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estudiar el efecto de la exposici&#243;n en relaci&#243;n con factores dependientes de la persona y el lugar&#44; y evaluar la evoluci&#243;n cl&#237;nica y funcional de dicha exposici&#243;n sobre el aparato respiratorio&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Desarrollo de la experiencia</span><p id="p0015" class="elsevierStylePara elsevierViewall">A trav&#233;s del n&#250;mero de tel&#233;fono 112 se tuvo conocimiento de un brote respiratorio agudo en una piscina p&#250;blica&#46; La primera actuaci&#243;n urgente fue comprobar el agente qu&#237;mico causante&#44; la cantidad de afectados y su situaci&#243;n cl&#237;nica&#44; y la alarma social generada&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Se defini&#243; &#171;caso&#187; como todo usuario o trabajador de la piscina que el 21 de julio de 2005 y a partir de las 17&#58;30 h hab&#237;a requerido asistencia m&#233;dica en cualquier dispositivo sanitario por presentar alguna de las manifestaciones cl&#237;nicas recogidas en la encuesta epidemiol&#243;gica&#46; Actuaron como controles los usuarios o trabajadores de la piscina que no presentaron s&#237;ntomas ni precisaron asistencia m&#233;dica&#44; seleccionados por los casos entre sus familiares&#44; amigos o trabajadores que estaban presentes en la piscina pero no enfermaron&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">Mediante una encuesta epidemiol&#243;gica &#40;telef&#243;nica o presencial&#41; realizada a los casos y controles se recogieron las variables personales &#40;edad&#44; g&#233;nero&#44; altura&#44; peso&#44; enfermedad respiratoria previa&#41;&#44; ubicaci&#243;n en el recinto &#40;distancia al foco&#44; si estaba ba&#241;&#225;ndose o no&#41;&#44; olor percibido&#44; sintomatolog&#237;a &#40;n&#225;useas&#44; v&#243;mitos&#44; tos&#44; picor en garganta&#44; dolor tor&#225;cico&#44; dificultad al respirar&#44; cefalea&#44; v&#233;rtigos&#44; escozor en ojos&#44; lagrimeo y ojo rojo&#41;&#44; enfermedad previa&#44; tratamiento recibido&#44; necesidad de ingreso hospitalario y pruebas complementarias realizadas &#40;radiograf&#237;a&#44; 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La edad se categoriz&#243; en los 2 grupos mencionados anteriormente&#46; Se plante&#243; un estudio de casos y controles estimando la <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; de enfermar con su intervalo de confianza &#40;IC&#41; del 95&#37;&#44; mediante an&#225;lisis de regresi&#243;n log&#237;stica simple&#46; Se utilizaron los programas Excel 2000 y SPSS &#40;versi&#243;n 12&#41;&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">A todos los casos mayores de 5 a&#241;os se les cit&#243; por carta para realizarles una espirometr&#237;a<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">5</span></a> al segundo y quinto mes del accidente&#44; con el fin de valorar su funci&#243;n respiratoria&#46; Independientemente de ello&#44; al sexto mes se revisaron las historias cl&#237;nicas para observar la evoluci&#243;n cl&#237;nica de todos los casos&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">El suceso se produjo porque los operarios introdujeron accidentalmente hipoclorito s&#243;dico en un recipiente de &#225;cido clorh&#237;drico ubicado en la caseta de mantenimiento de la piscina&#44; por lo que se produjo inmediatamente una emanaci&#243;n de cloro gas&#46; La inspecci&#243;n ambiental de los setos pr&#243;ximos a la caseta revel&#243; una coloraci&#243;n amarillenta tipo clorosis a 2 m de altura&#46; Pocos metros m&#225;s adelante la nube bajaba y&#44; conforme se alejaba hacia el