Prevalencia y tratamiento del asma en adultos: análisis descriptivo de la encuesta nacional de salud de Chile 2016-2017 / Prevalence and treatment of asthma in adults: descriptive analysis of the Chilean National Health Survey 2016-2017

Objetivo: Describir la prevalencia de diagnóstico autorreportado de asma, comorbilidades, patrones de tratamiento y calidad de vida (CdV) autopercibida en la población chilena, utilizando datos de la Encuesta Nacional de Salud (ENS) de 2016-2017. Métodos: Se analizó la población de la ENS 2016-2017 con ≥ 15 años. Los individuos con asma fueron identificados por autorreporte. Se evaluaron variables sociodemográficas, CdV y salud (autopercepción y/o EQ-5D-3L), estado nutricional, comorbilidades y patrón de tratamiento. Resultados: La prevalencia de asma fue de 5,4% (IC 95%: 4,5-6,5). Se reportó una frecuencia casi 2 veces mayor de CdV autopercibida (6,3% [IC 95%: 3,4-11,3] frente a 3,6% [IC 95%: 2,8-4,5]) y de salud (16,4% [IC 95%: 11,4-23,1] frente a 7,7% [IC 95%: 6,6-8,9]) muy mala/mala/menos que regular en el grupo con asma en comparación con el total de individuos de la ENS. El grupo de asma tuvo mayor frecuencia de al menos algunos problemas en todos los dominios EQ-5D-3L. La comorbilidad más frecuente fue la sintomatología depresiva. El 63% de los encuestados que reconocían tener asma no recibían ningún tratamiento en el momento de la encuesta. Con mayor frecuencia el tratamiento para el asma fue prescrito por un médico general (62,4%/55,4%, medicación de rescate/controlador) y el acceso fue a través del sistema público (65,9%/82,5%, medicación de rescate/controlador). Alrededor de un tercio de la población utilizaba monoterapia con SABA (32,8%). Conclusión: La prevalencia de asma fue del 5,4% y los asmáticos relataron peor CdV y salud. Se observó una baja tasa de tratamiento y de los tratados la mayoría usaba solo medicación de rescate.

Objective: To describe diagnosed asthma prevalence, self-reported comorbidities, treatment patterns and self-perceived quality of life (QoL) in Chilean population, using National Health Survey (NHS) data from 2016-2017. Methods: 2016-2017 NHS population aged ≥ 15 years was analyzed. Asthma individuals were identified by self-report. Sociodemographic variables, QoL and health (self-perception and/or EQ-5D-3L), nutritional status, comorbidities and treatment pattern were evaluated. Results: Asthma prevalence was 5.4% (95% CI: 4.5-6.5). Compared with NHS total individuals, asthma group showed almost 2 times higher frequency of self-perceived QoL (6.3% [95% CI: 3.4-11.3] vs 3.6% [95% CI: 2.8-4.5]) and health (16.4% [95% CI: 11.4-23.1] vs 7.7% [95% CI: 6.6-8.9]) named as very bad/bad/less than regular. In addition, asthma group had a greater frequency of at least some problems in all EQ-5D-3L domains. Depressive symptoms were the most frequently observed comorbidity. 63% of respondents who acknowledged having asthma were not receiving any treatment at the time of the survey. Asthma treatment was most frequently prescribed by a general physician (62.4%/55.4%, rescue/controller medication) and the access occurs in the public system (65.9%/82.5%, rescue/controller medication). About one third of the population used SABA monotherapy (32.8%). Conclusion: Asthma prevalence was 5.4% and asthmatics reported worse QoL and health. A very low treatment rate was observed and those treated, most were under rescue medication.

Avances en tuberculosis en el 54º congreso chileno de enfermedades respiratorias. 2ª parte: nuevas normas técnicas chilenas para el control y eliminación de la tuberculosis / New Chilean technical standards for the control and elimination of tuberculosis

