Resumo em Espanhol:

En este documento se informa sobre la fase de inscripción de un estudio de la historia natural de la neoplasia de cuello uterino basado en la población de Guanacaste, una provincia rural de Costa Rica con tasas constantemente elevadas de cáncer cervicouterino invasor. Las principales metas del estudio son investigar el papel de la infección por virus del papiloma humano (VPH) y otros factores relacionados con la etiología de la neoplasia cervicouterina de alto grado, así como evaluar las nuevas tecnologías de detección de cáncer de cuello uterino. Se comenzó por seleccionar una muestra aleatoria de segmentos censales y enumerar todas las mujeres de 18 años o más que residían en ellos, con ayuda de varios agentes de extensión del Ministerio de Salud de Costa Rica. De las 10 738 mujeres que reunían las condiciones exigidas para participar, se entrevistó a 10 049 (93,6%) que dieron su consentimiento informado por escrito. Una vez concluida la entrevista sobre los factores de riesgo de cáncer de cuello uterino, se les realizó un examen pélvico a las que declararon haber tenido actividad sexual previa. Dicho examen incluyó una determinación del pH vaginal y recolección de células del cuello de útero para diagnóstico citológico con tres técnicas diferentes. Se recolectaron otras células cervicouterinas para determinar la presencia y cantidad de ADN de 16 tipos diferentes de VPH y se tomaron dos imágenes fotográficas del cuello uterino, que fueron interpretadas en un establecimiento externo por un colposcopista experto. Por último, se tomaron muestras de sangre para inmunovaloración y análisis de micronutrientes. Las mujeres con diagnóstico citológico anormal o cervigrama positivo, junto con una muestra de todo el grupo, se enviaron a otros servicios para colposcopia, y se tomaron biopsias en los casos en que se observaron lesiones. El tamizaje realizado para efectos de la inscripción servirá de base para un estudio de casos prevalentes y controles (testigos) y se realizará un activo seguimiento de los miembros de la cohorte sin enfermedad grave, a intervalos no mayores de un año, para estudiar la historia natural de la infección por VPH y los orígenes de las lesiones intraepiteliales escamosas de alto grado. Aquí se dan detalles de la operación realizada sobre el terreno, con referencia en particular a la realización de esta clase de estudio en un país en desarrollo. También se presentan datos descriptivos de la prevalencia de la enfermedad y la exposición a varios factores de riesgo.

Resumo em Inglês:

This paper reports on the enrollment phase of a population-based natural history study of cervical neoplasia in Guanacaste, a rural province of Costa Rica with consistently high rates of invasive cervical cancer. The main goals of the study are to investigate the role of human papillomavirus (HPV) infection and its co-factors in the etiology of high-grade cervical neoplasia, and to evaluate new cervical cancer screening technologies. To begin, a random sample of censal segments was selected and enumeration of all resident women 18 years of age and over was conducted with the aid of outreach workers of the Costa Rican Ministry of Health. Of the 10 738 women who were eligible to participate, 10 049 (93.6%) were interviewed after giving written informed consent. After the interview on cervical cancer risk factors was administered, a pelvic examination was performed on those women who reported previous sexual activity. The pelvic examination included a vaginal pH determination and collection of cervical cells for cytologic diagnosis using three different techniques. Additional cervical cells were collected for determination of the presence and amount of DNA from 16 different types of HPV, and two photographic images of the cervix were taken and interpreted offsite by an expert colposcopist. Finally, blood samples were collected for immunologic and micronutrient assays. Women with any abnormal cytologic diagnosis or a positive Cervigram, as well as a sample of the whole group, were referred for colposcopy, and biopsies were taken when lesions were observed. The enrollment screening will serve as the basis for a prevalent case-control study, and the members of the cohort free from serious disease will be followed actively, at intervals of no more than a year, to study the natural history of HPV infection and the origins of high-grade squamous intraepithelial lesions (HSIL). Details of the field operation are outlined, with particular reference to the realization of this kind of study in developing countries. Descriptive data on the prevalence of disease and exposure to various risk factors are also presented.