sur&#44; volv&#237;a a subir&#46; Se confirm&#243; que la direcci&#243;n del viento era la misma&#46; En posteriores inspecciones se constat&#243; que la piscina no ten&#237;a licencia de reapertura&#44; los productos de tratamiento del agua no estaban correctamente identificados y carec&#237;a de las correspondientes fichas de datos de seguridad&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">El aforo m&#225;ximo de la piscina&#44; seg&#250;n el Jefe de &#193;rea de Deportes del Ayuntamiento de la localidad&#44; es de 537 personas&#44; y se estima que en el momento del accidente hab&#237;a unas 150 personas&#44; de las cuales el 40&#37; eran menores de 15 a&#241;os&#44; otro 40&#37; 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No se pudo clasificar a 7 casos atendidos por desconocer su edad&#46; Tanto en ni&#241;os como en j&#243;venes&#47;adultos&#44; algunas variables fue desconocida&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0065" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#t0015">tabla 2</a> se describe el cuadro cl&#237;nico que presentaron los casos&#46; El 85&#44;3&#37; de los ni&#241;os y el 82&#44;1&#37; de los j&#243;venes&#47;adultos presentaron disnea&#46; En los ex&#225;menes complementarios realizados en urgencias s&#243;lo se observ&#243; un patr&#243;n intersticial microalveolar difuso &#40;de 16 radiograf&#237;as&#41;&#44; 2 acidosis &#40;de 6 an&#225;lisis&#41; y un patr&#243;n respiratorio obstructivo &#40;de 3 espirometr&#237;as&#41;&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia><p id="p0070" class="elsevierStylePara elsevierViewall">Seg&#250;n el an&#225;lisis de regresi&#243;n log&#237;stica simple &#40;<a class="elsevierStyleCrossRef" href="#t0020">tabla 3</a>&#41;&#44; el riesgo de sufrir una intoxicaci&#243;n era mayor en los ni&#241;os que ten&#237;an una enfermedad respiratoria previa &#40;OR &#61; 10&#44;8&#59; IC del 95&#37;&#44; 1&#44;4-86&#44;3&#41; y en los que se encontraban a menos de 40 metros del lugar del accidente &#40;OR &#61; 4&#44;5&#59; IC del 95&#37;&#44; 1&#44;1-18&#44;7&#41;&#46; Los factores determinantes del ingreso hospitalario fueron ser ni&#241;o&#44; estar ba&#241;&#225;ndose en el momento del accidente y presentar sintomatolog&#237;a general o combinaci&#243;n de s&#237;ntomas generales&#44; irritativos y disnea&#46;</p><elsevierMultimedia ident="t0020"></elsevierMultimedia><p id="p0075" class="elsevierStylePara elsevierViewall">El primer seguimiento cl&#237;nico se realiz&#243; a 55 casos &#40;84&#44;6&#37;&#41;&#46; De ellos&#44; 23 no dispon&#237;an de historia cl&#237;nica&#44; 22 no ten&#237;an datos en su historia y en 10 casos persist&#237;an los s&#237;ntomas respiratorios&#46; En el segundo seguimiento cl&#237;nico s&#243;lo hab&#237;a un caso con cl&#237;nica respiratoria&#46; De los 9 trabajadores que estaban en el recinto &#40;3 camareras&#44; 2 operarios&#44; 2 socorristas&#44; una taquillera y un polic&#237;a local&#41;&#44; s&#243;lo el responsable de la mezcla accidental de productos qu&#237;micos precis&#243; asistencia m&#233;dica por presentar s&#237;ntomas respiratorios&#59; no utiliz&#243; equipo de protecci&#243;n individual ni acudi&#243; al seguimiento cl&#237;nico y funcional&#46; El operario de la empresa que transport&#243; el producto no present&#243; ning&#250;n s&#237;ntoma&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">De los 49 casos citados para realizar la primera espirometr&#237;a acudieron 34&#44; de los cuales 7 presentaron una relaci&#243;n entre el volumen espiratorio m&#225;ximo en el primer segundo &#40;FEV<span class="elsevierStyleInf">1</span>&#41; y la capacidad vital