Epidemics and epidemiology: back to the future.

The word "epidemiology" was written for the first time in a report on the plague in Alghero in 1583. Although its etymology has it intricacy. For centuries it has been concerned with understanding and trying to control and prevent epidemics. During the cholera epidemic in London in 1848 the London Society of Epidemiology was formed, main instrument of public health since then. The increase in chronic diseases -supposedly no communicable- gave way to the epidemiology of black boxes and the predominance of risk factors. And later to an enormous methodological progress increasingly complex and intricate but professionally very appealing. So few epidemiologists have experience in field control of epidemics. Thus, perhaps it is convenient to return, although partially, to the origins. Looking at the future.

[Deaths by COVID-19: Not all were registered and others should not be accounted for]. / Defunciones por COVID-19: no están todas las que son y no son todas las que están.

The death counts from COVID-19 have generated public controversy. The regional health councils' need for information regardind the cases, has generated a variety of formats and procedures, used to report this information. Consecuently, this data has not always been communicated in a comparable maner to the Ministry of Health. The compilation of mortality statistics is complex. Central and autonomous public administrations are involved, and not in the same way. The medical death certificate (DC) is the main source of information that allows to specify place of occurrence and causes of death. The on-line registration of the DC in the computerized civil registry and/or digital medical records, would allow to establish a statistical processing circuit, and to obtain a death count more quickly according to causes of death in the event of a health emergency. This requires a multi-level institutional agreement for a total telematics statistic process of death causes in Spain.

[Updated medical death documents: Medical Death Certificate and the Birth Statistics Bulletin]. / Documentos médicos de la defunción actualizados: certificado médico de defunción y boletín estadístico de parto.

Public health physicians have constantly urged that the Medical Death Certificate (CMD in Spain) and the notification of perinatal deaths be adapted to WHO standards. The new CMD came into effect in January 2009, whilst significant changes were made to the Birth Statistics Bulletin (BEP acronym in Spanish) in 2007. In this article the certifying doctor is informed on their novel and key aspects. The health significance of this medico-legal act is emphasised. At the same time associated issues are mentioned that still need to be resolved in Spain. The CMD unifies the medical certificate and the death statistics bulletin on one form and complies with WHO recommendations. It asks whether the death has been the result of an already registered traffic or work accident, and if an autopsy (clinical) has been performed. For place of death, it means the place where the cadaver has been recognised and the death certified. The approximate time of the causes of death must also be indicated. The BEP registers the births and deaths in labour. It includes the education level and occupation levels of the mother and father, and still has the number of weeks gestation and the birth weight in grams. Notification of legal deaths and perinatal deaths still need to be improved; the confidential transfer of causes of death to doctors and researchers; and death statistics according to cause with less delay between the events and their availability and publication.

Medical societies' recommendations for immunization with Human Papillomavirus vaccine and disclosure of conflicts of interests.

OBJECTIVE: To review the recommendations on Human Papillomavirus (HPV) vaccination issued by different medical societies, as well as disclosures of any conflict of interests regarding such recommendations. METHODS: The search for recommendations was mainly conducted through the Internet, together with a bibliography search on Pubmed (November 2008). The countries were selected to encompass a broad range of healthcare systems and income levels. RESULTS: In all, 18 documents were identified: 4 from the U.S., 5 from Canada, and 1 from France (all 10 in favor of recommending vaccination), 5 from Spain (3 in favor of vaccination and 2 recommending no vaccination until further evidence of the vaccine effectiveness to prevent cervical cancer becomes available), 2 from Argentina (one in favor of vaccination and another pointing to the missing information on the vaccine's cost-effectiveness), and 1 from Chile (recommending no vaccination until more information becomes available). Only two documents disclose specific conflicts of interests for authors (American Cancer Society and Chilean Working Group on HPV). One of the Canadian documents did not include any conflict of interest statement, although Merck and GSK are listed among the sponsors. CONCLUSIONS: Disclosure of conflicts of interest in documents where medical societies issue recommendations on HPV vaccination is very unusual. However, lack of disclosure is more frequent (near twice) when recommendations are in favor of the vaccination.

