El programa RADAR para la prevención del suicidio en adolescentes de la región de Aysén, Chile: resultados preliminares / RADAR: a program for the prevention of suicide in adolescents in the region of Aysen, Chile, preliminary results

OBJETIVO: Dar a conocer los resultados preliminares del programa comunitario RADAR (Red para la Atención y Derivación de Adolescentes en Riesgo suicida). MÉTODO: Durante el 2016, RADAR fue implementado como prueba de concepto en dos colegios de Puerto Aysén de la Región de Aysén, Chile. Se capacitó un total de 409 participantes (entre alumnos, profesores de los colegios, apoderados y profesionales de la salud) para la pesquisa y derivación de adolescentes en riego de suicidio. RESULTADOS: De un total de 144 alumnos que pasaron los sistemas de pesquisa de RADAR, se detectaron 29 casos en riesgo suicida (20%) y 27 fueron derivados oportunamente al Servicio de Urgencia del Hos pital de Puerto Aysén. En la segunda campaña de pesquisa de RADAR, 3 meses después, el 90% de los casos ya no presentaba riesgo suicida. CONCLUSIÓN: Estos resultados muestran la alta proporción de adolescentes en riesgo suicida que no son visibilizados por el sistema de salud y la factibilidad de implementar RADAR en la comunidad como una intervención preventiva efectiva.

OBJECTIVE: We present the preliminary results of the implementation of RADAR: a community suicide prevention program in adolescents implemented in two high schools in a south region of Chile. METHOD: In a pilot study, during 2016, we implemented RADAR in two high schools of Puerto Aysen, in in the Region of Aysen of Chile. A total of 409 actors were trained (among students, school teachers, caregivers and health professionals) for the screening and referral of high suicide risk adolescents. RESULTS: Out of a total of 144 students who passed the RADAR screening systems, 29 cases were detected as suicide risk (20%) and 27 of them were opportunely referred to the Emergency Service of the Hospital of Puerto Aysen. In the second RADAR screening campaign, 3 months later, 90% of the cases no longer presented suicide risk. CONCLUSION: These results show the high proportion of ado lescents at risk of suicide who are not visible by the health system and the feasibility of implementing RADAR in the community as an effective suicide prevention intervention.

Proposals for the prevention of lung cancer in the health system of Mexico / Propuestas para la prevención de cáncer de pulmón en el sistema de salud en México

Abstract The management of lung cancer is challenging. However, nowadays the main goal is to achieve a significant overall survival accompanied by a good quality of life. Because smoking is associated with up to 71% of cancer deaths, the first policy that should be established is one that promotes strategies for healthy lifestyles by providing information about lung cancer, risk factors, protection factors, and precautionary data. Furthermore, an effective screening method that would allow early diagnosis should be established. Following diagnosis, the patient should be genotyped to identify predisposing mutations to give personalized medicine to the patient. The health system policies should include information that affects the health of the population and simultaneously allows for early diagnoses, resulting in a higher survival rate.

Resumen El manejo del cáncer de pulmón es un reto que tiene como objetivo una supervivencia global significativa que se vea rodeada de una buena calidad de vida. Si se considera que el tabaquismo está asociado hasta con 71% de las muertes por cáncer, la primera política que debe establecerse es la de proporcionar información sobre el cáncer de pulmón, factores de riesgo, factores de protección y datos de alarma mediante una estrategia de salud de línea de vida, además del establecimiento de un método de tamizaje efectivo que permita un diagnóstico temprano. Después del diagnóstico, debe realizarse una genotipificación para identificar mutaciones sensibles y para proporcionar un tratamiento personalizado al paciente. Las políticas del sistema de salud deben incluir información para que la población incida en su salud y también se puedan realizar diagnósticos tempranos que permitan una mayor supervivencia.

Challenges in the development and implementation of the National Comprehensive Cancer Control Program in Mexico / Retos del desarrollo e implementación del Programa Nacional de Control Integral del Cáncer en México

Abstract Chronic noncommunicable diseases (NCDs), including cancer, have become the leading cause of human morbidity and mortality. In Mexico, cancer is the third leading cause of death, with a high incidence among the economically active population, a high proportion of advanced stages at diagnosis and limited care coverage for patients. However, no public policy aimed at managing this important public health problem has been developed and implemented to date. This manuscript describes the first interinstitutional proposal of a National Program for Cancer Control, considering the known risk factors, early detection, treatment, palliative care and patient rehabilitation. This manuscript also outlines a series of thoughts on the difficulties and needs that the Mexican health system faces in achieving the main objectives of the program: to decrease the incidence of cancer, to increase survival and to improve the quality of life for this group of patients.

