The impact of a clinical training unit on integrated child health care in Mexico

This study had two aims: to describe the activities of a clinical training unit set up for the integrated management of sick children, and to evaluate the impact of the unit after its first four years of operation. The training unit was set up in the outpatient ward of a government hospital and was staffed by a paediatrician, a family medicine physician, two nurses and a nutritionist. The staff kept a computerized database for all patients seen and they were supervised once a month. During the first three years, the demand for first-time medical consultation increased by 477% for acute respiratory infections (ARI) and 134% for acute diarrhoea (AD), with an average annual increase of demand for medical care of 125%. Eighty-nine per cent of mothers who took their child for consultation and 85% of mothers who lived in the catchment area and had a deceased child received training on how to recognize alarming signs in a sick child. Fifty-eight per cent of these mothers were evaluated as being properly trained. Eighty-five per cent of primary care physicians who worked for government institutions (n = 350) and 45% of private physicians (n = 90) were also trained in the recognition and proper management of AD and ARI. ARI mortality in children under 1 year of age in the catchment area (which included about 25,000 children under 5 years of age) decreased by 43.2% in three years, while mortality in children under 5 years of age decreased by 38.8%. The corresponding figures for AD mortality reduction were 36.3% and 33.6%. In this same period, 11 clinical research protocols were written. In summary, we learned that a clinical training unit for integrated child care management was an excellent way to offer in-service training for primary health care physicians.

[Child health care program in Mexico. Evaluation of the quality of the integrated health care given in training centers]

OBJECTIVE

To assess the quality of the integral care of children under five years old (AIMCA) at three first level care units, that without additional resources, were selected by the Child Health Care Program (PASN) to function as statewide training centers.

MATERIAL AND METHODS

Using matching list, structure, validated by a consensus of experts and a pilot test, six components of the AIMCA were assessed. The study included children under five years old outpatient clinic, during a period of a week: on the average 30 at each unit.

RESULTS

Although there were differences between each health unit, in a high number of cases, the score given to each component of the AIMCA was optimum or satisfactory. The most relevant deficiencies were those related to the mother's training. The assessment allowed for correcting deficiencies in the AIMCA and others related with the organization of Training Centers.

CONCLUSIONS

It is possible to have an AIMCA of good quality, at first level units without additional resources. We propose that the mother's training be given mainly by a nurse, especially in children with factors of poor prognosis. The methodology used can be employed to evaluate the AIMCA periodically at training centers.

The primary care clinic as a setting for continuing medical education: program description

The Mexican Institute of Social Security (IMSS) is Mexico's Largest state-financed health care system, providing care to 50 million people. This system comprises 1450 family medicine clinics staffed by 14,000 family physicians, as well as 240 secondary care hospitals and 10 tertiary care medical centres. We developed a program of continuing medical education (CME) for IMSS family physicians. The program had 4 stages, which were completed over a 7-month period: development of clinical guidelines, training of clinical instructors, an educational intervention (consisting of interactive workshops, individual tutorials and peer group sessions), and evaluation of both physicians' performance and patients' health status. The pilot study was conducted in an IMSS family medicine clinic providing care to 45,000 people; 20 family physicians and 4 clinical instructors participated. The 2 main reasons for visits to IMSS family medicine clinics are acute respiratory infections and type 2 diabetes mellitus. Therefore, patients being treated at the clinic for either of these illnesses were included in the study. The sources of data were interviews with physicians and patients, clinical records and written prescriptions. A 1-group pretest-posttest design was used to compare physicians' performance in treating the 2 illnesses of interest. We found that the daily activities of the clinic could be reorganized to accommodate the CME program and that usual provision of health care services was maintained. Physicians accepted and participated actively in the program, and their performance improved over the course of the study. We conclude that this CME strategy is feasible, is acceptable to family physicians and may improve the quality of health care provided at IMSS primary care facilities. The effectiveness and sustainability of the strategy should be measured through an evaluative study.

Diagnostic value of tachypnoea in pneumonia defined radiologically

OBJECTIVE

To evaluate whether sensitivity and specificity of tachypnoea for the diagnosis of pneumonia change with age, nutritional status, or duration of disease.

