Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498920040002&lang=en vol. 15 num. 2 lang. en <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org <![CDATA[<B>Guanacaste, Costa Rica</B>: <B>a landmark for cervical cancer prevention</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200001&lng=en&nrm=iso&tlng=en <![CDATA[<B>Description of a seven-year prospective study of human papillomavirus infection and cervical neoplasia among 10 000 women in Guanacaste, Costa Rica</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200002&lng=en&nrm=iso&tlng=en OBJECTIVE:The Guanacaste study ("Guanacaste Project," or GP), was designed to investigate the role of human papillomavirus (HPV) infection and its cofactors in the development of cervical neoplasia and to evaluate new cervical cancer screening technologies. The follow-up phase of the GP was designed to study why a small proportion of women infected with HPV develop cervical intraepithelial neoplasia grade 2 (CIN 2), CIN 3, or cancer (these three together are globally referred to as > CIN 2, that is, CIN 2 or worse). The purpose of this article is to describe this prospective study in detail and to present the preliminary findings regarding the incidence of cervical neoplasia. METHODS: A cohort of 10 049 randomly selected women from 18 to 97 years old from Guanacaste, a province in northwestern Costa Rica, was intensively screened in 1993-1994 and then followed up for seven years after being enrolled. A questionnaire for demographic and risk factors was administered, and a pelvic examination was performed on sexually active women at each follow-up visit in order to obtain samples for screening tests and for research purposes. The final diagnosis given at the end of the enrollment phase categorized women into several groups according to the perceived risk of their developing either high-grade precursors of cancer or cancer. These groups were followed up at different intervals according to the risk of developing > CIN 2. The most active follow-up (every 6-12 months) was concentrated on the women most likely to develop > CIN 2, based on cytology (n= 492). The remainder of the cohort was followed either annually (n= 2 574) or after five to seven years of passive follow-up (n= 3 926). All women with possibly severe lesions detected by any technique were referred to colposcopy for further evaluation and treatment, and they were also censored from the study. Lesions >CIN 2 served as both the censoring outcome and our surrogate for cancer risk. RESULTS: Participation during follow-up was high (near 90%). Suspected > CIN 2 by any screening technique censored 4.6% of women. Most of the women censored because of suspected > CIN 2 came from the large group perceived at entry as being at low risk of developing > CIN 2, but the greatest rates of progression to > CIN 2 were observed among women perceived at entry to be at highest risk of >CIN 2, based on their cytology, virology, or sexual behavior. CONCLUSIONS: The GP is the largest population-based longitudinal cohort for the study of HPV and cervical neoplasia in the world, and its results will hopefully let us soon plan future worldwide prevention strategies. Research projects such as this one require the long-term commitment of a large multidisciplinary team and ample financial resources. The intensive effort and expertise applied in all aspects of this study were key factors in its success as a model of cooperative, interdisciplinary cancer research in Latin America. Quality control played an important role at all times during the study and made it possible to adapt new diagnostic and screening technology to Guanacaste. The systematic follow-up of a population-based group of close to 10 000 women in Guanacaste should permit careful, time-dependent evaluation of factors postulated to be linked to the development of cervical cancer as well as the evaluation of clinical markers of disease progression. The study results that have already been published have validated sensitive screening techniques and have also promoted the use of more affordable screening techniques in resource-poor, developing countries. The GP has also contributed to building knowledge for the search for vaccines against HPV as part of the effort to develop an effective tool to reduce the incidence and mortality of cervical cancer worldwide.