Community-based noncommunicable disease interventions: lessons from developed countries for developing ones.

Community-based programmes for prevention and control of cardiovascular diseases (CVD) started in Europe and the USA in the early 1970s. High mortality from CVD in Finland led to the start of the North Karelia Project. Since then, a vast amount of scientific literature has accumulated to present results and discuss experience. The results indicate that heart health programmes have a high degree of generalizability, are cost-effective and can influence health policy. In the 1980s the focus of programmes expanded from CVD to noncommunicable diseases (NCD), mainly because of the common risk factors. Attention has now turned to promoting this approach in developing countries, where the prevalence of NCD is growing. Theory and experience show that community-based NCD programmes should be planned, run and evaluated according to clear principles and rules, collaborate with all sectors of the community, and maintain close contact with the national authorities. In view of the burden of disease they represent and of globalization, there is a great need for international collaboration. Practical networks with common guidelines but adaptable to local cultures in a flexible way have proved to be very useful.

Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease.

OBJECTIVE: To determine the frequency of occurrence and long term evolution of subclinical carditis in patients with acute rheumatic fever. DESIGN: Valvar incompetence was detected by clinical examination and Doppler echocardiographic imaging during the acute and quiescent phases of rheumatic fever. Patients were followed prospectively and submitted to repeat examinations at one and five years after the acute attack. Persistence of acute mitral and aortic lesions detected solely by echocardiography (subclinical disease) was compared with that of disease detected by clinical examination as well (thereby fulfilling the latest 1992 Jones criteria for rheumatic carditis). SETTING: Three general hospitals with a university affiliation in Chile. PATIENTS: 35 consecutive patients fulfilling the revised Jones criteria for rheumatic fever. Clinical and echocardiographic examination was repeated in 32 patients after one year and in 17 after five years. Ten patients had subclinical carditis on admission, six of whom were followed for five years. MAIN OUTCOME MEASURES: Auscultatory and echocardiographic evidence of mitral or aortic regurgitation during the acute attack or at follow up. RESULTS: Mitral or aortic regurgitation was detected by Doppler echocardiographic imaging in 25/35 rheumatic fever patients as opposed to 5/35 by clinical examination (p = 0.03). Doppler echocardiography revealed acute valvar lesions in 10 of 20 rheumatic fever patients who had no auscultatory evidence of rheumatic carditis (subclinical carditis). Three of these subclinical lesions and three of the clinical or auscultatory lesions detected on admission were still present after five years of follow up, emphasising that subclinical lesions are not necessarily transient. CONCLUSIONS: Doppler echocardiographic imaging improves the detection of rheumatic carditis. Subclinical valve lesions, detected only by Doppler imaging, can persist. Echocardiographic findings should be accepted as a major criterion for the diagnosis of rheumatic fever.

Prevalence and mechanisms of macrolide resistance in Streptococcus pyogenes in Santiago, Chile.

Thirty-two macrolide-resistant Streptococcus pyogenes isolates were found among 594 clinical isolates collected from 1990 to 1998 in Santiago, Chile, for an overall prevalence of 7.2%. Among the 32 resistant isolates, 28 (87.5%) presented the M phenotype and 4 (12. 5%) presented the MLS(B) phenotype. Serotyping and pulsed-field gel electrophoresis analysis showed genetic diversity among the resistant isolates.

Distribution and prevalence of major risk factors of noncommunicable diseases in selected countries: the WHO Inter-Health Programme.

The Inter-Health Programme was launched in 1986 by WHO, with the collaboration of a coordination centre (National Public Health Institute, Finland) to control and prevent chronic noncommunicable diseases (CNCDs) among adults. Programmes for action were organized based on the concept that most major CNCDs share common risk factors and that those that are lifestyle related are modifiable through efficient interventions using multifactorial strategies involving community participation and behaviour changes carried out at the primary health care level. Twelve countries from all WHO Regions have joined the programme. A baseline survey was undertaken in all countries with a common protocol, following the criteria and methods employed in the MONICA Project. Altogether 36815 men and women aged 35-64 years were included in the present analysis from the following Inter-Health countries: Chile, China, Cyprus, Finland, Lithuanian SSR, Malta, Mauritius, Russian SFSR, United Republic of Tanzania, and USA. In addition to individual country analysis, centralized analysis was carried out at the Finnish National Public Health Institute and the Department of Community Health, Kuopio University, Finland. Reported here are the mean values of blood pressure, body mass index, and serum total cholesterol as well as specific prevalences of smoking, hypertension, obesity, and hypercholesterolaemia.