Resumen Las enfermedades crónicas no transmisibles (ECNT), incluido el cáncer, se han convertido en la principal causa de morbimortalidad de la humanidad. En México, el cáncer es la tercera causa de muerte, con una frecuencia elevada en población económicamente activa, una alta proporción de etapas avanzadas al momento del diagnóstico y una limitada cobertura de atención a quienes la padecen. No obstante, hasta el momento no se ha desarrollado e implementado una política pública dirigida al control de este importante problema de salud pública. Este manuscrito muestra la primera propuesta interinstitucional de un Programa Nacional para el Control del Cáncer, considerando los factores de riesgo conocidos, la detección temprana, el tratamiento y los cuidados paliativos y la rehabilitación del paciente. Asimismo se hacen una serie de reflexiones sobre las dificultades y necesidades a las que el sistema de salud mexicano se enfrenta para alcanzar los objetivos principales del programa: reducir la incidencia, incrementar la supervivencia y mejorar la calidad de vida de este grupo de pacientes.

Lessons learned in evaluating the Familias Fuertes program in three countries in Latin America / Lecciones aprendidas al evaluar el programa Familias Fuertes en tres países de América Latina

This report describes 1) the evaluation of the Familias Fuertes primary prevention program in three countries (Bolivia, Colombia, and Ecuador) and 2) the effect of program participation on parenting practices. Familias Fuertes was implemented in Bolivia (10 groups, 96 parents), Colombia (12 groups, 173 parents), and Ecuador (five groups, 42 parents) to prevent the initiation and reduce the prevalence of health-compromising behaviors among adolescents by strengthening family relationships and enhancing parenting skills. The program consists of seven group sessions (for 6-12 families) designed for parents/caregivers and their 10-14-year-old child. Parents/caregivers answered a survey before the first session and at the completion of the program. The survey measured two important mediating constructs: "positive parenting" and "parental hostility." The Pan American Health Organization provided training for facilitators. After the program, parents/caregivers from all three countries reported significantly higher mean scores for "positive parenting" and significantly lower mean scores for "parental hostility" than at the pre-test. "Positive parenting" practices paired with low "parental hostility" are fundamental to strengthening the relationship between parents/caregivers and the children and reducing adolescents' health-compromising behaviors. More research is needed to examine the long-term impact of the program on adolescent behaviors.

Este informe describe 1) la evaluación del programa de prevención primaria Familias Fuertes en tres países (Bolivia, Colombia y Ecuador) y 2) el efecto de la participación en el programa sobre las prácticas de crianza. El programa Familias Fuertes se llevó a cabo en Bolivia (10 grupos, 96 padres), Colombia (12 grupos, 173 padres) y Ecuador (5 grupos, 42 padres) para prevenir el inicio y reducir la prevalencia de comportamientos que constituyen un riesgo para la salud de los adolescentes, mediante el fortalecimiento de las relaciones familiares y la mejora de las habilidades de crianza. El programa consta de siete sesiones de grupo (para 6 a 12 familias) dirigidas a padres o cuidadores y sus hijos de 10 a 14 años de edad. Los padres o cuidadores respondieron a una encuesta antes de la primera sesión y al término del programa. La encuesta midió dos conceptos importantes: la "crianza positiva" y la "hostilidad parental". La Organización Panamericana de la Salud capacitó a los facilitadores. Después del programa, los padres o cuidadores de los tres países presentaron puntuaciones ­ medias significativamente mayores en "crianza positiva" y significativamente menores en "hostilidad parental" que en la encuesta previa. La prácticas de "crianza positiva" asociadas con una baja "hostilidad parental" son fundamentales para fortalecer la relación entre los padres o cuidadores y los niños, y reducen los comportamientos que constituyen un riesgo para la salud de los adolescentes. Es necesaria una investigación más amplia para analizar la repercusión a largo plazo del programa sobre los comportamientos de los adolescentes.

