Governance & Institutions COVID-19 Response Resources. . Banco Mundial; 2021 25/11/2021.

94. Barello S, Caruso R, Palamenghi L, Nania T, Dellafiore F, Boneti L, et al. Factors associated with emotional exhaustion in healthcare professionals involved in the COVID-19 pandemic: an application of the job demands-resources model. International Archives of Occupational and Environmental Health. 2021;94:1751–61.

95. Tullo J, Lerea M, López P, Alonso L. Impacto de la COVID-19 en la prestación de los servicios de salud esenciales en Paraguay. Rev Panam Salud Publica. 2020;44(e161).

96. Pan American Health Organization. Segunda ronda de la encuesta nacional sobre la continuidad de los servicios esenciales de salud durante la pandemia de COVID-19 de febrero a marzo del 2021 Washington, D.C.: PAHO; 2021 [Available from: https://iris.paho.org/bitstream/handle/10665.2/55059/OPSHSSHSCOVID-19210012_spa.pdf?sequence=1&isAllowed=y.

97. Haakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet.

98. Core Indicators [Internet]. PAHO. 2022 [cited May 15, 2022].

99. Pan American Health Organization. Actualización epidemiológica: Enfermedad por Coronavirus (COVID-19). Washington, D.C.: PAHO; 2021 2 de diciembre de 2021,.

100. Rueda de prensa semanal sobre COVID-19: Palabras de apertura de la directora, 12 de mayo de 2021 [press release]. Washington, D.C.: PAHO2021.

101. World Health Organization. The impact of COVID-19 on health and care workers: a closer look at deaths. In: WHO, editor. Health Workforce Department – Working Paper 1. Geneva2021.

102. Comisión Económica para América Latina y el Caribe. "El impacto del COVID-19 en los pueblos indígenas de América Latina-Abya Yala: entre la invisibilización y la resistencia colectiva". Santiago: Comisión Económica para América Latina y el Caribe (CEPAL); 2020.

103. International Monetary Fund. Fiscal Affairs D. Chapter 2 A Fair Shot - Fiscal Monitor, April 2021. USA: International Monetary Fund. p. ch002.

104. Bourdrel T, Annesi-Maesano I, Alahmad B, Maesano CN, Bind MA. The impact of outdoor air pollution on COVID-19: a review of evidence from in vitro, animal, and human studies. Eur Respir Rev. 2021;30(159).

105. Pozzer A, Dominici F, Haines A, Witt C, Münzel T, Lelieveld J. Regional and global contributions of air pollution to risk of death from COVID-19. Cardiovasc Res. 2020;116(14):2247-53.

106. Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology. 2000;28(1):13-24.

107. Weaver LJ, Kaiser BN. Syndemics theory must take local context seriously: An example of measures for poverty, mental health, and food insecurity. Soc Sci Med. 2020:113304.

108. Homer J, Milstein B, Hirsch GB. System Dynamics Modeling to Rethink Health System Reform. In: Apostolopoulos Y, Lemke MK, Hassmiller L, editors. Complex Systems and Population Health. Oxford: Oxford University Press; 2020.

109. World Health Organization. Responding to non-communicable diseases during and beyond the COVID-19 pandemic: state of the evidence on COVID-19 and non-communicable diseases: a rapid review. Geneva: World Health Organization; 2020.

110. Pan American Health Organization. Las ENT de un vistazo: Mortalidad de las enfermedades no transmisibles y prevalencia de sus factores de riesgo en la Región de las Américas. Washington, D.C.: PAHO; 2019.

111. Pan American Health Organization. ENLACE: Data Portal on Noncommunicable Diseases, Mental Health, and External Causes Washington, D.C.: PAHO; 2022 [Available from: https://www.paho.org/en/enlace.

112. Pan American Health Organization. COVID-19 and comorbidities in the Americas: Hands-on tool to estimate the population at increased and high risk of severe COVID-19 due to underlying health conditions for the Americas. Washington, D.C.: PAHO; 2021.

113. Pan American Health Organization. Sixth ad hoc Meeting of PAHO's Technical Advisory Group (TAG) on Vaccine-preventable Diseases. United States of America (virtual meeting). 16 November 2020. Washington, D.C.: PAHO; 2021.