forzada &#40;FVC&#41; &#60; 70&#37;&#59; de ellos 2 ten&#237;an un patr&#243;n obstructivo y uno un patr&#243;n mixto &#40;FVC y FEV1 &#60; 80&#37;&#41;&#46; De los 27 casos con relaci&#243;n FEV<span class="elsevierStyleInf">1</span>&#47;FVC normal&#44; 2 presentaron una FVC &#60; 80&#37;&#44; de los cuales uno ingres&#243; con patr&#243;n restrictivo y el otro se etiquet&#243; de mala t&#233;cnica&#44; pues s&#243;lo ten&#237;a alterado este par&#225;metro&#46; En la segunda espirometr&#237;a se invit&#243; a los mismos 49 casos&#44; pero s&#243;lo se la realizaron 19&#46; Ninguno de ellos present&#243; una relaci&#243;n FEV<span class="elsevierStyleInf">1</span>&#47;FVC &#60; 70&#37; y tan s&#243;lo uno ten&#237;a FVC y FEV<span class="elsevierStyleInf">1</span> patol&#243;gicos &#40;77 y el 66&#37;&#44; respectivamente&#41;&#46; Aunque se consider&#243; como un patr&#243;n restrictivo&#44; a la vista del flujo espiratorio forzado entre el 25 y el 75&#37; de las v&#237;as a&#233;reas &#40;FFF<span class="elsevierStyleInf">27-75</span>&#41;&#44; podr&#237;a tratarse de un patr&#243;n obstructivo de peque&#241;as v&#237;as&#44; probablemente previo o agravado por el accidente&#46; Este caso estuvo ingresado en el hospital&#44; ten&#237;a antecedentes de enfermedad respiratoria y segu&#237;a presentando s&#237;ntomas 9 meses despu&#233;s del accidente&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">En cuanto al seguimiento hospitalario&#44; s&#243;lo hab&#237;a informaci&#243;n disponible de 4 ingresados&#59; uno de ellos era el que ten&#237;a alterada la segunda espirometr&#237;a y continuaba el seguimiento en atenci&#243;n primaria&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">La coordinaci&#243;n por parte de los diferentes profesionales&#44; administraciones y afectados permiti&#243; controlar la alarma social&#44; informar adecuadamente a los trabajadores&#44; los afectados y los medios de comunicaci&#243;n&#44; y conocer el alcance sanitario del episodio t&#243;xico&#44; que podr&#237;a dar lugar a actuaciones judiciales&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Conclusiones</span><p id="p0095" class="elsevierStylePara elsevierViewall">Este brote surgi&#243; como consecuencia de la mezcla accidental de hipoclorito s&#243;dico y &#225;cido clorh&#237;drico&#44; liber&#225;ndose cloro gas que produjo un cuadro irritativo respiratorio&#44; especialmente en los ni&#241;os que estaban ba&#241;&#225;ndose y en los que estaban a menos de 40 m del lugar del accidente&#46; Todos los casos evolucionaron hacia la curaci&#243;n cl&#237;nica con normalidad de las pruebas funcionales&#44; excepto uno que ten&#237;a antecedentes de enfermedad respiratoria&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">La intervenci&#243;n coordinada permiti&#243; controlar la alarma social y valorar adecuadamente el impacto sobre la salud de los afectados por el accidente&#46; Esta experiencia puede servir para planificar actuaciones futuras ante casos similares&#46;</p></span></span>"
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        "resumen" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Se dise&#241;&#243; un estudio de casos y controles para investigar el accidente qu&#237;mico ocurrido en una piscina p&#250;blica en el verano de 2005 y describir los factores ambientales responsables&#44; analizar el efecto del cloro gas y valorar la evoluci&#243;n cl&#237;nica y funcional del aparato respiratorio&#46; Las intervenciones fueron las siguientes&#58; inspecciones ambientales&#44; encuesta epidemiol&#243;gica &#40;variables sociodemogr&#225;ficas&#41;&#44; ubicaci&#243;n en el momento