Estratégias de promoção da saúde e prevenção primária para enfrentamento das doenças crônicas: revisão sistemática / Health promotion and primary prevention strategies to fight chronic disease: a systematic review

OBJETIVO: Analisar as estratégias de promoção da saúde e prevenção primária no combate às doenças crônicas não transmissíveis (DCNT) no âmbito mundial e refletir sobre os desafios relacionados ao enfrentamento dessas enfermidades. MÉTODOS: Nesta revisão sistemática da literatura, foram revisados estudos acerca dos projetos indicados pelo Ministério da Saúde do Brasil como principais programas de intervenção de base comunitária: North Karelia Project, na Finlândia; Stanford Three-Community Study, Stanford Five-City Project, Minnesota Heart Health e Pawtucket Heart Health Program, nos Estados Unidos; CINDI, na Europa e Canadá; CARMEN na América Latina; Mirame, no Chile; e Tianjin, na China. Realizou-se consulta às bases de dados LILACS, Medline e SciELO e aos portais do Ministério da Saúde, Organização Pan-Americana da Saúde e Organização Mundial da Saúde. Foram incluídos os artigos originais baseados em dados primários. Como desfecho, avaliaram-se, nos estudos selecionados, colesterol, pressão arterial, obesidade, grau de atividade física, consumo de tabaco, hábitos alimentares e outros fatores de risco para DCNT. RESULTADOS: Foram selecionados 17 estudos. Os projetos North Karelia, Three Community Study e Five-City Multifactor Risk Reduction contribuíram para reduzir tabagismo, colesterol e pressão arterial. O Minnesota Heart Health Program e o Pawtucket Heart Health Program apresentaram efeitos modestos na redução dos fatores de risco para DCNT. Os programas CINDI e CARMEN demonstraram a importância das ações integradas para redução dos principais fatores de risco. O programa Mirame, que enfocou a intervenção educacional na população escolar, atingiu 30 000 escolares em 2001, com utilização de poucos recursos financeiros. O Projeto Tianjin alcançou redução no consumo de sal e na prevalência de hipertensão arterial e obesidade através da reorganização dos serviços de atenção primária à saúde. CONCLUSÕES: Essas experiências comunitárias bem sucedidas são importantes para estabelecer propostas para a implementação de políticas atuais mais efetivas, com o objetivo de desenvolver ações que integrem a promoção da saúde e a prevenção primária dos principais fatores de risco no combate às DCNT.

OBJECTIVE: To analyze health promotion and primary prevention strategies in the global fight against chronic noncommunicable diseases (NCDs) and to reflect on the challenges of overcoming these diseases. METHODS: In this systematic literature review, studies were analyzed on health programs identified by the Brazilian Health Ministry as the main global community intervention initiatives: the North Karelia Project, in Finland; the Stanford Three-Community Study, Stanford Five-City Project, Minnesota Heart Health and Pawtucket Heart Health Program, in the United States; the CINDI project, in Europe and Canada; CARMEN in South America; Mirame, in Chile; and Tianjin, in China. The LILACS, Medline, and SciELO databases were searched, as well as the Brazilian Health Ministry, Pan American Health Organization, and World Health Organization websites. Only original articles analyzing primary data were included. The outcomes evaluated in the studies were cholesterol, blood pressure, obesity, physical activity level, tobacco use, dietary habits, and other risk factors for NCDs. RESULTS: Seventeen studies were selected. The North Karelia Project, Three Community Study, and Five-City Multifactor Risk Reduction Project contributed to decrease tobacco use, cholesterol levels, and blood pressure levels. The Minnesota Heart Health Program and the Pawtucket Heart Health Program had moderate success in reducing the risk factors for NCD. The CINDI and CARMEN programs demonstrated the importance of integrated actions for decreasing the main risk factors. The Mirame project, which focused on educational interventions for school children, reached 30 000 students in 2001 without requiring a large financial investment. The Tianjin project was able to reduce salt intake, prevalence of arterial hypertension, and obesity by restructuring primary health care services. CONCLUSIONS: These successful experiences in community health improvement may serve as models for the implementation of more effective health policies, aiming at the development of actions that integrate health promotion and primary prevention of the main risk factors for NCDs.

