Factores clínicos y demográficos asociados con la mortalidad por dengue en Colombia: estudio de casos y controles / Demographic and clinical factors associated with dengue mortality in Colombia: a case-control study

Resumen: Objetivo: Identificar factores demográficos y clínicos asociados con la mortalidad por dengue grave en cinco departamentos de Colombia. Material y métodos: Análisis secundario de un estudio de casos y controles basado en pacientes admitidos de 2009 a 2013. Los casos fueron pacientes que murieron por dengue y los controles fueron pacientes con dengue grave sobrevivientes a la enfermedad. Se utilizó el procedimiento de Mantel-Haenszel para identificar los factores. Resultados: Analizando 58 casos y 121 controles, cuatro factores fueron asociados con la mortalidad por dengue: administración hospitalaria de dipirona (RMa=6.38 IC95% 2.41-16.86) y de acetaminofén (RMa=0.25 IC95% 0.10-0.61), presencia de comorbilidad (RMa=3.52 IC95% 1.51-8.18) y consulta previa por el mismo padecimiento (RMa=3.99 IC95% 1.63-9.77). Conclusiones: La administración de dipirona en pacientes con dengue grave se asoció con un aumento del riesgo de mortalidad. Si se considera que la dipirona fue retirada del mercado en 20 países por sus efectos secundarios, se puede desaconsejar su uso en el manejo del dengue.

Abstract: Objective: To identify demographic and clinical factors associated with mortality due to severe dengue in five departments in Colombia. Materials and methods: Case-control study with patients admitted between 2009 and 2013. The cases were patients who died from dengue and the controls where patients with severe dengue who survived the disease. A multivariate analysis using the Mantel-Haenszel procedure identified risk factors associated with dengue mortality. Results: We analyzed 58 cases and 121 controls and identified four factors: in-hospital administration of dypirone (ORa=6.38 95%CI 2.41-16.86) and paracetamol (ORa=0.25 95%CI 0.10-0.61), comorbidities (ORa=3.52 95%CI 1.51-8.18), and a prior visit to the hospital (ORa=3.99 95%CI 1.63-9.77). Conclusions: Administration of dypirone in patients with severe dengue was associated with a higher risk of mortality. Considering that 20 countries have banned dipyrone because of its adverse effects, we advise against its use.

Prevalence of skin diseases in children 1 to 6 years old in the city of Bogota, Colombia.

BACKGROUND: Skin diseases represent an important part of the morbidity among children and are possibly influenced by geographic, racial, social, cultural, and economic factors. Despite being so frequent around the world, skin diseases have not been important in developing strategies in public health. AIM: The purpose of this study was to evaluate the prevalence of skin diseases among the student population between 1 and 6 years of age in Bogotá, Colombia between March 2009 and June 2011. MATERIALS AND METHODS: This cross-sectional study was performed across a probabilistic, stratified, randomized sampling by proportional assignment (based on locality and type of institution) and was developed in schools in Bogotá, Colombia. RESULTS: A total of 2437 children between 1 and 6 years of age were examined, and 42.8% (1035) presented a dermatologic disease. Papular urticaria was the most frequent (62.9%) (IC: 58.4%; 67.1%), followed by dermatitis/eczema (13.0%) (IC: 10.8%; 15.4%), and infectious diseases (12.3%) (IC: 9.7%; 15.3%). CONCLUSION: The research demonstrates a high prevalence of papular urticaria as a result of flea and mosquito bites and infectious diseases of the skin in the studied population. The dermatologic diseases found are easy to diagnose, respond to the proper treatment, and are preventable. However, the fact that many of the examined children likely had not visited the doctor for the detected pathology could indicate the lack of access to health services affecting this population.

Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru.

