Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498919980009&lang=en vol. 4 num. 3 lang. en <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org <![CDATA[<strong>La eliminación de la lepra de las Américas</strong>: <strong>situación actual y perspectivas</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900001&lng=en&nrm=iso&tlng=en La lepra, enfermedad que antes evocaba una imagen sombría e inspiraba terror, ahora se puede curar gracias al esquema politerapéutico a base de rifampicina, clofazimina y dapsona que se ha venido usando desde 1981. En 1991 la Asamblea Mundial de la Salud, alentada por la eficacia de este régimen, fijó la meta de eliminar la enfermedad como problema de salud pública mundial y nacional para el año 2000. Esta meta, que equivale a reducir la prevalencia a menos de un caso por 10 000 habitantes, no debe confundirse con la de erradicar la enfermedad, que implica interrumpir por completo su transmisión. La eliminación de la lepra es una meta asequible que dependerá del uso enérgico y a gran escala del régimen poliquimioterapéutico. El presente trabajo describe y examina las iniciativas que se han puesto en marcha en América Latina para lograr la meta y los resultados observados hasta el momento. También se exploran los factores que inciden en la factibilidad de erradicar la enfermedad.<hr/>Leprosy, a disease that used to be shrouded in darkness and fear, can now be cured thanks to a multidrug treatment schedule with rifampicin, clofazimine, and dapsone which has been in use since 1981. In 1991 the World Health Assembly, enouraged by the efficacy of this treatment regimen, established the goal of eliminating the disease as a public health problem globally and nationally by the year 2000. This goal, which calls for reducing disease prevalence to less than one case per 10 000 inhabitants, should not be confused with the goal of eradicating the disease, which implies a complete interruption of its transmission. Eliminating leprosy is an attainable goal which will depend on the forceful and massive use of the multidrug treatment regimen. This paper describes and discusses the various initiatives that have been launched in Latin America for the purpose of achieving this goal and the results obtained so far. It also explores the factors that impact on the feasibility of eradicating the disease. <![CDATA[<strong>Rational use of rubella vaccine for prevention of congenital rubella syndrome in the Americas</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900002&lng=en&nrm=iso&tlng=en Rubella is a viral disease with minor morbidity and few complications unless it is contracted by a pregnant woman. Rubella infection during the first trimester of pregnancy often leads to fetal death or severe congenital defects (congenital rubella syndrome, CRS). Rubella remains endemic in many countries of Latin America and the Caribbean. It has been estimated that 20000 or more infants are perhaps born with CRS each year in Latin American and Caribbean countries. While the inclusion of rubella vaccination into routine childhood immunization will decrease rubella virus circulation among young children, it will not have immediate impact on the transmission of rubella among adults or the occurrence of CRS. A one-time mass campaign targeting both males and females 5 to 39 years of age with measles-mumps-rubella or measles-rubella vaccine followed by the use of measles-mumps-rubella vaccine in routine early childhood vaccination will prevent and control both rubella and CRS promptly. In April 1988, the Ministers of Health of the English-speaking Caribbean targeted rubella for elimination by the end of the year 2000 using the vaccination strategy outlined above. The rubella elimination experience of these countries will provide useful information for the eventual elimination of rubella virus from the Americas.<hr/>La rubéola es una enfermedad vírica que produce poca morbilidad y pocas complicaciones, a no ser que la contraiga una mujer embarazada. La infección con rubéola durante el primer trimestre del embarazo a menudo termina en muerte fetal o en deformidades congénitas graves (síndrome de anomalías congénitas por rubéola, o SCR). La rubéola sigue siendo endémica en muchos países de América Latina y el Caribe. Se estima que quizá 20 000 niños o más nacen cada año con SCR en países latinoamericanos y caribeños. Si bien la adición de la vacuna contra la rubéola a los programas de inmunización infantil de rutina disminuirá la circulación del virus entre los niños pequeños, no tendrá un impacto inmediato sobre la transmisión de la rubéola entre los adultos o sobre la frecuencia de SCR. Una campaña única dirigida a toda la población de hombres y mujeres de 5 a 39 años de edad en que se aplique la vacuna triple contra el sarampión, la parotiditis y la rubéola, o la vacuna doble contra el sarampión y la rubéola seguida de la vacuna triple como parte de la inmunización rutinaria de niños pequeños servirá para controlar y prevenir de manera inmediata tanto la rubéola como el SCR. En abril de 1988, los Ministros de Salud de países del Caribe angloparlante