RESUMO
<B>Background</B><BR>Mortality statistics are key inputs for evidence based health policy at national level. However mortality statistics alone does not provide necessary information for further identification of improvement opportunities which could be manageable in local health systems in the place where vital registration system is not established.<BR>This study intends to disclose the profile of death events among the urban poor, with aim to identify improvement opportunities from the view of quality management of local health system.<BR><B>Methods</B><BR>Eleven communities in Ancol, Jakarta, were selected for the survey, and the information of death events were collected from community leaders of rukun warga (RW), village office, health centers, hospitals, and public cemeteries. The families or co-habitants of the deceased cases under 55 years old were interviewed.<BR><B>Results</B><BR>Two hundred and twenty four of death events were identified. The number reported in the demography statistics was 114 in 24 months during the same period, while 67 cases less than 55 years old were investigated by interview regarding history prior to death. . Thirty-eight percent died at healthcare facilities while 59% died at home. Private services were consulted as frequently as public services. Case studies based on history review revealed “improvement opportunities” in local health systems, and some of those critically contributed to eventual deaths which would be prevented by improvement in quality management of local health systems.<BR><B>Conclusion</B><BR>Community death events were good tracer for assessment of actual performance of local health systems as well as for identifying improvement opportunities.
RESUMO
Risk of infection with leptospirae during farmwork was estimated using information from past leptospirosis outbreaks in both Miyagi Prefecture, Japan (around 1960) and northeastern Thailand (around 2000). Outbreaks of leptospirosis in Miyagi Prefecture were concentrated in October, while it occurred throughout the rainy season, showing a tendency to decentralize, in northeastern Thailand. In 1959, a large leptospirosis outbreak occurred in Miyagi Prefecture. The risk (1,600/100,000) of leptospira infection in the high-risk area during that outbreak was 3.4 times as high as that (470/100,000) in the middle-risk area. The risk in this year was 5.7 (high-risk area), 2.8 (middle-risk area) and 2.0 (low-risk area) times higher than that in the same area from 1960 to 1964 which could be considered as the average risk in the past time. In northeastern Thailand, the risk (50/100,000) of leptospira infection was 30 percent compared with that (170/100,000) in the middle-risk areas in Miyagi Prefecture from 1960 to 1964. Based on the risk, number of leptospirae invading into human body through skin during farmwork was estimated with the dose-response model. In Miyagi Prefecture and northeastern Thailand, the estimated numbers were 65-1,200 and 3.5-42 leptospirae per 100,000 exposures which means frequency of the daily farmwork, respectively. On the other hand, the calculation under possible environmental conditions (e.g. density of rats carrying leptospirae, water depth in paddy field) demonstrated that farmers had been in contact with 4,300 leptospirae only in an hour of their work. The result showing only a small part of leptospirae in contact invaded into human body primarily attributes to the strong structure of unwounded skin composed of stratified squamous epithelium and dermis. And also the result can be explained by a hydraulics theory. Although leptospirae being nearby skin surface can attach to skin since the water flow does not occur there, the spirochetes a little away from skin surface are easily transported with the flow and would be unable to invade into human body.