<hr/>OBJETIVOS: El estudio de cohorte de Guanacaste, o Proyecto Epidemiológico Guanacaste, fue diseñado para investigar el papel que desempeñan la infección por el virus del papiloma humano (VPH) y sus cofactores en el desarrollo de neoplasias cervicouterinas y para evaluar nuevas tecnologías de tamizaje del cáncer del cuello de útero. La fase de seguimiento de este proyecto se diseñó para analizar por qué una pequeña parte de las mujeres infectadas por el VPH desarrollan neoplasias intraepiteliales cervicouterinas (NIC) grados 2 y 3, o cáncer (que en lo adelante se llamarán en conjunto > NIC 2, es decir, NIC 2 o peor). El propósito de este artículo es describir en detalle ese estudio prospectivo y presentar los resultados preliminares relacionados con la incidencia de neoplasias cervicouterinas. MÉTODOS: Se realizó el tamizaje intensivo de una cohorte de 10 049 mujeres de 18 a 97 años de edad seleccionadas aleatoriamente en Guanacaste, provincia del noroeste de Costa Rica, en 1993-1994 con un seguimiento ulterior de siete años. A las participantes se les aplicó un cuestionario para conocer sus características demográficas y sus factores de riesgo, y a las sexualmente activas se les realizó además un examen pélvico en cada una de las visitas de seguimiento, a fin de obtener muestras para las pruebas de tamizaje y la investigación. El diagnóstico obtenido al final de la fase de captación permitió clasificar a las mujeres en varios grupos de acuerdo con el riesgo que presentaban de desarrollar cáncer o alguno de sus precursores de alto grado. Estos grupos tuvieron seguimientos a intervalos diferentes, según su riesgo de desarrollar > NIC 2. El seguimiento más activo (cada 6-12 meses) se concentró en las mujeres con mayores probabilidades de desarrollar > NIC 2, según los resultados citológicos (n = 492). Las mujeres restantes recibieron visitas de seguimiento anualmente (n = 2 574) o después de cinco a siete años de seguimiento pasivo (n = 3 926). A todas las mujeres en quienes se detectaron lesiones que pudieran ser graves, por cualquiera de las técnicas empleadas, se les remitió a una evaluación ulterior mediante colposcopia y a tratamiento médico, y se retiraron del estudio. Las lesiones > NIC 2 se utilizaron como criterio para la salida del estudio y como indicadores indirectos del riesgo de cáncer. RESULTADOS: La participación durante la fase de seguimiento fue alta (cercana al 90%). Cualquier indicio de > NIC 2, según cualquiera de las técnicas de tamizaje, fue motivo para eliminar a 4,6% de las mujeres participantes. La mayor parte de estas mujeres procedían del grupo que al inicio del estudio parecía tener un riesgo bajo de desarrollar > NIC 2, pero el mayor riesgo absoluto de progresión a > NIC 2 a partir de lesiones intraepiteliales escamosas de bajo grado se observó entre las mujeres que al incorporarse al estudio parecían estar en mayor riesgo de > NIC 2 según los resultados citológicos y virológicos y su comportamiento sexual. CONCLUSIONES: El Proyecto Epidemiológico Guanacaste es el estudio de cohorte de base poblacional de neoplasia cervicouterina más grande del mundo y se espera que sus resultados permitan elaborar en un futuro cercano estrategias preventivas en todo el mundo. Proyectos de investigación como este requieren del compromiso a largo plazo de un numeroso equipo multidisciplinario y de considerables recursos financieros. El intenso esfuerzo y la gran pericia demostrados en todas las facetas de este estudio constituyeron factores clave que explican su éxito como modelo de investigación cooperativa interdisciplinaria sobre el cáncer en América Latina. El control de la calidad desempeñó un papel importante en todas las etapas de la investigación y permitió adaptar las nuevas tecnologías de diagnóstico y tamizaje a las condiciones de Guanacaste. El seguimiento sistemático de un grupo poblacional de aproximadamente 10 000 mujeres de Guanacaste debe permitir una evaluación cuidadosa y cronológica de los factores que diversos autores han asociado con el desarrollo de cáncer cervicouterino, así como la evaluación de marcadores clínicos de la progresión de esta enfermedad. En los resultados publicados de este estudio se definen las técnicas de tamizaje más sensibles y se promueve la utilización de técnicas de tamizaje más asequibles para países en desarrollo y con pocos recursos. Este proyecto también ha aportado información útil para la búsqueda de vacunas contra los VPH, como parte de las iniciativas dirigidas a desarrollar vías eficaces para reducir la incidencia del cáncer cervicouterino y la mortalidad que ocasiona en todo el mundo. <![CDATA[<B>Diabetes in the English-speaking Caribbean</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200003&lng=en&nrm=iso&tlng=en Rates of diabetes mellitus in the English-speaking Caribbean have been rising in recent years, and they are projected to continue climbing in the new millennium. Prevalence rates across countries of the African diaspora mirror levels of Western acculturation, and available data emphasize the importance of obesity as a modifiable risk factor. The population-based Barbados Eye Studies have provided new information about the burden of ocular complications of diabetes such as retinopathy and lens opacities. Diabetes was shown to increase the risk of lens opacities, and 14% of prevalent cataract was attributed to diabetes. Persons with type 1 diabetes were particularly at increased risk of retinopathy, as a result of longer durations of illness and poor glycemic control. Other Caribbean studies have suggested that glycemic control in patients evaluated in various clinical settings is suboptimal, which raises important concerns about quality of care. Diabetics are at increased risk of mortality compared with nondiabetics, and that mortality risk increases with higher baseline levels of glycosylated hemoglobin, even among nondiabetics. These data highlight the need for urgent attention to public health and clinical strategies to prevent diabetes in unaffected persons as well as to prevent or reduce the burden of complications among those who are affected. Among the measures that should be adopted to stem the flood of diabetes in the Caribbean region are lifestyle interventions to promote better nutrition and to increase exercise; patient education, particularly about the central role of diabetes self-management; and the multidisciplinary team approach in the provision of care.