Barriers to prevention of cardiovascular disease in primary care settings in Argentina / Obstáculos en la prevención de las enfermedades cardiovasculares en entornos de atención primaria en Argentina

OBJECTIVE: To identify main barriers to preventing cardiovascular disease and implementing clinical practice guidelines in primary care, to pilot implementation of a tailored enactment of the adapted World Health Organization guidelines to prevent cardiovascular disease, and to assess the impact of the intervention in risk stratification. METHODS: A qualitative study was done with decision makers, health professionals, and staff from five primary health care centers, who were interviewed to identify the main barriers. A tailored intervention to apply the guidelines was then designed and implemented. To assess the impact of the intervention on risk factor screening, a before-and-after analysis was performed through a records review of independent samples of patients aged 40 years or older attending each center. RESULTS: The main barriers identified were lack of awareness of guidelines and lack of knowledge about preventing cardiovascular disease, communication problems within health teams, lack of motivation, and organizational problems. Before (n = 226) and after (n = 234) the intervention, screening of the main risk factors increased: blood pressure measurement from 44.3% to 72.6%, cholesterol measurement from 20.7% to 49.7%, smoking status assessment from 20.4% to 56.1%, diabetes status assessment from 25.5% to 93.6%, and previous vascular event status from 33.2% to 74.3%. Global risk stratification was not done at baseline, compared with 45.1% after the intervention. CONCLUSIONS: The main barriers identified were useful in designing a tailored intervention. Although no clinical outcomes were evaluated, this study shows that the implementation is feasible, with increased risk stratification as a first step at better patient management.

OBJETIVO: Determinar las principales barreras en la prevención de las enfermedades cardiovasculares y la aplicación de las directrices de práctica clínica en atención primaria, guiar la adecuada puesta en práctica de las directrices adaptadas de la Organización Mundial de la Salud para prevenir las enfermedades cardiovasculares, y evaluar la repercusión de la intervención en la estratificación del riesgo. MÉTODOS: Se llevó a cabo un estudio cualitativo dirigido a los encargados de adoptar las decisiones, los profesionales de la salud y el personal de cinco centros de atención primaria de salud, que fueron entrevistados con objeto de determinar las principales barreras. Posteriormente se diseñó y ejecutó una intervención adaptada para aplicar las directrices. Con objeto de evaluar la repercusión de la intervención sobre el tamizaje de los factores de riesgo, se llevaron a cabo un análisis anterior y posterior a la intervención mediante un examen de los registros de muestras independientes de pacientes de 40 años o mayores que acudían a cada centro. RESULTADOS: Las principales barreras detectadas fueron el desconocimiento de las directrices y la carencia de información sobre la prevención de las enfermedades cardiovasculares, los problemas de comunicación dentro de los equipos de salud, la falta de motivación y los problemas organizativos. Al comparar los datos previos a la intervención (n = 226) con los posteriores a esta (n = 234), se observó un incremento del tamizaje de los principales factores de riesgo: la medición de la presión arterial de 44,3 a 72,6%, la determinación del colesterol de 20,7 a 49,7%, la evaluación de la presencia de tabaquismo de 20,4 a 56,1%, la evaluación de la presencia de diabetes de 25,5 a 93,6% y la evaluación de la presencia de un episodio vascular anterior de 33,2 a 74,3%. Al inicio del estudio no se llevaba a cabo la estratificación del riesgo global, en comparación con el 45,1% de estratificación realizada posteriormente a la intervención. CONCLUSIONES: La determinación de las principales barreras fue útil para el diseño de una intervención adaptada. Aunque no se evaluaron los resultados clínicos, este estudio revela que la ejecución es factible, y que la mayor estratificación del riesgo constituye un primer paso en la mejora de la atención de los pacientes.

Abordagem do câncer da boca: uma estratégia para os níveis primário e secundário de atenção em saúde / Strategies for management of oral cancer in primary and secondary healthcare services

O avanço verificado no enfrentamento de neoplasias malignas por meio dos sistemas de saúde envolve melhorias nas áreas de vigilância, organização de redes de assistência, programas específicos voltados às prevenções primária e secundária e, obviamente, aos avanços técnico-científicos que caracterizam a abordagem diagnóstica e terapêutica. Embora seja notável o reconhecimento de avanços no manejo de neoplasias malignas em todas as áreas citadas, o câncer da boca permanece com indicadores de morbidade e mortalidade que parecem não acompanhar o acúmulo científico no conhecimento da doença. O presente manuscrito objetiva discutir os motivos desse descompasso, a necessidade de reorientação de prioridades na abordagem do câncer da boca e sua efetivação como política pública de saúde.

