チリにおける小児呼吸器感染に対する治療の動向

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ngSiJasra[

Innovating

Focus

in

Primary

Attention

in

Chile

--Control

_of

_Children's

_Respiratory

_Infections

_{using an}

_Alternative

Method

of a

Brief

Outpatient

Hospitalization

in

the

Clinics'

P.

Mancilla"',

G.

Girardi,

R.

Gamboa,

andP.

Astudilio,

C.

Aranda,

F.

Risopatron

1,

Introduction

Infant mortality

in

Chile

has

experienced a

con-stant decrease which

has

become

quite

noticeable

in

the

lastthirty _years,reaching

in

1990 a Levelof

16

per

thousand

of born alive, one of the lowest in

Latin

Arnerica and which iseven lower to what could

be

expected according tothe country's socio-economic evolution.

This

reduction

has

been

done

overall at the

ex-pense of Iateinfantmortality, which constituted

in

the 1960's decade around 2f3 of the deaths and

which now reaches only a

50%

of

the

total.

Nevertheless, this national average hide rather

important

differences

among the regions, which range

from

extremes of a

12.5

per thousand inthe

FirstRegion toa maximum ef 26,6per thousand in the Ninth Region, La

Araucania,

Ifthe decrease phenomenon inTotal

Infant

Mor-talityhas been registered, not the same

happens

with the infant death mortality's _proportion

pro-duced by Acute Respiratory Infections

(ARI)

which

register an even tendency, between a 16 and 17%

of deaths in children under 1 _year old

(16.2%

in

1990> and continue constituting the firstcause of

lateinfantmortality.

' _{f iJl･:tset4ilivampwnwwmavet:paS-6?ktaOYM} *' _{WCPT Representative}

of SouthAfrica

('vasumu"I'r'TasV;if

waMi+efkx)

Within

the totalof

deaths

consequence of

respi-ratory infections,bronchial _pneumonia and

bron-chial obstructive illnessrepresent close to a 90% if

the total

_(Fig.

I).

In

reference tomortality inthe 1to4 _{year group,}

Chile

registers one of

Latin

America'

s

lowest

rates,

which

in

1990

has

been

O.76

_per a thousand

chil-dren

in

thisage group.

However,

equally

in

this

group, ARIs have an even tendency and also

repre-sent a 16.2% of total

deaths

in_thisage group, also

being

91.8%

of

them

produced

by

bronchial-pneumonia and obstructive

bronchial

illness.

Besides

the magnitude which these

infant

deaths

produced

by

ARIs

represent,

it

should be _pointed

out the

fact

that a good portion of them, which

reaches close tea 60%, as repeated studies carried out inthe Southern and Western areas of Santiago,

have shown it,

they

die

at home, without any type

of medical attention and this situation has

been

confirmed in

the

VIII

Region

and _probably repeats

itself

in

therest of the country,

keeping

constant in the course of the lastyears.

On

the contrary to

what

happens

in

other countries of

Latin

America,

most of these

deaths

are caused

by

a virus, which

does

not respond toantibiotics,

Inreference tomortality,

ARIs

represent between

a

40

and

70%

of the totaloMce visits at the prirna-ry

level

attention, and obstructive

bronchial

illness

Fig.

1

20

15

10 5

o

%

of

ARI

inIMR 79 80 81 82 83 84 85 86 87 88 years

Relative

weight of

ARI

in

InfantMortaEity

Rate

(IMR)

being this

_percentage

higher in the winter months.

Within thistotal,an increasing role inobstructive

bronchial

illnessand pneumonia is played

by

en-vironmental contamination, specially inthe

Metro-politan

Area

;

obstructive

bronchial

illness

all alone represen'ts a third of thetotalchildren's offlce visits

in

thewinter months,

2.

TechnicalBases

From

the

technicalpoint of view, the team

au-thoring this publication has been implementing since 1987 in the First Attentien CIinics in

the

Metropolitan Area, a modern _procedure of

preven-tion and control of ARIs which includes a

treat-ment norm in which

the

illnessesare _grouped

by

syndromes

(illnesses

_quite alike

but

of

different

origin)

based

only on clinical examination criteria

due tosmall _{probabilities}of X rays or laboratory

support

in

these clinics with patterns of

decisions

and _preciseindicationsforeach levelofseverity.

The practicalappaication of thiscontrol system

in

the

ARIs

with a _pattern of

decisions

has obtain-ed the

following

results I

1) Good response from the _population which

comes forhelp with a good degree of

ance.

