Propuesta de análisis territorial para enfrentar la pandemia por SARS-CoV-2 basado en el perfil de neumonía e influenza en Ecuador 2016-2018 / Proposal for territorial analysis to face the SARS-CoV-2 pandemic based on the Profile of pneumonia and Influenza in Ecuador 2016-2018

Objetivo: Analizar determinantes sociodemográficos relacionados con IRAg y calcular un índice de priorización en los cantones de Ecuador para identificar áreas vulnerables para transmisión COVID-19. Diseño: Estudio observacional ecológico descriptivo. Emplazamiento: Doscientos veinticuatro cantones de Ecuador con fuentes de datos secundarios de información hospitalaria. Participantes: La unidad de medida fueron 224 cantones de Ecuador, en los cuales se analizó tasas de morbilidad y letalidad por IRAg con datos de egresos hospitalarios (2016-2018). Mediciones principales: Se estructuraron 8 variables sociodemográficas y se aplicaron pruebas correlacionales (modelo de regresión múltiple). El índice de priorización considera criterios de eficiencia, eficacia, tamaño de efecto y equidad; usando la suma para cada indicador, se calculó el puntaje de priorización. Resultados: Factores asociados con morbilidad por IRAg fueron: escolaridad, urbanización y densidad poblacional; para mortalidad fueron escolaridad y etnia (indígena) IRR:1,09 (IC95%:1,06-1,15), IRR:1,02 (IC95%:1,02-1,03) respectivamente. Con letalidad se asociaron los cantones con población mayor de 60 años (IRR:1,05 IC95%:1,03-1,07). Se obtuvo 86 cantones de alta prioridad, mayoritariamente localizados en la región sierra centro y la provincia de Morona Santiago. Conclusiones: Morbimortalidad por IRA grave en Ecuador se asoció a factores sociales y demográficos. Los ejercicios de priorización que consideran estos factores permiten identificar territorios vulnerables durante la propagación de enfermedades respiratorias. Determinantes sociales propios de cada territorio deben sumarse a factores individuales conocidos, para analizar riesgo y vulnerabilidad por COVID.(AU)

Objective: The present study seeks to analyse sociodemographic determinants related to severe acute respiratory infections (SARI) and calculate the priorization index in the cantons of Ecuador to identify areas probably most vulnerable to COVID-19 transmission. Design: This descriptive ecological observational study. Setting: 224 cantons (geographical area) of Ecuador with secondary data sources of hospital information. Participants: The unit of measurement was 224 cantons of Ecuador, in which analysed morbidity and lethality rates for SARI using hospital release data (2016-2018). Main measurements: Eight sociodemographic indicators were structuralized, and correlation tests applied for a multiple regression model. The priorization index was created with criteria of efficiency, efficacy, effect size (IRR) and equity. Using the sum of the index for each indicator, the priorization score was calculated and localized in a territorial map. Results: Morbidity associated factors where: school attendance years, urbanization and population density; for mortality resulted: school attendance and ethnics (indigenous) IRR: 1.09 (IC95%:1.06-1.15) and IRR: 1.024 (IC95%:102-1.03) respectively. With lethality where related cantons, with population older than 60 years, IRR: 1.049 (IC95%: 1.03-1.07); 87 cantons had high priority mostly localized in the mountain region and the Morona Santiago Province. Conclusions: Morbidity and mortality of SARI in Ecuador are associated to social and demographic factors. Priorization exercises considering these factors permit the identification of vulnerable territories facing respiratory disease propagation. The social determinants characteristic for each territory should be added to known individual factors to analyse the risk and vulnerability for COVID in the population.(AU)

[Proposal for territorial analysis to face the SARS-CoV-2 pandemic based on the Profile of pneumonia and Influenza in Ecuador 2016-2018]. / Propuesta de análisis territorial para enfrentar la pandemia por SARS-CoV-2 basado en el perfil de neumonía e influenza en Ecuador 2016-2018.