Progress in cancer management by health systems involves improvements in surveillance, organization of healthcare services, specific programs focused on primary and secondary prevention, and scientific and technical advances in diagnosis and treatment. Despite well-known progress in the management of malignant neoplasms in all the above areas, oral cancer displays persistently high morbidity and mortality rates, apparently failing to reflect the accumulated scientific knowledge on the disease. The current article discusses the reasons for this mismatch, the need for redefining priorities in oral cancer management, and the implementation of such priorities as a public health policy.

Evolución y estado actual de las enfermedades no transmisibles en Argentina / Evolution and current status of non-communicable diseases in Argentina

Las enfermedades no transmisibles (ENT) explican más del 60% de las muertes en Argentina. El país atravesó el proceso de transición epidemiológica a mediados del siglo XX, disminuyendo en forma progresiva la mortalidad por enfermedades transmisibles y dando paso a una mayor proporción de muertes de causas no comunicables. Las ENT no sólo constituyen las principales causas de mortalidad, sino que también son la principal causa de años potenciales de vida perdidos (APVP).MÉTODOS: Para la elaboración de este reporte, se estimaron las tasas de mortalidad ajustadas por edad tomando como referencia la población estándar argentina del año 2000, y se calcularon los APVP ajustados por edad para los principales grupos de causas de ENT entre 1987 y 2007. RESULTADOS: La mortalidad por causas cardiovasculares fue disminuyendo de manera sostenida y la mortalidad por tumores y por lesiones por causas externas se han mantenido estables. Las ENT son las principales responsables de los APVP, representando el 52% de los mismos. Si bien la cantidad de APVP por estas causas disminuyó aproximadamente un 30%, se observa que la reducción en los APVP por enfermedades transmisibles, maternas, perinatales y nutricionales disminuyó en mayor medida. Por su parte, los APVP por lesiones externas descendieron solamente un 7% desde 1987. Además, al analizar los datos por regiones se observa que las ENT explican cada vez mayor proporción de APVP. CONCLUSIONES: Estos hallazgos resaltan la necesidad de implementar medidas orientadas a la prevención y control de los principales determinantes de las ENT, mediante intervenciones poblacionales y a través de los servicios de salud. Por otro lado, el hecho de que la mortalidad por lesiones de causas externas se ha mantenido estable, pero han aumentado proporcionalmente como causas de APVP, obliga a jerarquizar acciones que las controlen.

Proceso para priorizar las líneas de investigación esencial de interés para el Ministerio de Salud de Chile / Definition of priorities in health research for the Ministry of Health

Health research oriented to solve the most relevant sanitary problems in Chile must be encouraged. In 2001, the National Health Research Fund (FONIS) was created by the National Research Council of the Ministry of Health and the National Scientifc Research Commission, to stimulate relevant health research that contributes to develop health care policies. In 2008 an experts meeting proposed eighty research areas. These areas were grouped in twelve thematic containers. Each of these containers were classifed as having maximal, intermediate or minimal priority. The seven most important containers were grouped in three areas. Among the latter, two were selected. One is evaluation of the Ministry programs and, within this area, with the following priorities in decreasing importance: primary prevention, health care priorities, and diseases included in the Explicit Guarantees plan. The second area corresponds to diseases with high prevalence, incidence, costs or impact, including the following priorities in diminishing importance: mental health, diseases of high prevalence and problems with social impact.

El análisis causa-raíz como oportunidad de mejora de la seguridad en la atención perinatal: análisis de un brote de infección intra-hospitalaria / Root Cause Analysis as an Opportunity to Improve the Safety of Perinatal Care: Analysis of a Nosocomial Infection Outbreak

