Resumo em Espanhol:
PROBLEMA: Se ha observado un aumento constante del índice de fracaso terapéutico de la combinación sulfadoxina-pirimetamina (SDX-PIR) en el tratamiento de la malaria por Plasmodium falciparum sin complicaciones. OBJETIVO: Cuantificar, mediante cromatografía de líquidos de alta resolución (HPLC), las concentraciones sanguíneas de SDX-PIR en pacientes con buena respuesta clínica y sin respuesta al tratamiento. MÉTODOS: En 2002 se llevó a cabo un estudio experimental con asignación aleatoria y sin anonimato para evaluar el tratamiento con la combinación SDX-PIR en una población de 79 pacientes de dos municipios del departamento de Antioquia en Colombia (Turbo: 45; Zaragoza: 34), de uno y otro sexo y de 1 a 60 años de edad, con malaria por Plasmodium falciparum sin complicaciones y una densidad de parasitemia de 500 a 50 000 anillos/µL. El tratamiento consistió en una sola dosis, administrada bajo supervisión médica, de SDX (25 mg/kg) y PIR (1,25 mg/kg) combinadas en comprimidos (500 mg y 25 mg de SDX y PIR, respectivamente) y se realizó seguimiento clínico y parasitológico por 21 días. Las concentraciones de SDX y PIR se midieron dos horas después de la administración del medicamento y el día del fracaso terapéutico en los casos en que se produjo. RESULTADOS: A las 2 horas de haberse administrado el medicamento la concentración sanguínea mediana de SDX fue de 136,6 µmol/L en los pacientes que mostraron respuesta clínica adecuada y de 103,4 µmol/L en quienes no respondieron al tratamiento (P = 0,13). La mediana de PIR fue 848,4 y 786,1 nmol/L en pacientes con respuesta clínica adecuada y fracaso terapéutico, respectivamente (P = 0,40). Las concentraciones tampoco mostraron diferencia significativa entre los casos de fracaso temprano y tardío. La correlación lineal entre las concentraciones de SDX y PIR fue cercana a cero (r = 0,13). DISCUSIÓN Y CONCLUSIONES: Con respecto a 1998, el fracaso del tratamiento con la combinación SDX-PIR aumentó de 13% a 22% en Turbo y de 9% a 26% en Zaragoza. La falta de respuesta en 2002 no pudo explicarse por concentraciones (menores) de los medicamentos en sangre.Resumo em Inglês:
PROBLEM: There has been a constant increase in the level of therapeutic failure of the sulfadoxine-pyrimethamine (SP) combination for treating uncomplicated Plasmodium falciparum malaria. OBJECTIVE: To use high-performance liquid chromatography to quantify blood levels of SP in patients with good clinical response and in patients who did not respond to treatment. METHODS: This experimental study was carried out in 2002 in Turbo and Zaragoza, two municipalities in the department of Antioquia in Colombia. There were 79 patients (45 in Turbo and 34 in Zaragoza), including both men and women, who ranged in age from 1 year to 60 years. All the patients had uncomplicated Plasmodium falciparum malaria, with a parasite density of 500 to 50 000 parasites/L. The patients were each randomly assigned to a treatment group. The treatment groups were not blinded; the physician who provided the medication also evaluated the therapeutic response. The treatment consisted of a single combination dose of sulfadoxine (25 mg/kg) and pyrimethamine (1.25 mg/kg) in tablets (500 mg of sulfadoxine and 25 mg of pyrimethamine). Clinical-parasitological follow-up was carried out for 21 days. Blood levels of sulfadoxine and pyrimethamine were measured two hours after the treatment was given and also the day of treatment failure, if that occurred. RESULTS: Two hours after the treatment was given, the median blood level of sulfa-doxine was 136.6 µmol/L in the patients who later showed a good clinical response, and it was 103.4 mol/L among those who did not respond to treatment (P = 0.13). The medians for pyrimethamine were 848.4 nmol/L in patients with a good clinical response and 786.1 nmol/L in patients with treatment failure (P = 0.40). There were no significant differences in drug levels between the early-failure cases and the late-failure cases. The linear correlation between the blood levels of sulfadoxine and pyrimethamine was close to zero (r = 0.13). CONCLUSIONS: Between 1998 and 2002, treatment failure with the SP combination increased from 13% to 22% in Turbo, and from 9% to 26% in Zaragoza. The lack of response in 2002 could not be explained by lower blood levels of the medications.Resumo em Espanhol:
OBJETIVOS: El presente estudio se basa en la Encuesta de Demografía y Salud del año 2000 en Haití. Los objetivos del estudio, que se basó en información sobre las mujeres de 15 a 49 años de edad que habían dado a luz en los tres años anteriores a la entre-vista, fueron: 1) examinar los factores que determinan la probabilidad de que las mu-jeres acudan a atención prenatal en las zonas rurales y urbanas del país y 2) dentro del grupo de mujeres con una o más consultas prenatales, examinar los factores que determinan el número de dichas consultas en las zonas rurales y urbanas. MÉTODOS: En el análisis multifactorial se emplearon modelos logísticos para deter-minar qué factores explicaban la decisión de acudir a control prenatal, y se usaron modelos binomiales negativos para determinar el número de consultas prenatales dentro del subgrupo de mujeres que consultaron por lo menos una vez. RESULTADOS: La probabilidad esperada de acudir a control prenatal, determinada según el valor medio de las variables de control, fue de 77,16% en las zonas rurales, en comparación con 85,83% en las zonas urbanas de Haití. Dentro del grupo de mu-jeres que acudieron a servicios de control prenatal, las madres en zonas rurales tuvieron un número esperado de consultas prenatales de 3,78, en comparación con 5,06 en las zonas urbanas. CONCLUSIONES: Un buen porcentaje de mujeres embarazadas tiene acceso a servicios de atención prenatal en Haití, pero las madres en zonas rurales que eligieron acudir a dichos servicios tuvieron un poco menos del mínimo de cuatro consultas recomendado por la Organización Mundial de la Salud. El nivel educativo de las madres y de sus parejas es un factor pronóstico muy importante en relación con el uso de servicios de atención prenatal. Las consultas repetidas se vieron obstaculizadas en las zonas rurales por el mayor tiempo de desplazamiento y la mayor distancia hasta el centro de salud. Los formuladores de políticas y los proveedores de atención sanitaria deben tener en cuenta estos resultados a la hora de tomar decisiones sobre la prestación y administración de los servicios de salud en Haití.Resumo em Inglês:
OBJECTIVES: This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Haiti. Using the DHS information on women aged 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2) for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. METHODS: The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. RESULTS: Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16%, compared to 85.83% in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 prenatal care visits, compared to 5.06 visits for the women in urban areas. CONCLUSIONS: A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centers in rural areas constituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti.Resumo em Português:
OBJETIVO: Propor um índice de sustentabilidade da água de uso urbano com indicadores que possam fundamentar o desenvolvimento de ações planejadas. MÉTODOS: Foram selecionados 11 indicadores (incluindo aspectos relativos a água e esgoto) com base nos parâmetros do Sistema Nacional de Informação sobre Saneamento (SNIS) para os anos-base 2000 e 2001. Para cada indicador foi atribuída uma nota e arbitrado um peso. A partir disso, foi calculado o índice de sustentabilidade da água urbana (ISAU), utilizando-se a fórmula ISAU = produto (Ii pi), onde Ii é a nota para cada indicador i, variando entre 0 e 100; e p i é o peso para cada indicador i, sendo sigmai n=1 p i = 1, onde n é o número de indicadores considerados. A pior qualidade da água é indicada por um valor igual a zero, e a melhor, por um valor igual a 100. RESULTADOS: O valor do índice de sustentabilidade da água urbana do Município do Rio de Janeiro foi de 58,99 e 59,57 para os anos de 2000 e 2001, respectivamente, valores que indicam qualidade boa da água. CONCLUSÕES: A melhora observada na qualidade da água no Rio de Janeiro possivelmente se deve à implantação, na década de 1990, de um programa de recuperação ambiental na região. O planejamento ambiental para uso racional e prevenção da destruição dos recursos hídricos é fundamental para a manutenção da sociedade.Resumo em Inglês:
OBJECTIVE: To propose an urban water sustainability index based on indicators that may serve as a foundation for developing planned actions concerning water resources. METHODS: Eleven indicators (covering aspects of water and sewage) were selected based on the parameters of Brazil's National Water and Sanitation Information System (Sistema Nacional de Informação sobre Saneamento) for the years 2000 and 2001. A score and a weight were assigned to each indicator. Based on that, the urban water sustainability index (UWSI) was calculated, using the formula UWSI = product (Ii pi), where Ii is the score attributed to each indicator i, ranging from 0 to 100, and p i is the weight for each indicator sigmai n=1 p i = 1 ,where n is the number of indicators considered). The lowest water quality is indicated by an index value of 0, and the best by an index value of 100. RESULTS: The urban water sustainability index for the city of Rio de Janeiro was 58.99 in 2000, and it rose to 59.57 in 2001, indicating water of good quality in both those years. CONCLUSIONS: The improvement in the quality of the water resources between 2000 and 2001 in the city of Rio de Janeiro is possibly the result of the implementation, in the 1990s, of an environmental management program in the Rio de Janeiro region. Environmental planning that includes rational use of water resources and methods to prevent their destruction is crucial to sustaining society.Resumo em Espanhol:
OBJETIVO: Determinar la estrategia más racional de vacunación con Candid 1 para prevenir la fiebre hemorrágica argentina (FHA) en los menores de 15 años que viven en el área endémica. MÉTODOS: Para el análisis de la efectividad estimada se diseñó un modelo de árbol de decisión, con dos posibles opciones: vacunar a todos los menores del área endémica (vacunación ampliada) o vacunar solamente a los menores de 15 años con mayor riesgo (vacunación selectiva). Estas opciones se compararon con la alternativa de no vacunar. La evaluación se complementó con un análisis de sensibilidad para identificar los valores umbral de las variables críticas que podrían modificar la decisión tomada. Las probabilidades empleadas se tomaron de estudios clínicos y epidemiológicos previos. RESULTADOS: Según el modelo empleado, la estrategia de vacunación ampliada fue la mejor opción, con una utilidad total esperada de 9,99998 (siendo 10 el valor máximo posible). El análisis de sensibilidad demostró que la vacunación selectiva sería la estrategia de mayor utilidad si la incidencia en la población de bajo riesgo se reduce a menos de 3 por 1 000 000 habitantes o si la tasa de reacciones adversas graves a la vacuna asciende a más de 9 por 100 000 habitantes. Ninguna variación de los parámetros empleados en el modelo respaldó la opción de no vacunar. CONCLUSIONES: Con los parámetros de riesgo y de beneficio empleados, se recomienda vacunar con Candid 1 a todos los menores de 15 años que viven en el área endémica de FHA. El modelo propuesto puede adaptarse a las necesidades futuras y ayudar a tomar decisiones mediante la incorporación de los datos prospectivos de la vigilancia de la enfermedad. Estos resultados pueden usarse como base para estudios de costo y eficacia y para otros análisis cuantitativos.Resumo em Inglês:
OBJECTIVE: To determine the most rational strategy of vaccination with Candid 1 vaccine in order to prevent Argentine hemorrhagic fever among children under 15 years old living an endemic area. METHODS: To analyze the estimated effectiveness, a decision tree model was designed, with two possible options: vaccinate all the children under age 15 in the endemic area ("expanded vaccination") or vaccinate only the children at greater risk ("selective vaccination"). These two options were compared with the alternative of not vaccinating. The evaluation was complemented with a sensitivity analysis to identify the threshold values of the critical variables that could change the decision. The probabilities that were used were taken from earlier clinical and epidemiological trials. RESULTS: According to the model that we used, the expanded vaccination strategy was the best option, with a total expected utility of 9.99998 (out of a maximum possible 10.0). The sensitivity analysis showed that selective vaccination would be the best strategy if the incidence in the population with low risk drops to less than 3 per 1 000 000 population or if the rate of serious adverse reactions to the vaccine reaches more than 9 per 100 000 inhabitants. No variation in the parameters used in the model supported the option of not vaccinating. CONCLUSIONS: Given the risk and benefit parameters that we used, we recommend vaccinating with Candid 1 all the children under age 15 who live in the area endemic for Argentine hemorrhagic fever. The proposed model can be fitted to future needs, and it can help in decision-making by incorporating prospective disease surveillance data. These results can be used as a basis for cost and efficacy studies and for other quantitative analyses.Resumo em Espanhol:
OBJETIVO: Determinar qué factores se asocian con el parto vaginal en mujeres que han tenido una cesárea. MÉTODOS: Un estudio anidado de casos y testigos se llevó a cabo en forma de un análisis de datos secundarios procedentes de un estudio de cohorte -original, retrospectivo y de carácter poblacional- en mujeres que tuvieron su primer hijo en 1985 en la ciudad de Campinas, São Paulo, Brasil, y que fueron entrevistadas 10 años más tarde, en 1995. La población estudiada se compuso de 1 352 mujeres cuyo primer hijo había nacido por cesárea y que también habían tenido como mínimo un parto posterior. El grupo de los casos (150 mujeres, o alrededor de 11% de la muestra) estuvo integrado por mujeres que tuvieron su segundo parto por la vía vaginal, y el grupo testigo se compuso de 1 202 mujeres que tuvieron su segundo parto por cesárea. Para cada uno de los posibles factores asociados se calcularon la razón de posibilidades y el intervalo de confianza de 95%. Se aplicó la prueba de tendencias de ji al cuadrado para analizar las variables categóricas. Se usó una regresión multifactorial incondicionada para estimar las razones de posibilidades ajustadas correspondientes a cada factor asociado. RESULTADOS: Los factores que mostraron una asociación estadísticamente significativa con el parto vaginal fueron un ingreso familiar mensual menor de cinco veces el salario mínimo mensual en el Brasil; depender del sistema nacional de salud brasileño para obtener atención sanitaria; poca edad materna; y una primera cesárea efectuada por presentación de nalgas o transversal, o por embarazo gemelar. Del grupo de mujeres que también tuvieron un segundo parto por cesárea, solamente 11% habían hecho un esfuerzo por tener un parto vaginal. CONCLUSIONES: El principal factor que determina el parto vaginal en mujeres que ya habían tenido una cesárea fue la presencia de factores sociales y económicos adversos.Resumo em Inglês:
OBJECTIVE: To identify factors associated with a vaginal second delivery in women who had one previous cesarean section. METHODS: A nested case-control study was carried out as a secondary data analysis of an original retrospective, population-based cohort study of women who delivered their first child during 1985 in the city of Campinas, São Paulo, Brazil, and who were interviewed 10 years later in 1995. The study population consisted of 1 352 women who had their first delivery by cesarean section and who had also had at least one subsequent delivery. The group of cases (150 women, around 11% of the sample) consisted of women who had a vaginal second delivery, and the control group was made up of 1 202 women who had a cesarean section at second delivery. For each possible associated factor we calculated the odds ratio and 95% confidence interval. For ordered categorical variables the c² test for trend was used. Unconditional multivariate regression analysis was used to estimate the adjusted odds ratio for each associated factor. RESULTS: The factors significantly associated with vaginal delivery were monthly family income below 5-fold the Brazilian minimum monthly wage, reliance on the Brazilian national health system for healthcare, low maternal age, and first cesarean section indicated because of fetal breech or transverse presentation, or twin pregnancy. Among those women who also had a cesarean section at their second delivery, only 11% had undergone a trial of labor. CONCLUSIONS: The main determining factors for a vaginal second delivery in women with a previous cesarean section were unfavorable social and economic factors.Resumo em Espanhol:
OBJETIVO: Determinar la prevalencia de experiencias con episodios de violencia física y psicológica en el lugar de trabajo entre miembros del personal de salud de Jamaica, así como los factores que se asocian con dichas experiencias. MÉTODOS: Un total de 832 miembros del personal de salud de plantilla respondieron al cuestionario estandarizado que se usó en este estudio transversal. La muestra se obtuvo en instalaciones públicas, entre ellas hospitales especializados, terciarios y secundarios de la zona metropolitana de Kingston; hospitales generales en las parroquias rurales; y centros de atención primaria de salud en zonas urbanas y rurales. También se hizo un muestreo en hospitales y centros médicos privados. RESULTADOS: La violencia