OBJECTIVE: The present study seeks to analyse sociodemographic determinants related to severe acute respiratory infections (SARI) and calculate the priorization index in the cantons of Ecuador to identify areas probably most vulnerable to COVID-19 transmission. DESIGN: This descriptive ecological observational study. SETTING: 224 cantons (geographical area) of Ecuador with secondary data sources of hospital information. PARTICIPANTS: The unit of measurement was 224 cantons of Ecuador, in which analysed morbidity and lethality rates for SARI using hospital release data (2016-2018). MAIN MEASUREMENTS: Eight sociodemographic indicators were structuralized, and correlation tests applied for a multiple regression model. The priorization index was created with criteria of efficiency, efficacy, effect size (IRR) and equity. Using the sum of the index for each indicator, the priorization score was calculated and localized in a territorial map. RESULTS: Morbidity associated factors where: school attendance years, urbanization and population density; for mortality resulted: school attendance and ethnics (indigenous) IRR: 1.09 (IC95%:1.06-1.15) and IRR: 1.024 (IC95%:102-1.03) respectively. With lethality where related cantons, with population older than 60 years, IRR: 1.049 (IC95%: 1.03-1.07); 87 cantons had high priority mostly localized in the mountain region and the Morona Santiago Province. CONCLUSIONS: Morbidity and mortality of SARI in Ecuador are associated to social and demographic factors. Priorization exercises considering these factors permit the identification of vulnerable territories facing respiratory disease propagation. The social determinants characteristic for each territory should be added to known individual factors to analyse the risk and vulnerability for COVID in the population.

Systematics and geographical distribution of Galba species, a group of cryptic and worldwide freshwater snails.

Cryptic species can present a significant challenge to the application of systematic and biogeographic principles, especially if they are invasive or transmit parasites or pathogens. Detecting cryptic species requires a pluralistic approach in which molecular markers facilitate the detection of coherent taxonomic units that can then be analyzed using various traits (e.g., internal morphology) and crosses. In asexual or self-fertilizing species, the latter criteria are of limited use. We studied a group of cryptic freshwater snails (genus Galba) from the family Lymnaeidae that have invaded almost all continents, reproducing mainly by self-fertilization and transmitting liver flukes to humans and livestock. We aim to clarify the systematics, distribution, and phylogeny of these species with an integrative approach that includes morphology, molecular markers, wide-scale sampling across America, and data retrieved from GenBank (to include Old World samples). Our phylogenetic analysis suggests that the genus Galba originated ca. 22 Myr ago and today comprises six species or species complexes. Four of them show an elongated-shell cryptic phenotype and exhibit wide variation in their genetic diversity, geographic distribution, and invasiveness. The remaining two species have more geographically restricted distributions and exhibit a globose-shell cryptic phenotype, most likely phylogenetically derived from the elongated one. We emphasize that no Galba species should be identified without molecular markers. We also discuss several hypotheses that can explain the origin of cryptic species in Galba, such as convergence and morphological stasis.

Consumo de riesgo de drogas utilizando la herramienta ASSIST modifcado en estudiantes, docentes y personal administrativo de una universidad pública / Drug risk use using the ASSIST modifed in students, teachers and administrative staff of a public university

El consumo de drogas es una importante causa de morbimortalidad a nivel mundial y su impacto genera gastos sanitarios, económicos y sociales importantes. Las mayores tasas de consumo de drogas se observan en la población entre 18 y 25 años en donde una proporción importante son estudiantes universitarios. El objetivo de este estudio fue calcular la prevalencia del consumo de riesgo de sustancias entre estudiantes, profesores y trabajadores de una universidad pública del Ecuador. Además, se realizó el cálculo de la consistencia interna (confabilidad) del cuestionario ASSIST modifcado. Pacientes y Métodos: Se realizó un estudio analítico transversal, se aplicó la prueba de Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) en dos grupos poblacionales (estudiantes y trabajadores ­ docentes). La consistencia interna de cada subescala del cuestionario fue evaluada con alfa (α) de Cronbach. Para estimar la prevalencia del consumo de riesgo se utilizó porcentajes con intervalos de confanza (IC) del 95%. Resultados: 4958 estudiantes y 425 profesores, trabajadores y empleados respondieron el cuestionario ASSIST. El cálculo de la consistencia interna (confabilidad) del instrumento, demostró un α de Cronbach satisfactorio (>0.7) para consumo de: tabaco, alcohol y marihuana. La prevalencia del consumo de riesgo alto para alcohol (5,3% para estudiantes y 4,9% para trabajadores y docentes), tabaco y cannabis fue elevada en los grupos estudiados. Además, el porcentaje de la población con consumo de riesgo moderado también fue signifcativo. Conclusión: En virtud de las elevadas tasas de consumo de riesgo alto y moderado para el consumo de drogas, es necesario la implementación de un programa Integral de promoción, prevención, tratamiento y rehabilitación dirigido a estudiantes universitarios. La prueba ASSIST modifcada mostró una consistencia interna satisfactoria en la evaluación del consumo de riesgo de substancias.