Many Latin American countries face the challenge of caring for a growing number of people with severe mental illnesses while promoting deinstitutionalization and community-based care. This article presents an overview of current policies that aim to reform the mental health care system and advance the employment of people with disabilities in Colombia, Costa Rica, and Peru. The authors conducted a thematic analysis by using public records and semistructured interviews with stakeholders. The authors found evidence of supported employment programs for vulnerable populations, including people with disabilities, but found that the programs did not include people with severe mental illnesses. Five relevant themes were found to hamper progress in psychiatric vocational rehabilitation services: rigid labor markets, insufficient advocacy, public subsidies that create conflicting incentives, lack of deinstitutionalized models, and lack of reimbursement for evidence-based psychiatric rehabilitation interventions. Policy reforms in these countries have promoted the use of medical interventions to treat people with severe mental illnesses but not the use of evidence-based rehabilitation programs to facilitate community integration and functional recovery. Because these countries have other supported employment programs for people with nonpsychiatric disabilities, they are well positioned to pilot individual placement and support to accelerate full community integration among individuals with severe mental illnesses.

Factores clínicos y demográficos asociados con la mortalidad por dengue en Colombia: estudio de casos y controles.

Objetivo. Identificar factores demográficos y clínicos asociados con la mortalidad por dengue grave en cinco de-partamentos de Colombia. Material y métodos. Análisis secundario de un estudio de casos y controles basado en pa-cientes admitidos de 2009 a 2013. Los casos fueron pacientes que murieron por dengue y los controles fueron pacientes con dengue grave sobrevivientes a la enfermedad. Se utilizó el procedimiento de Mantel-Haenszel para identificar los factores. Resultados. Analizando 58 casos y 121 controles, cuatro factores fueron asociados con la mortalidad por den-gue: administración hospitalaria de dipirona (RMa=6.38 IC95% 2.41-16.86) y de acetaminofén (RMa=0.25 IC95% 0.10-0.61), presencia de comorbilidad (RMa=3.52 IC95% 1.51-8.18) y consulta previa por el mismo padecimiento (RMa=3.99 IC95% 1.63-9.77). Conclusiones. La administración de dipirona en pacientes con dengue grave se asoció con un aumento del riesgo de mortalidad. Si se considera que la dipirona fue retirada del mercado en 20 países por sus efectos secunda-rios, se puede desaconsejar su uso en el manejo del dengue.

Prevalence of papular urticaria caused by flea bites and associated factors in children 1-6 years of age in Bogotá, D.C.

BACKGROUND: Papular urticaria is a chronic inflammatory disease caused by exposure to arthropod bites. The disease has been reported in children attending medical centers, but the causes as the risk factors associated with the disease have not been established. The objective of this study was to determine the prevalence of papular urticaria caused by flea bite and identify the risk factors in children between 1 to 6 years of age in Bogotá D.C, between March 2009 and June 2011. METHODS: A cross-sectional, two-stage, clustered study using random probability sampling and stratified with proportional allocation was carried out in children (1-6 years of age) in educational institutions in Bogotá D.C. to determine the prevalence of the disease. Children underwent a dermatological examination by general practitioners with a previous training. Furthermore, digital photographs of skin lesions were taken for further confirmation of the diagnosis by dermatologists. A structured survey was completed by the parents or caregivers, and it was evaluated using an unconditional logistic regression to identify factors associated with the disease. RESULTS: A total of 2437 children were included in the study. The prevalence of papular urticaria caused by flea bite in this population was 20.3% (CI 95%: 18.2 to 22.5%). The major risk factors associated with the disease were the presence of fleas in households (OR 1.74, CI 95%: 1.35 to 2.25), using mattresses without springs (OR 1.73, CI 95%: 1.20 to 2.50), the use of daily public transportation to carry the children to the educational institutions (OR 1.76, CI 95%: 1.07 to 2.89), having a soil/earth floor in the main bedroom (OR 6.81, CI 95%:1.16-39.96), and having siblings with a history of atopic dermatitis (OR 1.76 CI 95%: 1.07-2.89). CONCLUSIONS: A high prevalence of papular urticaria caused by flea bite was found in Bogotá D.C. The main factors associated with the disease might be modified with the implementation of prevention, control strategies in housing, educational institutions, and public transportation.

Factors associated with the severity and complication of patients with malaria hospitalized between 2009 and 2013 in three municipalities of Colombia, case control study.