establecieron la meta de eliminar la rubéola para fines del año 2000 mediante la aplicación de la estrategia de vacunación aquí descrita. La experiencia que han tenido estos países en sus actividades de eliminación de la rubéola será fuente de información provechosa para la eliminación futura del virus de la rubéola de todo el territorio americano. <![CDATA[<strong>Mortalidade por armas de fogo no estado do Rio de Janeiro, Brasil</strong>: <strong>uma análise espacial</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900003&lng=en&nrm=iso&tlng=en O aumento da mortalidade por armas de fogo no estado do Rio de Janeiro, Brasil, tem tomado um aspecto alarmante. O objetivo deste estudo foi caracterizar a evolução temporal da mortalidade por armas de fogo neste estado, no período de 1979 a 1992, conforme sexo, idade e região de residência (capital, cinturão metropolitano e interior do estado) e estudar a propagação da epidemia ao longo do tempo e do espaço, com a utilização de técnicas de análise estatística espacial. No período analisado, a mortalidade por armas de fogo teve o seu maior crescimento entre adolescentes de 15 a 19 anos, do sexo masculino; estas taxas variaram de 13 a 16% para este grupo, conforme a região de residência. Para o grupo das crianças de 10 a 14 anos, a mortalidade por armas de fogo teve um acréscimo de 10% ao ano. Foi nítida a interiorização da mortalidade por armas de fogo. No início da série, observou-se uma direção preferencial de disseminação, ao longo dos municípios situados na costa leste do estado, acompanhando o trajeto de uma rodovia federal. Entre 1990 e 1992, entretanto, a difusão ocorreu em praticamente todas as direções. A constatação empírica da expansão generalizada da mortalidade por armas de fogo nega as afirmações corriqueiras de concentração da violência nos bolsões de pobreza das metrópoles brasileiras. Os programas para prevenir e controlar a epidemia devem abordar o problema sob diferentes aspectos, enfocando questões tanto no plano coletivo (proliferação de armas entre a população vinculada ao contrabando internacional de armas, aumento da criminalidade, expansão do tráfico de drogas e exclusão de oportunidades sociais), assim como no plano individual (relações e interações dos jovens com seu ambiente, em nível da família, da escola e da sociedade).<hr/>Mortality caused by firearms has been increasing at an alarming rate in the state of Rio de Janeiro, Brazil. This study analyzes the gradual evolution of firearm mortality rates in this Brazilian state from 1979 to 1992, according to sex, age, and area of residence (capital city, metropolitan area, or the state's interior), and uses spatial statistical techniques to describe the propagation of this firearm mortality epidemic in time and space. During the period analyzed, mortality due to firearms showed the greatest increase among 15- to 19-year-old male adolescents, with yearly rates ranging from 13 to 16%, according to area of residence. For children 10 to 14 years of age, mortality caused by firearms increased by 10% annually in the same period. The highest annual increase occurred in the state's interior. At the beginning of the period studied, dissemination of firearm mortality was observed to follow a definite direction parallel to the federal road that runs along the east coast of the state. Between 1990 and 1992, however, the increase in deaths by firearms spread out in practically every direction. Empirical confirmation of a general expansion of firearm wound mortality contradicts the usual claim that violence is concentrated in areas of extreme poverty within Brazil's largest cities. Programs for prevention and control of this epidemic should focus on its various aspects and take into consideration both collective issues (such as proliferation of firearms among persons involved with international firearm smuggling, increases in criminal activity, expansion of drug trafficking, and exclusion from social opportunities) and personal issues (relationships and interaction of young people with their families, schools, and social environment). <![CDATA[<strong>La eliminación del sarampión en Cuba</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900004&lng=en&nrm=iso&tlng=en La vacuna antisarampionosa se empezó a usar en Cuba en 1971. En los años setenta se implantó una estrategia inicial para el control del sarampión, y a ella le siguieron iniciativas adicionales a principios de los años ochenta. Pese a haberse mejorado el programa de control, siguieron produciéndose brotes de la enfermedad. En 1986, después de revisar las experiencias recogidas a partir de las iniciativas de control ya establecidas, se adoptó una nueva estrategia de vacunación antisarampionosa. Con el tiempo, la nueva estrategia de vacunación contra el sarampión llegó a tener tres componentes principales: primero, una campaña única de vacunación de "puesta al día" dirigida a niños de 1 a 14 años de edad. Segundo, se procuró lograr y mantener una alta cobertura con la vacuna mediante el ofrecimiento de servicios de vacunación obligatoria para niños de 12 meses de edad ("vacunación de mantenimiento"). Por