Drug use is a major cause of global morbidity and its impact generates signifcant health, economic and social expenditures. The highest rates of drug use are seen in the population between the ages of 18 and 25, where a signifcant proportion are university students. The objective of this study was to calculate the prevalence of substance risk consumption among students, professors and workers at a public university in Ecuador. In addition, the calculation of the internal consistency (reliability) of the modifed ASSIST questionnaire was performed. Patients and Methods: A cross-analytical study was conducted, the Alcohol, Tobacco and Substances Consumption Detection (ASSIST) test was applied in two population groups (students and workers ­ teachers). The internal consistency of each subscale of the questionnaire was evaluated with Cronbach's alpha. Percentages with 95% CI were used to estimate the prevalence of risk consumption. Results: 4958 students and 425 teachers, workers and employees responded to the ASSIST questionnaire. The calculation of the internal consistency (reliability) of the instrument, proved Cronbach satisfactory (>0.7) for consumption of tobacco, alcohol and marijuana. The prevalence of high-risk alcohol use (5.3% for students and 4.9% for workers and teachers), tobacco and cannabis were high in the groups studied. In addition, the percentage of the population with moderate risk consumption was also signifcant. Conclusions: Under the high rates of high and moderate risk use for drug use, it is necessary to implement a comprehensive program of promotion, prevention, treatment and rehabilitation aimed at university students. The modifed ASSIST test showed satisfactory internal consistency in the assessment of substance risk consumption.

A new multiplex PCR assay to distinguish among three cryptic Galba species, intermediate hosts of Fasciola hepatica.

A molecular tool described here allows in one step for specific discrimination among three cryptic freshwater snail species (genus Galba) involved in fasciolosis transmission, a worldwide infectious disease of humans and livestock. The multiplex PCR approach taken targets for each species a distinctive, known microsatellite locus which is amplified using specific primers designed to generate an amplicon of a distinctive size that can be readily separated from the amplicons of the other two species on an agarose gel. In this way, the three Galba species (G. cubensis, G. schirazensis, and G. truncatula) can be differentiated from one another, including even if DNA from all three were present in the same reaction. The accuracy of this new molecular tool was tested and validated by comparing multiplex PCR results with species identification based on sequences at mitochondrial and nuclear markers. This new method is accurate, inexpensive, simple, rapid, and can be adapted to handle large sample sizes. It will be helpful for monitoring invasion of Galba species and for developing strategies to limit the snail species involved in the emergence or re-emergence of fasciolosis.

Seroprevalence of Trypanosoma cruzi Infection in Schoolchildren and in Pregnant Women from an Amazonian Region in Orellana Province, Ecuador.

Chagas disease is a parasitic disease caused by the protozoan parasite Trypanosoma cruzi and about 230,000 persons are estimated to be infected in Ecuador. However, limited studies have been performed in the Amazon region, on the eastern side of the country. We evaluated here the seroprevalence of Trypanosoma cruzi infection in 12 rural villages of the Loreto canton, Orellana Province in schoolchildren aged 5-15 years and in pregnant women. A total of 1,649 blood samples were tested for Trypanosoma cruzi antibodies by enzyme-linked immunosorbent assay and indirect hemaglutination, and discordant samples were tested by indirect immunofluorescence assay. We detected a seroprevalence of anti-Trypanosoma cruzi antibodies of 1.3% in schoolchildren aged 5-15 years, indicating the persistence of a constant and active vectorial transmission in the Loreto County and confirming the need of the implementation of nonconventional vector control. We also observed a seroprevalence of 3.8% in pregnant women, indicating a clear risk of congenital transmission. Further studies should help define this risk more precisely and implement current international guidelines for the diagnosis, treatment, and care of these cases.