psicológica fue más frecuente que la física. Durante el año anterior a la encuesta, 38,6% de los encuestados habían sido víctimas de abuso verbal; 12,4%, de acoso, y 7,7% de maltrato físico. En análisis multifactoriales se observó un menor riesgo de sufrir violencia física entre miembros del personal de salud que tenían 55 años de edad o más, que trabajaban de noche, o que trabajaban principalmente con pacientes mentalmente discapacitados, pacientes geriátricos, o pacientes con infección por VIH o sida. En los miembros del personal que trabajaban principalmente con pacientes psiquiátricos se detectó un mayor riesgo de sufrir ataques físicos que en otros trabajadores de la salud. De las diversas ocupaciones pertenecientes al ámbito de la salud, la de enfermería fue en la que más se halló la propensión a ser víctima de abuso verbal. En cuanto a grupos de edad, el acoso se observó con más frecuencia en trabajadores de salud entre las edades de 40 y 54 años. CONCLUSIONES: La violencia en el lugar de trabajo en Jamaica es un peligro ocupacional que merece la atención del sector sanitario. Es necesario evaluar el tipo de ambiente que propicia la violencia a fin de formular intervenciones eficaces en el país.Resumo em Inglês:
OBJECTIVE: To determine the prevalence of experiences with physical violence and psychological violence that health staff have had in the workplace in Jamaica, and to identify factors associated with those experiences of violence. DESIGN AND METHODS: A total of 832 health staff answered the standardized questionnaire that was used in this cross-sectional study. Sampling was done at public facilities, including specialist, tertiary, and secondary hospitals in the Kingston Metropolitan Area; general hospitals in the rural parishes; and primary care centers in urban and rural areas. Sampling was also done in private hospitals and private medical centers. RESULTS: Psychological violence was more prevalent than was physical violence. Verbal abuse had been experienced in the preceding year by 38.6% of the questionnaire respondents, bullying was reported by 12.4%, and physical violence was reported by 7.7%. In multivariate analyses there was a lower risk of physical violence for health staff who were 55 years or older, worked during the night, or worked mostly with mentally disabled patients, geriatric patients, or HIV/AIDS patients. Staff members working mostly with psychiatric patients faced a higher risk of physical assaults than did other health staff. Of the various health occupations, nurses were the ones most likely to be verbally abused. In terms of age ranges, bullying was more commonly experienced by health staff 40-54 years old. CONCLUSIONS: Violence in the health sector workplace in Jamaica is an occupational hazard that is of public health concern. Evaluation of the environment that creates risks for violence is necessary to guide the formulation of meaningful interventions for the country.Resumo em Português:
OBJETIVO: Analisar o padrão espacial das taxas de mortalidade por homicídio em homens com idade de 15 a 49 anos no Estado de Pernambuco, Brasil, nos períodos de 1980 a 1984 e de 1995 a 1998, e identificar conglomerados de violência. MÉTODOS: Os dados sobre mortalidade foram obtidos junto ao Sistema de Informações sobre Mortalidade do Ministério da Saúde. A média das taxas de mortalidade por homicídio foi estimada por município para os dois períodos. O coeficiente de Moran, que varia de - 1 a + 1, foi calculado para explorar a dependência espacial. Um coeficiente positivo indica um conglomerado de valores semelhantes, enquanto que um coeficiente negativo indica a adjacência de valores dessemelhantes. Para localizar os conglomerados de municípios com taxas de homicídio altas e baixas, foi utilizado o indicador local de autocorrelação espacial (LISA). Por último, foi construído o mapa de Moran, que permite identificar os municípios com LISA estatisticamente significativo e, ao mesmo tempo, pode revelar se o agrupamento de municípios tem taxas de homicídio altas ou baixas. RESULTADOS: Os resultados do coeficiente de Moran para os períodos investigados apresentaram valores positivos (0,392 e 0,291, respectivamente) e altamente significativos (P < 0,001). Comparando-se os dois períodos analisados através do mapa de Moran, foi possível observar, no primeiro período, um conglomerado de altas taxas de homicídios predominante na Região da Mata Sul, próxima à Região Metropolitana. No segundo, foram identificados dois conglomerados, um predominantemente urbano, situado na Região Metropolitana, e outro no interior do Estado, no chamado Polígono da Maconha. CONCLUSÕES: O estudo sugere que não são exatamente as condições socioeconômicas as responsáveis pelos conglomerados de homicídios, mas sim a sua associação com o tráfico e o comércio ilícito de drogas.Resumo em Inglês:
OBJECTIVES: To analyze the spatial distribution of homicide mortality rates among males 15 to 49 years old in the state of Pernambuco, Brazil, for the periods of 1980 to 1984 and 1995 to 1998, and to identify violence clusters. METHODS: Mortality data were obtained from the Brazilian Ministry of Health's Mortality Information System. The mean homicide mortality rate was estimated for each municipality in the state for the two periods. The Moran coefficient was calculated to determine spatial autocorrelation. (The Moran coefficient ranges from -1 to +1, with a positive coefficient indicating a cluster of similar values, and a negative coefficient indicating adjacent dissimilar values.) To identify clusters of municipalities with either high or low homicide mortality rates, the local indicator of spatial association (LISA) was used. Finally, a Moran map was constructed to identify municipalities with statistically significant LISA values and to identify clusters of municipalities with either high or low homicide mortality rates. RESULTS: The Moran coefficient for 1980-1984 was 0.392, and for 1995-1998 it was 0.291 (P < 0.001). In the 1980-1984 period, one cluster of high homicide mortality rates was found in the Mata Sul region of the state, close to the metropolitan region of the state capital, Recife. In the 1995-1998 period, two violence clusters were identified: a predominantly urban one in the Recife metropolitan region, and the other in the state interior, in an area known as the "Marijuana Polygon" (Polígono da Maconha). CONCLUSION: This study suggests that the violence clusters are not the result of the socioeconomic conditions per se, but rather the consequence of the interaction between poor economic conditions and drug trafficking.Resumo em Inglês:
The health system reform that was carried out in Colombia in 1993 was based on neoliberal doctrine. That reform increased the inequity in the allocation of resources, access to health services, and the distribution of spending on health. Societal organizations, academic groups, health workers, and some members of the political sector in Colombia have opposed the neoliberal reform, and they have supported the right to health as an alternative for dealing with the inequities in the health sector. According to liberal theories, only civil and political rights are fundamental, and liberty is assumed to be only the freedom of process and the absence of coercive mechanisms. However, there are arguments that support the viewpoint that health is a fundamental human right. This piece analyzes some ethical and moral principles that can help establish the moral foundations for the right to health. Among these principles are equality of opportunity, that part of being free is for people to have the right to develop themselves as human beings, that the right to health is connected to the right to life, that all people deserve equal respect (which requires the equal distribution of goods and of societal responsibilities), and that liberty is the opportunity that all persons should have to carry out the plans that they have for their lives, as chosen from a variety of socially useful alternatives.Resumo em Inglês:
Communicable diseases that have appeared or reappeared in recent years have demonstrated their great potential for spreading and their capacity to overwhelm a country's resources, causing major emergencies. The recent SARS epidemic showed that only health systems that have been strengthened and that have the response capacity for events of this kind will be able to handle future contingencies. Governments have recognized the need to support initiatives to strengthen their countries' capacities in surveillance, prevention, and the control of emergencies caused by epidemics. This piece identifies essential components that will make it possible to guide the efforts of governments, with the support of the Pan American Health Organization and other international organizations, toward achieving a common goal: establishing for countries warning and epidemic-emergency response systems that are appropriate and effective.