La incidencia de la tuberculosis (TBC) en Chile se ha ido incrementando en el último quinquenio, excepto al inicio de la pandemia de Covid-19, donde la pesquisa de TBC se redujo en forma importante. El escenario epidemiológico actual dista del objetivo propuesto en la Estrategia Nacional de Salud (ENS) de la década 2011-2020 (un plan nacional de gobierno para enfermedades relevantes en la población) que consistía en alcanzar una tasa de incidencia de todas las formas de TBC menor a 5 / 100.000 habitantes. La nueva ENS para la década 2021-2030 propone reducir la incidencia de la enfermedad mediante el diagnóstico oportuno y precoz focalizando las intervenciones en las poblaciones de riesgo de la enfermedad (grupos vulnerables), a modo de pesquisa activa y no solo como pesquisa por consultas espontáneas de sintomáticos respiratorios, o tamizajes masivos que pueden no seleccionar a la población de riesgo. También propone intervenir en la prevención priorizando el estudio y tratamiento de la población con Infección Tuberculosa Latente (ITL) de mayor riesgo de progresión hacia la enfermedad. Por último, se pretende mejorar la eficiencia del proceso de tratamiento de la TBC, optimizando el acceso y adherencia a las terapias de los casos activos de TBC como medida de incrementar la proporción de curación. Una nueva norma ministerial para el manejo y control de la TBC puede ayudar enormemente a esta propuesta. Esta norma entrada plenamente en vigencia el año 2022 entrega las herramientas operacionales para cumplir el objetivo señalado para la nueva ENS. La norma incorpora actividades tendientes a lograr una mayor cobertura de estudio y tratamiento de la ITL en grupos específicos, donde se incluyen, además de los contactos infantiles, a los contactos adultos y a otros grupos vulnerables. La terapia para esta condición se realizará utilizando la asociación de Isoniazida con Rifapentina de preferencia. Esta terapia se aplica bajo supervisión en una dosis semanal durante 3 meses (12 dosis) y ha demostrado mejor adherencia y menor toxicidad hepática. Para el diagnóstico oportuno de TBC la pesquisa se ha focalizado en los sintomáticos respiratorios (tos con expectoración) de más de 2 semanas en personas que pertenecen a alguno de los grupos vulnerables, o que tienen rasgos clínicos muy sugerentes de la enfermedad (fiebre, sudoración vespertina, hemoptisis, compromiso del estado general). Como herramienta diagnóstica deja de utilizarse la baciloscopía por su baja sensibilidad y es sustituida por pruebas moleculares, siendo la plataforma automatizada de amplificación de ADN del complejo M. tuberculosis más utilizada y disponible en los servicios de salud públicos el GeneXpert MTB/RIF Ultra, que además entrega información de la susceptibilidad a la rifampicina a través de la identificación de una mutación específica del genoma (gen rpoB). Con esta tecnología se agiliza el proceso diagnóstico (puede obtener resultados durante el día de ejecución, habitualmente no demoraría más de 2 horas) y es de alta sensibilidad (sensibilidad muy similar al cultivo). El tratamiento de la TBC sensible a los fármacos del esquema primario (rifampicina = R, isoniazida = H, etambutol = E y pirazinamida = Z) consiste en la administración diaria en la fase inicial (con los 4 fármacos) durante 2 meses y en la fase de continuación (con isoniazida y rifampicina) durante 4 meses, totalmente supervisado. La TBC con resistencia a rifampicina tiene tratamiento con un esquema acortado oral de 9 meses con nuevos fármacos: bedaquilina, linezolid, clofazimina y levofloxacino (6 meses con los 4 fármacos, seguido de 3 meses con clofazimina y levofloxacino). Estas terapias de alta calidad son seguras y prometen mejores resultados de curación. La nueva norma significa una mayor cobertura para la erradicación de los reservorios de la enfermedad y una mayor precisión en el diagnóstico de las fuentes de trasmisión comunitaria de la enfermedad, siendo un aporte significativo hacia la eliminación de la TBC en el país.