METHODS

Diagnostic testing of 110 children with acute respiratory infection, 51 of whom presented with tachypnoea. The gold standard was a chest roentgenogram. Thirty five children had a radiological image of pneumonia; 75 were diagnosed as not having pneumonia. Sensitivity, specificity, and percentage of correct classification of tachypnoea, by itself or in combination with other clinical signs for all children, by age groups, nutritional status, and disease duration were calculated.

RESULTS

Tachypnoea as the sole clinical sign showed the highest sensitivity (74%) and a specificity of 67%; 69% of cases were classified correctly. Sensitivity was reduced when other clinical signs were combined with tachypnoea, and there was no significant increase in correct classification, although specificity increased to 84%. In children with a disease duration of less than three days, tachypnoea had a lower sensitivity and specificity (55% and 64%, respectively), and a lower percentage of correct classification (62%). In children with low weight for age (< 1 Z-score), tachypnoea had a sensitivity of 83%, a specificity of 48%, and 60% correct classification. Sensitivity and specificity did not vary with age groups.

CONCLUSIONS

Tachypnoea used as the only clinical sign is useful for identifying pneumonia in children, with no significant variations for age. In children with low weight for age, tachypnoea had higher sensitivity, but lower specificity. However, during the first three days of disease, the sensitivity, specificity, and percentage of correct classification were significantly lower.

[Impact of health services, sanitation and literacy in the mortality of children under 5 years of age]]

OBJECTIVE

To analyze differences of the impact of health care services, sanitation and literacy on the mortality rates of children under five years of age, in two Mexican states with marked socioeconomic differences: Chiapas and Nuevo Leon.

MATERIAL AND METHODS

The study design was ecologic, based on a retrospective analysis of data published by the Health Ministry (Secretaría de Salud), National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática) and the National Population Council (Consejo Nacional de Población), on the tendencies of mortality among children under five years and on the changes of selected indicators corresponding to the period 1990-1997.

STUDY DESIGN

ecologic study. This was based on a retrospective analysis of data published by Secretaría de Salud, Instituto Nacional de Estadística e Informática and Consejo Nacional de Población, about the tendencies of mortality among children under five years, and about the changes of selected indicators. The analysis was carried out in the period comprised between 1990-1997. For both states the registered variations were calculated and the trends were determined through analysis of simple linear regression; the independent variable corresponded to the study years. Partial correlation analysis between the various mortality trends studies and between and the selected indicators, were calculated.

RESULTS

During the studied period there was a steady decline of children mortality, which was more marked in Chiapas. In both entities, this decrease was closely related to the decline in mortality due to acute diarrhea, and also correlated with a descent in measles and acute respiratory infections. In Chiapas, the indicators which correlated more significantly with this decline in mortality were vaccination coverage and literacy. In Nuevo Leon, the indicators with greater correlation were the increase in the number of nurses, of lodgings with piped water and vaccination coverage.

CONCLUSIONS

During the analyzed period, the mortality rate of children under five years of age decreased in the states of Chiapas and Nuevo Leon. To sustain or accelerate the decline in childhood mortality it is mandatory to continue with the currently implemented programs, and in Chiapas, and similar states, to increase the available infrastructure to provide health care.

A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico

In Tlaxcala State, Mexico, we determined that 80% of children who died from diarrhoea or acute respiratory infections (ARI) received medical care before death; in more than 70% of the cases this care was provided by a private physician. Several strategies have been developed to improve physicians' primary health care practices but private practitioners have only rarely been included. The objective of the present study was to evaluate the impact of in-service training on the case management of diarrhoea and ARI among under-5-year-olds provided by private and public primary physicians. The training consisted of a five-day course of in-service practice during which physicians diagnosed and treated sick children attending a centre and conducted clinical discussions of cases under guidance. Each training course was limited to six physicians. Clinical performance was evaluated by observation before and after the courses. The evaluation of diarrhoea case management covered assessment of dehydration, hydration therapy, prescription of antimicrobial and other drugs, advice on diet, and counselling for mothers; that of ARI case management covered diagnosis, decisions on antimicrobial therapy, use of symptomatic drugs, and counselling for mothers. In general the performance of public physicians both before and after the intervention was better than that of private doctors. Most aspects of the case management of children with diarrhoea improved among both groups of physicians after the course; the proportion of private physicians who had five or six correct elements out of six increased from 14% to 37%: for public physicians the corresponding increase was from 53% to 73%. In ARI case management, decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups; the proportion of private physicians with at least three correct elements out of four increased from 13% to 42%, while among public doctors the corresponding increase was from 43% to 78%. Hands-on training courses thus seemed to be effective in improving the practice of physicians in both the private and public sectors.

