Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498920030010&lang=en vol. 14 num. 5 lang. en <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org <![CDATA[<b>A standard method for measuring blood pressure in the Americas</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Rubella and the Americas</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Working meeting on blood pressure measurement</b>: <b>suggestions for measuring blood pressure to use in populations surveys</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000003&lng=en&nrm=iso&tlng=en As part of the Pan American Hypertension Initiative (PAHI), the Pan American Health Organization and the National Heart, Lung, and Blood Institute of the National Institutes of Health of the United States of America conducted a working meeting to discuss blood pressure (BP) measurement methods used in various hypertension prevalence surveys and clinical trials, with the objective of developing a BP measurement protocol for use in hypertension prevalence surveys in the Americas. No such common protocol has existed in the Americas, so it has been difficult to compare hypertension prevention and intervention strategies. This piece describes a proposed standard method for measuring blood pressure for use in population surveys in the Region of the Americas. The piece covers: considerations for developing a common blood pressure measurement protocol, critical issues in measuring blood pressure in national surveys, minimum procedures for blood pressure measurement during surveillance, and quality assessment of blood pressure. <![CDATA[<b>Reunión de trabajo sobre la medición de la presión arterial</b>: <b>recomendaciones para estudios de población</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000004&lng=en&nrm=iso&tlng=en Como parte de la Iniciativa Panamericana sobre la Hipertensión Arterial, la Organización Panamericana de la Salud y el Instituto Nacional del Corazón, los Pulmones y la Sangre, uno de los Institutos Nacionales de Salud de los Estados Unidos de América, llevaron a cabo una reunión de trabajo para examinar los métodos de medición de la presión arterial (PA) empleados en estudios de prevalencia y ensayos clínicos sobre la hipertensión arterial. El objetivo era desarrollar un protocolo para la medición de la PA que pudiera usarse en los estudios de prevalencia de hipertensión arterial que se realizan en las Américas. Ningún protocolo común de este tipo ha existido antes en la Región, y debido a ellos ha sido difícil comparar las estrategias de intervención y prevención en torno a la hipertensión arterial. Este artículo describe un método estándar que se ha propuesto para medir la PA en estudios de población en la Región de las Américas. El artículo examina todo lo que encierra la elaboración de un protocolo común para medir la PA, aspectos críticos de la medición de la PA en estudios nacionales, los procedimientos mínimos para la medición de la PA durante actividades de vigilancia y la evaluación de la calidad de la PA. <![CDATA[<b>Rubella and congenital rubella syndrome</b>: <b>global update</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000005&lng=en&nrm=iso&tlng=en Worldwide, it is estimated that there are more than 100 000 infants born with congenital rubella syndrome (CRS) each year. In 1998, standard case definitions for surveillance of CRS and rubella were developed by the World Health Organization (WHO). In 2001, 123 countries/territories reported a total of 836 356 rubella cases. In the future more countries are expected to report on rubella as a global measles/rubella laboratory network is further developed under the coordination of the WHO. Operational research is being conducted to improve rubella surveillance. This includes projects on initiating CRS surveillance, comparative studies on diagnostic laboratory methods, and molecular epidemiology research to expand the global understanding of patterns of rubella virus circulation. In 1996 a WHO survey found that 78 of 214 reporting countries/territories (36%) were using rubella vaccine in their routine immunization services. By the end of 2002 a total of 124 of the 214 counties/territories (58%) were using rubella vaccine. Rubella vaccine use varies by stage of economic development: 100% for industrialized countries, 71% for countries with economies in transition, and 48% for developing countries. A safe and effective rubella vaccine is available, and there are proven vaccination strategies for preventing rubella and CRS. A WHO position paper provides guidance on programmatic aspects of rubella vaccine introduction. The introduction of rubella vaccine is cost-effective and cost-beneficial but requires ongoing strengthening of routine immunization services and surveillance systems.