114. World Health Organization. Preventing noncommunicable diseases (?NCDs)? by reducing environmental risk factors. Geneva: World Health Organization; 2017.

115. Di Ciaula A, Krawczyk M, Filipiak KJ, Geier A, Bonfrate L, Portincasa P. Noncommunicable diseases, climate change and iniquities: What COVID-19 has taught us about syndemic. Eur J Clin Invest. 2021;51(12):e13682.

116. Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2020;396(10255):874.

117. Non-Communicable Disease (NCD) Alliance. . Briefing note: Impacts of COVID-19 on people living with NCDs. Geneva: Non-Communicable Disease (NCD) Alliance; 2020.

118. Al-Oraibi A, Nellums LB, Chattopadhyay K. COVID-19, conflict, and non-communicable diseases among refugees. EClinicalMedicine. 2021;34:100813.

119. Azadnajafabad S, Ghasemi E, Saeedi Moghaddam S, Rezaei N, Farzadfar F. Non-communicable Diseases' Contribution to the COVID-19 Mortality: A Global Warning on the Emerging Syndemics. Arch Iran Med. 2021;24(5):445-6.

120. Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health. 2020;74(11):964-8.

121. Pan XF, Yang J, Wen Y, Li N, Chen S, Pan A. Non-Communicable Diseases During the COVID-19 Pandemic and Beyond. Engineering (Beijing). 2021;7(7):899-902.

122. Yadav UN, Rayamajhee B, Mistry SK, Parsekar SS, Mishra SK. A Syndemic Perspective on the Management of Non-communicable Diseases Amid the COVID-19 Pandemic in Low- and Middle-Income Countries. Front Public Health. 2020;8:508.

123. Boes S, Sabariego C, Bickenbach J, Stucki G. How to capture the individual and societal impacts of syndemics: the lived experience of COVID-19. BMJ Glob Health. 2021;6(10).

124. Herrick C, Reubi D. The future of the global noncommunicable disease agenda after Covid-19. Health Place. 2021;71:102672.

125. McMahon NE. Understanding COVID-19 through the lens of ‘syndemic vulnerability’: possibilities and challenges. International Journal of Health Promotion and Education. 2021;59(2):67-9.

126. Pirrone I, Dieleman M, Reis R, Pell C. Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts. Glob Health Action. 2021;14(1):1927332.

127. Winslow CE. The cost of sickness and the price of health. Word Health Organization. 1951. Bull World Health Organ. 2006;84(2):153-8.

128. Bardey D, Cremer H, Lozachmeur J-M. Competition in Two-Sided Markets with Common Network Externalities. Review of Industrial Organization. 2014;44(4):327-45.

129. Katz ML, Shapiro C. Network Externalities, Competition, and Compatibility. The American Economic Review. 1985;75(3):424-40.

130. Oderanti FO, Li F, Cubric M, Shi X. Business models for sustainable commercialisation of digital healthcare (eHealth) innovations for an increasingly ageing population. Technological Forecasting and Social Change. 2021;171:120969.

131. Economic Commission for Latin America and the Caribbean/PanAmerican Health Organization. COVID-19 Report. Health and the economy: a convergence needed to address COVID-19 and retake the path of sustainable development in Latin America and the Caribbean. 2020.

132. Mohamed B. Coronavirus as a Global Complex Problem Looking for Resilient Solutions. Business Management and Strategy, Macrothink Institute. 2020;11(1):94 - 109.

133. World Health Organization. Health Systems Governance for Universal Health Coverage Action Plan Department of Health Systems Governance and Financing. Geneva: WHO; 2014.

134. Organisation for Economic Co-operation and Development. COVID-19 in Latin America and the Caribbean: An overview of government responses to the crisis. Tackling coronarivirus (COVID-19): Contributing to a global effort. . Paris: OECD; 2020.

135. Pan American Health Organization. Indice de preparación ante emergencias y desastres en salud. Washington, D.C.: PAHO; 2019.

136. World Health Organization. Consideraciones para aplicar y ajustar medidas de salud pública y sociales en el contexto de la COVID-19. Geneva: Organización Mundial de la Salud; 2020.

137. Casalí P, Goldschmit A, Cetrágolo O. Respuestas de corto plazo a la COVID-19 y desafíos persistentes en los sistemas de salud de América Latina.: Oficina de la OIT para los Países Andinos; 2021 Enero 2021.