La seguridad del paciente es un problema grave de salud pública en todo el mundo. El análisis causal con un enfoque sistemático y participativo es una herramienta útil para mejorar la seguridad. OBJETIVOS: Aplicar un análisis causa raíz (ACR) y proponer acciones para corregir estas causas y/o minimizar el riesgo de ocurrencia de eventos similares. MÉTODOS: Análisis Causa Raíz de un evento centinela ocurrido en Unidad de Cuidados Intensivos Neonatales del Hospital Penna de Bahía Blanca, Argentina, en las siguientes etapas: 1) Identificación y selección del evento; 2) Recopilación de la información y descripción del evento; 3) Construcción del mapa de los hechos; 4) Análisis de los factores contribuyentes y estudio de las barreras (físicas, administrativas, organizacionales) que pueden prevenir daños, 5) Desarrollo de soluciones y plan de acción. RESULTADOS: Se seleccionó un brote intra-hospitalario por Staphylococcus aureus meticilino resistente, calificado como catastrófico(muerte de un neonato y de frecuencia ocasional). Con el análisis causal se identificaron los factores humanos proximales y las fallas latentes del sistema relacionadas con aspectos de la organización, la gestión de la información, el manejo del contexto y la cultura corporativa. Como principales barreras de contención se reconocieron la adecuada comunicación entre los profesionales de la salud y la sistematización de los procesos relacionados con la adherencia del personal a las normas de bioseguridad. Luego se diseñó un plan de acción destinado a fortalecer estas barreras. CONCLUSIONES: El ACR es un método factible de implementar para el equipo de salud. Su uso permitiría mejorar la seguridad de los pacientes a través de la identificación y corrección de las fallas latentes del sistema

Patient safety is a serious global public health issue.The causal analysis with a systematic and participatory approachis a useful tool for improving safety. OBJECTIVE: to perform the causal analysis of a sentinel event in order to identify improvement opportunities, propose actions aimed at increasing patient safety and promote a collaborative approach by the health team. METHODS: Root Cause Analysis (RCA) of a sentinel event occurred in the Neonatal Intensive Care Unit of Hospital Penna de Bahía Blanca, Argentina, which included the following steps: 1)identification and selection of the event; 2) information collection and description of the event; 3) construction on the map of the facts; 4) analysis of contributing factors and study of the barriers(physical, administrative, organizational) that may prevent damage, 5) Developing solutions and action plan. RESULTS: an intrahospital methicillin-resistant Staphylococcus aureus out break that affected six new borns and caused one death was selected. The causal analysis permitted the identification of proximal human factors as well as latent system failures associated with organizational factors and factors related to information management, context management and corporative culture. Appropriate communication between health professionals and systematization of processes aimed at guarantying personal adherence to bio-security norms were identified as the main barriers. Interventions oriented to strengthen these barriers were proposed. CONCLUSIONS: ACR is a feasible method to be implemented by the health team. Its use permitted patient safety improvement through the identification and correction of the latent failures of the system

Las enfermedades crónicas no transmisibles en México: sinopsis epidemiológica y prevención integral / Chronic non-communicable diseases in Mexico: epidemiologic synopsis and integral prevention

El gobierno federal desarrolla acciones para reducir la mortalidad por las "enfermedades crónicas no transmisibles" (ECNT). Una de ellas es la creación de unidades médicas de especialidad (Uneme) diseñadas para el tratamiento especializado de las ECNT (sobrepeso, obesidad, riesgo cardiovascular y diabetes). La intervención se basa en la participación de un grupo multidisciplinario entrenado ex profeso, la educación del paciente sobre su salud, la incorporación de la familia al tratamiento y la resolución de las condiciones que limitan la observancia de las recomendaciones. El tratamiento está indicado con base en protocolos estandarizados. La eficacia de la intervención se evalúa en forma sistemática mediante indicadores cuantitativos predefinidos. Se espera que las Uneme resulten en ahorros para el sistema de salud. En suma, este último desarrolla mejores medidas de control para las ECNT. La evaluación del desempeño de las Uneme generará información para planear acciones preventivas futuras.

The federal government has implemented several strategies to reduce mortality caused by chronic non-communicable diseases (CNTD). One example is the development of medical units specialized in the care of CNTD (i.e. overweight, obesity, cardiovascular risk and diabetes), named UNEMES (from its Spanish initials). These units -consisting of an ad-hoc, trained, multi-disciplinary team- will provide patient education, help in the resolution of obstacles limiting treatment adherence, and involve the family in patient care. Treatment will be provided using standardized protocols. The efficacy of the intervention will be regularly measured using pre-specified outcomes. We expect that these UNEMES will result in significant savings. In summary, our health care system is developing better treatment strategies for CNTD. Evaluating the performance of the UNEMES will generate valuable information for the design of future preventive actions.

Cooperation partners in information sharing within the context of an Asian cancer network.