del accidente&#44; olor percibido y seguimiento cl&#237;nico y espirom&#233;trico de la funci&#243;n respiratoria&#46; Se encuestaron 65 casos y 48 controles&#46; El suceso se produjo al mezclar accidentalmente &#225;cido clorh&#237;drico e hipoclorito s&#243;dico&#44; lo que gener&#243; cloro gas&#46; Los s&#237;ntomas predominantes fueron tos y disnea&#46; El riesgo de enfermar en ni&#241;os era 10 veces mayor si ten&#237;an una enfermedad respiratoria previa y 4 veces superior si estaban a una distancia inferior a 40 m del lugar del accidente&#46; Todos los casos evolucionaron hacia la curaci&#243;n&#44; excepto uno que ten&#237;a antecedentes asm&#225;ticos&#46;</p>"
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        "resumen" => "<p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">A case-control study was designed to investigate a chemical accident that occurred in a swimming-pool in the summer of 2005&#46; The aim was to describe the environmental factors involved in the accident&#44; to assess the effect of chlorine gas on the respiratory system&#44; and to perform a clinical and spirometric follow-up&#46; The following interventions were carried out&#58; environmental inspection&#44; epidemiologic survey &#40;including sociodemographic variables&#41;&#44; location at the time of the accident&#44; perception of an abnormal smell&#44; and clinical and spirometric outcomes to assess respiratory function&#46; Sixty-five cases and 48 controls were identified and interviewed&#46; The accident was produced by accidental admixture of hydrochloric acid with sodium hypochlorite resulting in chlorine gas release&#46; The main clinical symptoms were dyspnea and cough&#46; The risk of becoming ill was 10-fold higher in children with a previous lung disease and was 4-fold higher when the distance from the chlorine source was less than 40 m&#46; All cases recovered completely&#44; except one who had a history of asthma&#46;</p>"
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                  \t\t\t\t">Olor<a class="elsevierStyleCrossRef" href="#tf0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Peso &#40;kg&#41;<a class="elsevierStyleCrossRef" href="#tf0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Distancia &#40;m&#41;<a class="elsevierStyleCrossRef" href="#tf0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;220&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t">S&#237;ntomas irritativos&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enfermedad previa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;87 &#40;1&#44;36-86&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#44;0-49&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distancia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hasta 40 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;5 &#40;1&#44;08-18&#44;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;72 &#40;0&#44;41-1&#44;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#225;s de 40 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;33 &#40;0&#44;5-11&#44;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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NOTA DE CAMPO
Investigación de un brote respiratorio agudo por exposición a cloro gas en una piscina pública
Investigation of an outbreak of acute respiratory illness due to exposure to chlorine gas in a public swimming pool
Diego Almagro Nievasa,
Autor para correspondencia
diegoalmagro.sspa@juntadeandalucia.es

Diego Almagro Nievas. Técnico de Salud de Epidemiología y Programas. Distrito Sanitario Metropolitano de Granada. Gustavo Doré, 3, bajos. 18015 Granada. España.
