[Local public health networks. Apropos of an experience]

Public health action on a territory is complex and requires the involvement of multiple actors, who do not always act coordinately. Networks of organizations structures including the whole of the local actors facilitate the generation of synergies and enable greater effectiveness and efficiency of the joint action from the different actors on a same landscape. We present 3 years experience of four Public Health Committees in a region of Catalonia (Spain), composed by the main actors in public health planning. Each of the committees is organized on a plenary and working groups on issues arising from the regional health diagnosis, and coincident with the Health Plan of the Region. Coordination in no case implies the loss or dilution of the firm of the actor generator of intervention initiative in public health, but their empowerment and collaboration by the other actors. In conclusion welcomes the creation of a culture of collaboration and synergies between the different organizations concerned. Lack of specificity is observed in establishing operational objectives, and the need for greater coordination and involvement of the components of the various working groups.

[Smoke-free areas: persuasion and enforcement]

This paper presents the actions taken by the public health services in the city of Barcelona (Catalonia, Spain) to improve compliance with the requirements of the new 28/2005 tobacco control law. These were essentially informative at first, with a second phase where authority enforcement mechanisms were activated. In workplaces, educational settings and transport the law was incorporated without incidents nor relevant complaints, except for isolated incidents in some university or mass transport settings. In food establishments the process has been more complex. Estimating the frequency of related events, there are 17.5 formal citizen complaints for 100,000 person-years. Inspections generated by citizen complaints resulted in 3.3 administrative proceedings for 100,000 person-years, mostly for incurring in serious violations. Effectively enforcing the law required active information and communication policies, as well as the real enforcement by health authority. This caused an important workload to the public health services.

[Innovating the service management of public health: the experience of the Barcelona Public Health Agency (Spain)]

We describe the evolution of the organization of public health services in the city of Barcelona (Catalonia, Spain) until the creation of the Barcelona Public Health Agency. This Agency is a consortium created by the Barcelona City Council and the Government of Catalonia as the sole entity responsible for regional and local public health services in the city. The underlying logic for the Agency's design, as well as its mission, vision and value statements, strategy, services' portfolio, and the role of leadership in the process, are analyzed. Aspects related to the Agency's quality and communication plans, as well as the design of its processes, and its policy in terms of alliances for research and training in public health, are discussed. Finally, the main challenges for the future are described.

[Community outbreak of pneumonia due to Legionella pneumophila: importance of monitoring hospital cooling towers]

OBJECTIVE

Description of an outbreak of legionnaires' disease originating in one of the cooling towers of a hospital.

PATIENTS AND METHODS

This study included patients with confirmed pneumonia caused by Legionella pneumophila serogroup 1 and related to the Vallcarca neighborhood of Barcelona (Spain) in August 2004. Exposure was determined by a standardized questionnaire. An environmental investigation was carried out to identify the source of the outbreak. A descriptive analysis including incidence rates estimation was performed, as well as molecular study to document the genetic identity among human and environmental strains.

RESULTS

Thirty-three cases of L. pneumophila pneumonia were detected. Median age was 68 years and 70% of the affected patients were men. Incidence rate among residents in less than 200 meters of the source and older than 65 was 888.9 cases/100,000 inhabitants. Lethality rate was 6%. Four seasonal cooling towers that were not registered with the authorities were identified in a health care center. L. pneumophila was isolated from all four and at least one colony in each tower had the same genetic profile as the strains isolated from patients.

CONCLUSIONS

An association was demonstrated between a community outbreak of legionellosis and unregistered seasonal cooling towers located in a hospital. All risk facilities should be registered and inspected to ensure that they fulfill current legislation requirements.

[The organization of public health in the USA: a federal model]

The present article analyzes the structure of public health services in the USA. It aims to describe the perspective of 200 years of a federal organization of public health services, which could be useful in the current context in Spain. Information was obtained by interviews with key informants from the three levels of government (federal, state, and local) and with academics (many of whom had previous experience as public health officers). Special attention is paid to the organization, financing and activities of local and state health departments, as well as to the relationships between these departments. The implications for a country like Spain, which has evolved in a short period from a highly centralized system to a decentralized system based on 17 Autonomous Communities, is discussed.

