Municipal Health Care Centers Research Articles

A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study.

Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%. The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.

Is patient activation a mediator of the effect of a health promoting intervention in adults at high risk of type 2 diabetes? A longitudinal path model analysis within a randomised trial

BackgroundExploring mediators of preventive intervention effects has important implications for the planning of complex interventions. Our aim was to assess the extent to which knowledge, skills and confidence to manage health, here measured as “patient activation”, was a mediator of the effect of the intervention “Live your life without diabetes” on weight, waist circumference and systolic blood pressure at 12 months follow-up in adults at high risk of type 2 diabetes.MethodsAutoregressive path models with three time points of measurement, and contemporaneous and constant b paths were used in a randomised controlled trial (RCT). The RCT took place in a Danish municipal healthcare center and included 127 individuals aged 28 to 70 years with fasting plasma glucose: 6.1–6.9 mmol/l and/or glycated haemoglobin (HbA1c): 42.0–47.9 mmol/mol. Participants were randomised to routine care (n = 64), or intervention (n = 63). The intervention group received an empirical and theory-based intervention delivered over four two-h group sessions during five weeks, and two further sessions after one and six months. The outcomes were weight, waist circumference and systolic blood pressure, and the mediator was patient activation, measured by the self-reported Patient Activation Measure (PAM). Data for the present study was derived from questionnaires and clinical measures from baseline, three- and 12-months follow-up.ResultsMediated effects via PAM on: weight: − 0.09 kg (95% CI − 0.38 to 0.20) out of the total effect − 1.09 kg (95% CI − 3.05 to 0.87); waist circumference: − 0.04 cm (95% CI − 0.36 to 0.28) out of the total effect − 1.86 cm (95% CI − 4.10 to 0.39); and systolic blood pressure: − 0.31 mmHg (− 1.10 to 0.49) out of the total effect − 2.73 mmHg (95% CI − 6.34 to 0.87).ConclusionWe found no mediating effects of patient activation as a single variable of the intervention “Live your life without diabetes” on weight, waist circumference and systolic blood pressure at 12 months follow-up in adults at high risk of type 2 diabetes. Our study demonstrates an analytic approach for estimating mediating effects in complex interventions that comply with the criteria on temporal ordered data. Future studies should include possible interacting variables.

Effect of Mindfulness-Based Stress Reduction on dehydroepiandrosterone-sulfate in adults with self-reported stress. A randomized trial.

Long‐term stress can lead to long‐term increased cortisol plasma levels, which increases the risk of numerous diseases. Dehydroepiandrosterone (DHEA) and its sulfated form dehydroepiandrosterone‐sulfate (DHEAS), together DHEA(S), have shown to counteract some of the effects of cortisol and may be protective during stress. The program “Mindfulness‐Based Stress Reduction” (MBSR) has shown to have positive effects on stress. The present study examined a possible effect of MBSR on DHEAS in plasma compared to a waiting list and a locally developed stress reduction program (LSR) in people with self‐reported stress. The study was a three‐armed randomized controlled trial conducted in a municipal health care center in Denmark. It included 71 participants with self‐reported stress randomized to either MBSR (n = 24) or LSR (n = 23), or a waiting list (n = 24). Blood samples were collected at baseline and at 12 weeks follow‐up to estimate effects of MBSR on DHEAS. The effect of MBSR on DHEAS was statistically significant compared to both the waiting list and LSR. We found a mean effect of 0.70 µmol/L (95% confidence interval [CI] = 0.18–1.22) higher DHEAS in the MBSR group compared with the waiting list group and a mean effect of 0.54 µmol/L (95% CI = 0.04–1.05) higher DHEAS in the MBSR group compared with the LSR group. Findings indicate an effect on DHEAS of the MBSR program compared to a waiting list and LSR program in people with self‐reported stress. However, we consider our findings hypothesis‐generating and validation by future studies is essential.