Resumo em Espanhol:

Con el objetivo de formular una hipótesis sobre los factores que influyen en los ingresos hospitalarios por esquizofrenia en Costa Rica, se realizó un estudio en personas de ambos sexos internadas por primera vez con ese diagnóstico (grupos 295.0 a 295.9 de la Clasificación internacional de enfermedades, novena revisión) en el período de 1979 a 1981. Se calcularon las tasas de incidencia anuales a partir de los casos hospitalizados y de la población de todo el país. La incidencia anual detectada tuvo un promedio de 48,2 casos por 100 000 habitantes. Se observó una mayor frecuencia de primeros ingresos en hombres de 40 a 44 años y en mujeres de 45 a 49. Tuvieron la mayor incidencia las mujeres solteras, seguidas de las divorciadas. La escolaridad mostró una relación inversa significativa con la tasa de ingresos por esquizofrenia, ya que se observó una mayor incidencia en mujeres sin ocupación y amas de casa. Mediante análisis de regresión logística se estudió la asociación entre la tasa de hospitalización por esquizofrenia y 10 características de los cantones. El análisis reveló que solo dos variables--la distancia entre el cantón y el hospital y el volumen de la cosecha de café por habitante-- mostraban una asociación directa significativa con las tasas de ingreso por esquizofrenia. Los cantones donde se registró el mayor número de nacimientos de niños con diagnóstico de esquizofrenia en la adultez fueron los más cercanos al hospital psiquiátrico y los que tenían poca actividad industrial o agrícola, poca densidad poblacional y altos porcentajes de personas solteras y divorciadas.

Resumo em Inglês:

The factors that influence hospital admissions for schizophrenia in Costa Rica were investigated in people of both sexes who were admitted for the first time with this diagnosis (codes 295.0 to 295.9 of the International Classification of Diseases, Ninth Revision) in the period 1979 to 1981. Annual incidence rates were calculated using the number of hospitalized cases and the total population of the country. The average annual incidence was found to be 48.2 cases per 100 000 inhabitants. High frequencies of first admissions were seen among males 40 to 44 years of age and females 45 to 49. Incidence was highest among unmarried women, followed by divorced women. There was a significant inverse relationship between educational attainment and rates of admission for schizophrenia, and incidence rates were highest among unemployed women and housewives. The association between rate of hospitalization for schizophrenia and 10 characteristics of the cantons was studied by means of logistic regression. Only two variables--the distance between the canton's principal town and the hospital and the volume of coffee harvest per resident--showed a direct significant association with admission rates for schizophrenia. The cantons which had the highest number of births of children who were diagnosed as schizophrenic in adulthood were those closest to the psychiatric hospital and those that had a low level of industrial or agricultural activity, low population density, and high proportions of single or divorced persons.

Resumo em Espanhol:

Este estudio se realizó con el fin de mostrar que el dengue hemorrágico (DH) se da en Puerto Rico, si bien es una enfermedad subnotificada, lo que se debe en parte a su subdiagnóstico en los hospitales. La vigilancia de casos graves de dengue permitió determinar que hubo 986 hospitalizaciones por sospecha de dengue en el período de 1990-1991. En esa época, el sistema de vigilancia identificó 20 casos de DH, incluidos tres de síndrome de choque por dengue (SCD). Nuestra subsecuente revisión de los expedientes de los 986 pacientes reveló que en 102 de ellos había razones para apoyar el diagnóstico clínico de DH (88) y de SCD (14). Entre estos 102 había 57 que dieron resultados virológicos o serológicos positivos a dengue y que reunían los criterios de caso de dengue establecidos por la OMS (fiebre, manifestaciones hemorrágicas, trombocitopenia y excesiva permeabilidad capilar). En el grupo de 57 pacientes, la media de edad era de 38 años y preponderaban los hombres (34, o sea 59,3%), incluidos ocho casos de SCD y dos (3,5%) defunciones (en mujeres de 16 y 55 años de edad). Los síntomas hemorrágicos fueron leves y con frecuencia se observaron hemoconcentración, hipoalbuminemia y concentraciones elevadas de aspartato y alanina aminotransferasas. Las hospitalizaciones duraron unos 5 días en término medio. La descripción clínica de estos casos de DH en Puerto Rico coincide con descripciones anteriores de la enfermedad en la literatura médica, pero la distribución por edad de los pacientes es similar al patrón que se suele encontrar en las Américas (donde afecta a todos los grupos de edad), en contraste con el de Asia Sudoriental (donde afecta principalmente a niños pequeños). El número de casos identificados en nuestro estudio fue casi tres veces mayor que el número notificado por el sistema de vigilancia establecido. Nuestros resultados indican que es necesario mejorar la capacidad de los clínicos locales para reconocer y notificar los casos de DH.

