Variability in the Timing of Respiratory Syncytial Virus Epidemics in Guatemala, 2008-2018.

BACKGROUND: The description of local seasonality patterns in respiratory syncytial virus (RSV) incidence is important to guide the timing of administration of RSV immunization products. METHODS: We characterized RSV seasonality in Guatemala using the moving epidemic method (MEM) with absolute counts of RSV-associated acute respiratory infections (ARI) from hospital surveillance in Santa Rosa and Quetzaltenango departments of Guatemala. RESULTS: From Week 17 of 2008 through Week 16 of 2018, 8487 ARI cases tested positive for RSV by rRT-PCR. Season onsets varied up to 5 months; early seasons starting in late May to early August and finishing in September to November were most common, but late seasons starting in October to November and finishing in March to April were also observed. Both epidemic patterns had similar durations ranging from 4 to 6 months. Epidemic thresholds (the levels of virus activity that signal the onset and end of a seasonal epidemic) calculated prospectively using previous seasons' data captured between 70% and 99% of annual RSV detections. Onset weeks differed by 2-10 weeks, and offset weeks differed by 2-16 weeks between the two surveillance sites. CONCLUSIONS: Variability in the timing of seasonal RSV epidemics in Guatemala demonstrates the difficulty in precisely predicting the timing of seasonal RSV epidemics based on onset weeks from past seasons and suggests that maximal reduction in RSV disease burden would be achieved through year-round vaccination and immunoprophylaxis administration to at-risk infants.

Biomass smoke exposure and somatic growth among children: The RESPIRE and CRECER prospective cohort studies in rural Guatemala.

BACKGROUND: Cooking-related biomass smoke is a major source of household air pollution (HAP) and an important health hazard. Prior studies identified associations between HAP exposure and childhood stunting; less is known for underweight and wasting. Few studies had personal HAP measurements. METHODS: 557 households in rural Guatemala were enrolled in the CRECER study, the follow-up study of the RESPIRE randomized intervention trial. They were assigned to three groups that received chimney stoves at different ages of the study children. Multiple personal carbon monoxide (CO) exposure measurements were used as proxies for HAP exposures. Children's heights and weights were measured from 24 to 60 months of age. Height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and weight-for-height z-score (WHZ) were calculated based on the World Health Organization's Multicentre Growth Reference Study. HAZ, WAZ, and WHZ below -2 were classified as stunting, underweight, and wasting, respectively. Generalized linear models and mixed effects models were applied. RESULTS: 541 children had valid anthropometric data, among whom 488 (90.2 %) were stunted, 192 (35.5 %) were underweight, and 2 (0.3 %) were wasted. A 1 ppm higher average CO exposure was associated with a 0.21 lower HAZ (95 % CI: 0.17-0.25), a 0.13 lower WAZ (95 % CI: 0.10-0.17) and a 0.06 lower WHZ (95 % CI: 0.02-0.10).The associations for HAZ were stronger among boys (coefficient = -0.29, 95 % CI: -0.35 - -0.22) than among girls (coefficient = -0.15, 95 % CI: -0.20 - -0.10). A 1 ppm-year higher cumulative CO exposure was associated with a higher risk of moderate stunting among boys (OR = 1.27, 95 % CI: 1.05-1.59), but not among girls. DISCUSSION: In this rural Guatemalan population, higher HAP exposure was associated with lower HAZ and WAZ. The associations between HAP and HAZ/stunting were stronger among boys. Reducing HAP might benefit childhood somatic growth in rural populations of low-income countries.

Estimating personal exposures to household air pollution and plastic garbage burning among adolescent girls in Jalapa, Guatemala.