<hr/>Las tasas de diabetes mellitus en los países del Caribe de habla inglesa se han venido incrementando en los últimos años y se espera que continúen aumentando en el nuevo milenio. Las tasas de prevalencia en los países receptores de la diáspora africana reflejan los niveles de aculturación occidental y los datos disponibles subrayan la importancia de la obesidad como factor de riesgo modificable. Los Estudios de Oftalmología de Barbados (Barbados Eye Studies), de base poblacional, han brindado nueva información acerca de la carga que constituyen las complicaciones oculares de la diabetes, tales como la retinopatía y la catarata. Mediante ellos se demostró que la diabetes aumentaba el riesgo de sufrir cataratas y que 14% de los casos diagnosticados eran atribuibles a la diabetes. Las personas con diabetes tipo 1 tenían, específicamente, un mayor riesgo de padecer retinopatía como resultado de una enfermedad más prolongada y un control deficiente de la glucemia. Según otros estudios realizados en el Caribe, el control de la glucemia en pacientes evaluados en diversas instancias clínicas no es el óptimo y pone en duda la calidad de la atención. Los diabéticos tienen un mayor riesgo de morir que las personas que no tienen esta enfermedad, y ese mayor riesgo se incrementa a medida que aumenta la concentración basal de glucohemoglobina, incluso entre personas sin diabetes. Estos datos resaltan la urgente necesidad de idear estrategias clínicas y de salud pública dirigidas tanto a prevenir la diabetes, como a prevenir o reducir la carga de complicaciones clínicas que sufren las personas ya afectadas por esta enfermedad. Entre las medidas que deben adoptarse para reducir la frecuencia de la diabetes en la Región del Caribe están las intervenciones basadas en estilos de vida que favorecen una mejor alimentación y la práctica de ejercicio físico; la educación de los pacientes, en particular sobre el papel central que debe desempeñar su propio control de la glucemia; y el enfoque multidisciplinario en la provisión de la atención. <![CDATA[<B>Assessing the impact of health sector reform in Costa Rica through a quasi-experimental study</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200004&lng=en&nrm=iso&tlng=en OBJETIVO: Valorar el impacto de la reforma del sector de la salud iniciada en Costa Rica en 1995 sobre la mortalidad de niños y adultos y la equidad en el acceso a los servicios de salud. MÉTODOS: La reforma del sector de la salud se inició en Costa Rica en 1995 en algunos distritos, pero en otros su adopción fue posterior. Esto permitió efectuar un análisis de series temporales, usando un diseño cuasiexperimental con observaciones anuales de 1985 a 2001 en cada uno de los 420 distritos que tenía Costa Rica en 1984. Las series temporales se dividieron en tres períodos que permitieron agrupar a los distritos en tres categorías (grupo pionero, intermedio y tardío) según el momento en que iniciaron el proceso de reforma: 1995-1996; 1997-2000; 2001 o después, respectivamente. Las series incluyeron datos de defunción desagregadas por sexo, grupos de edad y tres grandes grupos de causas de muerte (enfermedades transmisibles, de origen social, o crónicas); estimaciones de población por edad y sexo; dos variables que miden la intervención (si el distrito ha adoptado o no la reforma y, en caso de que sí, el número de años desde que adoptó la reforma); y ocho variables para controlar efectos de confusión. Los datos se obtuvieron de los registros de defunciones y nacimientos, censos de población y estimaciones demográficas. Se usaron modelos de regresión múltiple de Poisson con efectos fijos para estimar el impacto de la reforma en la mortalidad. También se valoró el acceso de la población a los servicios de salud en el primer nivel de atención antes y después de la reforma. El indicador de acceso utilizado fue el porcentaje de personas que vivían a menos de 4 km de distancia de un servicio que ofreciera consultas médicas. RESULTADOS: Según lo estimado por los modelos de regresión, la adopción de la reforma redujo significativamente la mortalidad de los niños en 8% y la de los adultos en 2%. El efecto fue de 14% en la mortalidad de adultos debida a enfermedades transmisibles o desencadenadas por procesos infecciosos, nulo en la debida a causas sociales y similar al total (2%) en la mortalidad debida a enfermedades crónicas. Se estima que la reforma salvó aproximadamente 120 vidas de niños y 350 vidas de adultos en el año 2001 únicamente. La reforma se puso