Seasonal diarrhoeal mortality among Mexican children

The study investigated the effects on diarrhoeal deaths among under-5-year-old Mexican children of the following variables: season (summer or winter), region (north versus south), age group, and place of death. Examination of death certificates indicated that the distribution of deaths in 1989-90 was bimodal, with one peak during the winter and a more pronounced one during the summer. In 1993-94, however, the winter peak was higher than that in the summer (odds ratio (OR) = 2.04). These findings were due mostly to deaths among children aged 1-23 months (OR = 1.86). Diarrhoeal mortality was highest among children aged 6-11 months (OR = 2.23). During the winter, there was a significant increase in the number of deaths that occurred in medical care units and among children who had been seen by a physician before they died, but deaths occurring at home showed no seasonal variation. In the northern states, the reduction in diarrhoeal mortality was less in winter than in summer (OR = 2.62). In the southern states, the proportional reduction during the winter was similar to that in the summer.

The quality of private and public primary health care management of children with diarrhoea and acute respiratory infections in Tlaxcala, Mexico

In Tlaxcala, Mexico, 80% of the children who died from diarrhoea or acute respiratory infections (ARI) in 1992-1993 received medical care; in more than 70% of cases it was provided by a private general practitioner (GP). The present study evaluated the quality of case management by private and public GPs to children under five years of age with diarrhoea and ARI. During the clinical observation, the treatment and counselling given to the mother were assessed with the WHO guidelines as reference standard. A total of 41 private and 40 public GPs were evaluated for the management of diarrhoea, and 59 private and 40 public GPs for the management of ARI. For diarrhoea, half of the private GPs gave inadequate rehydration therapy, 63% gave incorrect advice on diet, 66% and 49% made an incorrect correct decision in the prescription of antimicrobial and symptomatic drugs, respectively. Public GPs generally performed better in diarrhoea management: 7% gave inadequate rehydration therapy, 13% gave wrong advice on diet, 3% made a wrong decision in the prescription of symptomatic drugs and 28% gave a wrong decision in antimicrobial prescription. In the management of ARI, 66% and 58% of private GPs made a wrong decision in the prescription of antimicrobial and symptomatic drugs, respectively, compared to 30% and 20% of public GPs, respectively. Counselling to the mother given by both private and public GPs was considered inadequate in most cases of diarrhoea and ARI. These results clearly show that private doctors, as important providers of medical care, need to be included in the strategies to improve the quality of care of children with diarrhoea and ARI. Future research needs to address the determinants of the clinical practice of private doctors in countries like Mexico.

[Mortality for diarrheic disease in Mexico: problem of accessibility or quality of care?]

OBJECTIVE

To evaluate the access to health services and the process of care provided to children under five years old who died from acute diarrhea (AD).

MATERIAL AND METHODS

In four states of Mexico, a cross-sectional study was carried out. Deaths from AD that occurred in the lapse of one year were included. Information about clinical characteristics of the illness, process of care and access to the health facilities were obtained through verbal autopsy. Descriptive analysis and comparison of data between rural and urban communities were performed.

RESULTS

Five-hundred and fifty three deaths were analysed. Most of the children were not enrolled in a public care health system. The main children's characteristics were the following: residence in rural communities; age less than one year; died at home or had short illness duration. Geographic and economic access barriers were identified in rural areas. Oral rehydration salts were provided as a part of household treatment in about 75% of children. 20% of them received non-medical care, specially from traditional healers. Primary medical care was provided to 60% of cases; the drawbacks of the process were related to a high rate of medication prescription, lack or referral to hospital, and lack of recommendation for a new visit in presence of alarm signs. Public physicians and those from rural communities prescribed oral rehydration therapy in a greater proportion.

CONCLUSIONS

The problem of access to health services in rural communities was confirmed. However, low quality of care provided by primary level physicians was found in both rural and urban areas. We propose the creation of clinical teaching centers to improve the quality of the process of medical care as a strategy to decrease mortality due to AD.