[On the exercise of health authority: principles, regulations and uncertainty]

Implementing health authority is a basic public health service. Part of the responsibility of public health managers is to ensure compliance with regulations. These are developed when certain risks are considered inadmissible. Mostly, the exercise of health authority deals with the routine application of detailed norms, although there is always some uncertainty, as shown by the frequent use of cautionary measures by health officers during inspections. However, epidemiologic surveillance periodically involves situations in which human health is damaged and there is no reference regulation; in these situations, health authorities must act according to their own criteria, weighing the risks of intervention against those of nonintervention. In this article, we present 3 such scenarios: using coercion in the treatment of patients with smear-positive tuberculosis, regulation of activities with soy beans posing asthma risks, and setting limits to the professional activity of an HIV-positive physician.

El Cuadro de Mando Integral como instrumento de dirección en una organización de salud pública

OBJECTIVE

The Balanced Scorecard is a tool for strategic planning in business. We present our experience after introducing this instrument in a public health agency to align daily management practice with strategic objectives.

METHODS

Our management team required deep discussions with external support to clarify the concepts behind the Balanced Scorecard, adapt them to a public organization in the health field distinct from the business sector in which the Balanced Scorecard was designed, and adopt this instrument as a management tool. This process led to definition of the Balanced Scorecard by our Management Committee in 2002, the subsequent evaluation of the degree to which its objectives had been reached, and its periodic redefinition. In addition, second-level Balanced Scorecards were defined for different divisions and services within the agency. The adoption of the Balanced Scorecard by the management team required prior effort to clarify who are the stockholders and who are the clients of a public health organization. The agency's activity and production were also analyzed and a key processes model was defined. Although it is hard to attribute specific changes to a single cause, we believe several improvements in management can be ascribed, at least in part, to the use of the Balanced Scorecard.

CONCLUSION

The systematic use of the Balanced Scorecard produced greater cohesion in the management team and the entire organization and brought the strategic objectives closer to daily management operations. The organization is more attentive to its clients, has taken steps to improve its most complex cross-sectional processes, and has developed further actions for the development and growth of its officers and its entire personnel. At the same time, its management team is more in tune with the needs of the agency's administrative bodies that compose its governing board.

Acerca de los clientes de las organizaciones de salud pública

Public services must satisfy a variety of agents: users of these services, the citizens who pay the taxes that finance them, politicians, and those that work in them. To obtain public services that give priority to the citizen-user, knowledge of clients, their expectations, preferences, complaints and degree of satisfaction is essential. This article presents the process of internal discussion in our agency about its clients, who differ from those of an industrial or commercial organization. A proposal for the classification of clients, as well as the process that has led to a client portfolio, are presented and steps to improve services from the perspective of the client are suggested.

[Portfolio of services in a public health organization]

Health services in Spain are currently being improved. Definition of the services portfolio has been one of the elements in this process, from which public health services have been largely left out. In the present article public health services are examined from the perspective of the Public Health Agency of Barcelona. We propose a scheme to classify services into productive public health services, health care services, services that are intermediate products, support services, and liaison or coordinating services. Indicators of productivity, result, impact, and cost are explored, and a catalogue of services for a public health organization with a well defined population and area is proposed.

De la perrera municipal al centro de acogida de animales de compañía de Barcelona

This article aims to present changes in public health policy and services related to pet dogs and cats in the city of Barcelona from 1983 to 2001. Initially the center's activity was limited to the custody and euthanasia of stray animals, serving not only the city but also the rest of the province. With the formulation of a city Plan for Pet Animals, the activities were redirected, concentrating on services within the city limits and stimulating adoption. Participation of both professional and humane organizations was sought, premises were renovated, responsible ownership of animals was promoted, controlled urban colonies of cats were established, and adoptions become the cornerstone of policy, centering the activity of the shelter toward its clients. Changes in the shelter's activity since 1998 reflects a clear decrease in the number of animals retained, as well as in the proportion subjected to euthanasia. This decrease may reflect an improvement in the problem of stray animals. These developments have also resulted in a positive change in the relationship with the media and animal welfare organizations.

An outbreak of Legionnaires' disease in an inner city district: importance of the first 24 hours in the investigation

OBJECTIVE

To present the main results of the investigation of an outbreak of Legionnaire's disease that occurred in an inner city district of Barcelona between 15 October and 15 November 2000.

METHODS

Epidemiological surveys of patients and environmental investigations were initiated on the day the first five cases were notified. Water samples and smears from cooling tower trays were taken for microbiological analysis. Maps of the distribution of cases and possible contamination foci were elaborated. Incidences were calculated for each census tract.