138. Arancibia Gutiérrez E, Giraldo Palacio M. Local Governance Processes: An Analysis of the Regional Governance and Social Coordination Observatory Regarding COVID-19 in Yucatan, Mexico. Journal Of Public Governance And Policy. 2020;1(9):133 - 51.

139. Martínez-Córdoba P-J, Benito B, García-Sánchez I-M. Efficiency in the governance of the Covid-19 pandemic: political and territorial factors. Globalization and Health. 2021;17(1):113.

140. Bell JA, Nuzo JB. Global Health Security Index: Advancing Collective Action and Accountability Amid Global Crisis, 2021. Washington, D.C.: Nuclear Threat Initiative; 2021.

141. Organisation for Economic Co-operation and Development. Policy Responses to Coronavirus (COVID-19). Tourism Policy Responses to the coronavirus (COVID-19). Paris: OECD; 2020.

142. Comisión Económica para América Latina y el Caribe. Observatorio COVID-19 en América Latina y el Caribe: acciones por país. 2021.

143. Enríquez SC. Primeras lecciones y desafíos de la pandemia de COVID-19 para los paises deal SIC. In: Ciudad de México CEpALyeCC, 2021, editor. 2021.

144. González E HC, Hopkins K, Horwitz L, Nagovitch P, Sonneland HK & ZissisC. . El coronavirus en América Latina. AS/COA. 2021.

145. Acosta L. Capacidad de respuesta frente a la pandemia de COVID-19 en América Latina y el Caribe. Rev Panam Salud Publica. 2020;44(e109).

146. Páges C, Aclan C, Alfonso M, Arroio R, Irigoyen J, Mejía I, et al. From lockdown to reopening: Strategic considerations for the resumption of activities in Latin America and the Caribbean within the framework of Covid-19. Washington, D.C.: Inter-American Development Bank; 2020.

147. Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T, et al. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nature Human Behaviour. 2021.

148. Harrison C, Horwitz L, Zissis C. Timeline: Tracking Latin America's Road to Vaccination. AS/COA2021. Available from: https://www.as-coa.org/articles/timeline-tracking-latin-americas-road-vaccination.

149. Organisation for Economic Co-operation and Development. COVID-19 in Latin America and the Caribbean: Regional socio-economic implications and policy priorities. Paris: OECD; 2020.

150. Congressional Research Service. Latin America and the Caribbean: Impact of COVID-19. Washington, D.C.: CRS; 2021.

151. United Nations, Konrad-Adenauer-Stiftung, Inter-American Development Bank. Post Pandemic COVID-19 Economy Recovery. Enabling Latin America and the Caribbean to better harness e-commerce and digital trade. Panama: United Nations; 2020.

152. Comisión Económica para América Latina y el Caribe. Estudio Económico de América Latina y el Caribe. CEPAL, Santiago; 2020.

153. Comisión Económica para América Latina y el Caribe. The recovery paradox in Latin America and the Caribbean: Growth amid persisting structural problems: inequality, poverty and low investment and productivity. CEPAL; 2021.

154. Comisión Económica para América Latina y el Caribe. Panorama Social de América Latina, 2021. Santiago: Comisión Económica para América Latina y el Caribe; 2022. Contract No.: LC/PUB.2021/17-P.

155. International Monetary Fund. Fiscal Monitor Database of Country Fiscal Measures in Response to the COVID-19 Pandemic Washington, D.C.: IMF; [Available from: https://www.imf.org/en/Topics/imf-and-covid19/Fiscal-Policies-Database-in-Response-to-COVID-19.

156. Comisión Económica para América Latina y el Caribe. Panorama fiscal de América Latina y el Caribe. Los desafíos de la política fiscal en la recuperación transformadora pos Covid-19. Santiago: CEPAL; 2021.

157. Lustig N, Tommasi M. El COVID-19 y la protección social de los grupos pobres y vulnerables en América Latina: un marco conceptua. Revista CEPAL. 2020;2020-12(132):283-95.

158. World Health Organization/Europe. Strengthening health-system emergency preparedness. Toolkit for assessing health-system capacity for crisis management. 2008 [Part 1. User manual. 2008:[Available from: https://www.euro.who.int/__data/assets/pdf_file/0008/157886/e96187.pdf.