, Rafael Acuña Castillob, Antonio Hernández Jerezc, Alberto Robles Montesd
a Unidad de Epidemiología y Programas del Distrito Metropolitano de Granada, Granada, España
b Técnico de Salud Ambiental del Distrito Metropolitano de Granada, Granada, España
c Departamento de Toxicología, Facultad de Medicina, Universidad de Granada, Granada, España
d Enfermero del Centro de Salud de Albolote de Granada, Granada, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Introducci&#243;n</span><p id="p0010" class="elsevierStylePara elsevierViewall">Las intoxicaciones por gases irritantes pueden ocurrir en gran variedad de circunstancias&#44; pero son m&#225;s frecuentes en el &#225;mbito industrial<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">1</span></a> y dom&#233;stico<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">2</span></a>&#46; La intoxicaci&#243;n ambiental por cloro gas es relativamente frecuente en piscinas&#44; pero est&#225; muy poco documentada<a class="elsevierStyleCrossRefs" href="#bb0020"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Los objetivos de este estudio fueron describir los factores ambientales que contribuyeron a la presentaci&#243;n de la alerta en salud p&#250;blica&#59; analizar el efecto de la exposici&#243;n aguda al cloro gas&#59; estudiar el efecto de la exposici&#243;n en relaci&#243;n con factores dependientes de la persona y el lugar&#44; y evaluar la evoluci&#243;n cl&#237;nica y funcional de dicha exposici&#243;n sobre el aparato respiratorio&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Desarrollo de la experiencia</span><p id="p0015" class="elsevierStylePara elsevierViewall">A trav&#233;s del n&#250;mero de tel&#233;fono 112 se tuvo conocimiento de un brote respiratorio agudo en una piscina p&#250;blica&#46; La primera actuaci&#243;n urgente fue comprobar el agente qu&#237;mico causante&#44; la cantidad de afectados y su situaci&#243;n cl&#237;nica&#44; y la alarma social generada&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">Se defini&#243; &#171;caso&#187; como todo usuario o trabajador de la piscina que el 21 de julio de 2005 y a partir de las 17&#58;30 h hab&#237;a requerido asistencia m&#233;dica en cualquier dispositivo sanitario por presentar alguna de las manifestaciones cl&#237;nicas recogidas en la encuesta epidemiol&#243;gica&#46; Actuaron como controles los usuarios o trabajadores de la piscina que no presentaron s&#237;ntomas ni precisaron asistencia m&#233;dica&#44; seleccionados por los casos entre sus familiares&#44; amigos o trabajadores que estaban presentes en la piscina pero no enfermaron&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">Mediante una encuesta epidemiol&#243;gica &#40;telef&#243;nica o presencial&#41; realizada a los casos y controles se recogieron las variables personales &#40;edad&#44; g&#233;nero&#44; altura&#44; peso&#44; enfermedad respiratoria previa&#41;&#44; ubicaci&#243;n en el recinto &#40;distancia al foco&#44; si estaba ba&#241;&#225;ndose o no&#41;&#44; olor percibido&#44; sintomatolog&#237;a &#40;n&#225;useas&#44; v&#243;mitos&#44; tos&#44; picor en garganta&#44; dolor tor&#225;cico&#44; dificultad al respirar&#44; cefalea&#44; v&#233;rtigos&#44; escozor en ojos&#44; lagrimeo y ojo rojo&#41;&#44; enfermedad previa&#44; tratamiento recibido&#44; necesidad de ingreso hospitalario y pruebas complementarias realizadas &#40;radiograf&#237;a&#44; gasometr&#237;a y espirometr&#237;a&#41;&#46; En el caso de los ni&#241;os m&#225;s peque&#241;os se entrevist&#243; a los padres&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Varios trabajadores&#47;testigos&#44; incluida la taquillera&#44; informaron sobre la cantidad de personas que podr&#237;a haber en el recinto en el momento del accidente&#46; Los s&#237;ntomas se agruparon en 3 categor&#237;as cl&#237;nicas&#58; sintomatolog&#237;a general &#40;n&#225;useas&#44; v&#243;mitos&#44; cefaleas y v&#233;rtigos&#41;&#44; irritativa &#40;tos&#44; picor en la garganta&#44; dolor tor&#225;cico&#44; escozor de ojos&#44; lagrimeo y ojo rojo&#41; o disnea&#46; La muestra de estudio se clasific&#243; seg&#250;n la edad en 2 grupos&#58; ni&#241;os &#40;&#60; 15 a&#241;os&#41; y j&#243;venes&#47;adultos &#40;&#8805; 15 a&#241;os&#41;&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico efectuado incluy&#243; el test de la &#967;<span class="elsevierStyleSup">2</span> para variables cualitativas y la t de Student para las cuantitativas&#46; La edad se categoriz&#243; en los 2 grupos mencionados anteriormente&#46; Se plante&#243; un estudio de casos y controles estimando la <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; de enfermar con su intervalo de confianza &#40;IC&#41; del 95&#37;&#44; mediante an&#225;lisis de regresi&#243;n log&#237;stica simple&#46; Se utilizaron los programas Excel 2000 y SPSS &#40;versi&#243;n 12&#41;&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">A todos los casos mayores de 5 a&#241;os se les cit&#243; por carta para realizarles una espirometr&#237;a<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">5</span></a> al segundo y quinto mes del accidente&#44; con el fin de valorar su funci&#243;n respiratoria&#46; Independientemente de ello&#44; al sexto mes se revisaron las historias cl&#237;nicas para observar la evoluci&#243;n cl&#237;nica de todos los casos&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">El suceso se produjo porque los operarios introdujeron accidentalmente hipoclorito s&#243;dico en un recipiente de &#225;cido clorh&#237;drico ubicado en la caseta de mantenimiento de la piscina&#44; por lo que se produjo inmediatamente una emanaci&#243;n de cloro gas&#46; La inspecci&#243;n ambiental de los setos pr&#243;ximos a la caseta revel&#243; una coloraci&#243;n amarillenta tipo clorosis a 2 m de altura&#46; Pocos metros m&#225;s adelante la nube bajaba y&#44; conforme se alejaba hacia el sur&#44; volv&#237;a a subir&#46; Se confirm&#243; que la direcci&#243;n del viento era la misma&#46; En posteriores inspecciones se constat&#243; que la piscina no ten&#237;a licencia de reapertura&#44; los productos de tratamiento del agua no estaban correctamente identificados y carec&#237;a de las correspondientes fichas de datos de seguridad&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">El aforo m&#225;ximo de la piscina&#44; seg&#250;n el Jefe de &#193;rea de Deportes del Ayuntamiento de la localidad&#44; es de 537 personas&#44; y se estima que en el momento del accidente hab&#237;a unas 150 personas&#44; de las cuales el 40&#37; eran menores de 15 a&#241;os&#44; otro 40&#37; ten&#237;a entre 15 y 30 a&#241;os&#44; y el 20&#37; restante eran mayores de 30 a&#241;os&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">En urgencias de atenci&#243;n primaria se atendi&#243; a 30 personas con s&#237;ntomas respiratorios que percibieron un olor &#171;intenso&#44; como a lej&#237;a&#187; y vieron salir &#171;una neblina&#187; de la caseta&#46; En urgencias hospitalarias se atendieron 30 ni&#241;os &#40;8 ingresos&#41; y 12 adultos &#40;ning&#250;n ingreso&#41;&#46; El tratamiento aplicado consisti&#243; en oxigenoterapia&#44; corticoides y broncodilatadores&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Se encuest&#243; a un total de 65 casos y 48 controles&#46; El 70&#37; de los ni&#241;os fueron casos&#44; frente al 48&#44;3&#37; de los j&#243;venes&#47;adultos&#46; En la <a class="elsevierStyleCrossRef" href="#t0010">tabla 1</a> se recogen las caracter&#237;sticas de la muestra de estudio y la relaci&#243;n estad&#237;stica entre las variables&#46; No se pudo clasificar a 7 casos atendidos por desconocer su edad&#46; Tanto en ni&#241;os como en j&#243;venes&#47;adultos&#44; algunas variables fue desconocida&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0065" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#t0015">tabla 2</a> se describe el