Waste collection services are uncommon in rural areas of low-resource countries, causing waste accumulation and subsequent dumping and burning of garbage. Air pollution from household garbage burning, including plastics, has been observed in Jalapa, Guatemala in addition to household air pollution (HAP) from cooking. Adolescent girls often help with these cooking and household tasks, but little is known about their exposures. We characterized 24-h exposures to HAP and household garbage burning in adolescent girls by measuring fine particulate matter (PM2.5), black carbon (BC), urinary biomarkers of polycyclic aromatic hydrocarbons (PAHs), bisphenol A (BPA), and phthalates. We recruited 60 girls between 13 and 17 years of age who helped with cooking activities and lived with participants of the Household Air Pollution Intervention Network (HAPIN) trial. We recruited n = 30 girls each from the control (wood-burning stove) and intervention (liquefied petroleum gas stove) arms. We also measured real-time kitchen concentrations of BC in 20 homes (33%). PM2.5 and BC were measured in n = 21 control and n = 20 intervention participants. Median concentrations of personal PM2.5 and BC and kitchen BC were lower (p < 0.05) in the intervention arm by 87%, 80%, and 85%, respectively. PAH metabolite concentrations were lower (p < 0.001) for all nine metabolites in intervention (n = 26) compared to control participants (n = 29). Urinary BPA concentrations were 66% higher in participants who reported using cosmetics (p = 0.02), and phthalate concentrations were 63% higher in participants who had reported using hair products during the sample period (p = 0.05). Our results suggest that gas stoves can reduce HAP exposures among adolescents who are not primary cooks at home. Biomarkers of plastic exposure were not associated with intervention status, but some were elevated compared to age- and sex-matched participants of the National Health and Nutrition Examination Survey (NHANES).

Seroprevalence of high incidence congenital infections among pregnant women in Coatepeque, Guatemala and surrounding areas, 2017-2018.

Maternal infections during pregnancy can potentially cause birth defects and severe adverse effects in infants. From 2017 to 2018, we investigated the seroprevalence of five antibodies among 436 mother-infant pairs enrolled in a pregnancy cohort study in Coatepeque, Guatemala. Upon enrollment (< 20 weeks gestational age) and shortly after delivery, we measured the prevalence of IgG and IgM antibodies against Toxoplasma gondii (T. gondii), rubella, and cytomegalovirus (CMV) in mothers and newborns and used rapid tests to detect HIV and syphilis (Treponema pallidum) in mothers. The mean cohort age was 24.5 years. Maternal T. gondii IgM and IgG seropositivity was 1.9% and 69.7%, respectively. No women were positive for HIV, syphilis, or rubella IgM. Maternal rubella IgG seropositivity was 80.8% and significantly increased with age. Maternal CMV IgM and IgG seropositivity were 2.3% and 99.5%, respectively. Of the 323 women tested at both timepoints, IgM reactivation occurred in one woman for T. gondii infection and in eight for CMV. No newborn was seropositive for CMV IgM or rubella IgM. One newborn was seropositive for T. gondii IgM. Congenital T. gondii and CMV infections are important public health issues for pregnant women, newborns, and healthcare providers in Coatepeque and Guatemala.

Plastic waste generation and emissions from the domestic open burning of plastic waste in Guatemala.

Domestic, or household-level, open burning of plastic waste is a source of air pollutants and greenhouse gases that are often neglected in emission inventories. Domestic open burning is a considerable concern in Guatemala due to the lack of access to waste collection services, particularly in rural areas. This paper offers the first attempt to estimate emissions from the domestic open burning of waste at the city and departmental levels in Guatemala. Data were collected from the Xalapán region of Jalapa, Guatemala and analyzed to determine the change in plastic waste generation over time as well as the socioeconomic factors that may affect the extent of plastic waste generation and burning. The annual per capita masses of plastic waste burned were used to estimate emissions from domestic open burning of plastic waste in the region of Xalapán, the cities of Jutiapa and Guatemala city, and all 22 departments in Guatemala. Our results show that rural areas burn more waste domestically, likely because of a lack of access to waste collection, and 30.4% of OC, 24.0% of BC, 23.6% of PM2.5, and 2.4% of CO2 emissions in Guatemala may not be accounted for by excluding open plastic burning as a source.