RESULTS

A total of 54 patients related to the outbreak were identified, with a case fatality rate of 5.5%. Incidence rate in the area closest to the cooling tower (6.40/1000) was significantly higher than that of the rest of the neighbourhood (2.23/1.000, RR 2.87, 95%CI 1.37-6.12, P = 0.0035). Cultures positive for Legionella pneumophila serogroup 1, subtypes Pontiac, Philadelphia or Allentown, were obtained from eight patients. On the 39th day of the investigation it was found that the strain isolated in one of the cooling towers coincided with the serogroup, subtype and molecular profiles identified in clinical samples.

CONCLUSIONS

Rapid coordination of clinicians, microbiologists, epidemiologists and environmentalists permitted the source of infection and the affected cases to be correlated within a few days.

Treatment of skin carcinomas of the face by high-dose-rate brachytherapy and custom-made surface molds

PURPOSE

To analyze the results obtained in a prospective group of patients with basal or squamous cell skin carcinomas of the face treated by high-dose-rate (HDR) brachytherapy via custom-made surface molds.

METHODS AND MATERIALS

A total of 136 patients with basal or squamous cell carcinomas of the face were treated between March 1992 and March 1997 by surface molds and HDR brachytherapy with iridium-192. Nineteen patients were treated with standard Brock applicators and 117 patients with custom-made polymethyl methacrylate applicators, built over a plaster mold obtained of the patient's face. Minimum dose administered to the tumor was 6000 to 6500 cGy in 33 to 36 fractions at 180 cGy/fraction in lesions of up to 4 cm. Lesions greater than 4 cm were boosted up to 7500-8000 cGy after a 3-week pause.

RESULTS

With the custom-made surface molds, the dose distribution was uniform in the surface of the skin and at 5 mm depth in the whole area of the applicator. Differences between the areas of maximum and minimum dose at this depth never reached values higher than 5% of the prescribed dose. At the edges of the custom-made molds dose gradient was sharp, with the detected dose at 5 mm from the applicator being negligible. All the patients were complete responders. There were 3 local recurrences, 1/73 patients treated for primary tumor and 2/63 patients treated for recurrent tumor. Actuarial local control at 5 years for all patients was 98%, for those patients with primary tumors 99%, and for recurrent patients 87%. The treatment tolerance was excellent in all cases. No severe, early, or late, complications were detected.

CONCLUSIONS

Radiotherapy is a highly effective treatment of skin carcinomas of the face. Custom-made molds, to be used in conjunction with HDR brachytherapy equipment, make possible a uniform dose distribution, with a sharp dose gradient in the limits of applicators. Custom-made surface molds are easy and safe to use, and they fit very accurately for daily treatment. Local control is excellent with minimal sequelae or complications. Probably they will become the standard way of treatment of face skin carcinomas in the near future.

[Study of comparative immunity of patients with M. tuberculosis and atypical Mycobacteria infection and infection by human immunodeficiency virus (HIV)]

The purpose of this retrospective study was to determine the basal immune status, in patients with human immunodeficiency virus (HIV) infection, who were affected from tuberculosis (TB) caused by Mycobacterium tuberculosis or atypical mycobacterium. In the current study, we report our experience with 280 patients diagnosed TB and HIV: fifty cases were eligible for enrollment at random with M. tuberculosis (group I) and we compare with 23 cases of atypical mycobacterias (group 2). When we analyze statistically both groups, we detected in group 2 the existence of a CD4 Lymphocytes count decrease and a mean IgA raised, opposite to group I (P < 0.0001). On other side, our investigation on survival showed that this was lower in atypical mycobacterias group (group 2) with a median time of survival of 10 months, opposite to 2,9 years in group I.

[Tuberculosis and human immunodeficiency virus infection. A prospective study of 215 patients]