<hr/>Se calcula que cada año nacen en el mundo más de 100 000 niños con síndrome de rubéola congénita (SRC). La Organización Mundial de la Salud (OMS) estandarizó en 1998 las definiciones de casos para la vigilancia del SRC y de la rubéola. En 2001, 123 países o territorios notificaron 836 356 casos de rubéola y se espera que el número de países se incremente a medida que se desarrolla, bajo la coordinación de la OMS, una red mundial de laboratorios para la detección del sarampión y la rubéola. Se están realizando investigaciones para mejorar la vigilancia de esta última enfermedad, entre ellas algunos proyectos encaminados a echar a andar la vigilancia y a comparan métodos diagnósticos, así como estudios de epidemiología molecular para lograr entender más a fondo los patrones de circulación del virus de la rubéola en el mundo. En 1996 una encuesta efectuada por la OMS reveló que 78 (36%) de los 214 países o territorios que habían notificado casos de la enfermedad aplicaban la vacuna contra la rubéola como parte de su régimen de vacunación estándar. Para fines de 2002 un total de 124 de esos 214 (58%) países o territorios aplicaban la vacuna antirrubeólica cuyo uso depende del nivel de desarrollo económico: 100% en países industrializados, 71% en países con economías en transición y 48% en países en desarrollo. Se dispone de una vacuna inocua y eficaz y se ha demostrado la eficacia de algunas estrategias de vacunación para la prevención de la rubeóla y el SRC. En un trabajo de posición de la OMS se ofrece orientación acerca de lo que entraña, desde el punto de vista programático, emprender la vacunación antirrubeólica. Se trata de una medida cuya efectividad y beneficios superan su costo, pero que exige un continuo fortalecimiento de los servicios de vacunación y sistemas de vigilancia habituales. <![CDATA[<b>Reference values for erythrocyte cholinesterase activity in the working population of </b><b>Antioquia</b><b>, </b><b>Colombia</b><b>, according to the Michel and EQM techniques</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000006&lng=en&nrm=iso&tlng=en OBJETIVO: Establecer valores de referencia de la actividad de la colinesterasa eritrocitaria (EC 3.1.1.7) para la población laboral activa de dos regiones del departamento de Antioquia, Colombia, situadas a diferentes alturas sobre el nivel del mar. MÉTODOS: Se diseñaron dos muestras representativas de la población laboral activa de 18 a 59 años de edad residente en el valle de Aburrá (1 540 m sobre el nivel del mar) y en el cercano oriente antioqueño (2 150 m sobre el nivel del mar). Se excluyeron los trabajadores que empleaban sustancias inhibidoras de la colinesterasa en su trabajo o en el hogar, los que presentaban alguna enfermedad que alterara los niveles de colinesterasa y los que manifestaron no contar con buena salud. Se midió la actividad de la colinesterasa eritrocitaria con los métodos de Michel y EQM® en 827 personas, 415 de Aburrá y 412 del Oriente. Las proporciones se compararon mediante la prueba de ji al cuadrado, incluida la versión de Fisher. La prueba de la t de Student para muestras independientes se utilizó para la comparación de dos promedios. Para comparar simultáneamente tres o más promedios se empleó el análisis de la varianza, seguido del análisis de rangos múltiples de Newman-Keuls (ARM-NK). Cuando las variables no tenían distribución normal o cuando las varianzas no eran homogéneas se usó el análisis de la varianza no paramétrico de Kruskal y Wallis para comparar las medianas. Se emplearon los programas SPSS 9.0, SGPlus 7.1 y EpiInfo 6.04. En todas las pruebas estadísticas se aplicó un nivel de significación P < 0,05. RESULTADOS: Los valores de actividad de la colinesterasa eritrocitaria obtenidos en esta investigación para la población estudiada mediante los dos métodos analíticos utilizados fueron: Michel: 0,857 delta de pH/hora (IC95%: 0,849 a 0,866) y EQM®: 35,21 U/g oxihemoglobina (IC95%: 34,82 a 35,60). Por el método de Michel: la actividad enzimática difirió significativamente entre regiones (Aburrá y Oriente) según el ARM-NK; dentro de cada región, la actividad enzimática masculina fue significativamente mayor que la femenina según el ARM-NK; en ninguno de los estratos por región y sexo hubo influencia estadísticamente significativa de la edad en la actividad enzimática, cualquiera que fuera el método utilizado. Por el método de EQM® no se encontraron diferencias estadísticamente significativas entre regiones, entre sexos ni entre grupos de edad. CONCLUSIÓN: Los valores de la actividad de la colinesterasa eritrocitaria encontrados por las dos técnicas analíticas fueron significativamente superiores a los valores foráneos utilizados actualmente como valores de referencia en Colombia, lo que plantea problemas clínicos y epidemiológicos. Se propone que los datos de este estudio se adopten como valores de referencia en Colombia.