cuadro cl&#237;nico que presentaron los casos&#46; El 85&#44;3&#37; de los ni&#241;os y el 82&#44;1&#37; de los j&#243;venes&#47;adultos presentaron disnea&#46; En los ex&#225;menes complementarios realizados en urgencias s&#243;lo se observ&#243; un patr&#243;n intersticial microalveolar difuso &#40;de 16 radiograf&#237;as&#41;&#44; 2 acidosis &#40;de 6 an&#225;lisis&#41; y un patr&#243;n respiratorio obstructivo &#40;de 3 espirometr&#237;as&#41;&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia><p id="p0070" class="elsevierStylePara elsevierViewall">Seg&#250;n el an&#225;lisis de regresi&#243;n log&#237;stica simple &#40;<a class="elsevierStyleCrossRef" href="#t0020">tabla 3</a>&#41;&#44; el riesgo de sufrir una intoxicaci&#243;n era mayor en los ni&#241;os que ten&#237;an una enfermedad respiratoria previa &#40;OR &#61; 10&#44;8&#59; IC del 95&#37;&#44; 1&#44;4-86&#44;3&#41; y en los que se encontraban a menos de 40 metros del lugar del accidente &#40;OR &#61; 4&#44;5&#59; IC del 95&#37;&#44; 1&#44;1-18&#44;7&#41;&#46; Los factores determinantes del ingreso hospitalario fueron ser ni&#241;o&#44; estar ba&#241;&#225;ndose en el momento del accidente y presentar sintomatolog&#237;a general o combinaci&#243;n de s&#237;ntomas generales&#44; irritativos y disnea&#46;</p><elsevierMultimedia ident="t0020"></elsevierMultimedia><p id="p0075" class="elsevierStylePara elsevierViewall">El primer seguimiento cl&#237;nico se realiz&#243; a 55 casos &#40;84&#44;6&#37;&#41;&#46; De ellos&#44; 23 no dispon&#237;an de historia cl&#237;nica&#44; 22 no ten&#237;an datos en su historia y en 10 casos persist&#237;an los s&#237;ntomas respiratorios&#46; En el segundo seguimiento cl&#237;nico s&#243;lo hab&#237;a un caso con cl&#237;nica respiratoria&#46; De los 9 trabajadores que estaban en el recinto &#40;3 camareras&#44; 2 operarios&#44; 2 socorristas&#44; una taquillera y un polic&#237;a local&#41;&#44; s&#243;lo el responsable de la mezcla accidental de productos qu&#237;micos precis&#243; asistencia m&#233;dica por presentar s&#237;ntomas respiratorios&#59; no utiliz&#243; equipo de protecci&#243;n individual ni acudi&#243; al seguimiento cl&#237;nico y funcional&#46; El operario de la empresa que transport&#243; el producto no present&#243; ning&#250;n s&#237;ntoma&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">De los 49 casos citados para realizar la primera espirometr&#237;a acudieron 34&#44; de los cuales 7 presentaron una relaci&#243;n entre el volumen espiratorio m&#225;ximo en el primer segundo &#40;FEV<span class="elsevierStyleInf">1</span>&#41; y la capacidad vital forzada &#40;FVC&#41; &#60; 70&#37;&#59; de ellos 2 ten&#237;an un patr&#243;n obstructivo y uno un patr&#243;n mixto &#40;FVC y FEV1 &#60; 80&#37;&#41;&#46; De los 27 casos con relaci&#243;n FEV<span class="elsevierStyleInf">1</span>&#47;FVC normal&#44; 2 presentaron una FVC &#60; 80&#37;&#44; de los cuales uno ingres&#243; con patr&#243;n restrictivo y el otro se etiquet&#243; de mala t&#233;cnica&#44; pues s&#243;lo ten&#237;a alterado este par&#225;metro&#46; En la segunda espirometr&#237;a se invit&#243; a los mismos 49 casos&#44; pero s&#243;lo se la realizaron 19&#46; Ninguno de ellos present&#243; una relaci&#243;n FEV<span class="elsevierStyleInf">1</span>&#47;FVC &#60; 70&#37; y tan s&#243;lo uno ten&#237;a FVC y FEV<span class="elsevierStyleInf">1</span> patol&#243;gicos &#40;77 y el 66&#37;&#44; respectivamente&#41;&#46; Aunque se consider&#243; como un patr&#243;n restrictivo&#44; a la vista del flujo espiratorio forzado entre el 25 y el 75&#37; de las v&#237;as a&#233;reas &#40;FFF<span class="elsevierStyleInf">27-75</span>&#41;&#44; podr&#237;a tratarse de un patr&#243;n obstructivo de peque&#241;as v&#237;as&#44; probablemente previo o agravado por el accidente&#46; Este caso estuvo ingresado en el hospital&#44; ten&#237;a antecedentes de enfermedad respiratoria y segu&#237;a presentando s&#237;ntomas 9 