Comparación de la capacidad discriminatoria de los puntajes de riesgo GRACE y TIMI para eventos cardiovasculares durante la hospitalización en pacientes con infarto agudo de miocardio sin elevación ST y angina inestable / Comparison of the discriminatory capacity of GRACE and TIMI risk scores for cardiovascular events during hospitalization in patients with acute myocardial infarction without ST elevation and unstable angina

En pacientes con síndrome coronario agudo los puntajes de riesgo GRACE y TIMI son herramientas para estimar el pronóstico de desenlaces cardiovasculares. Las comparaciones entre ambos puntajes en poblaciones latinoamericanas son escasas. Objetivo Comparar la capacidad discriminatoria de los puntajes GRACE y TIMI para eventos cardiovasculares durante la hospitalización en pacientes con infarto de miocardio sin elevación ST (IMSEST) y angina inestable (AI). Diseño Cohorte retrospectiva. Lugar y sujetos 378 pacientes con diagnóstico de IMSEST o AI atendidos durante el período 2011 ­ 2014 en el Hospital Carlos Andrade Marín de la ciudad de Quito. Mediciones principales Puntaje de riesgo GRACE, puntaje de riesgo TIMI, aparición de eventos cardiovasculares (muerte, reinfarto, angina refractaria e intervención coronaria de urgencia) durante la hospitalización. Capacidad discriminatoria de los puntajes evaluada mediante curvas ROC. Resultados En los pacientes predominó el sexo masculino (78%). En orden de frecuencia los eventos cardiovasculares fueron: intervención coronaria de urgencia (51%), angina refractaria (12%), muerte (9%) y reinfarto (5%). El score GRACE presentó resultados de área bajo la curva (AUC) mayores y estadísticamente signifcativos para muerte (AUC: 0.72; ρ<0.0001), mientras que para angina refractaria e intervención coronaria de urgencia, el score TIMI tuvo resultados estadísticamente signifcativos; sin embargo su AUC no presentó valores representativos. Para el reinfarto el score GRACE presentó valores estadísticos limítrofes con una AUC baja. Conclusión El score GRACE tiene una mejor capacidad pronóstica para muerte y reinfarto frente al score TIMI en pacientes con IMSEST y AI

The risk scores GRACE and TIMI are tools to estimate the prognosis of cardiovascular outcomes in patients with acute coronary syndrome. There are few comparisons between the two scores in Latin American populations. Objective To compare the discriminatory ability of GRACE and TIMI scores for cardiovascular events during hospitalization in patients with myocardial infarction without ST elevation (NSTEMI) and unstable angina (UA). Design Retrospective cohort. Subjects and settings 378 patients with a diagnosis of NSTEMI or UA attended during the period 2011-2014 in the Carlos Andrade Marín Hospital, Quito-Ecuador. Main measurements GRACE risk score, TIMI risk score, cardiovascular events (death, reinfarction, refractory angina and emergency coronary angioplasty) during hospitalization. Discriminatory capacity of the scores assessed by ROC curves. Results Male patients were the most frequent (78%). The frequency of cardiovascular events was: emergency coronary angioplasty (51%), refractory angina (12%), death (9%) and re-infarction (5%). The GRACE score showed higher and statistically signifcant results of area under the curve (AUC) for death (AUC: 0.72; ρ<0.0001), whereas for refractory angina and emergency coronary angioplasty the TIMI score had statistically signifcant results; however the AUC did not provide representative values. For re-infarction the GRACE score presented borderline statistical values with low AUC. Conclusion The GRACE score has a better prognostic value for death and reinfarction compared to TIMI score in patients with NSTEMI and AI

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.

BACKGROUND: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS: From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

WHO global survey on maternal and perinatal health in Latin America: classifying caesarean sections.

BACKGROUND: Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. METHODS: We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. RESULTS: The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. CONCLUSION: The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.

Bayesian clinical reasoning: does intuitive estimation of likelihood ratios on an ordinal scale outperform estimation of sensitivities and specificities?