A pilot randomised trial comparing a mindfulness-based stress reduction course, a locally-developed stress reduction intervention and a waiting list control group in a real-life municipal health care setting

BackgroundThe purpose of the present study was to conduct a pilot randomised controlled trial (RCT) to lend support to a larger effectiveness RCT comparing Mindfulness-Based Stress Reduction (MBSR), a locally-developed stress reduction intervention (LSR) and a waiting list control group in a Danish municipal health care center setting.MethodsA three-armed parallel pilot RCT was conducted among 71 adults who contacted a Danish municipal health care center due to stress-related problems. Recruitment was made between January and April 2018 and followed usual procedures. Exclusion criteria: 1) acute treatment-demanding clinical depression or diagnosis of psychosis or schizophrenia, 2) abuse of alcohol, drugs, medicine, 3) pregnancy. Randomisation was performed by an independent data manager using the REDCap electronic data capture tool. The primary outcome was a description of RCT feasibility (recruitment and retention rates regarding intervention participation and 12-week follow-up). Secondary outcomes were completion rates regarding questionnaire data and proposed effect-estimates of outcome measures considered to be used in the following real RCT. Type of intervention and outcome assessment were not blinded.ResultsWe recruited 71 of 129 eligible individuals from the target population (55, 95%CI: 46–64). Forty-two (59%) were females. Median age: 44 years (1-quartile:34, 3-quartile:50). Twenty-nine (41%) had < 16 years of education. Forty-eight (68%) were employed; 30 of these 48 (63%) were on sick leave. Mean scores for perceived stress (PSS): 25.4 ± 5.3; symptoms of anxiety and depression (SCL-5): 2.9 ± 0.6, and well-being (WHO-5): 31.7 ± 8.5 indicated a need for intervention. 16/24 (67, 95%CI: 45 to 84) who were allocated to MBSR and 17/23 (74, 95%CI: 52 to 90) who were allocated to LSR participated in ≥5 sessions. The loss to follow-up at 12 weeks: MBSR: 5 (21% (95% CI: 7 to 42), LSR: 5 (22% (95% CI: 7 to 44) and waiting list: 4 (17% (95% CI: 5 to 37). This was acceptable and evenly distributed. The results indicated MBSR to be superior.ConclusionsAn RCT assessing the effectiveness of stress reduction interventions in a real-life municipal health care setting is feasible among adults with a clear need for stress reduction interventions based on scores on mental health.Trial registrationClinicalTrials.gov. Identifier: NCT03663244. Registered September 10, 2018.

The Use of Telerehabilitation Technologies for Cardiac Patients to Improve Rehabilitation Activities and Unify Organizations: Qualitative Study.

BackgroundCardiovascular disease is a leading cause of death globally causing 31% of all deaths worldwide. The Danish health care system is characterized by fragmented delivery of services and rehabilitation activities. The Teledialog Telerehabilitation Program for cardiac patients was developed and tested to rectify fragmentation and improve the quality of care. The Teledialog program was based on the assumption that a common communication platform shared by health care professionals, patients, and relatives could reduce or eliminate the fragmentation in the rehabilitation process and improve cooperation between the health professionals.ObjectiveThis study aimed to assess the interorganizational cooperation between health care professionals across sectors (hospitals, municipal health care centers) in a cardiac telerehabilitation program.MethodsTheories of networks between organizations, the sociology of professions, and the “community of practice” approach were used in a case study of a cardiac telerehabilitation program. A triangulation of data collection techniques were used including documents, participant observation (n=76 hours), and qualitative interviews with healthcare professionals (n=37). Data were analyzed using NVivo 11.0.ResultsThe case study of cooperation in an interorganizational context of cardiac telerehabilitation program is characterized by the following key themes and patterns: (1) integrated workflows via a shared digital rehabilitation plan that help integrate workflow between health care professions and organizations, (2) joint clinical practice showed as a community of practice in telerehabilitation developed across professions and organizations, and (3) unifying the organizations as cooperation has advanced via a joint telerehabilitation program across municipalities and hospitals.ConclusionsThe Teledialog Telerehabilitation Program was a new innovative cardiac program tested on a large scale across hospitals, health care centers, and municipalities. Assessments showed that the Teledialog program and its associated technologies helped improve interorganizational cooperation and reduce fragmentation. The program helped integrate the organizations and led to the creation of a community of practice. Further research is needed to explore long-term effects of implementation of telerehabilitation technologies and programs.Trial RegistrationClinicalTrials.gov NCT01752192; http://clinicaltrials.gov/ct2/show/NCT01752192 (Archived by WebCite at http://www.webcitation.org/6yR3tdEpb)

Mother-to-child transmission of HIV in the Southern Region of Santa Catarina, from 2005 to 2015: analysis of risk factors to seroconversion in newborns