Resumo em Inglês:

The aim of the study reported here was to demonstrate that dengue hemorrhagic fever (DHF) occurs in Puerto Rico, that it is underreported, and that this underreporting is due partly to underdiagnosis in hospitals. Surveillance for severe dengue identified 986 hospitalizations for suspected dengue in 1990-1991. At the time, the surveillance system routinely identified 20 DHF cases, including three with dengue shock syndrome (DSS). Our subsequent review of these 986 patients' hospital records identified 102 whose records supported a clinical diagnosis of DHF (88) or DSS (14). Of these 102, 57 had positive virologic or serologic results for dengue and met the World Health Organization criteria for DHF (fever, hemorrhagic manifestations, thrombocytopenia, and excessive capillary permeability). This group of 57 patients had a mean age of 38 years, contained a preponderance of males (34, 59.3%), included eight cases of DSS, and involved two (3.5%) fatalities (in females 16 and 55 years old). Hemorrhagic manifestations were mild; hemoconcentration, hypoalbuminemia, and elevated aspartate and alanine aminotransferase levels were frequently encountered. The median duration of hospitalization was five days. The clinical description of these laboratory-positive DHF cases in Puerto Rico is consistent with previous descriptions of DHF in the medical literature; but the patients' age distribution is similar to the pattern typically found in the Americas (where all age groups tend to be affected), as opposed to Southeast Asia (where mostly small children are affected). The number of DHF cases identified by our study was nearly three times that reported through the established surveillance system. Our findings indicate that recognition and reporting of DHF by local clinicians needs to be improved.

Resumo em Português:

Com o objetivo de avaliar a cobertura vacinal em crianças de 0 a 5 anos, um estudo transversal com base em inquérito domiciliar foi realizado em 1992 no Distrito Sanitário de Pau da Lima, Salvador, Bahia, Brasil, através do recurso à técnica de amostragem por conglomerados. Foram sorteadas 30 microáreas homogêneas no que diz respeito às características socioeconômicas. Informações sobre o estado vacinal de 385 crianças foram obtidas a partir da verificação do cartão de vacinação e da senha de campanha, ou, na ausência destes, a partir da informação verbal da mãe ou responsável. A cobertura vacinal encontrada foi de 70% para a vacina antipólio; de 56% para a vacina tríplice; de 74% para a vacina anti-sarampo; e de 87% para a BCG, considerando-se as diversas fontes de informação em todas as faixas etárias. Estes resultados indicam uma possível superestimação das taxas obtidas a partir de registros rotineiros dos serviços de saúde e das campanhas. Os autores discutem as implicações das baixas coberturas encontradas em todas as faixas etárias e, mais acentuadamente, entre menores de 1 ano.

Resumo em Inglês:

To evaluate vaccination coverage in children 0 to 5 years of age, a cross-sectional study based on a household survey was carried out in 1992 in the Pau de Lima Health District, Salvador, Bahia, Brazil, using a cluster sampling technique. The district was subdivided into 30 small areas that were homogeneous with respect to socioeconomic characteristics. Information on the vaccination status of 385 children was obtained through verification of a vaccination card or campaign voucher, or, in the absence of these items, through verbal confirmation from the mother or other responsible person. Based on all the sources of information, the study found vaccination coverage rates in the entire age range of 69% for polio vaccine; 56% for DTP; 74% for measles vaccine; and 87% for BCG. These results suggest that rates obtained from routine records of the health services and vaccination campaigns may be overestimates. The authors discuss the implications of the low coverage rates found in the entire age group and especially among children under 1 year old.

