Diagnostic evaluation of people with hypertension in low income country: cohort study of "essential" method of risk stratification.

OBJECTIVES: To explore the predictive power of a risk stratification method for people with hypertension based on "essential" procedures (that is, available in economically less developed areas of the world), comparing it in the same population with the results given by the method suggested by the 1999 World Health Organization-International Society of Hypertension (WHO-ISH) guidelines. DESIGN: Prospective cohort study of outcomes according to cardiovascular risk profile at baseline. SETTING: Primary care in a poor rural area of the Ecuadorian forest. PARTICIPANTS: 504 people with hypertension prospectively monitored for a mean of 6.7 (SD 2.3) years. INTERVENTIONS: Essential data included blood pressure, medical history, smoking, age, sex, and diagnosis of diabetes; the WHO-ISH methods additionally included measurement of fasting blood glucose, total cholesterol, and creatinine, urinalysis, and electrocardiography. MAIN OUTCOME MEASURES: Cardiovascular events and total deaths. RESULTS: With both methods there was a highly significant association between the level of predicted risk and the incidence of cardiovascular events and of total deaths: up to three quarters of all cardiovascular events and two thirds of all deaths were reported among people classified as at high or very high risk with either method. The predictive discrimination of the essential method is comparable with the WHO-ISH with C statistics (95% confidence interval) of 0.788 (0.721 to 0.855) and 0.744 (0.673 to 0.815), respectively, for cardiovascular events and 0.747 (0.678 to 0.816) and 0.705 (0.632 to 0.778) for total mortality. CONCLUSIONS: The risk stratification of patients with hypertension with an essential package of variables (that is, available and practicable even in the economically less developed areas of the world) serves at least as well as the more comprehensive method proposed by WHO-ISH.

Community participation eliminates yaws in Ecuador.

Yaws is no longer a national and international health priority for intervention, but there is still a negative perception of the disease in the few affected communities. A survey in 1988 in the northern region of Ecuador documented a prevalence of 16.5% of clinical cases and 96.3% of serological cases. A continuous, long-term community-based surveillance programme was therefore put in place focusing on yaws as one of the sentinel diseases. The results of this intervention are reported here. In 1993, a second survey showed a reduction in the prevalence of clinical cases to 1.4% and of serological cases to 4.7%. Between 1993 and 1998, no other clinical cases were detected and the serological prevalence in 1998 was 3.5%, corresponding with clinical cases of primary or congenital syphilis, latent yaws under follow-up, and individuals with low serological titres indicating a 'serological scar'. These data indicate that yaws has been eliminated. Another important outcome of the intervention is the increased self-confidence in the communities that health problems can be tackled.

Treatment and control of arterial hypertension in a rural community in Ecuador.

Cardiovascular diseases are widespread in developing countries, but little is known about cardiovascular risk profiles in rural communities. To assess the importance of arterial hypertension in a rural district of Ecuador, we screened 4284 of the 8876 adults who lived in the area. 1542 (36%) individuals had hypertension, only four (0.3%) of whom were well controlled by treatment. We monitored all deaths for 2.5 years, and noted that cardiovascular diseases were the primary cause of death in the adult population. Furthermore, of the individuals who died of a cardiovascular disease, four out of five had a history of hypertension. Our findings indicate that in this rural area of Ecuador the high prevalence of uncontrolled hypertension is a major cause of total mortality.