2) An important

increase

inthe

_power

of

ing

medical _problems

in

the clinics, mainly

expressed in a dramatic reduction in the

number of children sent to the

Pediatric

and

Urgency Servicesto behospitalizedand a

no-IMR

35

30

25 20 l5 ].o

o

89

90

91

in

Chile

1980-1990

ticeabledecrease in interofflceconsultations

with bronchio-pulmonary clinics and

tals.

3) A rational and modern therapeutic

ment avoiding the use of medications of

doubtful medical

indication

with a minimum

tonone

increase

in

the pharmacy expenses,

4) A

greater

integrationof the health_groups in

a clinic around a common language and

cise

therapeutical

measures.

We should _pinpoint that

for

the

better

use ofthis

norms, they should _go

together

with a _program

which allows to identify the

high

risk

_groups

giving them high _priorityattention and that at the same time,makes aware and educates the

popula-tions

in

the recognizing of the severity degree of

the

ARIs

toobtain self-care

in

light

ARIs

and early visit and treatment inmoderate and severe ARIs.

The obviously positive results of the first experi-ences carried out between 1987 and 1990 insome

Primary Attention Clinicsand the obtaining of an

important increase

in

the

resolution capacity

in

the

clinics,where clearly stands out themanagement of

obstructive bronchialdiseaseand a "Brief

Hospitali-zation Room", associated to seeing the important

increaseof thesediseases,specially inthe

Metropoii-tan

Area

related to the_pollutionincreasemade this

program to expand

in

sieptember

1990

to a total of

33

First

Aid

Clinicsinthe

Metropolitan

Region to

increase

afterward to 60

in

1991

and to a 132 in

Innovating Focus in

Region and 60 inother regions ranging

from

the

II

tothe XIIinwhich infantmortality

due

specifically

toARI ishigher.

Each one of thesesyndromes

have

a precise

defi-nition, differentlevelsof severity and a specific

treatment according tothe leveL

In

the

case ef obstructive

lung

disease,

which

is

the rnost frequent _pathology, a "scorei'

exists which

permits toclassify the patientwhen he arrives and

depending

on

his

seore, will receive

different

diag-nostic procedures, combining medicines in aerosol

therapy and chest physical therapy. Inthe cases of

scoreG between 7 and

10,

which

is

the most

fre-quent, we use the

diagram

of `'Abbreviated

Hospi-talization"and with

1!

or more points,the patient

is

sent

irnmediately

tothe

hospital.

In the cases of bronchial-pneumonia often

assoc-iated with obstructive

lung

disease,

if

the child

is

less

than

3

months, issent to

be

hospitalized im-mediately,

but

ifthe child isolder than that

has

a

light

to

moderate respiratory dithculty,we try an amburatory treatment on an out-patient basiswith

a compromise on

the

_part of the mother to

careful-ly watch the child's evolution and _gives security

that the follow-up will be strict and an evaluation after 24 hours.

3.

Main

Results

of

the

Program

The

program has

been

implemented with 6 basic activities :

1) Installationof "Room

for

Brief

Hospitaliza-tion"which

implies

the

furnishing

the

following

physicalresources 1

. 1Compressor Pump

(by

suctien and mist

producing)

' 1Oxygen

Cilinder

. 1Regulator

Valve

with _a compen$ated

flow

meter

･

₁

_Humidifier

. 24 Nalaton Catheters

(to

_{suck secretions)}

.

₂₄

_Hudson

_{Mist Producers}

. 1_gurney . 1_crib

Primary Attention inChile 435

.1

bench

or

foot

stool

/

The

room's

distribution

was established among

the central

_group

and the

_priorities

defined by the

Directors

of

Primary

Services

of the

Health

'

ices.

2) Incorporationof new inhaledmedications

Each

room received a set of

Salbutamol

surized inhalators and Sambutamol _plus

tusona

inhalatorsi all of

them

with

their

chambers. These medications were

distributed

cording to the amount of _population at risk. _The

utilization of thesemedications implied at the same

time,a reduction in_theuse of symptomatic

tions

or of

doubtful

technical

indication,

giving

ority to the

indication

of a more modern and

technically

correct therapy.

3)

Addtng

new

human

resources at the

_primary

levei

This

program

has

incorporated toPrimary

tion,doctors with knowledge in pediatrie

logy

(one

per each 3 rooms, each one with 22hours

weekly), and a physio-therapist with specific

ing

inthe subject, at the rate of

1

_per each room of

BriefHospitalizatienand each one with 33 hours of

work _per week.

4) Educational activities

These

have

included

the specific training of the

program's physio-therapi$t,

including

one clinical

meeting _per week and 1 workshop of

practicelasting

70

hours

with a

demanding

tion which

had

to

be

approved to enter the

gram.