Resumo em Espanhol:

En abril de 1993 se llevó a cabo un estudio de 108 trabajadoras sexuales que ejercían la prostitución en Georgetown, Guyana. En el estudio se investigaron, mediante entrevistas y exámenes de sangre, las relaciones entre seroprevalencia de VIH y conocimientos sobre el sida, comportamientos riesgosos, características de los clientes y uso de condones. Las trabajadoras sexuales callejeras --en contraste con las que trabajaban en bares, hoteles y en Port Georgetown-- por lo general cobraban menos, estaban en peor situación económica y tenían clientes en circunstancias similares. Por lo tanto, se clasificaron como pertenecientes a un estrato socioeconómico más "bajo", mientras que las otras trabajadoras se clasificaron como de estrato más "alto". En todo el grupo de trabajadoras sexuales se encontró una seroprevalencia general de 25% (95%IC: 17%-33%). Las 50 mujeres clasificadas como de estrato bajo tenían una seroprevalencia relativamente alta (42%, comparada con 10% en el estrato alto), y a ese subgrupo pertenecían 21 de las 27 seropositivas a VIH. Según la información dada por las participantes, también se relacionaban con esos estratos el origen de los clientes (guyaneses o extranjeros), el consentimiento a tener relaciones sin condón y el uso de condón por los clientes. Las participantes de estrato alto consentían más a menudo a tener sexo sin condón. Las mujeres de ambos estratos tenían pocos conocimientos acerca de la causa del sida y la transmisión de VIH y un número importante de las trabajadoras declaró haber contraído alguna enfermedad de transmisión sexual o consumido drogas ilegales en los 2 años anteriores. Los clientes guyaneses usan condones menos que los extranjeros, lo que sugiere un riesgo más alto de adquirir VIH de esos clientes y también de infectarlos con el virus. La seroprevalencia de VIH fue más alta entre las trabajadoras que dijeron haber tenido clientes guyaneses que entre las que recibían solamente a clientes extranjeros. Fue además estadísticamente mayor entre las que tenían más de cinco clientes a la semana. La seropositividad a VIH fue relativamente alta entre las 12 trabajadoras que declararon haber usado cocaína. En general, los resultados de este trabajo sustentan el principio de que deben fortalecerse las intervenciones dirigidas a las trabajadoras sexuales y sus clientes. En particular, debe hacerse un esfuerzo para intensificar la promoción, distribución y mercadeo social de los condones; mejorar los servicios de enfermedades de transmisión sexual que ofrecen tratamiento y orientación personal a las trabajadoras sexuales y aumentar las actividades educativas dirigidas a los clientes guyaneses.

Resumo em Inglês:

A study of 108 female sex workers engaged in prostitution in Georgetown, Guyana, was made in April 1993. Based on interviews and procurement of blood samples, the study investigated relationships between HIV seroprevalences and AIDS knowledge, risk behaviors, client characteristics, and condom use. Street-walkers--as distinct from sex workers in bars, hotels, and Port Georgetown--tended to charge less, be worse off socioeconomically, and have clients who were similarly disadvantaged; they were therefore classified as belonging to a "lower" socioeconomic stratum, while the other workers were classified as belonging to a "higher" stratum. The overall HIV seroprevalence found among the sex workers was 25% (95%CI: 17%-33%). But the 50 subjects in the lower stratum had a relatively high seroprevalence (42%, as compared to 10% among those in the higher stratum), accounting for 21 of the 27 HIV-seropositive subjects. Reported patterns of client origins (Guyanese or foreign), worker willingness to have sex without a condom, and condom use by clients differed by stratum. Participants in the higher stratum were more disposed to having sex without a condom. The workers' knowledge of what causes AIDS and how HIV is transmitted was low in both strata; substantial numbers of workers said they had contracted a sexually transmitted disease within the past two years or were users of illicit drugs. Condom use is reportedly less common among Guyanese than foreign clients, suggesting a greater risk of contracting HIV from Guyanese clients or infecting Guyanese clients with it. The HIV seroprevalence among workers who said they had only Guyanese clients was statistically greater than the rate among those who said they had only foreign clients. The HIV seroprevalence among those reporting more than five clients per week was statistically greater than among those reporting fewer. HIV seropositivity was relatively high among the 12 workers who said they used cocaine. Overall, the findings supported the view that interventions targeted at female sex workers and their clients should be strengthened--more specifically, that concerted efforts should be made to intensify condom promotion, distribution, and social marketing; to improve STD services that provide treatment and counseling for female sex workers; and to increase educational activities among the workers' Guyanese clients.