159. Awoke M, Negin J, Moller J, Farell P, Yawson A, Biritwum R, et al. Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana. Global health action. 2017;10(1):1301723. .

160. Global Commission on Evidence to Address Societal Challenges. The Evidence Commission report: A wake-up call and path forward for decisionmakers, evidence intermediaries, and impact-oriented evidence producers. Hamilton: McMaster Health Forum; 2022.

161. Pan American Health Organization. A guide for evidence-informed decision-making, including in health emergencies. Washington, D.C.: PAHO; 2022.

162. Pan American Health Organization. Ongoing Living Update of COVID-19 Therapeutic Options: Summary of Evidence. Rapid Review, 4 May 2022. Washington, D.C.: PAHO; 2022.

163. Palmero A, Carracedo S, Cabrera N, Bianchini A. Governance frameworks for COVID-19 research ethics review and oversight in Latin America: an exploratory study. BMC Medical Ethics. 2021;22(1):147.

164. Mansilla C, Herrera CA, Boeira L, Yearwood A, Lopez AS, Colunga-Lozano LE, et al. Characterising COVID-19 empirical research production in Latin America and the Caribbean: A scoping review. PLoS One. 2022;17(2):e0263981.

165. Chapman E, Illanes E, Reveiz L, Saenz C. [Mapping of research protocols, publications, and collaborations on COVID-19 in Latin America and the CaribbeanMapeamento de protocolos de pesquisa, publicações e colaborações sobre COVID-19 na América Latina e no Caribe]. Rev Panam Salud Publica. 2022;46:e42.

166. Carracedo S, Palmero A, Neil M, Hasan-Granier A, Saenz C, Reveiz L. The landscape of COVID-19 clinical trials in Latin America and the Caribbean: assessment and challenges. Rev Panam Salud Publica. 2020;44:e177.

167. World Health Organization. World Health Assembly Resolution: Strengthening clinical trials to provide high-quality evidence on health interventions and to improve research quality and coordination. Geneva: WHO; 2022.

168. Pan American Health Organization. Strengthening national evidence-informed guideline programs. A tool for adapting and implementing guidelines in the Americas. Washington, D.C.: PAHO; 2018.

169. Pan American Health Organization. Consideraciones sobre el uso de antivirales, anticuerpos monoclonales y otras intervenciones para el manejo de pacientes con COVID-19 en América Latina y el Caribe, 26 de abril del 2022. Washington, D.C.: PAHO; 2022.

170. Pan American Health Organization. Guía para el cuidado de pacientes adultos críticos con COVID-19 en las Américas. Versión 3. Washington, D.C.: PAHO; 2021.

171. Pan American Health Organization. Directrices para la profilaxis y el manejo de pacientes con COVID-19 leve y moderada en América Latina y el Caribe. Versión abreviada, octubre del 2021. Washington,D.C.: PAHO; 2021.

172. International Social Security Association. Telemedicina: buenas prácticas en América Latina: ISSA; 2021 [Available from: https://ww1.issa.int/es/analysis/telemedicina-buenas-practicas-en-america-latina.

173. Centers for Disease Control and Prevention. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic Washignton, D.C.: CDC; 2020 [updated June 10 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.

174. Pan American Health Organization. COVID-19 and telemedicine Washington, D.C.: PAHO; 2020 [Available from: https://www3.paho.org/ish/index.php/en/telemedicine.

175. Saigí-Rubio F, Torrent-Sellens J, Robles N, Pérez-Palaci J, MI B. Estudio sobre telemedicina internacional en América Latina: motivaciones, usos, resultados, estrategias y políticas. In: Desarrollo. BId, editor. 2021. p. 953.

176. Asociación Internacional de la Seguridad Social. Telemedicina: buenas prácticas en América Latina 2021 [Available from: https://ww1.issa.int/es/analysis/telemedicina-buenas-practicas-en-america-latina.

177. World Trade Organization. Revista general de la evolución del entorno comercial internacional. Informe anual del Director General. Geneva: WTO; 2020.