The incidence of tuberculosis (TB) in Chile has been increasing in the last five years except at the beginning of the Covid-19 pandemic where TB screening has clearly decreased. The current epidemiological scenario is far from the goal proposed in the National Health Strategy (NHS) of the decade 2011-2020 (a national government plan for relevant diseases in the population) which was to achieve an incidence rate of all forms of TB less than 5/100,000 inhabitants. The new NHS for the decade 2021-2030 proposes to reduce the incidence of the disease through timely and early diagnosis by focusing interventions on populations at risk of the disease (vulnerable groups), as an active screening and not only as screening for spontaneous consultations of respiratory symptomatic or mass screenings that may not select the population at risk. It also proposed to intervene in prevention prioritizing the study and treatment of the population with Latent Tuberculosis Infection (LTI) at higher risk of progression to the disease. Finally, it intends to improve the efficiency of the TB treatment process, optimizing access and adherence to therapies of active TB cases as a measure to increase the cure rate. A new ministerial standard for the management and control of TB can greatly help this proposal. This standard, fully effective in 2022, provides the operational tools to meet the objective set for the new NHS. The standard incorporates activities aimed at achieving greater coverage of study and treatment of LTI in specific groups, which include, in addition to child contacts, adult contacts and other vulnerable groups. Therapy for this condition will be performed using the combination of isoniazid with rifapentine preferably. Therapy is administered under supervision and patients receive therapy once a week for 12 doses for 3 months. This therapy has shown better adherence and lower liver toxicity. For the timely diagnosis of TB, case finding has focused on respiratory symptoms (cough and expectoration) for more than 2 weeks, in individuals that belong to one of the vulnerable groups, or that have additional clinical features very suggestive of the disease (fever, afternoon sweats, hemoptysis, compromise of the general condition). Smear sputum as a diagnostic tool is no longer used due to low sensitivity and it was replaced by molecular tests in automated platform for DNA amplification of the mycobacterium TB complex. The more used and available in public health services is GeneXpert MTB / RIF Ultra, which also provides information on susceptibility to rifampicin through the identification of a specific genome mutation (rpoB gene). With this technology, the diagnostic process is streamlined (you can obtain results during the day of execution, usually it would not take more than 2 hours) and sensitivity is high (sensitivity very similar to culture). Treatment of TB sensitive to first line drugs (rifampicin, isoniazid, ethambutol and pyrazinamide) consists of daily administration in the initial phase (with four drugs) for 2 months and in the continuation phase (with isoniazid and rifampicin) for 4 months, fully supervised. In rifampicin resistant TB, the treatment is a shortened oral regimen of 9 months with new drugs: bedaquiline, linezolid, clofazimine and levofloxacin (six months with four drugs, followed by three months with clofazimine and levofloxacin). These high-quality therapies are safe and promise better healing results. The new national standards mean a greater coverage for the eradication of the reservoirs of the disease and a greater precision in the diagnosis of the sources of community transmission of tuberculosis, being a significant contribution towards the path of control and elimination of TB in the country.

Intersetorialidade e Educação Popular em Saúde: no SUS com as Escolas e nas Escolas com o SUS / Intersector Integration and Popular Education in Health: in the SUS with Schools and in Schools with the SUS

RESUMO Em 1988, a Constituição Federal do Brasil deu as bases para a criação do Sistema Único de Saúde (SUS), garantindo a saúde como direito. Em 2013, a Política Nacional de Educação Popular em Saúde (PNEPS) amplia as conquistas nessa área ao reafirmar os princípios desse Sistema: universalidade, integralidade, equidade e participação social, esta essencial para o debate de Educação Popular em Saúde. Nesse contexto, o papel da universidade, segundo as Diretrizes Curriculares Nacionais (DCN) para os cursos de graduação em Medicina de 2014, de atuar sobre as necessidades da população, promovendo saúde e transformando a realidade da sociedade, é fundamental na formação dos estudantes, bem como no seu vínculo com a comunidade. O grupo de execução deste trabalho levantou a proposta de refletir sobre a realidade do SUS na perspectiva de estudantes da Educação de Jovens e Adultos (EJA) das escolas municipais de Uberlândia (MG), dialogando com seus saberes a fim de empoderar a população por meio da construção compartilhada de conhecimento. Nas vivências, identificamos o desconhecimento da população sobre seus direitos e o próprio SUS, e, assim, priorizamos o debate e o diálogo utilizando a amorosidade, princípio da PNEPS, para conseguirmos trabalhar os princípios desse Sistema de Saúde, bem como os direitos da população relativos à saúde. Notamos que a nossa formação ainda é centrada no médico, visto que houve uma dificuldade inicial de estabelecer o contato de forma confortável com ambas as partes. Por trabalharmos com pessoas, naturalmente surgiram demonstrações sobre suas insatisfações com o nosso sistema de saúde, e foi preciso utilizar isso para apontar possíveis soluções e como protagonizar essa luta sem colocar a responsabilidade da melhoria e consolidação de nossa saúde somente nas mãos de terceiros. Era preciso compreender a importância do SUS e saber como mudá-lo por meio, principalmente, da participação social. O objetivo foi alcançado pelo estabelecimento de um vínculo que possibilitou a construção conjunta de conhecimento, trazendo maior autonomia tanto ao grupo quanto aos participantes, aumentando nossa perspectiva de uma mudança na luta pela saúde que almejamos em nossa formação e futura atuação profissional.