[Health policies (population interventions) in health services. 2008 SESPAS Report]. / Políticas de salud (actuaciones poblacionales) en los servicios asistenciales. Informe SESPAS 2008.

Health interventions addressed to the population as a whole from health care services are scarce and only exceptionally involve coordination among public health services (vaccinations and, in some autonomous communities, secondary breast cancer prevention). Health education programs addressed to schools are one of the most frequent interventions but their outcomes are not systematically evaluated. However, primary health care services carry out many clinical preventive activities. While the aims of these activities are laudable, the interventions themselves have substantial limitations, because they are an important source of dependency, a powerful incentive to consume drugs, and are also inefficient and inequitable ways of spending health resources. These limitations justify the testing of combined approaches between public health services and citizens' collectives to improve and protect community health. Developing community health programs based on cooperation between primary health care services and public health services requires strategies that produce appreciable results in the short term to both health sectors, as well as to the population, so that these programs stimulate the process and encourage further development. The settings in which collaboration is most promising are population health surveillance and monitoring in basic health areas, control of communicable diseases and epidemic outbreaks, health promotion and health protection programs through simultaneous clinical and community-based interventions, and improved management of all health services in local communities through joint evaluation. The resources needed to carry out these activities should be drawn from a reduction of clinical preventive activities that reduce workload and from an increase in the number and quality of the public health workforce.

Epidemics and epidemiology: back to the future / Epidemias y epidemiología: regreso al futuro

The word “epidemiology” was written for the first time in a report on the plague in Alghero in 1583. Although its etymology has it intricacy. For centuries it has been concerned with understanding and trying to control and prevent epidemics. During the cholera epidemic in London in 1848 the London Society of Epidemiology was formed, main instrument of public health since then. The increase in chronic diseases —supposedly no communicable— gave way to the epidemiology of black boxes and the predominance of risk factors. And later to an enormous methodological progress increasingly complex and intricate but professionally very appealing. So few epidemiologists have experience in field control of epidemics. Thus, perhaps it is convenient to return, although partially, to the origins. Looking at the future. (AU)

La palabra «epidemiología» se escribió por primera vez en un informe sobre la peste en Alghero, en 1583. Aunque su etimología tiene su intríngulis. Durante siglos se ha ocupado en comprender y tratar de controlar y prevenir las epidemias. Durante la epidemia de cólera en Londres en 1848 se creó la Sociedad de Epidemiología de Londres, principal instrumento de salud pública desde entonces. El aumento de las enfermedades crónicas —supuestamente no transmisibles— dio paso a la epidemiología de las cajas negras y al predominio de los factores de riesgo. Y más tarde a un enorme desarrollo metodológico cada vez más complejo e intrincado, pero profesionalmente muy atractivo. Muy pocos epidemiólogos tienen experiencia en el control de epidemias en el campo. Así, quizás convenga volver, aunque sea parcialmente, a los orígenes. Mirando al futuro. (AU)

Towards unity for health in the Barceloneta: an innovative experience in community-based primary health care.

CONTEXT: This paper describes a unique experience in community-based primary care in the Barceloneta, an economically deprived neighbourhood in Barcelona, Spain. The paper analyzes the reasons for the successes and failures of the project in light of TUFH principles. METHODS: The Primary Care Team (PCT) that staffed and ran the Health Centre in the Barceloneta facilitated the active participation of entities and individuals from the neighbourhood in deciding questions of care provision and resource allocation. They also collaborated with other service providers in the neighbourhood including pharmacists, with whom the PCT developed a program for monitoring diabetic and hypertensive patients in the local pharmacies. RESULTS: The health centre registered some of the best outcomes in Barcelona, including: time spent with each patient; capacity for the physicians to resolve patient visits without a referral; and patient satisfaction. Outcomes for patients followed by their local pharmacists were equivalent to those seen in the clinic, with lower costs. Despite these impressive results, conflicts among and between various stakeholders led to the project's termination. CONCLUSIONS: Innovations in any system can lead to conflicts of interest between stakeholders, derailing even demonstrably effective programs. A stable partnership with other stakeholders, particularly the community and health care administrators, in this case, is key. However, the community is not monolithic, and efforts must be made to ensure that other stakeholders do not widen intercommunity disputes. Effective dissemination of information on the impact of the project on the population is important to maintain relationships with the various stakeholders.