Antigenic and genomic diversity of human rotavirus VP4 in two consecutive epidemic seasons in Mexico

In the present investigation we characterized the antigenic diversity of the VP4 and VP7 proteins in 309 and 261 human rotavirus strains isolated during two consecutive epidemic seasons, respectively, in three different regions of Mexico. G3 was found to be the prevalent VP7 serotype during the first year, being superseded by serotype G1 strains during the second season. To antigenically characterize the VP4 protein of the strains isolated, we used five neutralizing monoclonal antibodies (MAbs) which showed specificity for VP4 serotypes P1A, P1B, and P2 in earlier studies. Eight different patterns of reactivity with these MAbs were found, and the prevalence of three of these patterns varied from one season to the next. The P genotype of a subset of 52 samples was determined by PCR. Among the strains characterized as genotype P[4] and P[8] there were three and five different VP4 MAb reactivity patterns, respectively, indicating that the diversity of neutralization epitopes in VP4 is greater than that previously appreciated by the genomic typing methods.

Serotype specificity of the neutralizing-antibody response induced by the individual surface proteins of rotavirus in natural infections of young children

The relative contribution of the rotavirus surface proteins, VP4 and VP7, to the induction of homotypic as well as heterotypic neutralizing antibodies (NtAbs) in natural infections was studied. The NtAb titers of paired sera from 70 infants with serologically defined primary rotavirus infections were determined with a panel of rotavirus reassortants having one surface protein from a human rotavirus (serotypes G1 to G4 for VP7 and P1A and P1B for VP4) and the other surface protein from a heterologous animal rotavirus strain. A subset of 37 children were evaluated for epitope-specific antibodies to the two proteins by an epitope-blocking assay. The infants were found to seroconvert more frequently to VP4 than to VP7 by both methods, although the titers of the seroconverters were higher to VP7 than to VP4. Both proteins induced homotypic as well as heterotypic NtAbs. G1 VP7 frequently induced a response to both G1 and G3 VP7s, while G3 VP7 and P1A VP4 induced mostly homotypic responses.

Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea

A prospective cohort study was conducted to analyze factors associated with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study took place in four primary health care clinics in Mexico City, two belonging to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty-two patients with ARI and 155 with AD were included. Data about study variables and the assessment of compliance were obtained through patient interviews and direct observation. Factors associated with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 60% for ARI and 55.5% for AD in both health care systems. Prescription of an antibiotic was justified only in 13.5% of cases. Associated factors were: increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16-3.26); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an inadequate physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was higher in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to modify physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.

Mothers' health-seeking behaviour in acute diarrhoea in Tlaxcala, Mexico

This study, a cross-sectional survey, was conducted to assess how mothers take care of their children with diarrhoea and to develop a model of health-care seeking behaviour. Multistage sampling was used. Mothers whose children aged less than five years had suffered from diarrhoea in the last fortnight were included. Nurses interviewed the mothers to collect data. Variables included in the interview were: mothers' characteristics, children's characteristics, clinical data, treatment given by the mother, maternal health-seeking behaviour and mothers' information about diarrhoea and dehydration. Variables corresponding to the clinical data were grouped to identify dehydration signs and the need for medical care. Dehydration was defined as the presence of two or more of the following reported signs: thirst, sunken eyes, sunken fontanelle, or scanty urine. The need for medical care was defined as the presence of one or more of the following characteristics: illness lasting more than three days, vomiting, fever, bloody diarrhoea or dehydration. A sample of 747 mothers was obtained. Household treatments consisted of herbal teas to stop diarrhoea (52.3%), liquids to prevent dehydration (92.2%), symptomatic drugs (35.2%) and changes in feeding patterns (36.3%), which consisted in suppressing milk and dairy products and interrupting breast feeding (12.2%). Mothers sought medical assistance when they perceived a worsening of clinical conditions. Clinical signs statistically associated with their decision were: bloody diarrhoea, vomiting, illness longer than three days, weight loss, and fever. The signs of dehydration were not associated with health care-seeking because the mother did not recognise them. It is concluded that maternal educational programmes should emphasise, besides the proper use of oral rehydration therapy, teaching mothers to identify signs of dehydration as an indication to seek timely medical care.

[Death caused by acute diarrhea in children: a study of prognostic factors]

OBJECTIVE

To identify prognostic factors of death due to acute diarrhea related to the process disease-health care-death in the State of Tlaxcala, Mexico.

