Gonzalo Gutiérrez

Seroepidemiología de la enfermedad de Chagas en México

The lack of information about Chagas disease in Mexico, as well as the controversy concerning its importance, was the basis for the seroprevalence study of Trypanosoma cruzi in the National Seroepidemiology Survey (NSS). This information was representative of the national situation with regard to disease prevalences and other factors related to the nations health. Unfortunately the NSS was not a very good information source for the study of trypanosomiasis americana, because its coverage in the disperse rural areas was poor. Nevertheless, the results of the NSS indicated that Chagas disease has an irregular distribution in Mexico with seroprevalences of 1.6, 0.5 and 0.2 for the different dilution levels used in the evaluation. The survey data showed Chagas disease to be less important than that mentioned by other authors. The NSS data confirmed the areas of disease transmission already reported and identified some new ones in Hidalgo, Chiapas and Veracruz. The survey also detected migratory workers with Chagas antibodies in Baja California border cities, a situation which indicates a risk for blood transfusion in areas of the country presumed to be free of the disease. Three quarters (74.5%) of the seropositive population were less than 39 years old. Moreover, the fact that children of less than four year were infected suggests that natural transmission is still very important in some areas. Although the seroprevalences were greater in the lower socio-economic groups, some persons of the higher socio-economic level were also affected. This situation may be explained by the fact that many of these persons own vacation homes in tropical areas.

Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea.

A prospective cohort study was conducted to analyze factors associated with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study took place in four primary health care clinics in Mexico City, two belonging to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty-two patients with ARI and 155 with AD were included. Data about study variables and the assessment of compliance were obtained through patient interviews and direct observation. Factors associated with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 60% for ARI and 55.5% for AD in both health care systems. Prescription of an antibiotic was justified only in 13.5% of cases. Associated factors were: increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16-3.26); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an inadequate physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was higher in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to modify physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.

Strengthening preventive care programs: a permanent challenge for healthcare systems; lessons from PREVENIMSS México

BackgroundIn 2001, the Instituto Mexicano del Seguro Social (IMSS) carried out a major reorganization to provide comprehensive preventive care to reinforce primary care services through the PREVENIMSS program. This program divides the population into programmatic age groups that receive specific preventive services: children (0-9 years), adolescents (10-19 years), men (20-59 years), women (20-59 years) and older adults (> = 60 years). The objective of this paper is to describe the improvement of the PREVENIMSS program in terms of the increase of coverage of preventive actions and the identification of unmet needs of unsolved and emergent health problems.MethodsFrom 2003 to 2006, four nation-wide cross-sectional probabilistic population based surveys were conducted using a four stage sampling design. Thirty thousand households were visited in each survey. The number of IMSS members interviewed ranged from 79,797 respondents in 2003 to 117,036 respondents in 2006.ResultsThe four surveys showed a substantial increase in coverage indicators for each age group: children, completed schemes of vaccination (> 90%), iron supplementation (17.8% to 65.5%), newborn screening for metabolic disorders (60.3% to 81.6%). Adolescents, measles - rubella vaccine (52.4% to 71.4%), hepatitis vaccine (9.3% to 46.2%), use of condoms (17.9% to 59.9%). Women, measles-rubella vaccine (28.5% to 59-2%), cervical cancer screening (66.7% to 75%), breast cancer screening (> 2.1%). Men, type 2 diabetes screening (38.6% to 57.8%) hypertension screening (48-4% to 64.0%). Older adults, pneumococcal vaccine (13.2% to 24.9%), influenza vaccine (12.6% to 52.9) Regarding the unmet needs, the prevalence of anemia in children was 30% and a growing prevalence of overweight and obesity, type 2 diabetes, and hypertension was found in men, women and older adults.ConclusionPREVENIMSS showed an important increase in the coverage of preventive services and stressed the magnitude of the old and new challenges that this healthcare system faces. The unsolved problems such as anemia, and the emerging ones such as overweight, obesity, among others, point out the need to strength preventive care through designing and implementing innovative programs aimed to attain effective coverage for those conditions in which prevention obtains substandard results.

Características asociadas al subregistro de muerte en niños del estado de Guerrero, México

Objective. To estimate the frequency of underregistered children deaths in rural areas and to identify associated characteristics. Material and methods. The study was conducted in three stages. In the first, three strata of communities were formed according to the number of inhabitants; then a representative number of villages was randomly selected from each stratum. A census was made in each village to determine the deaths occurred between June 1993 and July 1994. In the second stage, the verbal autopsy method was used with the mothers of the dead children to determine the cause of death and investigate the study variables. In the third stage, registration of death was verified through the death certificates. Results. An underregistration frequency of 68.9% was found; in communities of less than 500 inhabitants underregistration reached 73.2% and in larger communities it was 60.5%. Characteristics associated to underregistration were the lack of birth and death certificate, age younger than one month, lack of information on the concept and purpose of a Public Registration Office, distance from the Public Registration Office and to the doctor of more than 30 minutes, and community smaller than 1 000 inhabitants. Conclusions. A modification in the current organization of the death registration procedure is proposed and the use of a birth certificate designed by the National Health System.