<hr/>OBJECTIVE: To establish reference values for erythrocyte cholinesterase (EC 3.1.1.7) activity for the active working population of two regions of the department of Antioquia, Colombia, that are located at different altitudes above sea level. METHODS: We took representative samples from populations of active working persons 18 to 59 years old from two regions in the department of Antioquia: (1) the Aburrá Valley (1 540 m above sea level) and (2) the near east of the department (2 150 m above sea level). We excluded workers who were using cholinesterase-inhibiting substances in their work or at home, those who had a disease that altered their cholinesterase levels, and those who said they were not in good health. We measured the erythrocyte cholinesterase activity using two methods: (1) the Michel method and (2) the EQM method (EQM Research, Cincinnati, Ohio, United States of America). We carried out the measurements with 827 people, 415 from the Aburrá Valley and 412 from the near east region. We compared proportions using the chi-square test and Fisher's exact test. We utilized the Student's t test for independent samples to compare two averages. To simultaneously compare three or more averages, analysis of variance was used, followed by the Newman-Keuls multiple-range test. When the variables were not normally distributed or when the variances were not homogeneous, Kruskal-Wallis nonparametric analysis of variance was used to compare the medians. Three computer software programs were used in the statistical analysis: SPSS 9.0, SGPlus 7.1, and Epi Info 6.04. In all the statistical tests the level of significance was set at P < 0.05. RESULTS: The average erythrocyte cholinesterase activity value that we found for the studied population by using the Michel method was 0.857 delta pH/hour (95% confidence interval (CI): 0.849 to 0.866), and the average value found through the EQM method was 35.21 U/g hemoglobin (95% CI: 34.82 to 35.60). With the Michel method: (1) the enzymatic activity differed significantly between the two regions, according to the Newman-Keuls test; (2) within each region, the enzymatic activity was significantly higher among males than among females, according to the Newman-Keuls test; and (3) in none of the region-sex strata was there a statistically significant influence of age on the enzymatic activity. Using the EQM method, there were no statistically significant differences by region, sex, or age group. CONCLUSIONS: The erythrocyte cholinesterase activity values found by the two analytical techniques were significantly higher than the values from outside Colombia that are now being used as reference values in the country, which poses both clinical and epidemiological problems. We recommend that the data from this study be adopted as the reference values in Colombia. <![CDATA[<b>Indicators of the effectiveness of epidemiological surveillance for acute flaccid paralysis in </b><b>Brazil</b><b> from 1990 through 2000</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000007&lng=en&nrm=iso&tlng=en OBJETIVOS: Descrever e comparar os indicadores de qualidade de vigilância epidemiológica para paralisias flácidas agudas nos períodos pré (1990 a 1994) e pós-certificação (1995 a 2000) do Brasil como zona livre da poliomielite. MÉTODOS: Foram consideradas as seguintes variáveis: prevalência mínima (notificação > ou = 1 caso em 100 000 indivíduos com menos de 15 anos de idade), notificação negativa (ausência de casos informada semanalmente por no mínimo 80% das unidades notificadoras em cada região), tempo de investigação do caso (investigação de 80% ou mais dos casos notificados de paralisias flácidas agudas até 48 horas depois da notificação) e investigação diagnóstica (coleta de duas amostras de fezes para cultura viral nas 2 semanas seguintes ao início da deficiência motora em 80% ou mais dos casos de paralisias flácidas agudas). Os resultados foram classificados como adequados se fossem iguais ou superiores ao valor considerado como efetivo, ou como inadequados se estivessem abaixo desse valor. Foi calculada a razão percentual de valores adequados alcançados em cada unidade federada em cada ano, para cada pesríodo do estudo. Também foram apresentadas as médias finais por período, unidade e região. RESULTADOS: Considerando os resultados para o Brasil como um todo, o indicador de prevalência mínima apresentou redução de 1,3 para 0,9 por 100 000 menores de 15 anos no período pós-certificação, mas a diferença não foi significativa (P > 0,08). A notificação negativa manteve valores médios adequados nos dois períodos (87 e 84%), mas a razão percentual de efetividade foi 6,6% menor no período pós-certificação (P > 0,21). O tempo de investigação de casos de paralisia flácida aguda melhorou sua efetividade em 10,9% (P > 0,06) no período pós-certificação. A coleta de fezes permaneceu inadequada nos dois períodos (54 e 52%). CONCLUSÕES: Apesar da ausência de casos autóctones de poliomielite por vírus selvagem no Brasil no período pós-certificação, são ainda desfavoráveis os indicadores de qualidade da vigilância epidemiológica, o que pode retardar a detecção e investigação de casos de paralisias flácidas agudas e comprometer o programa de erradicação global da poliomielite. As novas estratégias de informação que estão sendo disponibilizadas para o sistema de saúde do Brasil poderão promover uma melhora na efetividade do programa nacional de controle da poliomielite.