Burden of Diarrhoeagenic Escherichia coli in Santa Rosa, Guatemala in active health-services surveillance during 2008-2009 and 2014-2015.

OBJECTIVE: To describe the epidemiology of laboratory-confirmed Diarrhoeagenic Escherichia coli (DEC) cases from active facility-based surveillance in Guatemala. METHODS: We collected clinical and risk factor data on enrolled patients (aged 0-52 years) with acute diarrhoea at government healthcare facilities (1 hospital and 6 clinics) in Santa Rosa, Guatemala, during 2008-2009 and 2014-2015. Stool samples were analysed, E. coli identified through culture and biochemical tests, PCR amplification of genes encoding pathotype-specific virulence factors identified specific DEC pathotypes. Healthcare-seeking adjusted incidence rates were calculated. RESULTS: A total of 3041 diarrhoea cases were captured by surveillance (647 hospitalisations (H), 2394 clinic visits (CV)); general E. coli prevalence was 17.9%. DEC pathotypes were identified in 19% (n = 95/497) and 21% (n = 450/2113) in diarrhoea H and CV, respectively. Enteropathogenic E. coli (EPEC) was most frequently isolated (8.2% (n = 41) in diarrhoea H, 12.0% (n = 255) in diarrhoea CV), followed by ETEC (6.8% (n = 34) in H, 6% (n = 128) in CV) and STEC (0.6% (n = 3) in H, 0.6% (n = 13) in CV). We did not find evidence of a difference in severity between DEC and non-DEC diarrhoea. Incidence of DEC clinic visits and hospitalisations was 648.0 and 29.3, respectively, per 10,000 persons aged ≤5 years and 36.8 and 0.4, respectively, per 10,000 persons aged >5 years. CONCLUSIONS: DEC pathotypes, especially EPEC and ETEC, were detected frequently from patients presenting with diarrhoeal illness in Santa Rosa, Guatemala. Our findings suggest that preventive interventions should be prioritised for young children.

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings.

Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.

Sensitivity and representativeness of one-health surveillance for diseases of zoonotic potential at health facilities relative to household visits in rural Guatemala.

Most human and animal disease notification systems are unintegrated and passive, resulting in underreporting. Active surveillance can complement passive efforts, but because they are resource-intensive, their attributes must be evaluated. We assessed the sensitivity and representativeness of One-Health surveillance conducted at health facilities compared to health facilities plus monthly household visits in three rural communities of Guatemala. From September 2017 to November 2018, we screened humans for acute diarrheal, febrile and respiratory infectious syndromes and canines, swine, equines and bovines for syndromic events or deaths. We estimated the relative sensitivity as the incidence rate ratio of detecting an event in health facility surveillance compared to household surveillance from Poisson models. We used interaction terms between the surveillance method and sociodemographic factors or time trends to assess effect modification as a measure of relative representativeness. We used generalized additive models with smoothing splines to model incidence over time by surveillance method. We randomized 216 households to health facility surveillance and 198 to health facility surveillance plus monthly household visits. Health facility surveillance alone was less sensitive than when combined with household surveillance by 0.42 (95% CI: 0.34, 0.53), 0.56 (95% CI: 0.39, 0.79), 0.02 (95% CI: 0.00, 0.10), 0.28 (95% CI: 0.15, 0.50) and 0.22 (95% CI: 0.03, 0.92) times for human acute infections, human severe acute infections, and deaths in canines, swine and equines, respectively. Health facility surveillance alone underrepresented Spanish speakers (interaction p-value = 0.0003) and persons in higher economic assets (interaction p-values = 0.0008). The trend in incidence over time was different between the two study groups, with a larger decrease in the group with household surveillance (all interaction p-values <0.10). Surveillance at health facilities under ascertains syndromes in humans and animals which leads to underestimation of the burden of zoonotic disease. The magnitude of under ascertainment was differentially by sociodemographic factors, yielding an unrepresentative sample of health events. However, it is less time-intensive, thus might be sustained over time longer than household surveillance. The choice between methodologies should be evaluated against surveillance goals and available resources.