The program's

doctors

have

weekly clinical and

bibliographical

meetings

in

the hospital$they are

encharged of, to improve the doctors and other

professional'straining

in

Primary

Care,

5)

Physio-therapist

care

In

Fig.

2

are summarized the number of children

attended

to

and number of

Brief

Hospitalizations

carried out on children with acute episodes of

'

chial obstruction. In _general,children are treated

in the BriefHospitalizationSystem with a ranking

twice a puff of

Salbutamol

in spray each 10

min-utes

in

aerochamber with physio-therapy.

He

is

evaluated after one

hour

of the treatrnent.

Those

who present a rank of

6

or

less

are sent

home

with

a _prescription of

Salbutamol

and a control next

day. Those who continue with a ranking of 7 or more are _given now

Betametasona

and Salbutamol

and after 2 hours are _given a new ranking. Those

who still show a score of 6 or more are considered

failureof

treatment

and are sent to

the

hospital.

Those with lower rankings are sent home with a

Salbutamol

prescriptionand a control next day. In

general the failure percentage has been only of

4.6%.

It

isimportant

to

enhance the great

importance

of physio-therapist

in

the program's success.

These

professionals traditionallynot considered

in

the

pri-mary care team,

have

worked with _great technical

efficiency and

have

become

a necessary member of

the Primary Health Attention work teams.

6) Medical activities

The work of the doctors integrated to the

pro-gram can be summarized as

follows

[

a) Training of _{professionals}and the rest of the healthteam of the clinics.

b)

Coordination

and

local

work of

the

program.

c} Direct attention of _patients in the Pediatric

Pneumology

specialty.

Attended

Patients

(

×

100)

25

20

15

10

5

o

Jan

Feb

Mar

Apr

May

Jun

Fig.2

[I]Attended

'90

-e--

Hospitalization

+Hospitalization '91

meAttended

The Attended Patientsand

Short

Hospitalization

in

The Metropolitan Region

(1990

d)

Auditing

of

dead

patients who

dies

conse-quence of respiratory problems.

This

is

done

in

the clinics they are encharged of.

Community

educa-tion. 7)

Other

activities In conjunction with the

Communications

Depart-ment of the Ministry of Health,work has been done in_preparing basic messages f6rthe development of a broad ranging _presscampaign, written, radio and TV about

the

subject of ARIs and air _pollution. Pamphlets and _posters were checked to reinforce themessages at a community educational

ievel.

8) Establishing a system ef epidernic monitor-ing Taking into account the great need of counting with a _quick and reliable system of Epidemic

Vigi-lance,

in

Mid

1992

was established a system based

in

sentry sites,which utilized information compiled

daily

in

11

clinics of

Primary

Attention,

strategical-lydistributedjnthe 4 cardinal _pointsof Santiago, with a total_population attended to by theChildren PublicHealth System. In these clinics

daily

information

is

_gathered about children attended for bronchio-pneumonia, specially those under two and itisrelated to the number of

total

oMce visits

in

this

age group. This index iscorreiated with _the dailymaximum particles and gases

(Ozone

and

Sulfur

Dioxide),

Hospitalization

400

350

300

250

200

150 100

50

o

Jul

Aug

Sep

Oct

Nov

Dec

t

Start

of

Program

'90

alll[IIAttended

'91 '92 + Hospitalization'92

-1992)

Innovating Focus in

mean temperature and humidity. The

measure-ments are done daily

in

the city of

Santiago

through the

MACAM

net of the

Metropolitan

En-vironmental Health Service.

As

a control group the

clinic of Los

Andes

has

been

used with an assigned

population of 9500 inhabitants. Ithas climate

char-acteristics not so differentto

Santiago's

besides

it

was also used as a control clinic in a

previous

study carried out in 1988.

The

results of this

Vigilance

System

can be

ana-lyzed

in

Figs.

3,

4

where an increaseinthe

(RatesllOOO,

Hum,

Part.)

leo

80

60 40 20

o

13

18

23

28

3

(JUNE)

---･

_t.-/

t.

--"'

x

t.ttttt

"

'

tt'fi.../.tlnl'1"1.t1ttttttt/.lut'.ml

1-;g.t.1..t t.i''･1.t

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1/･･1-･1sliag1:' 1/t

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'1$.l.llIlxlijle'

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ttl11t

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tttllem'1ll''si.'-1

t/..zatt

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/ttt''tt../

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'i'

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t.t

1ff

'

'

t/t

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.t.

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1 11 II1･･.t

.//t./t...

it'it/t'/I

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Primary Attention inChile 437

'

al-pneumonia in the cold months can be ed, coinciding with an increase in the _general taminatien of

the

city, but where _you can observe a

bigger

relation with the increase of

Ozone

and

Sulfur

Dioxide.