ABSTRACT In 1988, the Federal Constitution of Brazil established the foundations for the Unified Health System (SUS), guaranteeing health as a right. In 2013, the National Policy on Popular Education in Health (PNEPS) broadened the achievements in this area by reaffirming the principles of the System: universality, comprehensiveness, equality and social participation, essential to the debate on Popular Education in Health. According to the National Curricular Guidelines (DCN) for Medical Undergraduate Courses from 2014, the University's role is fundamental in training students to act on the needs of the population, promoting health, transforming the outlook of society, and their relations with the community. The group that conducted this study raised the proposal to reflect on the reality of the SUS from the perspective of Youth and Adult Education students (EJA) from the municipal schools of Uberlândia, Minas Gerais, drawing on their learnings to empower the population through shared knowledge. In the experiences, we identified a lack of knowledge among the public in relation to their rights and the SUS. Thus, we prioritized the debate and dialogue focusing on the PNEPS principle of lovingness in order to work on the principles of the health system and the public's rights in relation to health. It was revealed that our training remains doctor-centered, bearing in mind the initial difficulty in establishing comfortable contact on both sides. By virtue of working with people, demonstrations of dissatisfaction with our health system naturally arose and these were used to identify possible solutions and how to lead the way in this struggle without transferring the responsibility for improving and consolidating health care solely into the hands of third parties. We needed to understand the importance of the SUS and how to change it through, primarily, social participation. The goal was achieved by establishing a bond that enabled the joint construction of knowledge, bringing greater autonomy to both the group and the participants, broadening our perspective of a change in the fight for health that we strive for in our undergraduate training and our future medical practice.

Contexto político y económico del surgimiento de la salud pública moderna en el periodo 1872-1914 / Political and economic context at the beginning of modern public health in 1872-1914

Este artículo estudia el periodo denominado por los historiadores como el gran siglo XIX o siglo XIX largo, que comprende todo el siglo XIX más las décadas que antecedieron y acompañaron a la Primera Guerra Mundial y que corresponde con la expansión y consolidación del imperialismo clásico. Desde la perspectiva de la salud pública, es importante por la transición de la higiene pública a la moderna salud pública, caracterizada ya hacia 1880 por el advenimiento de la teoría bacteriológica y su influencia en las medidas de sanidad estatal. El surgimiento de la salud pública y la medicina estatal en América Latina es una consecuencia lógica de la instauración de modos de producción capitalista en los países del continente, ya que las relaciones sociales y económicas de los individuos con el Estado fueron duramente afectadas y transformadas por los procesos de incipiente industrialización y consolidación del modelo de producción capitalista, lo cual implicó la consolidación de un cuerpo burocrático y un aumento de la intervención en la vida de los ciudadanos por la vía de las políticas sociales. En Colombia, la burguesía en el poder respondió a los problemas de salud pública (apoyada por la Fundación Rockefeller), como las distintas epidemias de viruela, cólera, malaria o fiebre amarilla, que recorrieron con mayor o menor severidad el país desde los litorales Atlántico o Pacífico hasta el interior con el riesgo de diezmar las poblaciones obreras y afectar el intercambio comercial del país con Estados Unidos.

This article analyzes the period that historians call the Big or Long XIX Century, which encompasses, besides the XIX century, the preceding decades and the decades of World War I. It corresponds to the expansion and consolidation of classic imperialism. From the public health perspective, the Big XIX century is important with the beginning of bacteriological theory in 1880 and the transition from hygiene to public health with governments controlling sanitary. The appearance of state medicine in the Latin American region is a logical consequence of the implementation of capitalist modes of production given that the social and economic relationships between the people and the state were harshly affected and transformed by the incipient industrialization and consolidation of the capitalist production model. The state apparatus consolidated a bureaucratic body and increased its intervention in citizens’ everyday lives via social policies. In the case of Colombia, the beginning of hygiene practices and, later on, of bacteriology occurred in particular ways. This can be observed along the XIX century, a period in which the bourgeoisie in power responded, supported by the Rockefeller Foundation, mostly to episodic events such as the smallpox, cholera, malaria or yellow fever epidemics, which run through the country with different degrees of severity from both the Atlantic and Pacific coasts towards the interior of the country, threatening to reduce the population of workers and to affect the commercial exchange of the country with the United States.