178. Economic Commission for Latin America and the Caribbean. Las restricciones a la exportación de productos médicos dificultan los esfuerzos por contener la enfermedad por coronavirus (COVID-19) en América Latina y el Caribe. Santiago: ECLAC; 2020.

179. World Trade Organization. How WTO members have used trade measures to expedite access to COVID-19 critical medical goods and services. Information note. Geneva: WTO; 2020.

180. Binnicker Matthew J, Kraft Colleen S. Challenges and Controversies to Testing for COVID-19. Journal of Clinical Microbiology.58(11):e01695-20.

181. Ceci A, Muñoz-Ballester C, Tegge AN, Brown KL, Umans RA, Michel FM, et al. Development and implementation of a scalable and versatile test for COVID-19 diagnostics in rural communities. Nature Communications. 2021;12(1):4400.

182. Alcántara R, Peñaranda K, Mendoza-Rojas G, Nakamoto JA, Martins-Luna J, del Valle-Mendoza J, et al. Unlocking SARS-CoV-2 detection in low- and middle-income countries. Cell Reports Methods. 2021;1(7):100093.

183. Connor A, Hariharan N, Carson S, Sanders KC, Bradford Vosburg K, Sabot O. Health Affairs Blog [Internet]2021. [cited 2022].

184. Faust L, Zimmer AJ, Kohli M, Saha S, Boffa J, Bayot ML, et al. SARS-CoV-2 testing in low- and middle-income countries: availability and affordability in the private health sector. Microbes and Infection. 2020;22(10):511-4.

185. Post L, Ohiomoba RO, Maras A, Watts SJ, Moss CB, Murphy RL, et al. Latin America and the Caribbean SARS-CoV-2 Surveillance: Longitudinal Trend Analysis. JMIR Public Health Surveill. 2021;7(4):e25728.

186. Pan American Health Organization. List of Priority Medical Devices in the Context of COVID-19, 13 August 2020. Washington, D.C.: PAHO; 2020.

187. Thanh Le T, Andreadakis Z, Kumar A, Gómez Román R, Tollefsen S, Saville M, et al. The COVID-19 vaccine development landscape. Nature Reviews Drug Discovery. 2020;19:305-6.

188. Heaton PM. The Covid-19 Vaccine-Development Multiverse. New England Journal of Medicine. 2020;383(20):1986-8.

189. Francis AI, Ghany S, Gilkes T, Umakanthan S. Review of COVID-19 vaccine subtypes, efficacy and geographical distributions. Postgraduate Medical Journal. 2021:postgradmedj-2021-140654.

190. GAVI. What are whole virus vaccines and how could they be used against COVID-19? Geneva: GAVI; 2020 [30 December 2020].

191. McDonald I, Murray SM, Reynolds CJ, Altmann DM, Boyton RJ. Comparative systematic review and meta-analysis of reactogenicity, immunogenicity and efficacy of vaccines against SARS-CoV-2. npj Vaccines. 2021;6(1):74.

192. Ghazy RM, Ashmawy R, Hamdy NA, Elhadi YA, Reyad OA, Elmalawany D, et al. Efficacy and Effectiveness of SARS-CoV-2 Vaccines: A Systematic Review and Meta-Analysis. Vaccines. 2022;10(3).

193. Andrews N, Stowe J, Kirsebom F, Toffa S, Rickeard T, Gallagher E, et al. Covid-19 Vaccine Effectiveness against the Omicron (B.1.1.529) Variant. N Engl J Med. 2022.

194. Yaffe H. Cuba’s five COVID-19 vaccines: the full story on Soberana 01/02/Plus, Abdala, and Mambisa [Internet]. London: LSE. 2021. [cited 2022]. Available from: https://blogs.lse.ac.uk/latamcaribbean/2021/03/31/cubas-five-covid-19-vaccines-the-full-story-on-soberana-01-02-plus-abdala-and-mambisa/.

195. Brooks D. Las vacunas para el covid-19 que se están desarrollando en América Latina (además de la de AstraZeneca-Oxford). BBC News Mundo. 2020 Aug 14, 2020.

196. Pan American Health Organization. Covax- Working for global equitable access to COVID-19 vaccines Washington, D.C.: PAHO; 2020 [Available from: https://www.who.int/es/initiatives/act-accelerator/covax.