MATERIAL AND METHODS

A case-control design was used. Cases were defined as children who died between the ages of seventy-two hours and five years between 1992 and 1994. An event of acute diarrhea was the main cause of death stated in the death certificate. Case ascertainment was done through the verbal autopsy method. Controls were children who had suffered acute diarrhea with at least one sign of dehydration or alarm and had overcome the diarrheal episode. Controls were randomly selected from the population at large and were matched by age with cases.

RESULTS

One hundred and six cases and the same number of controls were taken. Using a logistic regression procedure in which severity of illness and days of evolution were controlled for, the prognosis-worsening predictors were: visit provided by private physician (OR 8.9); inappropriate treatment (OR 10.4); a working mother (OR 8.7); mother's lack of knowledge to identify dehydration signs (OR 8.1); siblings' malnutrition (OR 28.2); and malnutrition prior to the diarrheal event (OR 7.5).

CONCLUSIONS

These findings suggest that factors worsening the outcome of the diarrheal episode are: malnutrition, the inappropriate treatment provided by private physicians, and the deficient household care of the diarrheal episode.

[Urban-rural variations in medical care of children with diarrhea in Mexico]

OBJECTIVE

To study the urban and rural variations of medical care for acute diarrhea among children under five years old.

MATERIAL AND METHODS

Data from the 1993 Effective Household Treatment National Survey were analyzed. A number of 338 children from urban areas and 300 from rural areas were included in the study. Variables included were: household treatment, health-seeking behavior, mothers' previous training to manage acute diarrhea, use of oral rehydration salts (ORS) and availability of and access to health care.

RESULTS

Oral rehydration therapy (ORT) as part of the household treatment and feeding the regular diet were more frequently found in rural areas. Less than 50% of children received medical care in both settings. In urban areas most children were cared for by private physicians. About 30% of children needed medical care but they were not taken to medical facilities. Physicians in rural areas prescribed ORS more frequently, while those from urban areas prescribed medication and restrictive diets in a greater proportion. Physicians working in public facilities prescribed ORT in greater proportions than private ones. Mothers from rural areas had received more training to manage diarrhea but they had restricted access to medical care in comparison to mothers from urban areas.

CONCLUSIONS

It is necessary to improve health care education of urban populations, to increase access and coverage of health services in rural areas and to strength activities to improve the quality of medical care provided by private physicians and by those working in urban areas.

Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico

To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.

Impact of oral rehydration and selected public health interventions on reduction of mortality from childhood diarrhoeal diseases in Mexico

Reported are the results of an analysis of mortality trends from diarrhoeal diseases among under-5-year-olds in Mexico between 1978 and 1993 in relation to the impact of education, basic sanitation, and selected medical care practices. The study period was divided into three stages; the first pre-dated the widespread application of oral rehydration therapy (ORT); the second, covered the implementation of a nationwide programme promoting ORT; and the third included additional measures, such as immunization and improvements in basic sanitation. Mortality rates decreased progressively, at an average of 1.8% per year in the first stage, 6.4% in the second, and 17.8% in the third. The importance of literacy campaigns for women and the promotion of ORT was confirmed. Both of these measures reduced mortality; however, a greater reduction resulted from a massive immunization campaign against measles and improvements in sanitation (expansion of the drainage and piped water systems, improved water chlorination procedure, and effective prohibition of the use of sanitary sewage for vegetable irrigation).

Changing physician prescribing patterns: evaluation of an educational strategy for acute diarrhea in Mexico City

