Bulletin of the Pan American Health Organization最新文献

The study reported here analyzes the influence of formal education on the behavior and age at onset of carcinoma of the cervix in 2204 women in Quito, Ecuador, between 1985 and 1994. The results indicate that education had a considerable degree of influence on the behavior of this neoplasia. That is, women with primary education or less were found to have almost twice the cervical cancer incidence of those with secondary or higher education, while those who were illiterate had almost six times the incidence found among university-educated women. Overall, it seems reasonable to consider women's education a key factor in defining risk groups for cervical cancer-so much so that grouping by instructional level would make it possible to improve the effectiveness of cervical cytology-based preventive measures.

Interview data collected in March-September 1987 as part of an international multi-center study were used to assess Pap test coverage in the municipality of São Paulo and determine characteristics that made study subjects more likely or less likely to have been tested. The data analyzed came from interviews with 967 women. Information gathered during the interviews included demographic and socioeconomic data as well as information about use of health service facilities, use of oral contraceptives, breast self-examination, smoking, alcoholism, and prior Pap testing. The results showed that 666 (69%) of the women said they had received a Pap test in the past; 588 (61%) said they had one within three years of the interview; and 399 (41%) said they had one during the past year. Statistically significant relationships were found between Pap testing sometime in the past (and also Pap testing within the preceding three years) and age, education, marital status, use of oral contraceptives, breast self-examination, and consulting with a physician during the year preceding the interview. Adjustment for all the other statistically significant variables through multivariate analysis influenced but did not undo the statistical significance of each of these relationships. Overall, the results of this study point to levels of Pap test coverage exceeding those found by other São Paulo studies. One reason could have been this study's inclusion of Pap tests obtained at medical clinics that were not specifically accredited to give the test; another, which does not exclude the first, could have been a real increase in coverage resulting from increasing dissemination of messages in the 1980s stressing the importance of Pap testing. It is also noteworthy that 40% of the women interviewed said they had not had the test within the preceding three years. Characteristics associated with those not having had the test were youth (being 15-24 years old), being single, having low socioeconomic status, not having consulted a physician for a year, not having used oral contraceptives, and not having performed breast self-examination for a year. Knowing these characteristics could help implement measures to increase Pap test coverage of specific subgroups.

The eruption of the Cerro Negro volcano near León, Nicaragua, on 9 April 1992 distributed an estimated 1.7 million tons of ash over a 200 square kilometer area. An assessment was conducted to evaluate the health effects on approximately 300,000 residents, using routine data obtained by the national epidemiologic surveillance system. It was found that rates of visits to health care facilities for acute diarrheal and respiratory illnesses increased in two study communities, one within and one near the disaster zone. Specifically, visits for acute diarrhea were nearly 6 times more numerous than before the eruption in both communities, while visits for acute respiratory diseases were 3.6 times more frequent in Malpaisillo (the community near the disaster zone) and 6.0 times more frequent in Telica (the community within it). Most of the visits were for infants and children less than 5 years old. Increased diarrheal disease morbidity, which commonly occurs after volcanic eruptions, demands detailed investigation of the type and quality of water supplies following heavy ashfall. Ash-related respiratory problems should be further examined to determine the spectrum of such diseases and the timing of illness onsets among infants and other special population subgroups. Data collected on health conditions before and after an eruption by passive surveillance can be used to detect eruption-related morbidity. Systems already in place, such as Nicaragua's national epidemiologic surveillance system, can be modified or extended so as to increase their sensitivity to new cases and hence their ability to provide appropriate notification to medical relief agencies.

Infection with Neisseria meningitidis group B has been difficult to detect, partly because this bacterial group's polysaccharide is a weak immunogen. This article describes work carried out to test a new procedure (MB-Dot-ELISA) employing a high-titered horse antiserum for detection of N. meningitidis group B antigens. The study assayed cerebrospinal fluid samples from 585 subjects, 574 with suspected meningitis cases and 11 with neurologic disorders. The results of the assay indicated a sensitivity of 0.991 and a specificity of 0.826. These results were superior to those obtained with latex agglutination and in substantial agreement with the results of counterimmunoelectrophoresis and bacteriologic methods. Overall, the MB-Dot-ELISA was found to be sensitive, inexpensive, and suitable for public health laboratory investigations.

In mid-1993 Ecuador's Health Research Institute conducted a survey to evaluate the general nutrition and vitamin A status of children in five provinces (three in the mountains and two on the coast) containing pockets of extreme poverty. The survey enrolled 1555 children 12-59 months old who constituted a multi-phased stratified cluster sample obtained by random selection methods. Among its other aims, the survey sought to assess all or part of the study subjects' serum retinol levels, dietary vitamin A intake and ocular signs of vitamin A deficiency, and to weigh the influence on vitamin A status of age, sex, parental (maternal) education, residence in a rural or urban area, and the ethnic background of the residence area. Questionnaire interviews were conducted to gather information about each survey child's identify, diet, pathologic history, and breast-feeding history; a blood sample was obtained; and the child was weighed, measured, and given a complete physical examination (including an eye examination). Of the 1232 survey children whose serum retinol levels were measured, 18% and 2% were found to have levels below 0.7 and 0.35 mumol/L, respectively. Low serum retinol levels were more common among children of mothers who had relatively little education and resided in rural areas. The presence of Bitot's spots was confirmed in two of the study children. Interviews conducted with 39% of the study children's families to assess the children's diets showed the risk of insufficient vitamin A intake to be greater in the mountain provinces and among Indian populations, children born to mothers with no formal education, children living in rural areas, and underweight and stunted children. Forty-eight percent of the study population had serum retinol levels between 0.70 and 1.05 mumol/L, indicating marginal vitamin A deficiency. It would therefore appear that dietary supplementation would cause a substantial part of the Ecuadorian population to improve its vitamin A status. Overall, the results of the survey were consistent with a previous national survey and confirmed the existence of a pronounced subclinical vitamin A deficiency that clearly constitutes a public health problem, especially in Ecuador's rural Andean areas.

No published information is currently available about formal "do not resuscitate" (DNR) orders for pediatric patients in developing countries, even though there has been extensive discussion of how to determine who should be involved. This article reports the experience of a clinical ethics committee that recommended DNR orders at a pediatric public hospital in Chile. The committee consisted of four permanent physician members and temporary members including clergymen, nurses, the head of the patient's hospital unit, and the attending physician. Attending physicians submitted cases to the committee on a voluntary basis, and the committee's recommendations were not binding. During the 1990-1993 study period the committee recommended issuing DNR orders for 16 of the 34 patients it evaluated. The hospital records of these 16 patients were retrospectively reviewed for information about the patient's age and diagnosis, the committee's specific recommendations, and the outcome of the case. It was found that the committee typically recommended specific measures to help the child's parents and attending staff in addition to the DNR order. The average patient age was 2 years and 2 months. Nearly all of the patients had chronic and multiple pathologies. In all cases the committee recommendations (taken by consensus) were followed by the attending physician with the consent of the patient's parents. Eleven of the 16 patients for whom DNR orders were issued died during the study period. The five others remained alive despite respiratory insufficiency, severe neurologic damage, or hepatic failure. In general the committee's recommendations appeared useful, providing stronger arguments for DNR decisions and suggesting further support measures for patients, their families, and the attending professionals. This finding supports the idea that clinical ethics committees can provide both valuable support and an opportunity to arrive at better decisions in the public hospitals of developing countries.