BACKGROUND: Malaria worldwide annual reported cases range between 250 and 500 million and nearly half a million deaths are reported every year. Colombia has a vast expanse of territory with environmental and social conditions conducive to malaria transmission, which is the reason why it has second place in Latin America for the number of cases of malaria. METHODS: This is a retrospective, paired, case-control study that compares patients with severe malaria and malaria patients without mention of complication. Medical records of patients with confirmed malaria diagnosis were reviewed. The objective of this study was to identify factors associated with complicated malaria in three municipalities of Colombia during the period 2009-2013. RESULTS: A total sample of 180 medical records was collected, 60 corresponding to cases and 120 to controls following a 1:2 ratio. From the total sample, 88.33 % (159) of subjects were originally from Tumaco, 7.78 %, most of the patients of the study (104) were diagnosed and treated in 2013. Among the laboratory findings, the platelet count was found to have statistically significant differences between cases and controls; this was also true for total bilirubin value and transaminases. The most prevalent severity finding was clinical jaundice, followed by elevated bilirubin (25 %) and elevated transaminases (44.4 %). Thrombocytopenia was found in 11/44 cases (20 %) and only five of 60 patients (8.3 %) presented severe anaemia. The multivariate analysis showed that a platelet count <100,000 and clinical jaundice not associated with organ failure, were the two variables associated with severe malaria in the patients described. CONCLUSIONS: Most of the cases studied, despite meeting criteria of severity, were shown not to be as morbid or severe as in other countries. Clinical jaundice and thrombocytopaenia are associated with severe malaria, and they can be used by general practitioners or primary care physicians to promptly identify patients who may have severe malaria.

Análisis de las demoras en salud en personas que enfermaron de gravedad o fallecieron por dengue en cinco ciudades de Colombia / Análise das demoras no atendimento em saúde em pessoas gravemente doentes ou que morreram de dengue em cinco cidades na Colômbia / Analysis of delays in healthcare in people seriously ill or dead from dengue in five cities in Colombia

Objetivo: Identificar demoras en la atención médica de personas que fallecieron o se recuperaron de dengue grave en cinco ciudades de Colombia. Materiales y métodos. Estudio cualitativo sobre personas que fallecieron por dengue (casos) o que se recuperaron (controles). Se entrevistó a los familiares y se analizaron sus itinerarios de búsqueda de atención en salud. Los datos fueron analizados desde el modelo de las "tres demoras", complementado con diagramas espacio-temporales y entrevistas a profesionales de salud. Resultados: A pesar de desconocer signos y síntomas, se buscó atención rápidamente. Para acceder a la primera consulta el recorrido no representó dificultades. Se presentaron fallas en la calidad del diagnóstico y un mayor número de instituciones consultadas en los casos que en los controles. Se evidenció un proceso de retorno a la demora 1 que puede influir negativamente en futuras decisiones en salud. Conclusiones: Complementar el análisis clásico de demoras con el análisis espacio-temporal de los itinerarios permite visibilizar fallas y aciertos en la calidad de la atención y aportar a la toma de decisiones.

Objetivo: Identificar demoras no atendimento em saúde de pessoas que faleceram ou se recuperaram de dengue grave em cinco cidades da Colômbia. Materiais e métodos: Estudo qualitativo com pessoas que faleceram em decorrência da dengue (casos) ou que se recuperaram (controles). Entrevistaram-se familiares e analisaram-se seus itinerários durante o processo de procura de atendimento nos serviços de saúde. Os dados foram analisados baseados no modelo das "três demoras", complementado com diagramas espaço-temporais e entrevistas com profissionais de saúde. Resultados: Ainda que os signos e sintomas fossem desconhecidos, procurou-se atendimento rapidamente. O percurso para o acesso à primeira consulta não apresentou dificuldades. Apresentaram-se erros na qualidade do diagnóstico e identificou-se maior número de instituições consultadas em casos do que em controles. Evidenciou-se um processo de retorno à demora 1, fato que pode influir negativamente em decisões futuras. Conclusões: Complementar a análise clássica de demoras com a análise espaço-temporal de itinerários permite identificar falhas e acertos na qualidade do atendimento para a tomada de decisões.