This paper presents the results of an intervention strategy designed to decrease drug prescription and increase the use of oral rehydration therapy (ORT) in the treatment of acute diarrhea aimed at family medicine practitioners in two primary health care units of the Mexican Social Security Institute. The intervention consisted of six successive stages: 1) Baseline study of prescribing practices by all 69 physicians in both clinics; 2) Training workshop attended by 36 physicians, including a critical analysis of relevant up-to-date literature, review of results of stage I, discussion of a previously designed treatment algorithm for acute diarrhea, and modification of it according to participant's experience; 3) Post-workshop evaluation; 4) Establishment of a peer review committee to discuss the treatment behavior of participating physicians; 5) Mid-term evaluation for 2 months after the committee stopped functioning; 6) Long-term evaluation at 6, 12 and 18 months, of 20 physicians who received the complete intervention (study group) and 20 physicians who received none (control group). The treatment behaviors of the study and control groups were similar on baseline, but differed significantly (P < 0.01) in the post-workshop evaluation. The study group showed a reduction in the use of antibiotics (from 78.8% to 39.3%) and restrictive diets (47.3% to 12.4%), and increased the use of ORT (31.4% to 58.4%) for children younger than 5 years old with acute diarrhea. In the mid-term evaluation, the use of antibiotics by the study group decreased to 27.6%, prescription of restrictive diets decreased to 6.4%, and use of ORT increased to 73.8% (P < 0.01, in all cases). In the long-term evaluation, persistent positive prescribing behavior was still present in the study group, with a significant difference (P < 0.05) compared to the control group, where no modification was found in the prescribing behavior throughout the study. The average proportion of cases treated according to the algorithm by the study group increased in 29.2% (31.3 to 60.5%) after the workshop, and 45.2% (31.3 to 76.5%) after peer review committee. This behavior was maintained during 18 months after the intervention (74%). The control group showed no significant modification in the average proportion of cases treated according to the algorithm during the study (2 years 7 months). The active participation of physicians in the workshop and in the peer review committee was identified as the key to the short and long-term success of the educational strategy.

[Reduction in the mortality from acute diarrheal diseases. The experiences of an action-research program]

In order to accelerate the descending mortality rate of acute diarrhea in children under five years of age in Mexico, six strategies were implemented. The results showed that after nine months, 49 per cent of mothers had been trained, and improved significantly their home management of diarrhea. The use of oral rehydration salts increased from 10 to 30 per cent; use of oral rehydration therapy increased from 77 to 83 per cent; and timely and appropriate demand for medical help increased from 51 to 62 per cent (p < 0.05). One hundred percent of all physicians received training, and they improved their therapeutic practices, as shown by a decrease in the use of antibiotics from 48 to 34 per cent; prescription of restrictive diets diminished from 33 to 4 per cent; and oral rehydration therapy increased from 74 to 87 per cent. Thirty-four verbal autopsies were carried out, and they showed that 70 per cent of the children who died did so in their homes or in their way to the hospital, despite the fact that 94 per cent of them had received medical care previous to their death, and that 84 per cent of these had been seen by a doctor within 24 hours previous to their death. In 85 per cent of these cases, the physician involved was a private physician of rural or marginal areas. Monthly analysis of death certificates showed that, during the first year of the program (1991), deaths due to diarrhea diminished 20 per cent, while the corresponding figure for 1992 was 52 per cent. In conclusion, the combination of strategies followed in the program made it possible to accelerate, on a short-term basis, the descending trend of deaths due to diarrhea. It was also shown that an intervention project such as the one presented here may efficiently link results from research to decisions taken by policy-makers, and that these can be effectively turned into actions.

[The verbal autopsy: a tool for the study of mortality in children]

The verbal autopsy (VA) is a technique that has been used since 1931, but it wasn't until the last decade that it has been more widely used by different investigators to study mortality both in infancy/childhood and adulthood. The VA consists of an interview directed to a care-giver (usually the mother) close to the deceased subject, and its objective is to disclose information about the cause of death. The VA has been particularly useful in those places where a reliable record of mortality is unavailable or nonexisting. This paper describes the assumptions on which the VA is based, and highlights its most important methodological aspects. Lastly, we stress the use of the VA as an useful too to assess the process associated with mortality, including the family's decision-making process to look for medical care as well as the response and characteristics of the medical care system. In this respect, we point out to the usefulness of the VA as an interface between epidemiology and ethnography, and stress its potential impact as a tool to learn more about the process of health-seeking behaviors, from the points of view of mothers and physicians.