último, se llevaron a cabo periódicamente campañas de "seguimiento" para niños de 2 a 6 años de edad. Con el fin de monitorear el territorio recorrido hacia le eliminación del sarampión, se ha hecho un esfuerzo por fortalecer la vigilancia de la enfermedad, de la cual forma parte la investigación de casos sospechados. Tanto la campaña general de "puesta al día" como la de "seguimiento" alcanzaron coberturas de más de 98% en los grupos de edad a los que fueron dirigidas. El programa de vacunación de rutina también ha mantenido una alta cobertura. La alta inmunidad poblacional contra el sarampión lograda mediante estas estrategias de vacunación dio por resultado una rápida reducción de la incidencia de la enfermedad. De 1989 a 1992, se notificaron menos de 20 casos anuales confirmados por laboratorios. En Cuba, el último caso confirmado por pruebas serológicas se presentó en julio de 1993. La estrategia para la eliminación del sarampión que se ha aplicado en Cuba ha interrumpido la transmisión de la enfermedad y ha impedido la circulación del virus causante en la isla. La experiencia de Cuba con la eliminación del sarampión sugiere que si se aplica una estrategia apropiada de vacunación, se puede erradicar el sarampión del mundo entero.<hr/>The vaccine against measles came into use in Cuba in 1971. During the seventies, a new early strategy for measles control was established, and it was followed by further efforts in the early eighties. Despite improvements to the control program, disease outbreaks continued to occur. In 1986, after examining the experience acquired through the control initiatives that were already in place, a new measles vaccination strategy was adopted. In time, the new vaccination strategy against measles came to have three main components: first, a single vaccination "catching-up" campaign targeting children 1 to 14 years of age. Second, efforts were made to achieve and maintain high vaccine coverage through mandatory vaccination services for 12-month-old children ("maintenance vaccination"). Finally, periodic "follow-up" campaigns were carried out for children 2 to 6 years of age. Steps were taken, for the purpose of monitoring the progress made so far toward eliminating measles, to strengthen disease surveillance systems, including the screening of suspected cases. The "catching-up" and "follow-up" campaigns both achieved greater than 98% coverage within targeted age groups. The routine vaccination program has also maintained high coverage. The high population immunity against measles that has been attained through these vaccination strategies has resulted in a rapid decrease in the incidence of the disease. From 1989 to 1992, less than 20 laboratory-confirmed cases were reported annually. In Cuba, the last case confirmed through serologic screening was reported in July 1993. Cuba's strategy for measles elimination has interrupted disease transmission and kept the causal virus from circulating on the island. Cuba's experience with measles elimination suggests that if an appropriate vaccination strategy is applied, measles can be globally eradicated. <![CDATA[<strong>Vitamin A deficiency in Latin America and the Caribbean</strong>: <strong>an overview</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900005&lng=en&nrm=iso&tlng=en Vitamin A deficiency (VAD) has been known to exist in Latin America and the Caribbean since the mid-1960s; however, except for pioneering work by the Institute of Nutrition of Central America and Panama/Pan American Health Organization on sugar fortification in Central America, there was little interest in controlling it because of the low frequency of clinical findings. More recently, implications of the effect of subclinical VAD on child health and survival has generated increased interest in assessing the problem and a greater commitment to controlling it. The information available by mid-1997 on the magnitude of VAD in countries of the Region was extensively reviewed. Internationally accepted methods and cutoff points for prevalence estimations were used to compile information from relevant dietary, biochemical, and clinical studies carried out between 1985 and 1997 in samples of at least 100 individuals. VAD in the Region of Latin America and the Caribbean is mostly subclinical. The national prevalence of subclinical VAD (serum retinol < 20 mg/dl) in children under 5 years of age ranges between 6% in Panama and 36% in El Salvador. The problem is severe in five countries, moderate in six, and mild in four. There are no recent data from Chile, Haiti, Paraguay, Uruguay, Venezuela, and the English-speaking Caribbean. The population affected amounts to about 14.5 million children under 5 years of age (25% of that age group). Schoolchildren and adult women may also have significant VAD. Actions currently implemented to control VAD include (a) universal or targeted supplementation, with sustained high coverage rates through national immunization days in some countries; (b) sugar fortification, which is well established in El Salvador, Guatemala, and Honduras (a significant effect has been documented in Guatemala and Honduras) and is under negotiation in Bolivia, Colombia, Costa Rica (to be resumed), Ecuador, Nicaragua, and Peru; and (c) limited dietary diversification activities.