Objective: Identify delays in receiving healthcare in cases of patients who either recovered from or died due to severe dengue in five Colombian cities. Method: Qualitative study with deceased persons from dengue (cases) or that recuperated (controls). Family members were interviewed and their itineraries were analyzed. The data was analyzed from the "three delay" model, complemented with spatiotemporal diagrams and interviews to health professionals. Results: Despite not knowing signs and symptoms, attention was rapidly sought. There were no difficulties accessing the route to the first consultation There were flaws in the quality of diagnosis and a higher number of institutions were consulted in cases than in controls. It was evidenced a return to delay 1 that could negatively influence future health decisions. Conclusions: Complementing the delay analysis with spatiotemporal analysis of the itineraries permits the visualization of flaws and successes in the quality of care for decision-making.

[Decentralization and health system reform: what is their impact on malaria incidence in Colombian municipalities?]. / Descentralización y reforma: ¿cuál es su impacto sobre la incidencia de malaria en los municipios colombianos?

INTRODUCTION: Colombia is one of the Latin-American countries with higher malaria incidence and its control is the responsibility of the departments and municipalities. OBJECTIVE: To assess the effect of decentralization within the context of the Social Security Health System on the incidence of malaria in Colombian municipalities. MATERIALS AND METHODS: An ecological trend study was carried out in municipalities which reported at least five cases of malaria in 5 of the 7 years between 1998 and 2004. Information on indicators of decentralization of the municipalities, population with health insurance in either the subsidized or contributive regimes as well as incidence of malaria was requested from the health authorities of the departments and municipalities. Socioeconomic and demographic variables were also collected. The behavior of the malaria rates was assessed in relation to the decentralization status of the municipalities. A repeated measure analysis was performed using the generalized estimating equation. RESULTS: The decentralization status of the municipality (IRR=2.36; 95%CI: 1.57-3.56), its proportion of unmet basic needs (IRR=9.35; 95%CI: 3.66-23.89) and of population younger than 40 years of age (IRR=1.8; 95%CI: 1.13-1.23) were associated with malaria incidence in Colombian municipalities. CONCLUSIONS: Decentralization status as well as socioeconomic and demographic factors are associated with increased malaria risk in Colombian municipalities.

Descentralización y reforma: ¿cuál es su impacto sobre la incidencia de malaria en los municipios colombianos? / Decentralization and health system reform: What is their impact on malaria incidence in Colombian municipalities?

Introducción. Colombia es uno de los países de América Latina con mayor incidencia de malaria. El control de la malaria en el país se lleva a cabo en el marco de un programa descentralizado de seguridad social en salud, bajo la responsabilidad de departamentos y municipios. Objetivo. Evaluar el efecto de la descentralización en el contexto del Sistema General de Seguridad Social en Salud, sobre la incidencia de malaria en municipios colombianos. Materiales y métodos. Se realizó un estudio ecológico de tendencia en municipios que notificaron, al menos, cinco casos anuales de malaria en cinco de los siete años del periodo 1998 a 2004, en el cual se solicitó información sobre indicadores de descentralización, afiliación a la seguridad social en salud y casos de malaria a entidades nacionales y a secretarías departamentales y municipales de salud. Se evaluó el comportamiento de las tasas de malaria teniendo en cuenta si el municipio era certificado o no. Se analizaron las medidas repetidas utilizando la ecuación estimada generalizada. Resultados. La certificación (Incidence Rate Ratio, IRR=2,36; IC95% 1,57-3,56), la proporción de población con necesidades básicas insatisfechas (IRR=9,35; IC95% 3,66-23,89) y la proporción de población menor de 40 años (IRR=1,18; IC95% 1,13-1,23) fueron factores asociados con el incremento de la incidencia de malaria en municipios colombianos. Conclusiones. Los factores socioeconómicos y demográficos, además del estado de certificación, se presentan como factores de riesgo para malaria en los municipios colombianos.