We analyze the cases of 215 adult patients affected from tuberculosis (TB) and infection due to human immunodeficiency virus (HIV) in the study period from December 6th, 1986 to January 31st of 1992. Disease affected specially the group of drug addict patients (DAP) with a 74.88%, followed by paid plasma donors (PPD) from our city with a 12.09%. Sexual transmission was the route of contamination with the HIV in 16 cases. In five cases atypical mycobacteria were detected. First-line anti-tuberculostatics drugs activity against Mycobacterium tuberculosis was excellent. A total of 17 cases with toxicity to any of these drugs were described. TB was located in the lung in 108 cases (50.23%), in 74 cases out of the lung (34.41%) and in 33 cases there was intrapulmonary as well as extrapulmonary affectation (15.34%). TB was diagnosed at the same time that a disease which met AIDS criteria in 13.49% of cases, TB was diagnosed first in 32.55% of cases, and AIDS was diagnosed before TB in only 7.91% of cases. Fever was the predominant symptom (88.84%), together with toxic status at admittance (80.47%) and deteriorated immune situation with lymphocytes count decrease (mean 1240/mm) and CD4 (mean value 134.5/mm) together with a mean raised IgA (492.85 mg/dl). Thorax radiography was normal in 34.88%. In 33 of these patients TB was localized in the lung, in 27.91% primary radiologic types were observed while in 31.16% reactivation types. In 51 cases (23.72%) tuberculosis was detected in patients (DAP) who were forwarded from the penitentiary system.(ABSTRACT TRUNCATED AT 250 WORDS)

[Candida laryngitis and HIV infection: description of 4 cases]

Candidiasic laryngitis is a very rare Candida spp infection of mucosa, appearing typically in immunosuppressed patients, mainly in patients with neoplasia, and, recently, in patients with Human Immunodeficiency Virus (VIH) infection. We present four cases of candidiasic laryngitis and HIV infection, as well as the clinical description and evolution of said cases after treatment with fluconazole. We review, as well, the cases published on the scientific literature. We maintain that in each HIV infected patient, with or without oral candidiasis, who shows dysphonia, candidiasic laryngitis should be ruled out.

[A serum immunoglobulin study in patients with tuberculosis and human immunodeficiency virus infection]

We present the immunoglobulin spectrum in a series of 156 HIV-infected patients who were affected of tuberculosis (TB) of different localization. Sixty-seven patients had lung TB, in 13 cases lung TB and an opportunistic infection were diagnosed simultaneously and in 76 cases TB was localized outside the lung. The cases were compared to 62 HIV-infected patients classified in stage 11 (CDC 1986) and to 85 cases of HIV-infected patients who suffered carinii pneumonia (PCP). The most outstanding differences were established between IgA of patients with lung TB and group PCP (p less than 0.001). IgG showed significant differences between lung TB patients and the PCP group (p less than 0.001).

[Pulmonary tuberculosis with normal chest radiography and infection by human immunodeficiency virus]

We report 16 cases of pulmonary tuberculosis with normal chest x-ray film associated with infection by the human immunodeficiency virus (HIV). These patients belong to a sample of 125 cases of tuberculosis and HIV infection observed during the same study period. The clinical features and the diagnostic methods are described. The unusual character of the finding and its relevance are discussed, as the presentation of pulmonary tuberculosis with normal chest x-ray film was relatively common in patients with HIV infection (12.8%) in our series. This possibility should be considered in the whole population of patients with HIV infection.

[Action of domperidone on dopamine-induced inhibition of gastric secretion]

The inhibitory action of dopamine on basal gastric secretion and that stimulated by pentagastrin with previous administration of domperidone in 26 male patients, between 18 and 48 years of age, suffering duodenal ulcer has been studied. The administration of domperidone (0.25 mg/kg) produces a significant reduction of the inhibitory action of dopamine on basal gastric secretion and that stimulated by pentagastrin at dose 0.15 microgram/kg/h. Besides dopamine shows a minor, non significant, inhibitory action on acid gastric secretion stimulated by maximal doses of pentagastrin, while showing no differences against the group without administration of domperidone.

Stimulation of IgG antibody formation by sublethal irradiation during persistently repeated immunization with Brucella abortas

Whole-body irradiation with 600 rads 8 or 10 days after the beginning of persistently repeated Brucella abortus immunization in the rabbit produces little change in the response. By contrast, irradiation with the same dose 2, 4 or 6 days after the beginning of repeated immunization stimulates the IgG response. This effect is explained by a repopulation of antigen-sensitive cells from precursor cells to a higher level than that previous to irradiation. In order to explain IgG stimulation, three main possibilities are considered. a) a T cell-dependent mechanism, consequent on a higher radioresistance of T than of B cells, or on a faster and more extensive repopulation by T cells; b) another T cell-dependent mechanism due to a greater radiosensitivity of the suppressor or inhibitory T-cell subpopulation, with the result of a predominance in the T cell population that helps IgG formation; c) a mechanism depending on antigen presence during the repopulation of antigen-sensitive cells from the precursor cells, according to previously obtained data suggesting the necessity for the persistence of a certain level of antigen for IgG formation