197. Obinna DN. Solidarity across borders: A pragmatic need for global COVID-19 vaccine equity. Int J Health Plann Manage. 2022;37(1):21-9.

198. United Nations Educational, Scientific and Cultural Organization. Covid-19 y vacunación en América Latina y el Caribe: Desafíos, Necesidades y oportunidades. Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura. Oficina Regional de Ciencia de la UNESCO para ALC; 2021.

199. Urrunaga-Pastor D, Bendezu-Quispe G, Herrera-Añazco P, Uyen-Cateriano A, Toro-Huamanchumo C, Rodriguez-Morales A, et al. Cross-sectional analysis of COVID-19 vaccine intention, perceptions and hesitancy across Latin America and the Caribbean. Travel Medicine and Infectious Disease. 2021;41(102059).

200. Argote Tironi P, Barham E, Zuckerman Daly S, Gerez JE, Marshall J, Pocasangre O. Messages that increase COVID-19 vaccine acceptance: Evidence from online experiments in six Latin American countries. PLoS One. 2021;16(10):e0259059.

201. World Health Organization. Therapeutics and COVID-19: living guideline Geneva: WHO; 2020 [Available from: https://app.magicapp.org/#/guideline/nBkO1E/section/nByvRL.

202. Pan American Health Organization. Considerations on the Use of Antivirals, Monoclonal Antibodies, and Other Interventions for the Management of COVID-19 Patients in Latin America and the Caribbean. Washington, D.C.: PAHO.

203. World Health O. Guidance on maintaining a safe and adequate blood supply during the coronavirus disease 2019 (COVID-19) pandemic and on the collection of COVID-19 convalescent plasma: interim guidance, 10 July 2020. Geneva: World Health Organization; 2020 2020. Contract No.: WHO/2019-nCoV/BloodSupply/2020.2.

204. Schneider ME. Blood Services Around the Globe. ASH Clinical News. 2021.

205. World Health Organization. ACT-Accelerator Strategic Plan & Budget, October 2021 to September 2022. Geneva: World Health Organization; 2021.

206. Pan American Health Organization. Arrival of COVID-19 vaccines to the Americas through COVAX Washington, D.C.: PAHO; 2021 [Available from: https://www.paho.org/en/covax-americas.

207. Pan American Health Organization. Impact of COVID-19 on Human Resources for Health and Policy Response:

the Case of Belize, Grenada, and Jamaica. Washington, D.C.: PAHO; 2022.

208. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020. Internet: KFF; 2020.

209. Surgo Ventures. U.S. Healthcare Workers: COVID-19 Vaccine Uptake & Attitudes Internet2021 [Available from: https://surgoventures.org/resource-library/survey-healthcare-workers-and-vaccine-hesitancy.

210. Dror AA, Eisenbach N, Taiber S, Morozov NG, Mizrachi M, Zigron A, et al. Vaccine hesitancy: the next challenge in the fight against COVID-19. European Journal of Epidemiology. 2020;35(8):775-9.

211. Gagneux-Brunon A, Detoc M, Bruel S, Tardy B, Rozaire O, Frappe P, et al. Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey. J Hosp Infect. 2021;108:168-73.

212. Kwok KO, Li K-K, Wei WI, Tang A, Wong SYS, Lee SS. Influenza vaccine uptake, COVID-19 vaccination intention and vaccine hesitancy among nurses: A survey. International Journal of Nursing Studies. 2021;114:103854.

213. Lin C, Tu P, Beitsch LM. Confidence and Receptivity for COVID-19 Vaccines: A Rapid Systematic Review. Vaccines. 2021;9(1):16.

214. Freeman D, Loe BS, Chadwick A, Vaccari C, Waite F, Rosebrock L, et al. COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II. Psychol Med. 2020:1-15.

215. Schwarzinger M, Watson V, Arwidson P, Alla F, Luchini S. COVID-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics. The Lancet Public Health. 2021;6(4):e210-e21.

216. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Reg Health Eur. 2021;1:100012.

217. Urrunaga-Pastor D, Bendezu-Quispe G, Herrera-Añazco P, Uyen-Cateriano A, Toro-Huamanchumo CJ, Rodriguez-Morales AJ, et al. Cross-sectional analysis of COVID-19 vaccine intention, perceptions and hesitancy across Latin America and the Caribbean. Travel Med Infect Dis. 2021;41:102059.