It would be a great mistake to analyze the health situation in Asia relying on the focus on individualism inherent in the sense of values of Europeans and Americans. Cooperation across fields is indispensable for effective control of the epidemic of disease we are facing in the 21st century. We need to concentrate efforts on bringing together specialists, not only within the various areas of medical practice, but also across such fields as economics, politics and information technology (IT). Asia differs from Europe and America in that it does not have any group political structure and therefore we must rely on voluntary integration of our efforts if we are to achieve the most effective application of our combined resources. Non-intervention in internal affairs is naturally a very important condition for success. Sharing of information while abiding by national regulations regarding medical data confidentiality does pose difficulties, but gentle persuasion to standardize processes with a shared commitment to overcoming problems should reduce opposition. Our common purpose in maintaining healthy societies, whether we be scientists, medical staff, economists, computer specialists or politicians, provides the bond. Ways and means by which this bond can be strengthened deserve our attention.

Health promotion for middle-aged Isan women, Thailand: a participatory approach.

It is increasingly clear that non-communicable diseases (NCDs), including cancer, diabetes, hypertension and atherosclerosis, are important not only for the developed but also the developing world. Prevention efforts depend on community-based interventions and for these to be successful a participatory approach is necessary. The present paper describes experiences with middle-aged females living in a village in Isan, the Northeastern area of Thailand, focusing on the steps necessary to develop trust between researcher and subjects, the actual conditions of the women involved and their problems. From this base a number of interventions are planned taking into account the wishes of the villagers themselves, including a project to facilitate participation in physical exercise, a prime measure for prevention of cancer and other NCDs.

Rabies and dog population control in Thailand: success or failure?

Despite a success in reducing rabies deaths from almost 200 to less than 20 annually, this may not be considered a success. More than 400,000 persons required rabies post-exposure prophylaxis (PEP) in 2003, more than 4 times as many as those in 1991 [93,641 cases in 1991; 183,815 in 1996 and 350,535 in 2001]. The number of samples submitted for testing in rabies diagnostic laboratories has been declining. However, the percent of samples that were confirmed infected with rabies during the 10 year period remained unchanged; within a range of 23 - 30% (MOPH report). Of the 6 million dogs roughly estimated to live in Thailand, there are no reliable data indicating their relative population densities or distribution patterns in various regions throughout the country. However, in a survey conducted by the Bureau of National Statistics and the Bangkok Metropolitan Administration in 1999, it was estimated that approximately 630,000 dogs dwell in Bangkok city (an area of 1 565 sq km). In this survey, approximately 110,000 of the dogs living in Bangkok were considered to be ownerless (stray or feral), whereas the remainder was believed to be owned or were community dogs. Nevertheless, it has not been known how many of the latter group can be accessible or are in compliance with local rabies control regulations. When the dog population statistics collected in 1999 are compared to an earlier survey conducted in 1992, the stray dog population appears to have almost tripled in size in Bangkok over the eight year

Evaluación del programa de prevención de cáncer de cuello uterino: Estado Nueva Esparta 2000-2002 / Evaluation of the cancer prevention program of cervix utery: Nueva Esparta State 2000-2002

El cáncer de cuello uterino es una alteración neoplásica de crecimiento lento, descontrolado y persistente del epitelio exocervical y endocervical, intraepitelial, luego invasivo. Es la primera causa de muerte por cáncer en la mujer. Para evaluar la cobertura alcanzada en la aplicación del Programa de Cáncer de Cuello Uterino en cuanto a pesquisas en Nueva Esparta durante el trienio 2000-2002. Se utilizaron datos de las citologías realizadas por la dirección del programa, encuestas y evaluación de los ambulatorios. Educación para la salud 81,39 por ciento, es adquirida en los ambulatorios, medios de comunicación 33,72 por ciento, en el hogar y escuela 29,17 por ciento. No existen limitaciones (infraestructura, materiales y personal) para ejecutar el programa. Se compararon los porcentajes de las metas del programa con los encontrados. Una cobertura de 11,93 por ciento para el 2000, 11,39 por ciento el 2001 y 7,77 por ciento el 2002 un promedio de 10,36 por ciento de cobertura, siendo la meta 30 por ciento de pesquisas citológicas adecuadas

HIV infection/acquired immunodeficiency syndrome at Siriraj Hospital, 2002: time for secondary prevention.