Abstract Objectives: to analyze both frequency and risk factors for seroconversion among newborns of HIV-positive mothers to HIV. Methods: a cohort study was conducted with children residing in Southern Region of Santa Catarina. Secondary data from the notification files and medical records of newborn's mothers of infected infants were used. The participants were all the newborns from 2005 to 2015 that were exposed to HIV through vertical transmission and attended a municipal health care center. Results: there were 104 cases of infant exposure to HIV. Seroconversion was confirmed in three cases, two of them died of AIDS during the study period. Breastfeeding (PR= 32.7; CI95%= 10.7-99.5; p= 0.002) and non-use of antiretroviral drugs during pregnancy (PR=18.2; CI95%= 2.0-163.0; p= 0.008) were risk factors for HIV seroconversion. Conclusions: seroconversion rates among neonates in Southern Region of Santa Catarina were similar to the national average. Seroconversion was associated with non-use of antiretroviral therapy during pregnancy and breastfeeding.

Breastfeeding knowledge of health professionals working in municipal healthcare centers in Maipu, Chile.

Healthcare provider’s knowledge has been identified as a factor associated with clinical practice skills and exclusive breastfeeding prevalence. To evaluate the level of knowledge and training in breastfeeding of healthcare provider’s that work in family healthcare centers of Maipu, Chile, (midwifes, physicians, nurses and nutritionists). To determine association among level of knowledge, profession and breastfeeding training. Quantitative, cross-sectional, analytical study. Participants were healthcare professionals regularly participating in healthy child exams of six month old babies. We used a validated survey based on the “Ten steps for successful breastfeeding”. Statistical analyses included frequencies, percentages, measures of central tendency as well as the association among level of knowledge, profession and training in breastfeeding. Results showed that of the total number of participants (n=78), 42.2% classified as “average”, 3.8% as “poor” and near 50% as “good” or “very good” knowledge. Nutritionists obtained the best scores in knowledge about breastfeeding with 50% of “very good”, followed by nurses and midwifes, with 39% and 35% respectively. On the other hand, most physicians obtained “good” (65.4%) and only 7.7% “very good”. Only 33% had had breastfeeding training at some point of their lives, and 6.4% had had one training session in the last year. We highlight that 34.6 to 42.3% of those who obtained “good” and “very good” scores had had breastfeeding training. Knowledge level was directly associated with breastfeeding training (p=0.033) and healthcare profession (p=0.019). Healthcare professionals have different levels of breastfeeding knowledge. Breastfeeding training sessions significantly increase knowledge, which could improve breastfeeding prevalence.

A high proportion of prehospital emergency patients are not transported by ambulance: a retrospective cohort study in Northern Finland

The number of missions in the emergency medical services (EMS) has increased considerably in recent years. People are requesting ambulance for even minor illnesses and non-medical problems, which is placing financial and resource burdens on the EMS. The aim of this study was to determine the rate of non-transportation missions in Northern Finland and the reasons for these missions. All ambulance missions in two hospital districts in Northern Finland during the 6-month period of January 1 through June 30, 2014, were retrospectively evaluated from the EMS charts to identify missions in which the patients were not transported by the EMS. The non-transportation rates and reasons were calculated and expressed as percentages. In 41.7% of the 13,354 missions, the patient was not transported from the scene by an ambulance. After a medical assessment and care was provided by the EMS, 48.2% of these non-transport patients were evaluated as not needing further treatment in the emergency department and were directed to contact the municipal health care center during office hours. There was no need for any medical care in 39.9% of non-transportation missions. This study showed a high rate of EMS missions resulting in non-transportation in two hospital districts in Northern Finland. In the majority of these missions there was no need for emergency admission to an emergency department or for any medical care at all. These findings indicate that an improvement in the dispatch process and primary care resources might be of benefit.