PIP: The Inter-Health Program was launched in 1986 by the World Health Organization (WHO) with the collaboration of Finland's National Public Health Institute to control and prevent chronic noncommunicable diseases (CNCDs) among adults. The program consists of interventions designed to modify the levels of the major risk factors of CNCDs in the community through an integrated, community-oriented approach to health promotion and maintenance. 12 countries from all WHO regions have joined the program. The effects of intervention activities were measured by examining changes in the status of risk factors in populations before and after a given intervention. A baseline survey was conducted in all of the Inter-Health countries with a common protocol to identify the relevant risk factors. 36,815 men and women aged 35-64 from Chile, China, Cyprus, Finland, Lithuania, Malta, Mauritius, Russia, Tanzania, and the US were surveyed. This paper reports the mean values of blood pressure, body mass index, and serum total cholesterol as well as specific prevalences of smoking, hypertension, obesity, and hypercholesterolemia.

Discontinuing rheumatic fever prophylaxis in selected adolescents and young adults. A prospective study.

OBJECTIVE: To assess the safety of discontinuing prophylaxis with antimicrobial agents in patients judged to be at relatively low risk for recurrence of acute rheumatic fever. DESIGN: Observational cohort study. SETTING: Public health clinics in the Southeast Health District of Santiago, Chile. PATIENTS: Fifty-nine patients (19 men, 40 women) ranging in age at study entry from 15 to 44 years (mean, 24.5 years). Forty-eight had completed their prescribed period of prophylaxis. Eleven refused or were allergic to intramuscular benzathine penicillin G and were non-compliant with oral sulfadiazine. INTERVENTION: In patients who did not have carditis during their previous attack(s), prophylaxis was discontinued after 5 years or at age 18, whichever was longer. In those with only mild mitral regurgitation or healed carditis, prophylaxis was stopped after 10 years or at age 25. Symptomatic intercurrent streptococcal throat infections were treated with antibiotics. MEASUREMENTS: Patients were seen every 3 months during the study (July 1982 to September 1988). For the first 4.25 years, throat cultures as well as sera samples for antistreptolysin O and anti-DNAse B assays were obtained at each visit. RESULTS: During laboratory surveillance, significant increases in antibody titers were detected in 56 instances (28.1 [95% CI, 21.7 to 36.5] per 100 patient-years), and 29 isolations of group A streptococci occurred (14.5 [CI, 10.1 to 20.8] per 100 patient-years). The patients were followed for a total of 3349 patient-months, during which time two acute rheumatic fever recurrences were observed (0.7 [CI, 0.2 to 2.6] per 100 patient-years). No recurrences occurred during an outbreak of acute rheumatic fever in 52 patients in the study area in 1986. CONCLUSIONS: These and other data indicate that acute rheumatic fever prophylaxis can safely be discontinued in young adults judged to be at low risk for recurrence and who are maintained under careful prospective surveillance.

[Alcohol drinking in parents and its relation with intellectual score of their children]. / Ingestión de alcohol en los padres y su relacion con el coeficiente intelectual de sus hijos.

Among children living in orphanages of the Metropolitan Region, the paternal alcohol ingestion patterns were investigated. According to abnormal parental alcohol ingestion, a sample of 291 children was studied, of whom 32% were living in simple protection homes for infants with normal intellectual coefficient and 52% in homes for mentally retarded boys. There was a higher frequency and intensity of abnormal alcohol ingestion among parents of infants living in homes for the mentally retarded. Among these, 29% of mothers were illiterate and 11% had incomplete primary school education compared to mothers of simple protection homes in whom the frequency of illiteracy was 10% and of incomplete primary education, 50%. Twenty percent of fathers of children living in homes for the mentally retarded were unemployed, 16% had occasional jobs and 11% had a stable work; these numbers were 11, 30 and 15% respectively for fathers of simple protection homes. Among infants living in homes for the mentally retarded, undernutrition was found in 44%, growth retardation in 51% and microcephaly in 34% compared to 33, 30 and 11% in children living in simple protection homes. Sixteen percent of the sample had fetal alcohol syndrome, 24% among those living in homes for the mentally retarded and 12% in simple protection homes. There was an inverse relationship between offspring intellectual coefficient and the number of drinking parents.

Anticardiolipin antibodies in acute rheumatic fever.