The authors retrospectively reviewed the medical records of HIV/AIDS patients who were admitted to the medical service, Siriraj Hospital from January 1, 2002 through December 31, 2002. Demographics, CD4 lymphocyte counts, discharge diagnoses, the incidence of Pneumocystis carinii pneumonia (PCP), cerebral toxoplasmosis and cryptococcosis in patients who received and did not receive appropriate chemoprophylaxis against those opportunistic infections when indicated, and outcome of the patients were collected. Three hundred medical records of 286 HIV/AIDS patients were available for review. One hundred and seventy two patients (60.1%) were male. Mean age of the patients was 36.8 +/- 9.91 years (range 14-74). The mean CD4 lymphocyte count that was determined in 165 patients was 74.7 +/- 134.21 cells/mm3 (range 0-894). Of the 300 admissions, 36 per cent were newly diagnosed HIV infection. Only 23 (7.7%) patients had received antiretroviral drugs at the time of hospitalization. The leading HIV-related diseases were tuberculosis (29.3%), Pneumocystis carinii pneumonia (18.7%), and cryptococcosis (15.7%). The rest of them included cytomegalovirus diseases (6.3%), lymphoma (6.3%), Salmonella bacteremia (6%), cerebral toxoplasmosis (5.7%), cryptosporidiosis (5.3%), disseminated Mycobacterium avium complex infection (1.0%), extrapulmonary histoplasmosis (1.0%), Candida esophagitis (1.0%), progressive multifocal leukoencephalopathy (1.0%), and rhodococcosis (0.7%). Among those for whom HIV infection was established and chemoprophylaxis for PCP, cerebral toxoplasmosis and cryptococcosis were indicated, 9.8 per cent vs 28.2 per cent, 3.6 per cent vs 5.1 per cent, and 10 per cent vs 15.2 per cent of whom received and did not receive the appropriate chemoprophylaxis developed PCP, cerebral toxoplasmosis and cryptococcosis respectively. One hundred and ninety (63.3%) patients were alive at discharge, 84 (28.0%) had died, 21 (7%) were referred to other hospitals, and 5 (1.7%) left hospital against medical advice. The mortality rate in newly diagnosed HIV and in known HIV without antiretroviral treatment were comparable but much lower in known HIV-infected patients who received antiretroviral therapy. Secondary prevention by detection of HIV-infected patients while they are asymptomatic and providing them with appropriate chemoprophylaxis against specific opportunistic infections as well as appropriate antiretroviral treatment would decrease morbidity, mortality, and improve the quality of life of HIV-infected patients in Thailand.

Prevention of thalassemia: experiences from Samui Island.

Thalassemia is one of the most important genetic disorders in Thailand. A model for prevention of thalassemia by combining 4 strategies including education, carrier screening, counseling and prenatal diagnosis was developed by a thalassemia task force. A thalassemia work group was formed in order to develop a mechanism to integrate the model for real use on Samui Island where thalassemia is common and a specific disease oriented program is required. 200 health professionals working on Samui Island participated in the thalassemia educational courses. The specific training courses were also provided for obstreticians, medical technologists and counselors. A team of well-trained health professionals was established to manage public education. Information booklets, posters, brochures and mass media including spot radio and newspapers were used as educational materials. For carrier screening, blood samples of pregnant women from all health care organizations on Samui Island were collected and screened for thalassemia carriers by using the osmotic fragility (OF) test/the dichlorophenol indophenol precipitation (DCIP) tests at Samui Hospital. Samples with positive results were sent to the Regional Medical Sciences Center in Surat Thani for thalassemia diagnosis. When a carrier was identified, her spouse was offered testing. For at-risk couples, details of the disorder were included in counseling to help them reach a decision that was right to them, in the context of their unique medical, moral and social situations. Amniotic fluid samples were collected for prenatal diagnosis. All patient information was registered by using computer software. After 1 year of integration by using facilities of the Ministry of Public Health service system, a wide range of problems were identified. They underlined the need for effective health service structure co-operation, adequate education of responsible health professionals, explicit policies and a clear line of responsibility at local, regional and national levels for service development and quality management. It is hoped that all information conducted in the present study will be useful to health authorities to develop an explicit policy and promote the health service structure co-operation in the country that will finally lead to successfully reducing the frequency of severe thalassemia in the future.