Introduction. Colombia is one of the Latin-American countries with higher malaria incidence and its control is the responsibility of the departments and municipalities. Objective. To assess the effect of decentralization within the context of the Social Security Health System on the incidence of malaria in Colombian municipalities. Materials and methods. An ecological trend study was carried out in municipalities which reported at least five cases of malaria in 5 of the 7 years between 1998 and 2004. Information on indicators of decentralization of the municipalities, population with health insurance in either the subsidized or contributive regimes as well as incidence of malaria was requested from the health authorities of the departments and municipalities. Socioeconomic and demographic variables were also collected. The behavior of the malaria rates was assessed in relation to the decentralization status of the municipalities. A repeated measure analysis was performed using the generalized estimating equation. Results. The decentralization status of the municipality (IRR=2.36; 95%CI: 1.57-3.56), its proportion of unmet basic needs (IRR=9.35; 95%CI: 3.66-23.89) and of population younger than 40 years of age (IRR=1.8; 95%CI: 1.13-1.23) were associated with malaria incidence in Colombian municipalities. Conclusions. Decentralization status as well as socioeconomic and demographic factors are associated with increased malaria risk in Colombian municipalities.

[Does the lack of availability of information represent a bottleneck for research and evaluation in health policy?]. / Disponibilidad de información: un cuello de botella para investigación y evaluación en politicas de salud?

OBJECTIVES: This article describes the difficulties encountered in obtaining information about health services, sanitation and health insurance coverage supply, use and coverage regarding a sample of Colombian municipalities during 1991-2000. The availability of information is also analysed in terms of decentralisation and municipal development. METHOD: This was a cross-sectional study of a random stratified sample of 495 Colombian municipalities; information regarding the variables of interest was requested at municipal and departmental level and from national sources. A scale was constructed for measuring the availability of information at local level. Non-parametric statistics were used for testing differences in availability of information in terms of certification and municipal category. RESULTS: Applying the scale revealed 51% availability of data regarding health service supply, 39% for data regarding service use and 45% for both types of information (supply and demand taken together). No information was available in 32% of the municipalities. Information was more readily available in non-certified and less developed municipalities. CONCLUSIONS: Study findings provided indirect evidence of difficulty in obtaining information regarding health systems at both municipal and departmental levels; this represents an important obstacle for health system management and evaluating performance, as well as for research and widening knowledge (and availability to such knowledge) in this area.

Disponibilidad de información ¿Un cuello de botella para investigación y evaluación en políticas de salud? / Does the lack of availability of information represent a bottleneck for research and evaluation in health policy?

OBJETIVOS: Describir las dificultades para obtener información de oferta, uso, cobertura, saneamiento básico y afiliación a la seguridad social en salud en una muestra de municipios colombianos para el período 1991-2000 y hacer un análisis de la disponibilidad de información en los municipios por estado de certificación y categorías de desarrollo municipal. MÉTODOS: Se realizó un estudio analítico de corte transversal en una muestra aleatoria estratificada de 495 municipios colombianos, en el cual se solicitó información de interés a nivel de las secretarías departamentales y municipales de salud que se complementó con información de fuentes nacionales. Para los datos solicitados a nivel territorial se construyó un indicador de disponibilidad de información. Para establecer si había diferencias en la disponibilidad de información según estado de certificación y categoría municipal, se utilizaron pruebas estadísticas no paramétricas. RESULTADOS: La aplicación del indicador mostró 51 por ciento de disponibilidad de información de las variables de oferta, 39 por ciento de las de uso y 45 por ciento de información total (oferta y uso). En 32 por ciento de los municipios no fue posible obtener información. La disponibilidad de información fue mayor en los municipios no certificados y de menor desarrollo socioeconómico. CONCLUSIONES: Los hallazgos del estudio proveen evidencia indirecta de importantes carencias en los sistemas de información locales y departamentales, que se constituyen en obstáculos no sólo para la gestión y evaluación de los servicios de salud sino para realizar investigación y generar conocimiento.