Ultrasound Core Laboratory for the Household Air Pollution Intervention Network Trial: Standardized Training and Image Management for Field Studies Using Portable Ultrasound in Fetal, Lung, and Vascular Evaluations.

Ultrasound Core Laboratories (UCL) are used in multicenter trials to assess imaging biomarkers to define robust phenotypes, to reduce imaging variability and to allow blinded independent review with the purpose of optimizing endpoint measurement precision. The Household Air Pollution Intervention Network, a multicountry randomized controlled trial (Guatemala, Peru, India and Rwanda), evaluates the effects of reducing household air pollution on health outcomes. Field studies using portable ultrasound evaluate fetal, lung and vascular imaging endpoints. The objective of this report is to describe administrative methods and training of a centralized clinical research UCL. A comprehensive administrative protocol and training curriculum included standard operating procedures, didactics, practical scanning and written/practical assessments of general ultrasound principles and specific imaging protocols. After initial online training, 18 sonographers (three or four per country and five from the UCL) participated in a 2 wk on-site training program. Written and practical testing evaluated ultrasound topic knowledge and scanning skills, and surveys evaluated the overall course. The UCL developed comprehensive standard operating procedures for image acquisition with a portable ultrasound system, digital image upload to cloud-based storage, off-line analysis and quality control. Pre- and post-training tests showed significant improvements (fetal ultrasound: 71% ± 13% vs. 93% ± 7%, p < 0.0001; vascular lung ultrasound: 60% ± 8% vs. 84% ± 10%, p < 0.0001). Qualitative and quantitative feedback showed high satisfaction with training (mean, 4.9 ± 0.1; scale: 1 = worst, 5 = best). The UCL oversees all stages: training, standardization, performance monitoring, image quality control and consistency of measurements. Sonographers who failed to meet minimum allowable performance were identified for retraining. In conclusion, a UCL was established to ensure accurate and reproducible ultrasound measurements in clinical research. Standardized operating procedures and training are aimed at reducing variability and enhancing measurement precision from study sites, representing a model for use of portable digital ultrasound for multicenter field studies.

Effectiveness of Gas and Chimney Biomass Stoves for Reducing Household Air Pollution Pregnancy Exposure in Guatemala: Sociodemographic Effect Modifiers.

Household air pollution (HAP) due to solid fuel use during pregnancy is associated with adverse birth outcomes. The real-life effectiveness of clean cooking interventions has been disappointing overall yet variable, but the sociodemographic determinants are not well described. We measured personal 24-h PM2.5 (particulate matter <2.5 µm in aerodynamic diameter) thrice in pregnant women (n = 218) gravimetrically with Teflon filter, impactor, and personal pump setups. To estimate the effectiveness of owning chimney and liquefied petroleum gas (LPG) stoves (i.e., proportion of PM2.5 exposure that would be prevented) and to predict subject-specific typical exposures, we used linear mixed-effects models with log (PM2.5) as dependent variable and random intercept for subject. Median (IQR) personal PM2.5 in µg/m3 was 148 (90-249) for open fire, 78 (51-125) for chimney stove, and 55 (34-79) for LPG stoves. Adjusted effectiveness of LPG stoves was greater in women with ≥6 years of education (49% (95% CI: 34, 60)) versus <6 years (26% (95% CI: 5, 42)). In contrast, chimney stove adjusted effectiveness was greater in women with <6 years of education (50% (95% CI: 38, 60)), rural residence (46% (95% CI: 34, 55)) and lowest SES (socio-economic status) quartile (59% (95% CI: 45, 70)) than ≥6 years education (16% (95% CI: 22, 43)), urban (23% (95% CI: -164, 42)) and highest SES quartile (-44% (95% CI: -183, 27)), respectively. A minority of LPG stove owners (12%) and no chimney owner had typical exposure below World Health Organization Air Quality guidelines (35 µg/m3). Although having a cleaner stove alone typically does not lower exposure enough to protect health, understanding sociodemographic determinants of effectiveness may lead to better targeting, implementation, and adoption of interventions.