[The verbal autopsy on children with a respiratory infection and acute diarrhea. An analysis of the disease-care-death process]

The study focuses on children between 72 hours and five years of age who died of acute respiratory infection (ARI) or acute diarrhea (AD) in the State of Tlaxcala. Peer Review Mortality Committee of the State contributed with the staff to the deaths analysis. Cases were included only when diagnosis was confirmed by verbal autopsy (VA). One hundred and thirty two cases were included (98 corresponding to ARI deaths and 34 to AD). The process related to medical care-seeking behaviors and prescribing practices by private and non-private physicians was analyzed through the VA. During the study period, 60% of children with ARI and 58.9% of children with AD died at home. More than 80% of these children had received medical care within three days preceding their death, and 50% of them had been seen by a physician within 12 hours prior to their death. Most of these visits were to a private doctor (71% for ARI and 86% for AD). Forty seven percent of treatments prescribed for ARI were judged to be wrong, either because of a bad choice of antibiotic or because the physician did not prescribe an antibiotic when the patient required it. Similarly, 65% of treatments for AD were considered erroneous, either due to the use of an antibiotic which was not justified or due to the lack of oral rehydration therapy when it was needed. Additionally, late referral to a hospital was considered as having direct influence at the death in half of the consultation. Families were too late in demanding medical care or demanded no care at all in 21.9% of cases of ARI and in 6.1% of cases of AD. We have found the VA to be useful in identifying problems related to the process of health-seeking behaviors and medical care. Our results suggest interventions that may lower the high mortality rates in Tlaxcala, such as training workshops directed to institutional and private physicians, and the implementation of top-of-line treatment centers where high-risk patients can be referred and also the health care workers can learn the correct treatment of both diseases. Future studies should focus on the identification of alarm signs and risk factors that may help to lower mortality due to ARI or AD, when recognized and treated at early stages.

[Medical prescription and treatment compliance in acute infectious diarrhea: indirect impact of an educational intervention]

As part of the evaluation of an educational intervention carried out at primary health care units in Mexico City a home visit was included for patients treated for acute infectious diarrhea. In such visit, effected for 401 patients before the educational intervention and for 406 after the same, it was possible to evaluate compliance with the treatment measured through the amount of prescribed drugs distributed by the institution but not consumed by patients. A significant improvement was observed in compliance with the treatment even though this was not the explicit objective of the intervention. Compliance is related to variables of different dimensions--characteristics of the physician, characteristics of the patient, physician-patient rapport, health condition and health concept--and the educational intervention tends to homogenize the patient's behavior as a result of more emphatic improvement in those subgroups with worst compliance levels.

[Diagnosis of streptococcal pharyngo-tonsillitis: clinical criteria or coagglutination?]

With the purpose of evaluating the usefulness of clinical data and a coagglutination test for the diagnosis of streptococcal pharyngeal tonsillitis, a study was carried out comparing both methods with the standard pharynx culture (gold standard). One hundred and forty-one patients clinically diagnosed with pharyngeal tonsillitis were analyzed. 80 other patients diagnosed with rhino-pharyngitis were used as control groups as well as a group of 66 healthy patients. It was found that the presence of pus in the tonsils and the absence of rhinorrhea and/or a productive cough were isolated clinical variables which showed a significant difference when comparing those cases with a positive or a negative culture (P less than 0.01). These clinical data had a sensitivity and adequate negative predictive values (68 to 83% and 90 to 92%, respectively); specificity was 44 to 74% and the positive predictive value from 24 to 36%. The gathering of combined clinical indexes with different symptoms and signs, were not greater than isolated data. The coagglutination test in those cases of pharyngeal tonsillitis showed greater better specificity (98%) and positive predictive value (93%), but saw no improvement in sensitivity (72%) nor in the negative predictive value (91%), which is why when faced with a negative coagglutination test, it is still necessary to perform a throat culture due to the risk which the patient may be exposed to when no treatment is given. The analysis of the advantages and disadvantages in the routine use of coagglutination and cultures in their particular cases, allows us to conclude that in daily clinical practice the use of clinical criteria is of greater usefulness.(ABSTRACT TRUNCATED AT 250 WORDS)

Colonization by Clostridium difficile in hospitalized children: risk factors and typification of the isolated strains