[Healthcare promotion in primary care: if Hippocrates were alive today ]. / Promoción de la salud en atención primaria: si Hipócrates levantara la cabeza .

This article argues for the need to implement community healthcare promotion initiatives in medical practice. Some of the community initiatives introduced in primary care, as well as scientific evidence and associated implementation factors are described. The need for effective coordination between primary care and public health services, working with the community, is underlined. Two specific coordination initiatives are explained by way of example. The first is a project to develop healthcare plans in health centres in the Balearic Islands, by means of a participatory process with the collaboration of citizens, local organisations and the town council (urban planning, mobility, social services, etc.). The second is the Interdepartmental Public Health Plan of Catalonia, which was established to coordinate cross-sectoral healthcare. A specific part of this plan is the COMSalud project, the purpose of which is to introduce a community perspective to health centres and which is currently being piloted in 16 health areas. We review the proposals of a 2008 research study to implement healthcare promotion in primary care, assessing its achievements and shortfalls. The Disease Prevention and Health Promotion Strategy of the Spanish Ministry of Health is recognised as an opportunity to coordinate primary and public health. It is concluded that this change of mentality will require both financial and human resources to come to fruition.

[Health reports as the centrepiece of public health services]. / Los informes de salud como eje de los servicios de salud pública.

The main objective of health reports is to contribute to the health improvement of a specific population. They are an essential support tool for the design and planning of health policies and can also be used for accountability and evaluation. This study assesses various types of health report, including that used by the City of Barcelona (Spain), with a focus on social determinants, as well as an international health report more centred on the impact of health services. Some suggestions are proposed about the appropriateness and best use of these documents, including: the need for effective communication between technical professionals and politicians through meetings and dialogue; commitment to transparency, both authors (by means of the declaration of interests) and in terms of the information reported and with the maximum level of participation; to promote the use of a conceptual framework of social determinants of health; a focus on health inequalities; the inclusion of information relevant to policy action; the organisation of information in such a way that it allows comparison or benchmarking with similar areas and prospectively; presenting the information in an attractive way using elements such as rankings, maps or other tools; and the design of communication strategies adapted to key stakeholders.

Defunciones por COVID-19: no están todas las que son y no son todas las que están / Deaths by COVID-19: not all were registered and others should not be accounted for

La exactitud en el número de defunciones por COVID-19 ha generado polémica pública. La urgencia en disponer de esta información conjuntamente con otros datos, para valorar la pandemia ha inducido una variedad de procedimientos y formatos de modo que los datos no siempre se han tramitado de forma comparable al Ministerio de Sanidad. La elaboración de las estadísticas de mortalidad es compleja. Intervienen varias administraciones centrales y autonómicas, y no de la misma manera. La principal fuente de información es el certificado médico de defunción (CD) que permite distinguir por lugar de ocurrencia y causas de muerte. La inscripción telemática del CD en el ya informatizado registro civil y/o en la historia clínica digital, permitiría disponer de un circuito de procesamiento estadístico, y obtener con celeridad del recuento de fallecidos según causa ante una emergencia sanitaria. Para ello, que se requiere un acuerdo institucional multilateral en España

The death counts from COVID-19 have generated public controversy. The regional health councils' need for information regardind the cases, has generated a variety of formats and procedures, used to report this information. Consecuently, this data has not always been communicated in a comparable maner to the Ministry of Health. The compilation of mortality statistics is complex. Central and autonomous public administrations are involved, and not in the same way. The medical death certificate (DC) is the main source of information that allows to specify place of occurrence and causes of death. The on-line registration of the DC in the computerized civil registry and/or digital medical records, would allow to establish a statistical processing circuit, and to obtain a death count more quickly according to causes of death in the event of a health emergency. This requires a multi-level institutional agreement for a total telematics statistic process of death causes in Spain