Resumo em Espanhol:

El presente artículo discute el futuro del intercambio comercial de servicios personales de salud en América del Norte en el contexto del Tratado de Libre Comercio (TLC) y la posible influencia de este último sobre la atención de salud de la población mexicana. En la primera parte se definen conceptos relacionados con el intercambio internacional de servicios en general y de servicios de salud en particular y se analizan los componentes del TLC que afectan a la prestación, regulación y financiamiento de estos servicios, así como a su futuro intercambio en la zona del TLC. Al final del artículo se hacen recomendaciones dirigidas a ayudar al sistema nacional de salud de México a enfrentar los riesgos y aprovechar las oportunidades que brinda la incorporación de la economía mexicana a un mercado más amplio.

Resumo em Inglês:

This article discusses the future of commercial trade in personal health services in North America within the context of the North American Free Trade Agreement (NAFTA) and the latter's potential influence on health care for the Mexican people. It begins by defining concepts related to international trade of services, particularly health services, and then proceeds to analyze elements of NAFTA that affect the delivery, regulation, and financing of such services, as well as their future trade within the NAFTA area. It concludes with some recommendations directed at helping Mexico's national health care system confront the risks posed while taking advantage of the opportunities offered by the Mexican economy's entry into a broader market.

Resumo em Inglês:

Research trends in the Region of the Americas and the technical cooperation of PAHO in this field were examined at the XXXI Meeting of the Advisory Committee on Health Research (ACHR). Changes in demographic profiles and in morbidity and mortality patterns have led to new ways of organizing health care and scientific research. There is also a new scientific paradigm that represents a departure from the conventional positivism and makes allowances for the complexity of natural social and historical processes. The State no longer plays the leading role in the development of science and technology, and the resources from international banks more often are being directed at consolidating the link between producers and users of knowledge and technology, and less at support of universities and resource training. The Inter-American Development Bank and the World Bank have approved projects with a total cost of nearly US$ 2 000 million, almost all of which is to be used to finance the reorganization of health systems. Regarding the allocation of national funds, the science and technology sector receives between 0.24% and 0.75% of the gross domestic product in Argentina, Brazil, Chile, Mexico, and Venezuela, in contrast to 2.7% in developed countries. The ACHR outlined objectives and plans to strengthen the research capability of the Region's countries in the next four years.

Resumo em Inglês:

The World Health Organization (WHO) has chosen the theme "Emerging Infectious Diseases--Global Alert, Global Response" for this year's World Health Day to call attention to the threat posed by infectious diseases that have been recently recognized in humans or that are making a comeback. Factors in the emergence and re-emergence of infectious diseases include deterioration of public health infrastructure, increasing microbial resistance to antibiotics, and social and ecological changes associated with human population growth. WHO emphasizes the need for committed partnerships among countries, international organizations, nongovernmental organizations, and individuals to improve disease surveillance and control capabilities in order to prevent and contain epidemics. For its part, WHO is strengthening the existing three-pronged global monitoring system, consisting of the WHO Collaborating Centers in the area of infectious diseases, the antimicrobial resistance monitoring networks, and the International Health Regulations. To adequately confront the problem of infectious diseases in the next century, there is a need for strong national disease surveillance and control programs; global disease monitoring and alert networks; rapid information exchange through electronic links, including the World Wide Web; and effective preparedness and rapid response capability to contain epidemics.

Resumo em Espanhol:

La Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (UNICEF) han desarrollado un método nuevo para estimar los niveles de mortalidad materna. Las estimaciones para 1990 efectuadas previamente, que están basadas en un modelo muy simplificado, existían únicamente para las distintas regiones y el mundo en su totalidad, pero no para países individuales. El modelo nuevo permite hacer estimaciones nacionales y regionales, tanto para países sin datos disponibles como para los que tienen datos de alcance nacional en una variedad de fuentes. En términos generales, las nuevas estimaciones (que representan un cálculo nuevo de las estimaciones ya efectuadas para 1990, y no cifras correspondientes a un año posterior) indican que en el pasado ha habido una subestimación notable de la mortalidad materna, especialmente en ciertas partes del África. Las nuevas cifras servirán de referencia para medir el progreso hacia la meta de reducir la mortalidad materna, para el año 2000, a la mitad de la que había en 1990. Esta meta ha sido respaldada por numerosas conferencias internacionales en la última década.