en marcha primero en las zonas menos densamente pobladas y de menor desarrollo socioeconómico. Como resultado, la brecha en la equidad del acceso a los servicios de salud en el primer nivel de atención se redujo significativamente. El porcentaje de personas sin acceso equitativo a los servicios de salud del primer nivel de atención se redujo en 15% entre 1994 y 2000 en las áreas que adoptaron la reforma en 1995-1996, mientras que en las áreas que no habían adoptado la reforma en 2000, la reducción fue solo de 3%. CONCLUSIÓN: La reforma redujo significativamente la mortalidad en Costa Rica y puso fin a una década de estancamiento en algunos indicadores, como la esperanza de vida. El efecto de la reforma se produjo probablemente gracias a su focalización en las regiones menos desarrolladas del país, lo cual dio lugar a un mejoramiento en la equidad de acceso al primer nivel de atención médica.<hr/>OBJECTIVE: To assess the impact of health sector reform in Costa Rica on that country's child and adult mortality rates and on the people's access to primary health care. METHODS: Health sector reform was initiated in Costa Rica in 1995 in some districts, but in others reforms were adopted later. This made it possible to perform a time series analysis, using a quasi-experimental study design, in which observations were made annually from 1985 through 2001 for each of the 420 districts that existed in Costa Rica in 1984. The time series were divided into three periods that allowed all districts to be grouped into three categories (pioneer, intermediate, and late) according to the year when they first implemented health sector reform: 1995-1996; 1997- 2000; and 2001 or after, respectively. For each of these periods, mortality rates were broken down by cause (communicable, socially-determined, or chronic disease), sex, and age group. The status of the reform process in a particular district was described by two indicators: (1) the presence or absence of health sector reform during a given period and, wherever such reforms had been adopted, (2) the number of years that had transpired since their adoption. Eight variables were used to control for confounders. Vital statistics and demographic data were obtained from the National Institute for Statistics and Census' [Centro Nacional de Estadística y Censos] electronic database. Poisson multiple regression analysis with fixed effects was used to estimate the impact of reform on child and adult mortality from different causes. Assessment of the population's access to primary care before and after the reform was based on the percentage of people who lived within a 4 km radius of a health facility that offered patient visiting hours two or more days a week. This information came from a previous study that used census data from 2000 and geographic information systems to map health care facilities throughout the country. RESULTS: Multiple regression showed that the reform was associated with an overall 8% reduction in deaths among children and with a 2% reduction in deaths among adults, both statistically significant. Also noted were a 14% reduction in deaths from communicable diseases or from conditions brought on by the presence of infectious processes, a 0% reduction in deaths from socially-determined causes, and a 2% reduction in deaths from chronic diseases. An estimated 120 child lives and 350 adult lives were saved by the reform in 2001 alone. Also, the percentage of people without equitable access to primary health services dropped by 15% between 1994 and 2000 in areas where health sector reform was implemented in 1995-1996, whereas areas that had not yet initiated health sector reform in 2000 experienced only a 3% reduction. CONCLUSION: Health sector reform significantly reduced mortality in Costa Rica and put an end to a decade of stagnation, as shown by certain health indicators, such as life expectancy. Equity in access to primary care improved considerably, perhaps because the first reforms were implemented in less developed areas of the country. <![CDATA[<B>Analysis of social and environmental risk for pleural involvement in severe pneumonia in children younger than 5 years of age</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200005&lng=en&nrm=iso&tlng=en OBJETIVO: Determinar fatores de risco sócio-ambientais associados ao desenvolvimento de comprometimento pleural em crianças de 3 a 59 meses internadas com pneumonia grave em um hospital do Nordeste brasileiro. MÉTODOS: Estudo observacional, transversal, descritivo, com componente analítico. Foram avaliados 154 pacientes hospitalizados com pneumonia grave, com ou sem comprometimento pleural. O comprometimento pleural foi definido segundo achados radiológicos. As seguintes variáveis sócio-ambientais foram analisadas: faixa etária, sexo, local de residência, condições do domicílio, freqüência à creche, fumo passivo, renda familiar, presença de bens de consumo, escolaridade e trabalho extra-domiciliar da mãe ou responsável pela criança. As informações foram obtidas através de entrevistas com o responsável pelo paciente ou consulta ao prontuário médico durante a hospitalização. RESULTADOS: A freqüência de comprometimento pleural foi de 25,3%. Os seguintes fatores foram associados à ocorrência de comprometimento pleural: residência em zona rural, dois cômodos ou menos no domicílio, renda familiar mensal inferior a 170 dólares e peso de nascimento <2 500 g. CONCLUSÕES: Os achados sugerem a necessidade de priorizar a melhoria das condições socioeconômicas e de moradia da população mais carente, principalmente aquela oriunda do meio rural. O setor saúde deve enfatizar a atenção primária, com enfoque preventivo desde o período pré-natal.