Cardiac rehabilitation after acute coronary syndrome comparing adherence and risk factor modification in a community-based shared care model versus hospital-based care in a randomised controlled trial with 12 months of follow-up

To investigate whether phase II cardiac rehabilitation (CR) conducted by a community model of shared care CR (SC-CR) including health care centres and general practice was feasible and provided acceptable results and to compare SC-CR to hospital-based CR (H-CR) in a randomised controlled trial. Patients were randomised to H-CR or SC-CR after admission for acute coronary syndrome. In SC-CR, the general practitioner took over the responsibility of the remaining rehabilitation, pharmacological treatment and risk factor management after the initial visit to the hospital outpatient clinic. The Municipal Health Care Centres provided courses on smoking cessation, nutrition, and exercise training and contributed to disease education and psychosocial support. The main endpoint was adherence to the CR programme and compliance with lifestyle modifications. In total, 1364 patients were screened, 327 (24%) were eligible, and 212 (65%) accepted participation. Phase II CR was completed by 192 (91%) of the participants. Full adherence to the CR programme was seen in 53% in SC-CR versus 54% in H-CR (relative risk (RR): 0.98, 95% confidence interval: 0.73-1.32). In H-CR, patients had higher rates of adherence to dietary advice and health education. In SC-CR, 12% of patients did not attend the risk factor evaluation and clinical assessment with their general practitioner. No difference in risk factor improvement was found. Exercise training was declined by 25% in both groups. Adherence to phase II CR was high in both groups. SC-CR did not improve adherence and efficacy, but had comparable effects on medication and risk factors. Thus, SC-CR was safe and effective.

Avaliação dos usuários crianças e adultos quanto ao grau de orientação para Atenção Primária à Saúde na cidade do Rio de Janeiro, Brasil

In the first half of 2014, 6,675 adults and caregivers of children using Primary Care (PC) services in Rio de Janeiro were interviewed using the Primary Care Assessment Tool - PCATool-Brazil. The aim was to arrive at an accurate overview of the extent to which PC services in all of the Planning Areas (PA) of the Rio de Janeiro City Health Department (CHD) - Municipal Health Secretariat have the essential and derivative attributes. This was a cross-sectional study of random, independent samples of the service users (children and adults). Results were measured using the scores assigned to PC attributes. In the opinion of adults and children using PC services, Type A Units - Municipal Healthcare Centers and Family Clinics staffed only with Family Health Teams, performed better than Type B units. The scores for the attributes "first contact accessibility", "comprehensive service - services provided", "community orientation" and "family orientation" still need to be improved. On the other hand "coordinated care" and "continuity" are on their way to quality scores, being always rated at around 6.0 or even higher.

Professional profile, well-being and job satisfaction among psychologists working in public healthcare services

Different work environments and working conditions can affect or influence levels of well-being and job satisfaction. This study's aim was to analyze the well-being and job satisfaction of 66 psychologists working in the public healthcare services of two municipal healthcare centers and a federal university. Data were submitted to descriptive, variance and correlation analyses. The results revealed general averages with values close to the scales' midpoints. The analysis of variance among the groups of psychologists working in the three different facilities showed significant differences in levels of satisfaction regarding working conditions and the perception of accomplishment/expressiveness. The satisfaction scales were significantly correlated with the well-being scales. The conclusion is that the results show possible interventions designed to reduce or eliminate negative factors and increase well-being and job satisfaction.

Early BCG vaccination is unrelated to pulmonary immunity againstMycobacterium tuberculosisin adults

To the Editor: Vaccination with Mycobacterium bovis bacille Calmette–Guerin (BCG) is performed for the prevention of tuberculosis. M. bovis BCG vaccination is among the most commonly applied of all vaccines worldwide [1]. M. bovis BCG vaccination efficiently reduces the morbidity and mortality of tuberculosis in children, especially miliary tuberculosis and meningitis [2]. Although recent investigations of Mycobacterium tuberculosis -specific immune responses by interferon-γ release assays (IGRAs) provide evidence on the effect of M. bovis BCG vaccination on the prevention of primary infection with M. tuberculosis [3–5], it has been suggested that this effect diminishes during adolescence [2, 6]. Consequently, adults are probably not protected from pulmonary tuberculosis by BCG vaccination. To date, no study has investigated the impact of M. bovis BCG vaccination performed in childhood on pulmonary immune responses in adults. The objective of this study was to assess the effect of childhood M. bovis BCG vaccination on systemic and pulmonary immune responses to M. tuberculosis in healthy adult individuals exposed to patients with acid-fast bacilli (AFB)-positive sputum smear-positive tuberculosis in Germany. An observational, cross-sectional, multicentre study was conducted by the German Ministry of Education and Research-funded research consortium on “Pulmonary Tuberculosis – Host and Pathogen Determinants of Resistance and Disease Progression (TB or Not TB)”. Healthcare workers (HCWs) with 1) ongoing professional contact with patients with AFB sputum smear-positive tuberculosis, 2) a cumulative professional exposure of at least 2 years, and 3) no clinical signs and/or symptoms of active tuberculosis were recruited at 18 German pulmonary medicine centres (centres are listed in the Acknowledgements section). Furthermore, household contacts (HHCs) without evidence of active tuberculosis were enrolled at three urban municipal healthcare centres ( i.e. Frankfurt, Hamburg and Hannover); their enrolment required 1) the absence of clinical signs and/or …