The Health Care in North Korea during the Period(1945-1948) between Liberation from Japanese Occupation and Establishment of North Korean Government / 의사학

This paper, mainly based on literature and documents from North Korea and Russia, described how health care system had been formulated during the period of between liberation from Japanese Occupation and formation of its own government in North Korea, which is so-called 'the Period of People's Democracy'. North Korea authorities, by themselves, address that their health care system is characterized by state medicine, universal free medical care, emphasis on preventive medicine, community(ho) doctors in charge, provisions of modern medical services in parallel with traditional ones, imposed high value on ideologies of medical personnel, and mass participation of health programs so on, taken rise since this period. Under North Korea's socialistic regime, authorities started to restructure health care system through national health care organizations and institutes, which partially provided medical service free. Also, they emphasized preventive medicine against 'capitalistic' treatment-oriented medicine, and community(ho) doctor in-charge was derived from this period. It showed that the mass participation on health program was equal hereafter and they had under bias toward more emphasis on ideology of medical personnel rather than their professionalism. The attempt to develop traditional medicine had been made during this period, however, much funding and support was not observed. In this period, it showed that a series of action to restructure health care system had been gradually carried out.

Cultural Hegemony of Medicine in Modern China: Focused on Debates between Modernists and Neotraditionalists, 1900s~1930s / 의사학

The paper is to explore into how cultural hegemony had been established in modern China, focused on ideological debates and political conflicts between modernists and traditionalists. Relying upon historical, anthropological, and medicohistorical researches respectively by Paul Cohen, Judith Farquhar and Paul Unschuld, I criticize three research paradigms that had prevailed in modern Chinese history: (i) the 'Chinese response to Western impact' perspective fails to explain how Chinese Western medical practitioners founded their own independent organization; (ii) a dichotomy of 'tradition versus modernity' is, from an epistemological viewpoint, incompatible with an ontological view of illness shared between traditional Chinese medicine and Western medicine; and (iii) while those Weberian social scientists tend to consider culture as the system of meanings and symbols, separated from their temporal and spatial matrix, they neglect political and historical spheres that are inevitably represented in cultural hegemony. My arguments are divided into two parts. The first part investigates that whereas Chinese modernists aggressively supported an immediate institutionalization of Western medicine for getting adapted to social Darwinian world, neotraditionalists tried to maintain medical identity through national essence backed up by Chinese civilization. In the second part, the paper illuminates how having emerged as a conceptual idea for moving beyond 'tradition versus modernity', 'state medicine' became popularized to solve public health problems in 1930s' rural China. In conclusion, cultural hegemonyyoriented debates that were seriously staged in the 1920s and 1930s between modernists and neo-traditionalists were transformed to "scientification of traditional Chinese medicine and popularization of Western medicine" a slogan proposed by Mao ZeDong.

The Development of Private Hospital in Modern Korea, 1885-1960 / 의사학

Modern hospital in Korea was the space of competition and compromise among different forces such as the state power and social forces, imperialism and nationalism, and the traditional and the modern medicine. Hospital in the Japanese colonialism was the object of control for establishing the colonial medical system. Japanese colonialism controlled not only the public hospital but also the private hospital which had to possess more than 10 infectious beds in the isolation building by the Controlling Regulation of Private Hospital. In fact, the private hospital had to possess more than 20 beds for hospital management. As a result, its regulation prevented the independent development of the private hospital. But because the public hospital could not accommodate many graduates of medical school, most of them had to serve as a practitioner. Although some practitioners had more than 20 beds in their clinics, they were not officially included in the imperial medicine. By concentrating on the trend of the number of bed in the hospital, this paper differs from most previous studies of the system of hospital, which have argued that the system of hospital was converted the public-centered hospital system under the colonial medical system into the private-centered hospital system under the U. S. medical system after the Liberation in 1945. After Liberation, medical reformers discussed arranging the public and the private hospital. Lee Yong-seol, who was a Health-Welfare minister, disagreed the introduction of the system of state medicine. Worrying about the flooding of practitioners, he did not want to intervene the construction of hospital by state power. Because the private hospital run short of the medical leadership and the fundamental basis, the state still controlled the main disease in the public health and the prevention of epidemics. This means the state also played important part in the general medical examination and treatment. The outbreak of Korean War in 1950 reinforced the role of state. The leadership of the public hospital verified the trend of the quantity of bed. The number of bed in the private hospital exceeded that of the public hospital in 1966 for the first time. Furthermore, the number of bed in the public hospital doubled that of private hospital in the new general hospital of 1950s. This means the system of hospital after the Liberation was not converted the public-centered hospital system into the private-centered hospital system, but maintained the public-centered hospital system until 1960s.