<hr/>OBJECTIVE: To determine social and environmental risk factors associated with pleural involvement among children from 3 to 59 months old who were hospitalized with severe pneumonia in northeastern Brazil. METHODS: This was an observational and descriptive cross-sectional study with an analytical component. We evaluated 154 patients hospitalized due to severe pneumonia, with or without pleural involvement. Pleural involvement was determined based on radiological findings. The following variables were analyzed: age, sex, place of residence, housing conditions, day care attendance, passive smoking, family income, presence of consumer goods in the home (e.g., television, radio, refrigerator, automobile), and schooling and occupation of the mother or other caregiver. The information was obtained by interviewing the mother or other caregiver or by consulting the inpatient medical chart. RESULTS: The frequency of pleural involvement among the 154 patients evaluated was 25.3%. The following factors were associated with pleural involvement: living in a rural area, being in a household with two or fewer rooms, family income below 170 U.S. dollars per month, and birthweight < 2 500 g. CONCLUSIONS: These findings indicate the need to improve the socioeconomic and living conditions of the less-privileged population, especially in rural areas. The health sector should emphasize primary care, focusing on a preventive approach beginning in the prenatal period. <![CDATA[<B>Smoky indoor cooking fires are associated with elevated hemoglobin concentration in iron-deficient women</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200006&lng=en&nrm=iso&tlng=en OBJECTIVE: Indoor air pollution from the burning of such biomass fuels as wood and agricultural waste is associated with a higher risk of a number of respiratory problems. The effect on other health outcomes, such as fetal growth, has not yet been adequately documented. The objective of this study was to determine whether, among women who burn biomass fuels for cooking indoors, the use of "smoky" fires is associated with elevated hemoglobin concentration in comparison to women using "smokeless" stoves, that is, stoves that are designed to reduce indoor air pollution. This research was conducted as part of a series of preliminary studies to determine the feasibility and potential health benefits of a randomized stove intervention to reduce indoor air pollution from the burning of biomass fuels for cooking. METHODS: A cross-sectional observational study was conducted in rural highland communities of Guatemala from March to August 1994. Venous blood samples were collected and analyzed for hemoglobin and ferritin. All the women studied burned biomass fuels and cooked indoors, and none of the women was pregnant. Eighty-nine indigenous women using smokeless stoves (designated as the not-exposed group) and 185 indigenous women from the same communities using smoky fires (the exposed group) were studied. Multiple linear regression analyses were used to investigate the relationship between exposure (smokeless stove or smoky fire) and hemoglobin concentration, with adjusting for potential confounding factors. RESULTS: No effect of exposure (smokeless stove or smoky fire) on hemoglobin concentration was found in univariate or multivariate analyses. In routine post hoc analysis to determine whether hemoglobin elevation is observed in some particular subgroup, we found that the use of a smoky fire was associated with a 5.2 g/L elevation in hemoglobin concentration among women with low ferritin stores (P <0.10). CONCLUSIONS: The elevation of hemoglobin concentration through exposure to indoor air pollution resulting from the burning of biomass fuels in smoky fires for cooking could have important implications for the diagnosis of anemia. However, considering the observational nature of this study, further research using more rigorous measures of exposure to carbon monoxide as well as additional measures of iron status are needed to confirm the relationships among iron status, exposure to smoke from the burning of biomass fuels indoors, and hemoglobin concentration of women living at moderately high altitude. Further study of this matter could help to assure that appropriate adjustments to anemia cutoffs are made, if warranted, and could assist in clarifying potentially negative outcomes of exposure to smoke from biomass fuels burned indoors.