The frequency of colonization by Clostridium difficile in 273 hospitalized children under 15 years of age was studied. Feces were collected from patients attending the infectious disease service at the Pediatric Hospital IMSS, during a period of 11 months. No colonization was detected in 16 neonates; whereas 10 of 103 children (9.7%) under one year of age, 7 of 84 children (8.3%) from one to five years and 3 of 70 children (4.2%) from five to 15 years of age were colonized. The use of antibiotics and the nutritional state were studied as possible risk factors for colonization. The frequency of colonization was not influenced by the nutritional state, whereas the treatment with antibiotics decreased significantly the colonization in children under one year of age but not in those children over one year of age. In children under one year of age, the cytotoxin was more frequent in cases of diarrhea, and in those over one year no association was found. The 50 strains isolated from these children were classified according to: toxigenicity, sensitivity to antibiotics, phages and bacteriocins. Strains acquired before hospitalization were more toxigenic than those acquired intrahospital. Twelve resistotypes were detected; one of them (V) was more frequent in intrahospital strains. Ten phagobacteriocin types were found, and two of then (D and I) were present only in intrahospital strains. Using this classification scheme, it was found that eight patients were colonized with two different strains at the same time.

[Infections by anaerobes in children: frequency of isolation and antimicrobial resistance]

We studied the frequency of isolation and antimicrobial susceptibility of strict anaerobic bacteria isolated in a paediatric hospital. A total of 1,753 samples from purulent material and hemocultures were processed. One hundred and thirty strains were isolated from 95 children: 44 from 48 cases of peritonitis (91.7%), 2 from 8 brain abscesses (25%), 23 from 124 soft tissue abscesses (18.5%), 4 from 64 empyemas or lung abscesses (6.3%) and 22 from 1,509 hemocultures (1.5%). Mixed infection (anaerobic and aerobic bacteria) was detected in 38.5% of the cases; however, in peritonitis 81.3% of the cases showed mixed infection. The more frequently isolated bacteria were: Bacteroides (44.6%), Clostridium (19.2%), Fusobacterium (7.7%) and gram positive cocci (7.7%). Propionibacterium acnes was isolated in 15 specimens; however, most of them were considered as contamination. Bacteroides was isolated more frequently from patients with peritonitis (51.6%). The susceptibility to five antibiotics was tested in 124 strains using the method of serial dilutions in agar plates. The genus Bacteroides showed a high resistance to penicillin (73.1%), moderate to clindamycin (11.5%) and low to cefoxitin, chloramphenicol and metronidazole (6.8%, 2% and 5.8%). The rest of the anaerobic strains tested (other gram negatives and grampositives) were highly sensitive to all the antimicrobials tested, except for clindamycin (26.7% and 36.9% resistance, respectively). Cefoxitin, chloramphenicol and metronidazole had the lower CMI50 and CMI90 for the genus Bacteroides; and for the rest of the bacteria, penicillin had the highest activity (CMI90 less than 0.025). Since the frequency of isolation of anaerobic bacteria in children with severe infections, presumably originated from the digestive tract, paranasal sinus and middle ear is high, anaerobic cultures must be practiced in these patients. Empiric antimicrobial treatment should also be started. This treatment should be with penicillin when the probability of isolation of Bacteroides is low (infections in the face, neck, thorax and soft tissues) and with metronidazole in intraabdominal infections. Because of the severity and probable etiology of brain abscesses, treatment with penicillin and chloramphenicol or metronidazole is recommended in these cases.

[Resistance of enterobacteria and Pseudomonas to old and new antimicrobial agents]

Antibiotic sensitivity to eight common use antibiotics for 9,538 enterobacteria and Pseudomonas strains isolated from hospitalized children was studied using the serial dilution plate technique. Minimum inhibitory concentration to seven new antibiotics for 310 strains was also determined. Enterobacteria showed high resistance (50-80%) to ampicillin, carbenicillin, sulbenicillin, chloramphenicol and trimethoprim/sulfamethoxazole; resistance to piperacillin, gentamicin, tobramycin, and netilmicin was moderate (15-45%), and resistance to amikacin, cefotaxime, moxalactam and aztreonam was low (2-10%). Pseudomonas strains showed less than 20% resistance to carbenicillin, piperacillin, amikacin and aztreonam. Enterobacteria isolated from urine samples showed low resistance to nitrofurantoin and nalidixic acid (15%). Therapeutic recommendation for most frequent infections caused by these etiologic agents based on the resistance values found were elaborated.

Haemophilus influenzae type b meningitis resistant to ampicillin and chloramphenicol

We report two cases of meningitis due to Haemophilus influenzae type b resistant to ampicillin and chloramphenicol. In one child the meningitis was preceded by pneumonia and pleural effusion. Both children responded to treatment with cefotaxime.