<hr/>OBJECTIVES: To describe and compare indicators of the quality of epidemiological surveillance for acute flaccid paralysis (AFP) before Brazil's certification as a poliomyelitis-free area (1990 through 1994) and after that certification (1995 through 2000). METHODS: The following variables were studied: minimum prevalence (reporting annually at least 1 case of AFP per 100 000 individuals younger than 15 years), negative reporting (weekly reporting of the absence of AFP cases by at least 80% of the reporting units in each region), time of investigation (investigating at least 80% of the AFP cases within 48 hours of their being reported), and diagnostic investigation (collection of two stool samples for viral culture in the 2 weeks following the onset of paralysis in 80% or more of the AFP cases). The results were categorized as adequate if they were equal to or higher than the value considered as being effective, or as inadequate if they were below this value. The percentage rate of adequate values was calculated for each of Brazil's 27 federal political divisions (26 states plus the Federal District) in each year, for each of the two periods studied. The final means per period, per federal political division, and per region were also calculated. RESULTS: For Brazil overall, minimum prevalence decreased from 1.3 per 100 000 individuals younger than 15 years in the precertification period to 0.9 per 100 000 in the postcertification period, but the difference was not statistically significant (P > 0.08). While negative reporting was adequate in both periods (87% and 84%, respectively), the percentage rate of effectiveness was 6.6% lower in the postcertification period (P > 0.21). The effectiveness in the time required to investigate AFP cases increased from 60.7% to 71.6% (P > 0.06). The collection of stool samples was inadequate both before and after certification (54% and 52%, respectively). CONCLUSIONS: Despite the absence of indigenous wild virus poliomyelitis cases in Brazil in the postcertification period, the quality of epidemiological surveillance indicators is still less than desirable. This may delay the detection and investigation of AFP cases and compromise the global poliomyelitis eradication effort. New information strategies that are being made available for the health system in Brazil may improve the effectiveness of the national poliomyelitis control program. <![CDATA[<b>Serological surveillance of measles in blood donors in Rio de Janeiro, Brazil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000008&lng=en&nrm=iso&tlng=en OBJECTIVES: To estimate the proportion of individuals seronegative for measles antibody among blood donors from a blood bank in the city of Rio de Janeiro, Brazil, and to describe their social and demographic characteristics, with the goal of exploring the potential use of plasma banks to supplement serological surveillance with relevant data in order to support the program of measles elimination in the city of Rio de Janeiro and elsewhere. METHODS: Plasma samples from 1 101 consecutive blood donations made in November 2000 at HEMORIO, the largest blood bank in the state of Rio de Janeiro, were tested for measles immunoglobulin G, using a commercial enzyme immunoassay and a plaque reduction neutralization test. We calculated the proportion (and 95% confidence interval (CI)) of samples seronegative for measles antibody for the total sample of blood donors and also for subgroups categorized by age, sex, neighborhood of residence, education, and occupation. We used the chi-square test to assess the statistical significance of differences in proportions and linear trends in proportions. RESULTS: Of the total group of blood donors, 6.9% of them (95% CI: 5.4%­8.4%) were seronegative for measles. Women had a higher proportion (10.1%; 95% CI: 6.8%­13.4%) of seronegative results than did men (5.6%; 95% CI: 4.0%­7.2%). In terms of age, 86.8% of seronegative individuals were born between 1971 and 1982. Seronegativity was inversely proportional to age (chi-square = 58.0; P < 0.0001). With regard to occupation, students had the highest