<hr/>OBJETIVO: La contaminación del ambiente doméstico por la combustión de materiales bioorgánicos utilizados como combustible, tales como la madera y los desechos agrícolas, está asociada con un mayor riesgo de padecer problemas respiratorios. Su efecto sobre otros aspectos de la salud, como el crecimiento fetal, no ha sido aún documentado adecuadamente. El objetivo del presente estudio, realizado en mujeres que utilizan combustible bioorgánico para cocinar en el interior de sus viviendas, fue determinar si el empleo de fuego "con humo" se asocia con una mayor concentración de hemoglobina en comparación con el uso de fogones "sin humo," es decir, cocinas diseñadas para reducir el nivel de contaminación del aire en el interior de las viviendas. Esta investigación es parte de una serie de estudios preliminares realizados para determinar la factibilidad y los posibles beneficios para la salud de una intervención aleatorizada dirigida a las cocinas, con el fin de reducir la contaminación del aire doméstico provocada por el empleo de combustibles bioorgánicos para cocinar. MÉTODOS: Entre marzo y agosto de 1994 se realizó un estudio observacional transversal en mujeres indígenas que utilizaban combustible bioorgánico y cocinaban en el interior de sus viviendas en comunidades rurales de las zonas montañosas de Guatemala. Se estudió a 89 mujeres que empleaban fogones sin humo (grupo no expuesto) y 185 mujeres de las mismas comunidades que empleaban fogones que generaban humo (grupo expuesto). Ninguna estaba embarazada. Se tomaron muestras de sangre venosa y se determinaron las concentraciones de hemoglobina y de ferritina. Mediante análisis de regresión lineal múltiple se investigó la relación entre la exposición (fogones sin humo o fogones con humo) y la concentración de hemoglobina, y se hicieron ajustes por posibles factores de confusión. RESULTADOS: No se encontró que la exposición al factor estudiado (fogones sin humo o con humo) tuviera algún efecto en la concentración de hemoglobina, ya fuera mediante análisis con una sola variable o con varias. Durante el análisis post hoc habitual para determinar si algún subgrupo particular presentaba elevación de la concentración de hemoglobina, se encontró que el empleo de fuego con humo para cocinar estaba asociado en grado significativo con la elevación de la concentración de hemoglobina en 5,2 g/L entre las mujeres con concentraciones bajas de ferritina (P < 0,10). CONCLUSIONES: La elevación de la concentración de hemoglobina debida a la exposición al aire doméstico contaminado por el empleo de combustible bioorgánico en fogones de cocina que producen humo podría tener implicaciones importantes para el diagnóstico de la anemia. Sin embargo, debido a la naturaleza observacional de este estudio, se requieren nuevas investigaciones donde se usen métodos más rigurosos para medir la exposición al monóxido de carbono y se realicen más mediciones de la cantidad de hierro en el organismo para confirmar la relación entre esta, la exposición al humo procedente de la combustión de materiales bioorgánicos para cocinar dentro de la vivienda y la concentración de hemoglobina en mujeres que viven a altitudes moderadamente altas sobre el nivel del mar. Estudios adicionales en este sentido podrían contribuir a que se ajusten los puntos de corte empleados para el diagnóstico de la anemia, si se justificara, y podrían ayudar a aclarar el posible efecto negativo de la exposición al humo producido por la combustión de materiales bioorgánicos dentro de las viviendas. <![CDATA[<B>Effects of lead exposure on the human body and health implications</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200007&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>¿Existe una asociación entre la frecuencia del síndrome de Down y la de malformaciones congénitas del tubo neural en familias?</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200008&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Los diabéticos deben controlar mejor ciertos parámetros clínicos para evitar complicaciones vasculares</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200009&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Se estudia la relación entre la obesidad en la adolescencia y la mortalidad en la adultez</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200010&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Se asocian la dureza del agua y la cantidad de fluoruro con una menor incidencia de infartos</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200011&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Las vacunas que contienen sales de aluminio son inocuas</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200012&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Una prueba sencilla determina el riesgo cardíaco en diabéticos</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200013&lng=en&nrm=iso&tlng=en OBJETIVO: Fazer um levantamento bibliográfico acerca dos riscos associados à exposição ao chumbo e seus compostos, especialmente nas populações expostas ocupacionalmente e nas crianças. FONTE DOS DADOS: Pesquisa do período de 1988 a 2002 nas bases de dados PubMed