Recent reports describe the association of antiphospholipid antibodies (aPL) with chorea or severe heart valve lesions in systemic lupus erythematosus, lupus-like disease, or the primary antiphospholipid antibody syndrome. We conducted a case series and a case-control investigation of patients with rheumatic fever with Sydenham chorea or other manifestations of rheumatic fever for anticardiolipin antibodies (aCL) during the acute attack and disease remission. Eighty percent of patients were positive for aCL during the rheumatic fever attack vs 40% when inactive (p = 0.035); IgG and IgM aCL increased significantly with disease activity. Individuals with or without Sydenham chorea were equally positive for aCL (76 and 83%, respectively). A significant association was found between IgM aCL and carditis: All patients with valvulitis had IgM aCL (100%) vs 37% of patients without valvular involvement (p = 0.02). aPL may play a role in the pathogenesis of some clinical manifestations of acute rheumatic fever.

[Alcohol consumption in the adult population from the metropolitan region: prevalence and consumption modalities]. / Consumo de alcohol en población adulta de la región metropolitana: prevalencia y modalidad de consumo.

A representative sample from the adult population of metropolitan Santiago was surveyed for prevalence and modality of alcohol consumption. The "problem drinker" was identified according to the CAGE questionnaire. Socioeconomic situation was classified according to the method of Graffar. 70% of male and 50% of female drinkers consumed less than 400 ml of ethanol per month. Prevalence of drinking in males and females was: all categories 56.2 and 19.8%, regular drinkers 40.8 and 14.4%; heavy drinkers 4 and 0.82% and problem drinkers 12.4 and 1.5%, respectively. 85% were weekend drinkers, 11% consumed alcohol throughout the week. Males consumed mostly wine and mixed alcoholic beverages, females mostly the latter. In males, drinking was related to age and not to socioeconomic condition, except for problem drinkers who were mostly found in the low category. Females problem drinkers were found mostly in the high socioeconomic group. These data may be used in planing intervention strategies to prevent damage caused by alcohol consumption.

[Non transmissible chronic diseases. A preventive approach]. / Las enfermedades crónicas no trasmisibles. Un enfoque preventivo.

Non transmissible chronic diseases, accidents and violence cause 70-80% of deaths in developed countries and 40-50% in underdeveloped ones, including Chile. Their relative contribution to mortality in Chile has increased from 34% to 64% in the last 30 years. Prevention is possible by controlling risk factors such as smoking, alcohol, obesity, hypertension and hypercholesterolemia. Preventive programs should be implemented based on available studies of the epidemiology of risk factors in our country. Population intervention to obtain better health habits and special actions for individuals with risks factors must be employed. Local health services, the community and the media must participate, the cornerstone of the program being population education, particularly those of younger age. A model to be followed is the Interhealth Project, sponsored by WHO and led by Finland (North Karelia).

[Risk factors for arterial hypertension in the natives of Easter Island]. / Factores de riesgo de hipertensión arterial en nativos de Isla de Pascua.

Blood pressure, weight, height and cardiovascular risk factors were evaluated in 73 adults of Easter Island (mean age 49 +/- 12.9 (SD) years) in January 1989 and 1990. Their mean blood pressure (BP) was 129 +/- 24/81 +/- 14, significantly higher by 7/5 mm Hg than in 1979 (p < 0.05). Of the population studied 30% of subjects were hypertensives. Both systolic (S) and diastolic blood pressure (DBP) correlated with age (r = 0.40, p < 0.005 and r = 24, p < 0.05 respectively). In males body mass index correlated strongly with SBP and DBP (r = 0.55, p < 0.005 and r = 0.52, p < 0.01). Forty eight % of subjects were obese, 60% smoked (14 cigarettes/day), 38% drank alcohol and 70% lead sedentary lives; their level of stress was considered average. In 23 normotensives or undiagnosed hypertensives 24 hour urine was collected for sodium, potassium, creatinine and kallikrein; mean urinary sodium excretion was 121 +/- 39 mmol/day; potassium excretion 59 +/- 29 mmol/day, creatinine excretion 1383 +/- 489 mg/day and kallikrein excretion 682 +/- 355 mU/day; of these, only urinary sodium was significantly lower than values determined in a group of 29 continental volunteers. Eleven natives that had never left the island had similar BP and risk factors than a sex and age paired sample, who has spent 10.9 +/- 7.8 years in the continent. The present study demonstrates that Easter Island natives have increased their mean BP in 10 years, elevated their BP with age and have lost the protection previously associated to staying in the island.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevalence of risk factors for chronic diseases. A study in the general population of the metropolitan area, 1986-1987]. / Prevalencia de factores de riesgo de enfermedades crónicas. Estudio en población general de la región metropolitana, 1986-1987.