Antibiotic use and hygiene interact to influence the distribution of antimicrobial-resistant bacteria in low-income communities in Guatemala.

To examine the effects of poor sanitation and hygiene on the prevalence of antimicrobial-resistant bacteria, we surveyed households in two rural and two urban communities in Guatemala (N = 196 randomly selected households). One adult (≥ 18-years old) and, when available, one child (≤ 5 years-old) provided a stool sample. Up to 48 presumptive Escherichia coli isolates were collected from each stool sample (n = 21,256 total) and were subjected to breakpoint assays for ten antibiotics. Mixed-effects logistic models were used to identify potential factors influencing the likelihood of harboring antibiotic-resistant bacteria. For nine out of ten antibiotics, the odds of detecting resistant bacteria decreased by ~ 32% (odds ratios, OR 0.53-0.8, P < 0.001) for every unit of improvement of a hygiene scale. Hygiene differences between households had a greater impact on prevalence compared to antibiotic use differences. The likelihood of detecting resistant isolates was lower for five antibiotics among households that boiled raw milk before consumption (OR 0.31-0.69), and higher for nine antibiotics in urban households (OR > 1.89-9.6). Poor hygiene conditions likely obscure effects of individual antibiotic use, presumably due to enhanced microbial transmission. Consequently, efforts to improve antibiotic stewardship should be coupled with improving hygiene conditions.

Inverse association between dengue, chikungunya, and Zika virus infection and indicators of household air pollution in Santa Rosa, Guatemala: A case-control study, 2011-2018.

BACKGROUND: Dengue, chikungunya, and Zika viruses are increasingly important public health problems. Burning vegetation, leaves, and other plant products have been shown to be effective mosquito repellents for their vector, Aedes spp., but there has been scant research on whether firewood cooking smoke in households influences mosquito populations or mosquito-borne diseases. About 2.9 billion people worldwide use biomass fuel for household cooking and heating, resulting in an estimated 1.6 million deaths annually from household air pollution (HAP)-related diseases. Global health agencies now encourage households to transition from biomass to clean fuels, but it is unclear whether such interventions may actually increase risk for mosquito-borne diseases. This retrospective case-control study evaluated associations between arboviral infections and cooking with firewood in Santa Rosa, Guatemala. METHOD: Vigilancia Integrada Comunitaria (VICo) was a prospective public health surveillance system for bacterial, parasitic, and viral causes of diarrheal, neurological, respiratory, and febrile illnesses in hospitals and clinics in the department of Santa Rosa, Guatemala. Enrolled VICo in-patients and out-patients during 2011-2018 were interviewed using standardized questionnaires on demographics and household characteristics. Blood and stool specimens were collected and tested to identify the etiologies presenting symptoms. Cases were defined as laboratory-positive for dengue, chikungunya, or Zika virus infections. Controls were laboratory-positive for bacterial and viral diarrheal illnesses (e.g., Salmonella, Shigella, Campylobacter, Escherichia coli, rotavirus, norovirus, sapovirus, or astrovirus). Cooking with firewood, kitchen location, stove type, and firewood cooking frequency were the independent exposure variables. Logistic regression models were used to analyze unadjusted and adjusted associations between arboviral infections and exposures of interest. RESULT: There were 311 arboviral cases and 1,239 diarrheal controls. Arboviral infections were inversely associated with cooking with firewood in the main house (AOR: 0.22; 95% CI: 0.08-0.57), cooking with firewood on an open hearth (AOR: 0.50; 95% CI: 0.33-0.78), and cooking with firewood ≥5 times per week (AOR: 0.54; 95% CI: 0.36-0.81), adjusting for age, sex, ethnicity, socioeconomic status index, number of people per household, community population density, community elevation, recruitment location, season, and admission year. CONCLUSION: Several primary determinants of HAP exposure were inversely associated with arboviral infections. Additional studies are needed to understand whether interventions to reduce HAP might actually increase risk for mosquito-borne infectious diseases, which would warrant improved education and mosquito control efforts in conjunction with fuel interventions.