Barriers in the treatment of latent tuberculosis infection (LTBI) in children: a case study

Objective: Analyze the barriers the families face in the treatment of latent TB infection (LTBI) in children. Methods: Descriptive study, in two stages. In the first, the medical records of 0 to 11 year-old children treated for LTBI at a municipal healthcare center in the city of Rio de Janeiro, Brazil, were analyzed. At the second, an interview with the families. In both stages, the personal, family, economic, social and healthcare service barriers were identified. Results: In the first stage; there were barriers in (47/228): the service 4 (8.5%); personal 4 (8.5%); family 21 (44.7%); physiological 12 (25.5%). At the second; the barriers at (50/85): economical 19 (38%); social 13 (26%); personal and family 18(36%). Conclusion: Unfavorable socioeconomic factors affected the care of child in both stages of study. Rethinking the way of dealing with the social determinants associated with tuberculosis may be the way to avoid abandonment and the disruption of LTBI treatment.

Lessons learnt from the Wenchuan earthquake: performance evaluation of treatment of critical injuries in hardest‐hit areas

Critical injury treatment in the hardest-hit areas after a great earthquake was retrospectively analyzed to determine how best to reduce mortality and disability and increase the rehabilitation rate through postquake medical relief. Retrospective analysis, primary sources, and secondary sources were comprehensively retrieved and analyzed. According to incomplete data, 30,620 injured were rescued by themselves among the hardest-hit areas in the 72 hours immediately following the earthquake. Critically injured patients accounted for 22% of total inpatients. Mortality rates declined with greater distance from the epicenter: rates were 12.21% for municipal healthcare centers in the hardest-hit areas, 4.50% for municipal medical units in peripheral quake-hit areas, 2.50% for provincial medical units in peripheral quake-hit areas, and 2.17% for Ministry of Health-affiliated hospitals in peripheral quake-hit areas. The number of injured with fractures on body, limbs or unknown-parts, severe conditions as well as other kinds of non-traumatic diseases received in second-line hospitals was much more than those treated in first-line hospitals with more severe injuries. Among 10,373 injured in stable condition transferred to third-line hospitals, 99.07% were discharged from hospitals within four months, while the mortality rate was 0.017%. The medical relief model of "supervising body helping subordinate unit, severely stricken areas assisting hardest-hit areas, least-hit areas supporting both hardest-hit and severely stricken areas, and self help and mutual assistance applied between hardest-hit areas" was roughly established for injured from severely stricken areas after the Wenchuan Earthquake. The "four-centralization" treatment principle, which referred to concentrating patients, experts, resources and treatment for those injured in critical condition effectively reduced the mortality from 15.06% to 2.9%. Timely, scientific, and standard on-site triage and postmedical transfer guided by accurate injury information determine rescue effect for the injured, while there is large space to fulfill as for treatment for critical diseases among the hardest-hit areas under extreme conditions after the Wenchuan earthquake.

Inter-tester Reliability in Classifying Acute and Subacute Low Back Pain Patients into Clinical Subgroups: A Comparison of Specialists and Non-Specialists. A Pilot Study

Many systems have been suggested for classifying low back pain (LBP); the most commonly used among physiotherapists involves a pathoanatomical/pathophysiological tissue classification system. Few studies have examined whether this form of classification of LBP disorders can be performed in a reliable manner between specialists with advanced training, or between specialists with advanced training and non-specialists who lack advanced training. The purpose of this paper was to examine the inter-tester reliability of two specialists, and the ability of a specialist and non-specialist to independently classify patients with LBP, utilizing clinical tests and history-based classification methods after a short educational course on the classification system. Subjects were acute or sub-acute patients with LBP who visited their occupational healthcare or municipal healthcare center. Inter-tester reliability between the specialist and non-specialists was at almost the same level: overall Kappa 0.60 (95%CI; 0.40 to 0.85), overall agreement 70%, as between the two specialists: overall Kappa 0.65 (95%CI; 0.33-0.86), overall agreement 77%. The findings suggest that a short educational course can provide rather reliable examination tools to allow non-specialized physiotherapists to classify patients according to tissue origination.