218. Kuter BJ, Browne S, Momplaisir FM, Feemster KA, Shen AK, Green-McKenzie J, et al. Perspectives on the receipt of a COVID-19 vaccine: A survey of employees in two large hospitals in Philadelphia. Vaccine. 2021;39(12):1693-700.

219. Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. COVID-19 Vaccination Hesitancy in the United States: A Rapid National Assessment. J Community Health. 2021;46(2):270-7.

220. Pan American Health Organization. Concerns, Attitudes, and Intended Practices of Healthcare Workers toward COVID-19 Vaccination in the Caribbean. Washington, D.C.: PAHO; 2021.

221. Puertas EB, Velandia-Gonzalez M, Vulanovic L, Bayley L, Broome K, Ortiz C, et al. Concerns, attitudes, and intended practices of Caribbean healthcare workers concerning COVID-19 vaccination: A cross-sectional study. Lancet Reg Health Am. 2022;9:100193.

222. Eguia H, Vinciarelli F, Bosque-Prous M, Kristensen T, Saigí-Rubió F. Spain's Hesitation at the Gates of a COVID-19 Vaccine. Vaccines (Basel). 2021;9(2).

223. Gadoth A, Halbrook M, Martin-Blais R, Gray A, Tobin NH, Ferbas KG, et al. Cross-sectional Assessment of COVID-19 Vaccine Acceptance Among Health Care Workers in Los Angeles. Ann Intern Med. 2021;174(6):882-5.

224. Pan American Health Organization. Experiencia y actitudes de vacunación contra COVID-19 entre los trabajadores de salud de 16 países de América Latina. Washington, D.C.: PAHO; 2022.

225. Pan American Health Organization. Policy Brief - Strengthening Human Resources for Health (HRH) to Respond to COVID-19 and Other Emerging Pandemics in the Caribbea. Washington, D.C.: PAHO; 2021.

226. Pan American Health Organization. Policy Brief - Addressing COVID-19 Vaccine Hesitancy Among Healthcare Workers in the Caribbean. Washington, D.C.: PAHO; 2021.

227. Pan American Health Organization. Recommendations to Adapt and Strengthen Response Capacity at the First Level of Care during the COVID-19 Pandemic. Washington, D.C.: PAHO; 2020.

228. Halcomb E, McInnes S, Williams A, Ashley C, James S, Fernandez R, et al. The Experiences of Primary Healthcare Nurses During the COVID-19 Pandemic in Australia. J Nurs Scholarsh. 2020;52(5):553-63.

229. Kearon J, Risdon C. The Role of Primary Care in a Pandemic: Reflections During the COVID-19 Pandemic in Canada. J Prim Care Community Health. 2020;11:2150132720962871.

230. World Health Organization. Role of primary care in the COVID-19 response. Geneva: WHO; 2020.

231. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 - Implications for the Health Care System. N Engl J Med. 2020;383(15):1483-8.

232. Pan American Health Organization. Human resources for health and the COVID-19 response in the Caribbean. Washington, D.C.: PAHO; 2020.

233. Rahman R, Ross A, Pinto R. The critical importance of community health workers as first responders to COVID-19 in USA. Health Promot Int. 2021;36(5):1498-507.

234. Inter-American Development Bank. Support the design and implementation of key digital interventions for COVID-19 in Latin America and the Caribbean Washington, D.C.: IADB; 2020.

235. Declaración Universal de Derechos Humanos, (1948).

236. Naciones Unidas. Pacto Internacional de Derechos Económicos, Sociales y Culturales 1966 [Available from: https://www.ohchr.org/SP/ProfessionalInterest/Pages/CESCR.aspx.

237. Comisión Económica para América Latina y el Caribe. Protección social universal en América Latina y el Caribe,. Santiago: CEPAL; 2019.

238. Etienne CF, Fitzgerald J, Almeida G, Birmingham ME, Monica B, Bascolo E, et al. COVID-19: transformative actions for more equitable, resilient, sustainable societies and health systems in the America. BMJ Global Health. 2020;5:e003509.

239. Weekly Press Briefing on COVID-19 [press release]. Washington, D.C.: PAHO, October 6, 2021 2021.

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