<hr/>Se sabe que la deficiencia de vitamina A (DVA) ha existido en América Latina y el Caribe desde mediados de los años sesenta. No obstante, si se exceptúan algunas iniciativas tempranas del Instituto de Nutrición de Centro América y Panamá, había escaso interés en controlarla debido a la detección infrecuente de signos clínicos. En época más reciente, las consecuencias de la DVA para la salud y la supervivencia infantiles ha suscitado gran interés en evaluar el problema y despertado un mayor empeño por controlarlo. La información que estaba disponible a mediados de 1997 sobre la frecuencia de la DVA en países de la Región se revisó minuciosamente. Se aplicaron métodos y puntos de corte aceptados mundialmente para la estimación de la prevalencia a fin de recopilar infomación obtenida de estudios alimentarios, bioquímicos y clínicos efectuados entre 1985 y 1997 con muestras de 100 personas como mínimo. La DVA en la Región de América Latina y el Caribe es eminentemente subclínica. La prevalencia nacional de la forma subclínica de DVA (retinol sérico < 20 µg/dL) en niños menores de 5 años oscila de 6% en Panamá a 36% en El Salvador. El problema es grave en cinco países, moderado en seis y leve en cuatro. No hay datos recientes para Chile, Haití, Paraguay, Uruguay, Venezuela y el Caribe de habla inglesa. En total la población afectada se aproxima a 14,5 millones de niños menores de 5 años (25% de ese grupo de edad). Los escolares y las mujeres en edad adulta también pueden tener una frecuencia elevada de DVA. Las medidas que actualmente están en marcha para controlar la DVA incluyen, entre otras, a) la suplementación dirigida a toda la población o a grupos particulares, con elevadas tasas de cobertura logradas durante los días en que se efectúan las inmunizaciones de alcance nacional en algunos países; b) la fortificación del azúcar, que ya se ha instaurado en El Salvador, Guatemala y Honduras (se ha observado un efecto notable en Guatemala y Honduras) y que está en proceso de negociación en Bolivia, Colombia, Costa Rica (donde está pendiente de reestablecerse), Ecuador, Nicaragua y Perú; y c) algunas actividades de diversificación alimentaria. <![CDATA[<strong>El desarrollo de valores de referencia para el perímetro braquial según la estatura y su comparación con otros indicadores utilizados para el tamizaje del estado nutricional</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900006&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>Riesgo de transmisión de enfermedades infecciosas por transfusión de sangre en Centro y Suramérica</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900007&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>Nueva revista electrónica de la OMS sobre salud reproductiva</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900008&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>Adelantos hacia la eliminación de la lepra</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900009&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>¿Cómo ven los médicos el auge de la medicina científicamente validada?</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900010&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>Tratamiento de la osteoporosis posmenopáusica</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900011&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<STRONG>Fórmula de la vacuna contra la influenza para la temporada 1998-1999</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900012&lng=en&nrm=iso&tlng=en Durante muchos años se han usado los valores de perímetro braquial inferiores a cierto límite como índice alternativo del estado nutricional de los menores de 5 años de edad en épocas de hambruna o crisis de refugiados y también como método adicional de tamizaje en situaciones normales. Sin embargo, recientemente se ha puesto en duda la independencia del perímetro braquial respecto de la edad y el sexo. Tras revisar las pruebas científicas en las que se basan el uso y la interpretación del perímetro braquial, un Comité de Expertos de la OMS recomendó nuevos valores de referencia de perímetro braquial según la edad en menores de 5 años. Sin embargo, en algunas situaciones es difícil evaluar la edad de un niño y en tales circunstancias el perímetro braquial según la altura puede ser una buena alternativa. La regla QUAC (del inglés Quaker arm circumference) para medir la altura es un medio sencillo para determinar el punto de corte del perímetro braquial correspondiente a una altura dada. Este artículo describe los valores de referencia del perímetro braquial y la construcción y uso del medidor QUAC, así como la utilización del método de curvas de características funcionales (receiver operating characteristic curve) para evaluar el rendimiento del perímetro braquial, el perímetro braquial según la edad y el perímetro braquial según la altura en la detección de niños malnutridos.