proportion of seronegative individuals (17.8%). In terms of education, most of the susceptible persons were in the categories of "incomplete university degree" or "incomplete high school." For the various areas of residence the proportions ranged from 2.1% to 11.4%. CONCLUSIONS: Blood bank plasma may constitute a useful and convenient source of complementary data for serological surveillance in adults of measles and other infections for which immunization and surveillance activities are implemented. This approach could be beneficial to other areas in Brazil and other countries where plasma from blood donors is available for surveillance. The use of residual sera from patients and plasma from blood donors represents a tradeoff between representativeness and timeliness as well as economy of resources.<hr/>OBJETIVOS: Determinar la proporción de personas seronegativas a anticuerpos contra el sarampión entre los donantes de un banco de sangre de la ciudad de Río de Janeiro, Brasil, y describir sus características sociales y demográficas, con el fin de explorar el uso eventual de los bancos de plasma para complementar la vigilancia serológica con datos que permitan apoyar el programa de erradicación del sarampión en la ciudad de Río de Janeiro y en otras localidades. MÉTODOS: Se estudió la presencia de inmunoglobulinas G contra el sarampión en muestras de plasma de 1 101 donaciones de sangre consecutivas realizadas en noviembre de 2000 en HEMORIO, el mayor banco de sangre del estado de Río de Janeiro, mediante un ensayo inmunoenzimático comercial y una prueba de neutralización por reducción de placas. Se calculó la proporción (y el intervalo de confianza (IC) de 95%) de las muestras negativas a anticuerpos contra el sarampión en la totalidad de las donaciones y en subgrupos conformados según la edad, el sexo, el vecindario de residencia, la educación y la ocupación laboral. La significación estadística de las diferencias entre las proporciones y entre sus tendencias lineales se determinó mediante la prueba de ji al cuadrado. RESULTADOS: Del total de donantes de sangre, el 6,9% (IC95%: 5,4 a 8,4%) resultó seronegativo al sarampión. Las mujeres tuvieron una mayor proporción de resultados seronegativos (10,1%; IC95%: 6,8 a 13,4%) que los hombres (5,6%; IC95%: 4,0 a 7,2%). En relación con la edad, 86,8% de las personas seronegativas nacieron entre 1971 y 1982. La seronegatividad fue inversamente proporcional a la edad (ji al cuadrado = 58,0; P < 0,0001). En cuanto a la ocupación laboral, los estudiantes presentaron la mayor proporción de seronegativos (17,8%), mientras que en lo referente a la educación, la mayoría de las personas susceptibles a la enfermedad se encontraban en la categoría de "estudios universitarios incompletos" o "estudios secundarios incompletos". La proporción de seronegativos entre las diferentes áreas de residencia estuvo entre 2,1% y 11,4%. CONCLUSIONES: El plasma de los bancos de sangre puede ser una fuente útil y conveniente de datos complementarios para la vigilancia serológica en adultos, tanto de sarampión como de otras enfermedades infecciosas para las que se hayan implementado actividades de inmunización y vigilancia. Este enfoque puede ser beneficioso en otras regiones de Brasil y en otros países en los que se pueda contar para la vigilancia con el plasma de los donantes de sangre. El empleo del remanente de los sueros de los pacientes y del plasma de los donantes de sangre representa una solución de compromiso entre la representatividad y la oportunidad, y el buen uso de los recursos. <![CDATA[<b>Fluoride in drinking water in </b><b>Cuba</b><b> and its association with geological and geographical variables</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000009&lng=en&nrm=iso&tlng=en OBJETIVO: Determinar la asociación entre las diferentes concentraciones del ión fluoruro en aguas de consumo y algunas variables geológicas y geográficas de Cuba, mediante el empleo de un sistema de información geográfica. MÉTODOS: De noviembre de 1998 a octubre de 1999 se estudiaron las concentraciones de fluoruro en fuentes de abastecimiento de agua de consumo de 753 localidades cubanas de 1 000 habitantes o más. Para el análisis de la información se utilizó el sistema de información geográfica MapInfo Professional (v. 5.5) con el método de superposición. Las variables de estudio fueron la concentración del ión fluoruro en fuentes de abastecimiento de agua, las características geológicas del territorio, los alineamientos, los tipos de fuente y las categorías de relieve (llanura o montaña). Los resultados se agruparon por localidad y municipio. RESULTADOS: En 83,1% de las localidades, las muestras de agua fueron recolectadas en pozos y manantiales y en el 16,9% restante, en presas y ríos. De las 753 localidades estudiadas, 675 (89,6%) presentaron concentraciones de fluoruro bajas o medias (< 0,7 mg/L). La región oriental del país fue la más afectada por concentraciones elevadas de fluoruro en las aguas, seguida de la región central. La mayoría de las localidades con altas concentraciones de fluoruro natural se localizaron en zonas ubicadas sobre rocas del arco volcánico del Cretácico. La presencia de fluoruro en las aguas de consumo estuvo asociada con los alineamientos de la corteza terrestre, no solo en los complejos rocosos de origen volcánico-sedimentario e intrusivo, sino también en las rocas carbonatadas, aunque se debe destacar que las mayores concentraciones de fluoruro coincidieron fundamentalmente con los dos primeros complejos rocosos mencionados anteriormente. Todas las localidades con concentraciones altas de fluoruro en el agua estaban vinculadas a pozos. CONCLUSIONES: La concentración de fluoruro en las fuentes de agua de consumo de 89,6% de las poblaciones cubanas con 1 000 habitantes o más es baja o mediana. Las características geológicas y geográficas pueden ayudar a identificar zonas con concentraciones óptimas y altas del ión fluoruro en las aguas de consumo.<hr/>OBJECTIVE: To determine the association between different concentrations of the fluoride ion in drinking water and some geological and geographical variables in Cuba, by using a geographic information system. METHODS: From November 1998 to October 1999 we studied the fluoride concentration in the sources of drinking water for 753 Cuban localities that had at least 1 000 inhabitants. For the information analysis we utilized the MapInfo Professional version 5.5 geographic information system, using the overlaying method. The study variables were the concentration of the fluoride ion in the water sources, the geological characteristics of the area, the alignments (geological characteristics that were found together), the types of water sources, and whether an area was a plain or mountainous. The results were grouped by locality and municipality. RESULTS: In 83.1% of the localities, the water samples were collected from wells and springs, and the remaining 16.9% came from dams and rivers. Of the 753 localities studied, 675 of them (89.6%) had low or medium fluoride concentrations (under 0.7 mg/L). The eastern region of the country was the one most affected by high fluoride concentrations in the waters, followed by the central region of the country. The majority of the localities with high natural fluoride concentrations were in areas located on Cretaceous volcanic arc rocks. The presence of fluoride in the drinking waters was related to the alignments with the earth's crust, in rock complexes of volcanic-sedimentary origin and of intrusive origin and also in carbonate rocks. However, the highest fluoride concentrations generally coincided with rock complexes of volcanic-sedimentary origin and of intrusive origin. All the localities with high fluoride concentrations in the water were associated with wells. CONCLUSIONS: The fluoride concentration is low or medium in the drinking water sources for 89.6% of the Cuban localities with at least 1 000 inhabitants. Geological and geographical characteristics can help identify areas with optimal or high concentrations of the fluoride ion in the drinking water. <![CDATA[<b>Missed opportunities for tetanus immunization of pregnant women in Juiz de Fora, Minas Gerais, Brazil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000010&lng=en&nrm=iso&tlng=en OBJETIVOS: Estimar as oportunidades perdidas de vacinação antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinação antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Único de Saúde em 69,5% (299) das mulheres; 27,6% (119) utilizaram outros convênios; e 2,8% (12) não fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8%) portavam o cartão de controle pré-natal e 85,6% (368) tiveram quatro ou mais consultas pré-natais. Com relação ao conhecimento do tétano, 92,1% (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5%) iniciaram a gestação não imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunização com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70% as oportunidades perdidas de imunização antitetânica na gestação e de 40,6% a cobertura vacinal das gestantes. CONCLUSÃO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organização Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunização antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinação, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinação em Juiz de Fora deve ser intensificada.