On

the other

hand

in

Fig.

5 can

be

observed, equally, that comparing the

frequency

of

tory

_path61ogy

visits between

Santiago

and

Los

Andes,

you can observe a

4.8%

higher

risk ed to becoming sick of

bronchial-pneumonia

in Santiago than inLos Andes.

(0zone,

SO,,Temp.) 70

60

50

40 30 20 10 8 13 18

23

26

(JULY)

eeglillncidence

(rates!1000)

--P

SO,

_(ppb)

uu'-'

Ozone

_(ppb)

+Tem.

(OC)

Humidity

(%)

･--"-

Particle

(elO)

Fig.

3

The Air Pollutionand The

Incidence

of Bronchopneumonia under

2

Years

Old,

(RatesllOOO,

Hum,

Part.)

(Ozene,

SO,,Temp.)

100

80

60

40

20 e 1 4 7 10

13

16 19 22

25

28 31 3 6 9

(AUGUST)

(SEPT)

tt

･H'

xx--x'N

l

_Il

fIllI

tt'1'

l[

･]f'lll

-'-]

1i1 ]I'/L' ll1'11ll

.

-F. _:E 1/

-Incidence

(ratesllOOO)

TT"-

S02

(ppb)

m-"=

Ozone

(ppb)

+Tern,

(OC)

--""

Humidity

_(%)

-'L-'

Particle

_(･10)

Santiago

_(n=40,993)

Los Andes

_(n=1,862)

ARI.

ARI D BNARI.A

ARI.B

Fig.5Epidernic Monitoring

_<May-August

'92} _{The Distribution}

of Diagnosis IRA=Acute Respiratory Infections (ARI)

SBO=Obstructive Bronchial Syndrome _COBS)

BRN=Bronchopneumonia{BN)

Bibliografia

l)Aranda C, Belmar R, et al.] El _problema de Ia

taminaci6n atmesferica en laciudad deSantiago.Enf

RespirCirTorEc6I69-78,1990.

2) Araflda C,Astudillo P,DiazMS: Correlaci6nantro

tarninantes atmosfericos _y mortalidad infantil_por

nconeumoma, Santiago,1988. Presentado al XXIV

CongresoChilenodeEniermedades Respiratorias,

tiago,)991,LibroderesUmenes, pag 40.

3)''Infeccienes _{RespiratoiasAgudas}

en losnifios de tos

pa{sesdeArnerica.Mortalidaden el Cono Sur''.OPS!

OMS, Instituto Nacional _de Epidemiolog{a "Emilie

Coni".1989,pag 3-6.

4) Girardi G, Abara S,Santa Cruz P:Programa decontrol

y manejo de Infeccionesrespiratorias agudas en el

rnenor de 1afio. Proyeeto _{deinvestigaci6n}con

amiento MINSAL y OPS. 1986-1988, Presentadoal

20 Curso Internacional deEnferrnedades Respiratorias en elNifie,Santiagode Chile,1989.

5) Castertin

_J,

Mercado R, Pruya _{M: Inciclenciade laIRA}

en mertalidad infantilextrahospitalaria en eiarea

oriente de Santiage,1985-1989. Presentadoal XVIII

Congreso Nacional dePediatria,Concepci6n,1990.

6)Comite de infecciones intrahospitalarihs _Hospital

equiel Gonzalez Cortes.

7)IturraP,Guzman M, et at.:Neumopatias agudas en el

nifio menor. Relaci6ncon laenfermedacl bronquial

structiva orfiica. Rev ChilePediatr ₅₃:_{334-337,1982.}

8)Abara S,GirardiG,et al.:Manejo delsindrome

uial obstructivo agudo dellactante en una sala de

hospitalizaci6n,Enf RespirCir TorEc 6:l92-197,

l990.

9)Astudillo P, Barna R: Programa de _{prevenci6n y}

manejo delasInfeccionesRespiratorias Agudas en el

nivel _prirnario. Memoria de_programas Sociales,

ustre MunicipalidaddeLas _Condes.1989.

10) Astudillo P, Mancilla P.GirardiG: Las _primeras80

hospitalizacionesabreviadas en Consultorioscle

i6nPrimaria. Presentadoal ''Curso _{de Infecciones}

piratoriasAgudas en elNifio",Santiago,1991.

11) Nerambuena P,MancillaP,et al.:

Analisis

deluso de

Salade Hospitalizaci6n Abreviada en ConsultorioSan

Bernardo. Presentado al X CongresoNacionalde