Air Pollutant Exposure and Stove Use Assessment Methods for the Household Air Pollution Intervention Network (HAPIN) Trial.

BACKGROUND: High quality personal exposure data is fundamental to understanding the health implications of household energy interventions, interpreting analyses across assigned study arms, and characterizing exposure-response relationships for household air pollution. This paper describes the exposure data collection for the Household Air Pollution Intervention Network (HAPIN), a multicountry randomized controlled trial of liquefied petroleum gas stoves and fuel among 3,200 households in India, Rwanda, Guatemala, and Peru. OBJECTIVES: The primary objectives of the exposure assessment are to estimate the exposure contrast achieved following a clean fuel intervention and to provide data for analyses of exposure-response relationships across a range of personal exposures. METHODS: Exposure measurements are being conducted over the 3-y time frame of the field study. We are measuring fine particulate matter [PM < 2.5µm in aerodynamic diameter (PM2.5)] with the Enhanced Children's MicroPEM™ (RTI International), carbon monoxide (CO) with the USB-EL-CO (Lascar Electronics), and black carbon with the OT21 transmissometer (Magee Scientific) in pregnant women, adult women, and children <1 year of age, primarily via multiple 24-h personal assessments (three, six, and three measurements, respectively) over the course of the 18-month follow-up period using lightweight monitors. For children we are using an indirect measurement approach, combining data from area monitors and locator devices worn by the child. For a subsample (up to 10%) of the study population, we are doubling the frequency of measurements in order to estimate the accuracy of subject-specific typical exposure estimates. In addition, we are conducting ambient air monitoring to help characterize potential contributions of PM2.5 exposure from background concentration. Stove use monitors (Geocene) are being used to assess compliance with the intervention, given that stove stacking (use of traditional stoves in addition to the intervention gas stove) may occur. CONCLUSIONS: The tools and approaches being used for HAPIN to estimate personal exposures build on previous efforts and take advantage of new technologies. In addition to providing key personal exposure data for this study, we hope the application and learnings from our exposure assessment will help inform future efforts to characterize exposure to household air pollution and for other contexts. https://doi.org/10.1289/EHP6422.

Design and Rationale of the HAPIN Study: A Multicountry Randomized Controlled Trial to Assess the Effect of Liquefied Petroleum Gas Stove and Continuous Fuel Distribution.

BACKGROUND: Globally, nearly 3 billion people rely on solid fuels for cooking and heating, the vast majority residing in low- and middle-income countries (LMICs). The resulting household air pollution (HAP) is a leading environmental risk factor, accounting for an estimated 1.6 million premature deaths annually. Previous interventions of cleaner stoves have often failed to reduce exposure to levels that produce meaningful health improvements. There have been no multicountry field trials with liquefied petroleum gas (LPG) stoves, likely the cleanest scalable intervention. OBJECTIVE: This paper describes the design and methods of an ongoing randomized controlled trial (RCT) of LPG stove and fuel distribution in 3,200 households in 4 LMICs (India, Guatemala, Peru, and Rwanda). METHODS: We are enrolling 800 pregnant women at each of the 4 international research centers from households using biomass fuels. We are randomly assigning households to receive LPG stoves, an 18-month supply of free LPG, and behavioral reinforcements to the control arm. The mother is being followed along with her child until the child is 1 year old. Older adult women (40 to <80 years of age) living in the same households are also enrolled and followed during the same period. Primary health outcomes are low birth weight, severe pneumonia incidence, stunting in the child, and high blood pressure (BP) in the older adult woman. Secondary health outcomes are also being assessed. We are assessing stove and fuel use, conducting repeated personal and kitchen exposure assessments of fine particulate matter with aerodynamic diameter ≤2.5µm (PM2.5), carbon monoxide (CO), and black carbon (BC), and collecting dried blood spots (DBS) and urinary samples for biomarker analysis. Enrollment and data collection began in May 2018 and will continue through August 2021. The trial is registered with ClinicalTrials.gov (NCT02944682). CONCLUSIONS: This study will provide evidence to inform national and global policies on scaling up LPG stove use among vulnerable populations. https://doi.org/10.1289/EHP6407.

Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala.

BACKGROUND: Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged ≥18 years hospitalized with ARI in Guatemala. METHODS: We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and ≥ 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician's discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases. RESULTS: Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults ≥18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases. CONCLUSIONS: Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality.

Prevalence and genetic diversity of viral gastroenteritis viruses in children younger than 5 years of age in Guatemala, 2014-2015.

BACKGROUND: Acute diarrhea is an important cause of morbidity and mortality in children and is associated with approximately 500,000 deaths/year globally. Rotavirus and norovirus are leading causes of acute diarrhea accounting for more than half of this burden. OBJECTIVE/STUDY DESIGN: To determine the prevalence and genotype distribution of acute diarrhea caused by rotavirus, norovirus, sapovirus and astrovirus among children <5 years of age at two departments in Guatemala from January 2014 to December 2015, we tested 471 stool specimens (202 samples from hospitalized children and 269 samples from children in ambulatory clinics) by real-time reverse transcription-PCR and genotyped positive samples. RESULTS: Rotavirus was detected in 20.4%, norovirus in 18.5%, sapovirus in 7% and astrovirus in 4.2% of the samples. Co-infection of rotavirus and norovirus was found in 2.6% of the samples. Most norovirus (87.4%) and rotavirus (81.3%) infections were detected in children in the 6-12 months age group. The proportion of patients with rotavirus (34%) and norovirus (23%) was higher in hospitalized patients compared to ambulatory patients, whereas the prevalence of sapovirus and astrovirus was similar in both settings. Of the 40 genotyped norovirus strains, 62.5% were GII.4 and 15% GII.3. Sapovirus genotypes included GI.1 (15.4%), GII.2 (15.4%), GII.5 (38.5%) and GIV.1 (30.8%). CONCLUSIONS: Our data demonstrate that in 2014-2015, gastroenteritis viruses account for 50% of acute diarrhea in children younger than 5 years of age in Guatemala, highlighting the importance of continuous surveillance to guide impact of the current rotavirus vaccine and formulation of future norovirus vaccines.

Burden of laboratory-confirmed shigellosis infections in Guatemala 2007-2012: results from a population-based surveillance system.

BACKGROUND: We describe the epidemiology and antimicrobial susceptibility patterns of culture-confirmed Shigella infections in facility-based surveillance sites in Guatemala. Current studies using quantitative molecular diagnostics suggest Shigella may contribute most to the global diarrheal disease burden. Since identification of Shigella requires culturing techniques using stool specimens and few laboratories in Guatemala routinely culture for this pathogen, little is known about the true burden of Shigella in Guatemala or, importantly, the antimicrobial resistance patterns. METHODS: Clinical, epidemiological, and laboratory data were collected on 5399 patients with acute diarrhea (≥3 loose stools in 24 h) from June 2007-August 2012. Multidrug resistance (MDR) was defined as resistance to ampicillin and trimethoprim/sulfamethoxazole. RESULTS: Five percent (261) of stool specimens yielded Shigella spp. The annual incidence of laboratory-confirmed infections ranged from 5.0 to 24.1 per 100,000 persons in Santa Rosa and 0.3 to 6.2 per 100,000 in Quetzaltenango; 58% of cases occurred in children < 5 years of age. Thirty patients were hospitalized; one patient died. Oral rehydration or intravenous solution was used to treat 72% of hospitalized and 15% of ambulatory cases. Fifty-nine percent of cases were S. flexneri and 51% of cases were MDR. CONCLUSIONS: Shigella is an important cause of bacterial diarrhea in children and prevalence of MDR highlights the importance of appropriate treatment regimens. This study demonstrates that strengthening laboratory capacity in Guatemala can help determine causes which can lead to prevention of diarrheal diseases, particularly in children. Such capacity building is also critical for rapid detection and control of public health threats at their source and therefore for global health security.