RATIONALE: Bedside use of Bayes' theorem for estimating probabilities of diseases is cumbersome. An alternative approach based on five categories of powers of tests from 'useless' to 'very strong' has been proposed. The performance of clinicians using it was assessed. METHODS: Fifty clinicians attending a course of tropical medicine estimated powers of tests and post-test probabilities using the classical vs. the categorical Bayesian approach. The estimation of post-test probability was assessed for real and dummy diseases in order to avoid the bias of previous knowledge. Accuracy of answers was measured by the difference with reference values obtained from an expert system (Kabisa). RESULTS: Clinicians estimated positive likelihood ratios (LRs) a median of -1.07 log(10) lower than Kabisa [interquartile range (IQR): -1.47; -0.80] when derived classically and -0.17 (IQR: -0.42; +0.04) when estimated categorically (P < 0.001). For negative LRs the median was +0.39 log(10) higher (IQR: +0.71; +0.08) when derived classically and -0.18 log(10) lower (IQR: +0.03; -0.36) when estimated categorically (P < 0.001). Twenty (40%) disclosed not being able to calculate post-test probabilities using sensitivities and specificities. Regardless the approach post-test probabilities were overestimated both for real and dummy diseases [respectively +1.23 log(10) (IQR: +0,67; +2.08) and +2.03 log(10) (IQR: +0.49; +2.42)] (P = 0277), but the range was wider for the latter (P = 0.001). CONCLUSIONS: Participants were more accurate in estimating powers with a categorical approach than with sensitivities and specificities. Post-test probabilities were overestimated with both approaches. Knowledge of the disease did not influence the estimation of post-test probabilities. A categorical approach might be an interesting instructional tool, but the effect of training with this approach needs assessment.

Intracluster correlation coefficients from the 2005 WHO Global Survey on Maternal and Perinatal Health: implications for implementation research.

Cluster-based studies involving aggregate units such as hospitals or medical practices are increasingly being used in healthcare evaluation. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC). Sample size calculations for cluster-based studies need to account for the ICC, or risk underestimating the sample size required to yield the desired levels of power and significance. In this article, we present values for ICCs that were obtained from data on 97,095 pregnancies and 98,072 births taking place in a representative sample of 120 hospitals in eight Latin American countries. We present ICCs for 86 variables measured on mothers and newborns from pregnancy to the time of hospital discharge, including 'process variables' representing actual medical care received for each mother and newborn. Process variables are of primary interest in the field of implementation research. We found that overall, ICCs ranged from a minimum of 0.0003 to a maximum of 0.563 (median 0.067). For maternal and newborn outcome variables, the median ICCs were 0.011 (interquartile range 0.007-0.037) and 0.054 (interquartile range 0.013-0.075) respectively; however, for process variables, the median was 0.161 (interquartile range 0.072-0.328). Thus, we confirm previous findings that process variables tend to have higher ICCs than outcome variables. We demonstrate that ICCs generally tend to increase with higher prevalences (close to 0.5). These results can help researchers calculate the required sample size for future research studies in maternal and perinatal health.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study.

OBJECTIVE: To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. DESIGN: Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. SETTING: 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data PARTICIPANTS: 106,546 deliveries reported during the three month study period, with data available for 97,095 (91% coverage). MAIN OUTCOME MEASURES: Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. RESULTS: Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. CONCLUSIONS: Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America.

BACKGROUND: Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics. METHODS: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data. FINDINGS: We obtained data for 97,095 of 106,546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24-43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43-57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%. INTERPRETATION: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Situación epidemiológica de las enfermedades de notificación obligatoria del Ecuador: 1998 / Situation epidemiologist of the diseases of obligatory notification of Ecuador: 1998

Esta revisión estadística tiene por objeto poner a disposición de los niveles provinciales y locales, la información epidemiológica obtenida del formulario EPI 1 (1998); útil para la definición de prioridades y toma de decisiones. Para ello, se escogió las cinco patologías con las tasas de incidencia más altas en cada provincia. Las tasas se calcularon por 100.000 habitantes para las patologías que afectan a la población general y 100.000 nacidos vivos para el tétanos neonatal. Según los resultados, las enfermedades más frecuentes fueron: el paludismo, como la primera causa de morbilidad, especialmente en la Costa y el Oriente, seguido por las intoxicaciones alimentarias. En tercer lugar, las enfermedades eruptivas...

Epidemiología comunitaria / Community epidemiology

El desarrollo teórico, metodológico y práctico de la Epidemiología Comunitaria tiene como antecedente la Declaración de Alma Ata y por lo tanto la formulación de la Estrategia de Atención Primaria para la Salud como política para que los pueblos aclcancen un estado de salud y vida satisfactorio