<hr/>OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 ± 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened. <![CDATA[<b>Cambios estructurales en el cerebro de pacientes con enfermedad de Alzheimer tratados con donepezil</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000011&lng=en&nrm=iso&tlng=en OBJETIVOS: Estimar as oportunidades perdidas de vacinação antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinação antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Único de Saúde em 69,5% (299) das mulheres; 27,6% (119) utilizaram outros convênios; e 2,8% (12) não fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8%) portavam o cartão de controle pré-natal e 85,6% (368) tiveram quatro ou mais consultas pré-natais. Com relação ao conhecimento do tétano, 92,1% (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5%) iniciaram a gestação não imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunização com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70% as oportunidades perdidas de imunização antitetânica na gestação e de 40,6% a cobertura vacinal das gestantes. CONCLUSÃO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organização Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunização antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinação, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinação em Juiz de Fora deve ser intensificada.<hr/>OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 ± 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened. <![CDATA[<b>Se comparan los resultados de la mastectomía y de la cirugía conservadora en pacientes con cáncer de mama</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000012&lng=en&nrm=iso&tlng=en OBJETIVOS: Estimar as oportunidades perdidas de vacinação antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinação antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Único de Saúde em 69,5% (299) das mulheres; 27,6% (119) utilizaram outros convênios; e 2,8% (12) não fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8%) portavam o cartão de controle pré-natal e 85,6% (368) tiveram quatro ou mais consultas pré-natais. Com relação ao conhecimento do tétano, 92,1% (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5%) iniciaram a gestação não imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunização com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70% as oportunidades perdidas de imunização antitetânica na gestação e de 40,6% a cobertura vacinal das gestantes. CONCLUSÃO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organização Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunização antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinação, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinação em Juiz de Fora deve ser intensificada.<hr/>OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 ± 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened. <![CDATA[<b>Posibilidad de detectar virus del papiloma humano mediante prueba urinaria</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000013&lng=en&nrm=iso&tlng=en OBJETIVOS: Estimar as oportunidades perdidas de vacinação antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinação antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Único de Saúde em 69,5% (299) das mulheres; 27,6% (119) utilizaram outros convênios; e 2,8% (12) não fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8%) portavam o cartão de controle pré-natal e 85,6% (368) tiveram quatro ou mais consultas pré-natais. Com relação ao conhecimento do tétano, 92,1% (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5%) iniciaram a gestação não imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunização com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70% as oportunidades perdidas de imunização antitetânica na gestação e de 40,6% a cobertura vacinal das gestantes. CONCLUSÃO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organização Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunização antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinação, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinação em Juiz de Fora deve ser intensificada.<hr/>OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 ± 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened. <![CDATA[<b>El uso de diuréticos en pacientes hipertensos podría contrarrestar la carestía de los antihipertensivos</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000014&lng=en&nrm=iso&tlng=en OBJETIVOS: Estimar as oportunidades perdidas de vacinação antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinação antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Único de Saúde em 69,5% (299) das mulheres; 27,6% (119) utilizaram outros convênios; e 2,8% (12) não fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8%) portavam o cartão de controle pré-natal e 85,6% (368) tiveram quatro ou mais consultas pré-natais. Com relação ao conhecimento do tétano, 92,1% (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5%) iniciaram a gestação não imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunização com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70% as oportunidades perdidas de imunização antitetânica na gestação e de 40,6% a cobertura vacinal das gestantes. CONCLUSÃO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organização Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunização antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinação, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinação em Juiz de Fora deve ser intensificada.