Risk factors for chronic diseases were studied in a random sample of 475 males and 728 females from the Metropolitan area of Santiago. A questionnaire was used to estimate the consumption of alcohol and tobacco and the level of physical activity. Weight and height were measured and socio-economic situation was classified according to Graffar. Prevalence rates for males and females were: hypertension 8.6 and 9.1%; obesity 13.2 and 22.7%; present sokers 50.7 and 43.4%; sedentarism 75.6 and 86.9%; alcohol consumption 56.2 and 19.8%. Thus, women show higher rates than males for hypertension, obesity and sedentarism. They smoked as much as males and consumed less alcohol. Among women a higher prevalence of obesity, alcohol consumption and sedentarism was observed in lower socio-economic classes. Among males, only sedentarism was more prevalent in lower socio-economic classes. The number of risk factors present was 1 in 28.6% of the population; 2 in 40.1%; 3 in 22.1%; 4 in 3.7% and 5 in 0.1%. Absence of risk factors was observed in only 5.4% of the population. The present data may help to design preventive strategies for diseases related to these risk factors.

[Epidemic outbreak of acute post streptococcal glomerulonephritis]. / Reflexiones sobre un brote epidémico de glomerulonefritis aguda postestreptocócica.

An outbreak of post streptococcal acute glomerulonephritis (PSAGN) was recorded in the South East Health Service (SEHS) of Santiago, Chile, between 1984 and 1987. Some aspects related to its epidemiology and natural history are discussed. This outbreak was preceded by streptococcal skin infection (SSI) in 60% of cases vs. 36% during the previous period. At the same time it was observed an increased isolation rate of group A beta hemolytic streptococci (GABHS) of skin origin, and a high prevalence of anti-DNase B antibodies (ADB) in the general population, what reveals an important skin-GABHS reservoir in the community. In Chile, skin infections with GABHS are frequently secondary to scabies. The trend of scabies in the last years has been similar to that of PSAGN. The need for control and treatment of scabies is emphasized to interrupt the epidemiological chain. The protection of household contacts with Benzathin Penicillin is recommended because lower secondary attack rate has been observed in prophylaxis versus non protected groups.

[Streptococcal antibodies in a general population. Comparative study in 2 periods at a health service]. / Anticuerpos antiestreptocócicos en población general. Estudio comparativo en dos períodos en un servicio de salud.

Antibodies to streptococcal Estreptolysin O and DNAse B were sampled from 1986 through 1989 in 135 healthy individuals of both sexes, grouped by age, at a metropolitan area of Santiago, Chile, and their geometric mean titers (GMT) were calculated. GMT of 110 U (Todd) for Antiestreptolysin and 194 U for Anti-DNAse B were recorded in the whole sample. Antiestreptolysin O titers were 62 UT for age group 5 to 9 years, 127 UT for 10 to 14 year olds and 114 UT for ages 15 or older. Anti-DNAse B titers for the same age groups were 158 U, 240 U and 198 U respectively. No significant differences were detected between these results and those from an earlier (1978 to 1981) study, except for Anti-DNase B titers in 5 to 9 years olds, which were significantly lower (GMT 158 U vs. 270 U) in the most recent screening.

Pharmacokinetics of benzathine penicillin G: serum levels during the 28 days after intramuscular injection of 1,200,000 units.

Because of published data suggesting the inadequacy of once-every-4-weeks intramuscular injections of benzathine penicillin G for secondary rheumatic fever prevention, serum penicillin levels were determined at 1, 3, 10, 21, and 28 days after administration of 1,200,000 units of this repository penicillin. A total of 193 samples were studied. Mean serum penicillin levels remained greater than or equal to 0.02 micrograms/ml for 21 days, but by 28 days only 44% of the serum samples had detectable levels of penicillin and only 36% had levels greater than or equal to 0.02 micrograms/ml. Patients weighing more than 45 kg had significantly lower serum penicillin levels than did those who weighed less. There were similar correlations with body surface area and with age. These data indicate that a significant percentage of patients receiving benzathine penicillin G prophylaxis for prevention of recurrent attacks of rheumatic fever are not protected during the fourth week. More frequent administration of benzathine penicillin G should be considered in instances of high risk of recurrence of rheumatic fever.