Perfil epidemiológico de pacientes portadores de TB internados em um hospital de referência na cidade do Rio de Janeiro

To determine the epidemiological profile of inpatients at a TB referral hospital. This was a descriptive, retrospective study of the medical charts of patients with TB hospitalized at the Hospital Estadual Santa Maria (HESM), in the city of Rio de Janeiro, Brazil, between January of 2002 and December of 2003. Data were collected using a standardized form. Of the 451 patients included in the study, 313 (69.4%) had been referred to the HESM from health care clinics, and 302 (67.0%) were male. Most of the patients were in the 30-59 year age bracket, 443 (98.2%) lived in the greater metropolitan region of Rio de Janeiro, and 298 (66.1%) lived in the city of Rio de Janeiro itself. The most common reason for hospitalization was poor health status (in 237, 52.5%). The most common comorbidity was AIDS (in 137, 30.4%). The most common signs and symptoms at admission were weight loss, fever and productive cough. Sputum smear microscopy was positive in 122 (71.0%) of the patients presenting with productive cough at admission. Of the 212 patients being retreated, 156 (73.6%) reported noncompliance with previous treatment. Regarding the outcome, 273 (65.8%) of the patients were referred to municipal health care centers, 83 (18.4%) died, 44 (9.8%) were cured, and 27 (6%) were discharged against medical advice. Providing hospitals specializing in TB is relevant for TB control, especially in metropolitan regions. In addition to taking biosafety measures, these hospitals must be prepared to treat patients with TB-related comorbidities and social problems. This study has resulted in improvements at the HESM.

Hepatitis A seroprevalence in children and adults in Kiev City, Ukraine

Ukraine is a zone of moderate hepatitis A endemicity. The changing epidemiology of the disease because of improved hygiene has shifted the burden of Hepatitis A to older age groups where the disease is more severe. Outbreaks have also become more common as more of the population has become susceptible to hepatitis A virus (HAV). To help guide decisions regarding use of hepatitis A vaccine in Ukraine, we examined the presence of antibody to HAV (anti-HAV) in 1001 persons aged 1 to 85 years, visiting four municipal healthcare centres in the Ukrainian capital, Kiev. Overall, the anti-HAV prevalence was 31.9%. Anti-HAV seropositivity increased with age from 9.2% among children aged 1-5 years to 81.7% among persons over 50 years, but less than 50% of subjects less than 50 years were HAV seropositive. No children under 2 years were seropositive. HAV seropositivity was twice as high in children aged 5-11 years old in the low socio-economic status group (income less than 150 US$ per family member per month) than in the middle/high group (11.1% compared to 6.3%) but this disparity disappeared by adolescence. The prevalence of anti-HAV antibodies in adults was not different with respect to district of residence within the city. Considering the proportion of HAV seronegative subjects in all age groups under 50 years, routine vaccination against HAV of children aged 1-2 years old would appear to be an effective schedule for hepatitis A prophylaxis in Kiev.

Ongoing development and evaluation of occupational health services for farmers in Finland

In Finland, occupational health services have been developed based on the 1979 law that was updated in 2002. Cooperation among OH specialists, researchers, authorities, OH-units, interest groups and clients is characteristic of the development of farmers' occupational health services (FOHS). The systematic planning and development of FOHS have been conducted since 1979 by the Finnish Institute of Occupational Health in collaboration with the Social Insurance Institution (SII) and the Farmers' Social Insurance Institution (FSII). In 1985, the National Board of Health issued an ordinance initiating FOHS in municipal health care centres according to the proposals of the research team. Thereafter, FOHS have been continually evaluated and developed. In addition, farmers' health hazards at work and their work related diseases, mortality and accidents have been studied in follow-up surveys in 1979, 1982, 1986, 1992 and 2004. A training program for FOHS personnel started in 1981. The functional adequacy and productivity of FOHS was studied in the surveys of 1989, 1995, 2000 and 2004. A recommendation for applying Good Occupational Health Practice-ordinance (GOHP) in FOHS was issued in 2000. Experiences, needs and expectations of farmers in relation to FOHS were studied in 1992, 2001 and 2004. The results of the survey of the year 2004 and the statistics of the SII an FSII show that functional adequacy of FOHS had improved from the level observed in 1996. The coverage of FOHS has increased from 32% in 1999 to 41% in 2004 of all insured farmers. According to the statistics of the SII the functional adequacy of FOHS has increased. The checking of working conditions is something that has increased in particular. Coverage of FOHS has also increased in some regions. The main limitations for GOHP in FOHS are still the lack of resources and training of OH personnel in many OHS units and the inactivity of farmers as well as local FOHS advisory boards. The most important challenges are to improve the effectiveness and coverage of FOHS.