La mortalidad por enfermedad diarreica en México: ¿problema de acceso o de calidad de atención?

Objetivo. Evaluar el proceso de atencion y el acceso a servicios de salud en menores de cinco anos fallecidos por enfermedad diarreica (ED), en cuatro estados de la Republica mexicana. Material y metodos. Se realizo un estudio transversal que incluyo defunciones ocurridas durante un ano; mediante autopsia verbal se obtuvo informacion de caracteristicas clinicas, atencion durante la enfermedad y acceso a los servicios de salud; se realizo un analisis descriptivo y comparativo de acuerdo con el tamano de la localidad. Resultados. De 553 defunciones, la mayoria ocurrio en ninos sin derecho a seguridad social o residentes en localidades rurales; la muerte en el hogar, la edad menor a un ano y la corta evolucion de la enfermedad caracterizaron a mas de la mitad de los casos. Se proporciono terapia de hidratacion oral por decision de la madre a casi 75% de los ninos; 20% recibio atencion no medica, principalmente de curanderos. La atencion medica fue otorgada en 60% de los casos; a una elevada proporcion le fue indicado algun medicamento y no se le envio a hospital ni se recomendo regresar ante la presencia de signos de alarma; la indicacion de hidratacion oral fue mayor por medicos de servicios publicos y en localidades rurales; en estas, el acceso geografico y economico fue menor. Conclusiones. Si bien se confirmo el problema de acceso a los servicios de salud, se identificaron fallas importantes en la atencion medica primaria. Se propone la creacion de unidades docente-asistenciales como una estrategia para la reduccion de la mortalidad por ED.

The impact of a clinical training unit on integrated child health care in Mexico

This study had two aims: to describe the activities of a clinical training unit set up for the integrated management of sick children, and to evaluate the impact of the unit after its first four years of operation. The training unit was set up in the outpatient ward of a government hospital and was staffed by a paediatrician, a family medicine physician, two nurses and a nutritionist. The staff kept a computerized database for all patients seen and they were supervised once a month. During the first three years, the demand for first-time medical consultation increased by 477% for acute respiratory infections (ARI) and 134% for acute diarrhoea (AD), with an average annual increase of demand for medical care of 125%. Eighty-nine per cent of mothers who took their child for consultation and 85% of mothers who lived in the catchment area and had a deceased child received training on how to recognize alarming signs in a sick child. Fifty-eight per cent of these mothers were evaluated as being properly trained. Eighty-five per cent of primary care physicians who worked for government institutions (n = 350) and 45% of private physicians (n = 90) were also trained in the recognition and proper management of AD and ARI. ARI mortality in children under 1 year of age in the catchment area (which included about 25,000 children under 5 years of age) decreased by 43.2% in three years, while mortality in children under 5 years of age decreased by 38.8%. The corresponding figures for AD mortality reduction were 36.3% and 33.6%. In this same period, 11 clinical research protocols were written. In summary, we learned that a clinical training unit for integrated child care management was an excellent way to offer in-service training for primary health care physicians.

Impacto de los servicios de salud, el saneamiento y la alfabetización en la mortalidad de menores de cinco años

Objective. To analyze differences of the impact of health care services, sanitation and literacy on the mortality rates of children under five years of age, in two Mexican states with marked socioeconomic differences: Chiapas and Nuevo Leon. Material and methods. The study design was ecologic, based on a retrospective analysis of data published by the Health Ministry (Secretaria de Salud), National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadistica, Geografia e Informatica) and the National Population Council (Consejo Nacional de Poblacion), on the tendencies of mortality among children under five years and on the changes of selected indicators corresponding to the period 1990-1997. Study design: ecologic study. This was based on a retrospective analysis of data published by Secretaria de Salud, Instituto Nacional de Estadistica e Informatica and Consejo Nacional de Poblacion, about the tendencies of mortality among children under five years, and about the changes of selected indicators. The analysis was carried out in the period comprised between 1990-1997. For both states the registered variations were calculated and the trends were determined through analysis of simple linear regression; the independent variable corresponded to the study years. Partial correlation analysis between the various mortality trends studies and between and the selected indicators, were calculated. Results. During the studied period there was a steady decline of children mortality, which was more marked in Chiapas. In both entities, this decrease was closely related to the decline in mortality due to acute diarrhea, and also correlated