<hr/>OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 ± 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened. <![CDATA[<b>New goal for vaccination programs in the Region of the Americas</b>: <b>to eliminate rubella and congenital rubella syndrome</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000015&lng=en&nrm=iso&tlng=en The vaccination programs of the countries in the Region of the Americas have produced notable results over the last several decades. In recognition of those accomplishments, in June 2003 the 132nd session of the Executive Committee of the Pan American Health Organization (PAHO) called on the Member States of PAHO to prepare, within one year, national action plans for the elimination of rubella and congenital rubella syndrome (CRS) by the year 2010. During the Executive Committee discussions, praise was given for the sustained efforts of the countries of the Region in the struggle to eradicate measles. The Executive Committee discussions also reiterated the recommendation that the countries establish specific line items for immunization within their national budgets, in order to protect the investments in immunization that the Region's countries have made. The analysis of results of mass vaccination against rubella indicates that the benefits coming from accelerated control greatly exceed the costs associated with the treatment and rehabilitation of children with CRS. Various factors have created an environment that supports the goal of eliminating rubella and CRS from the Americas by the year 2010. These factors include the rapid reduction in morbidity that has come from the accelerated rubella control strategy; the availability of a safe, affordable, efficacious vaccine; the evidence of the cost benefit of vaccinating against rubella; and the broad support provided by the public and by health authorities in the Member States of PAHO. <![CDATA[<b>Promoting the healthy, safe use of recreational waters</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892003001000016&lng=en&nrm=iso&tlng=en Las actividades acuáticas recreativas pueden ofrecer beneficios considerables para la salud y el bienestar de las personas. Por ejemplo, los lagos y los ríos pueden brindar un ambiente adecuado para el descanso, la actividad física y el esparcimiento. Además, muchos países de todas las latitudes dependen de sus extensas playas cubiertas de arena para atraer a los turistas, y los desembolsos de esos visitantes contribuyen a la economía local. Sin embargo, esas actividades acuáticas también pueden representar riesgos para la salud, ya que aguas contaminadas o poco seguras en lugares de recreo pueden conducir a infecciones y enfermedades, lesiones e incluso la muerte. Para ayudar a lidiar con este tipo de problemas, la Organización Mundial de la Salud (OMS) emitió recientemente un informe titulado Directrices para un Medio Acuático Recreativo Seguro (Guidelines for Safe Recreational Water Environments). El texto está dirigido a reducir las muertes y lesiones de los bañistas, así como a hacer las playas y los espacios recreativos acuáticos más seguros para el descanso, los ejercicios y el esparcimiento. El nuevo informe de la OMS trata sobre riesgos tales como el de ahogarse y recibir lesiones; la exposición al frío, el calor y las radiaciones solares; la calidad del agua; la contaminación de la arena de las playas; y la exposición a algas, agentes químicos y físicos, así como a organismos acuáticos peligrosos. Las directrices propuestas en el informe de la OMS deben servir de base para desarrollar estrategias nacionales e internacionales -como estándares y regulaciones-, para controlar los riesgos para la salud que se pueden encontrar en los medios acuáticos de recreo y, al mismo tiempo, deben ofrecer un marco de trabajo para las autoridades locales encargadas de tomar decisiones. Estas directrices también se pueden utilizar como material de referencia para las industrias y los operadores que preparan proyectos de desarrollo en áreas con medios acuáticos recreativos, como una lista de comprobación para interpretar y evaluar el eventual impacto para la salud de los proyectos recreativos y de cómo llevar a cabo la estimación de su impacto sobre el medio ambiente y la salud ambiental.