Occupational Safety and Health in Finland

In Finland, occupational safety is the responsibility of the employer, while the occupational safety and health laws are enforced by the Labour Inspection Service, an organization of the state. The Labour Inspection is divided in 11 administrative districts, and it employs 360 professionals. They are mandated to carry out site visits without prearranged appointments to inspect safe work situations, working hours, construction safety, or any aspect of accident risks. The inspectors are also mandated to verify the existence of sufficient occupational health services as prescribed by the Occupational Health Services Act for all employees. The occupational health services are typically provided by enterprise-owned medical departments, by mutually owned health care centers, by private practitioners, or by municipal health care centers. The latter are required by law to provide all services as prescribed by the legislation to anyone who comes to the facility. This situation is prevalent in the countryside, where there are very few private caregiving centers. Declaring occupational accidents and disease cases is mandatory, and the Inspection districts examine all accidents to establish causes and consequences, and to initiate prosecution in case of criminal negligence. Labour Inspection Districts are also notified of the new occupational disease cases as they are declared to insurance companies. Insurance for occupational disease, accidents, and death is an obligation of the employer, although they can choose the insurance company. The medical confidentiality between the workers and their occupational health care providers is very strict. Official statistics are maintained by the state Statistics Finland organization, and they may be used, for example, for research purposes by scientific institutes like the Finnish Institute of Occupational Health. Construction industry accounts for 25% of all fatal accidents (120 cases per 1 million working hours), followed by mechanical, wood, metal, machinery, and pulp and paper industry (10% each of fatal accidents) with rates ranging from 100–160 cases per 1 million working hours. There are some 5,000 occupational disease cases per year (rate 22/10,000 employed). The major disease categories include repetitive strain injuries (1,300 cases), respiratory allergies (600 cases), occupational skin diseases (1,000 cases), and 900 cases of noise-caused hearing loss. In 1998, 589 cases of asbestos-related diseases were reported.

Problems in the standardization of the polymerase chain reaction for the diagnosis of pulmonary tuberculosis

The recent increase in the number of tuberculosis cases has called the world's attention once again to a perennial health problem, especially prevalent in developing countries. The time elapsed between the diagnosis and the institution of therapy is an obstacle to tuberculosis control and there is an urgent need for the development of techniques for the disease's rapid diagnosis. To achieve this goal, molecular biology techniques have been exhaustively investigated. This work describes the use of a polymerase chain reaction for rapid diagnosis of tuberculosis in a developing country. The sensitivity and specificity of this technique is compared to standard techniques used in the microbiology laboratory. This study was undertaken in Ribeirão Preto, S. Paulo State, Brazil. Forty-two sputum samples from suspected cases of tuberculosis attending the municipal health care centers were sent to the microbiology laboratory. The samples were processed for the detection of Mycobacterium tuberculosis by acid-fast bacilli determination, culture in Lowenstein-Jensen medium, and by a polymerase chain reaction that amplified a fragment of 123 base pairs of the Mycobacterium tuberculosis genome. Of the forty-two samples studied, one was contaminated and excluded from the study, ten were culture positive, ten were positive for the presence of acid-fast bacilli, and sixteen were polymerase chain reaction positive. The sensitivity and specificity of this technique were 90% and 81%, respectively. The polymerase chain reaction presented a sensitivity comparable to the culture and the whole procedure took only one day to complete. The results presented here make it a strong candidate for rapid diagnosis of tuberculosis in clinical settings making it possible to begin the specific therapy early in the course of the disease. However, standardization of the technique is necessary, and the correlation with clinical findings is of paramount importance due to the high sensitivity of this technique.