e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); página da agência de controle de substâncias tóxicas e doenças do governo dos Estados Unidos (Agency for Toxic Substances and Disease Registry) na Internet; acervo bibliográfico do Laboratório de Toxicologia do Centro de Estudos da Saúde do Trabalhador e Ecologia Humana da Escola Nacional de Saúde Pública, Brasil. CONCLUSÕES: Os estudos científicos sobre a toxicologia do chumbo são desenvolvidos há mais de um século. Contudo, ainda são insuficientes as informações sobre os mecanismos de ação que originam os efeitos tóxicos desse metal. Os resultados da exposição ao chumbo sobre os ossos, os sistemas nervoso central e cardiovascular, os rins e o fígado devem ser estudados com maior profundidade, bem como os efeitos sobre a reprodução masculina e feminina, o sistema endócrino e a formação do feto. Também é essencial esclarecer se o chumbo tem efeitos teratogênicos e carcinogênicos em seres humanos.<hr/>OBJECTIVE: To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. DATA SOURCES: Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana,Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. CONCLUSIONS: The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study. <![CDATA[<B>Risk perception and strategies for mass communication on dengue in the Americas</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200014&lng=en&nrm=iso&tlng=en Dengue is clearly a very serious public health problem. In the Americas the number of dengue cases has been increasing since the 1960s, and outbreaks of the disease have been occurring more frequently. Furthermore, the density of infestation with the disease vector, the Aedes aegypti mosquito, is high in the Americas. The general strategy for preventing and controlling dengue and dengue hemorrhagic fever is based on promoting behavior changes that lead to incorporating the community in controlling the disease, particularly the vector. In order to achieve this, mass communication programs on dengue should have two primary aims: converting information into practice and encouraging the community to take over prevention and control measures. The new generation of programs should be designed based on the local sanitation structure (water distribution and waste disposal) as well as information on community organizations and the roles of different family members. Furthermore, the new programs should incorporate all the following ten components: epidemiological surveillance, intersectoral actions, community participation, managing the environment and basic services, patient care, case reporting, education, using insecticides and vector control, training, and preparing for emergencies. Communication should be aimed at modifying the behavior of individuals and the community by empowering them to carry out prevention and control measures. <![CDATA[<b>Challenges facing Caribbean countries 10 years after the International Conference on Population and Development in Cairo, Egypt</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000200015&lng=en&nrm=iso&tlng=en At the International Conference on Population and Development (ICPD) that was held in Cairo, Egypt, in 1994, participants acknowledged that population, economic growth, and sustainable development are concepts that are closely linked, and important strides were made in terms of increased recognition of sexual and reproductive rights. The Programme of Action ratified at that Conference was adopted as a platform for designing national and international policies in the areas of population and development for a period of twenty years. However, in Latin America and the Caribbean all types of obstacles-financial, institutional, and human-still stand in the way of attaining the goals of the Programme of Action, and some governments have established measures that undermine their people's exercise of sexual and reproductive rights. The Caribbean Subregional Meeting to Assess the Implementation of the Programme of Action of the International Conference on Population and Development 10 Years after its Adoption was held in Port of Spain, Trinidad and Tobago, in November of 2003. At the meeting, which was attended by representatives from 20 Caribbean countries and territories, a call was made for more rational use of available resources and for mobilization of additional funds for developing and implementing population and development programs and policies in the Caribbean. The meeting also saw the approval of the Caribbean Declaration, which lays out the challenges that should serve as the roadmap for taking actions to consolidate the progress achieved so far and come closer to attaining the goals established by the ICPD. In the Declaration, the countries and territories of the Caribbean asserted their commitment to continue legislative reforms at the national level while seeking to enforce these reforms in an effort to ensure implementation of the ICPD's Programme of Action and of the Caribbean Plan of Action for Population and Development that was adopted in 1996 by the Economic Community for Latin America and the Caribbean.