<hr/>Mid-upper-arm circumference (MUAC) based on a single cut-off value for all children under 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for height may be a good alternative. The height-based QUAC stick offers a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and construction and use of the QUAC stick are described in this article. Also described is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children. <![CDATA[<strong>Lucha integrada contra las enfermedades de la infancia</strong>: <strong>nueva estrategia para mejorar la salud infantil</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900013&lng=en&nrm=iso&tlng=en Every year in the Americas close to 257 000 children under 5 years of age die from illnesses that are preventable or easily treated. These deaths are mainly caused by acute respiratory infections, diarrhea, malaria, measles, and malnutrition. The "integrated management of childhood disease" strategy was designed by WHO and UNICEF as a methodology to be applied by basic health services in an effort to solve this important problem. The strategy includes case identification, classification, and management, and can be adapted to health care standards in each country. Its main objectives are lowering mortality rates and morbidity caused by prevalent childhood diseases as well as improving the quality of service. According to the World Development Report 1993: Investing in Health, published by the World Bank, this strategy is the most efficient health intervention in terms of its impact on the population's burden of death and disease, as well as its cost-effectiveness. <![CDATA[<strong>Salud, ambiente y desarrollo sostenible en México</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900014&lng=en&nrm=iso&tlng=en This article is based on "Salud, ambiente y desarrollo humano sostenible: el caso de México," a document prepared in June 1997 by the Comité Técnico Nacional para el Desarrollo Sostenible. It opens with information regarding the epidemiologic and demographic changes that have taken place in Mexico, such as the decrease in communicable diseases, the rise in noncommunicable diseases, and the less conspicuous increase in lesions resulting from accidents or acts of violence. This is followed by a discussion of priority problems and problems of lesser magnitude in environmental health, specifically those relating to water and air quality, as well as disposal of household and dangerous wastes. Finally, it proposes three areas of intervention in light of the structural problems detected: the absence of an integrated information system covering the area of health, environment, and development; the absence of channels of communication within and between institutions and sectors, and the lack of coordination in planning and implementing programs and actions in this field. <![CDATA[<strong>La salud reproductiva</strong>: <strong>parte integrante del desarrollo humano</strong>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900015&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums. <![CDATA[<STRONG>Cultura estadística e investigación científica en el campo de la salud</STRONG>: <STRONG>una mirada crítica</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900016&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums. <![CDATA[<STRONG>Ethics in reproductive and perinatal medicine</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900017&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums. <![CDATA[<STRONG>New generation vaccines</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900018&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums. <![CDATA[<STRONG>Overweight and weight management</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900019&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums. <![CDATA[<STRONG>El regreso de las epidemias</STRONG>: <STRONG>salud y sociedad en el Perú del siglo XX</STRONG>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49891998000900020&lng=en&nrm=iso&tlng=en The concept of reproductive health has changed throughout the years until it has come to be understood as a constant that goes beyond biological concerns and is related to the values, culture, and personal fulfillment of each human being. It encompasses, therefore, a wide range of action in individual and family life as well as in the collective development of populations. Promoting and maintaining reproductive health requires quality services with equitable access. PAHO has cooperated in this field with Member States for over 30 years, during which maternal and child mortality has diminished, the notion of integral adolescent health has been disseminated, the subject has been added to professional health curriculums, pertinent activities have been integrated into the health services, and new data have been gathered to inform policies and activities on reproductive health. The present situation of national health sector reforms presents a unique opportunity for approaching anew old problems related to reproductive health, to examine policies and strategies, and to implement changes that reaffirm the commitments made in international forums.