meses despu&#233;s del accidente&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">En cuanto al seguimiento hospitalario&#44; s&#243;lo hab&#237;a informaci&#243;n disponible de 4 ingresados&#59; uno de ellos era el que ten&#237;a alterada la segunda espirometr&#237;a y continuaba el seguimiento en atenci&#243;n primaria&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">La coordinaci&#243;n por parte de los diferentes profesionales&#44; administraciones y afectados permiti&#243; controlar la alarma social&#44; informar adecuadamente a los trabajadores&#44; los afectados y los medios de comunicaci&#243;n&#44; y conocer el alcance sanitario del episodio t&#243;xico&#44; que podr&#237;a dar lugar a actuaciones judiciales&#46;</p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Conclusiones</span><p id="p0095" class="elsevierStylePara elsevierViewall">Este brote surgi&#243; como consecuencia de la mezcla accidental de hipoclorito s&#243;dico y &#225;cido clorh&#237;drico&#44; liber&#225;ndose cloro gas que produjo un cuadro irritativo respiratorio&#44; especialmente en los ni&#241;os que estaban ba&#241;&#225;ndose y en los que estaban a menos de 40 m del lugar del accidente&#46; Todos los casos evolucionaron hacia la curaci&#243;n cl&#237;nica con normalidad de las pruebas funcionales&#44; excepto uno que ten&#237;a antecedentes de enfermedad respiratoria&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">La intervenci&#243;n coordinada permiti&#243; controlar la alarma social y valorar adecuadamente el impacto sobre la salud de los afectados por el accidente&#46; Esta experiencia puede servir para planificar actuaciones futuras ante casos similares&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">A case-control study was designed to investigate a chemical accident that occurred in a swimming-pool in the summer of 2005&#46; The aim was to describe the environmental factors involved in the accident&#44; to assess the effect of chlorine gas on the respiratory system&#44; and to perform a clinical and spirometric follow-up&#46; The following interventions were carried out&#58; environmental inspection&#44; epidemiologic survey &#40;including sociodemographic variables&#41;&#44; location at the time of the accident&#44; perception of an abnormal smell&#44; and clinical and spirometric outcomes to assess respiratory function&#46; Sixty-five cases and 48 controls were identified and interviewed&#46; The accident was produced by accidental admixture of hydrochloric acid with sodium hypochlorite resulting in chlorine gas release&#46; The main clinical symptoms were dyspnea and cough&#46; The risk of becoming ill was 10-fold higher in children with a previous lung disease and was 4-fold higher when the distance from the chlorine source was less than 40 m&#46; All cases recovered completely&#44; except one who had a history of asthma&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Casos &#40;n &#61; 27&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;010&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">25 &#40;96&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;270&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Enfermedad previa<a class="elsevierStyleCrossRef" href="#tf0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;12&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;520&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;87&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">4&#44;5 &#40;1&#44;08-18&#44;68&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#225;s de 40 m&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;33 &#40;0&#44;5-11&#44;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">0 &#40;0-0&#44;70&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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Información del artículo
ISSN: 02139111
Idioma original: Español
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