Hospitalization and death among patients with influenza, Guatemala, 2008-2012.

BACKGROUND: Influenza is a major cause of respiratory illness resulting in 3-5 million severe cases and 291,243-645,832 deaths annually. Substantial health and financial burden may be averted by annual influenza vaccine application, especially for high risk groups. METHODS: We used an active facility-based surveillance platform for acute respiratory diseases in three hospitals in Guatemala, Central America, to estimate the incidence of laboratory-confirmed hospitalized influenza cases and identify risk factors associated with severe disease (defined as admission to the intensive care unit (ICU) or death). We enrolled patients presenting with signs and symptoms of acute respiratory infection (ARI) and obtained naso- and oropharyngeal samples for real-time reverse transcriptase polymerase chain reaction (RT-PCR). We used multivariable logistic regression to identify risk factors for ICU admission or death, adjusted for age and sex. RESULTS: From May 2008 to July 2012, among 6326 hospitalized ARI cases, 446 (7%) were positive for influenza: of those, 362 (81%) had influenza A and 84 (18%) had influenza B. Fifty nine percent of patients were aged ≤ 5 years, and 10% were aged ≥ 65 years. The median length of hospitalization was 5 days (interquartile range: 5). Eighty of 446 (18%) were admitted to the ICU and 28 (6%) died. Among the 28 deaths, 7% were aged ≤ 6 months, 39% 7-60 months, 21% 5-50 years, and 32% ≥ 50 years. Children aged ≤ 6 months comprised 19% of cases and 22% of ICU admissions. Women of child-bearing age comprised 6% of cases (2 admitted to ICU; 1 death). In multivariable analyses, Santa Rosa site (adjusted odds ratio [aOR] = 10, 95% confidence interval [CI] = 2-50), indigenous ethnicity (aOR = 4, 95% CI = 2-13, and radiologically-confirmed pneumonia (aOR = 5, 95% CI = 3-11) were independently associated with severe disease. Adjusted for hospital utilization rate, annual incidence of hospitalized laboratory-confirmed influenza was 24/100,000 overall, 93/100,000 for children aged < 5 years and 50/100,000 for those ≥ 65 years. CONCLUSIONS: Influenza is a major contributor of hospitalization and death due to respiratory diseases in Guatemala. Further application of proven influenza prevention and treatment strategies is warranted.

Determining gestational age and preterm birth in rural Guatemala: A comparison of methods.

BACKGROUND: Preterm birth is the leading cause of death among children <5 years of age. Accurate determination of prematurity is necessary to provide appropriate neonatal care and guide preventive measures. To estimate the most accurate method to identify infants at risk for adverse outcomes, we assessed the validity of two widely available methods-last menstrual period (LMP) and the New Ballard (NB) neonatal assessment-against ultrasound in determining gestational age and preterm birth in highland Guatemala. METHODS: Pregnant women (n = 188) were recruited with a gestational age <20 weeks and followed until delivery. Ultrasound was performed by trained physicians and LMP was collected during recruitment. NB was performed on infants within 96 hours of birth by trained study nurses. LMP and NB accuracy at determining gestational age and identifying prematurity was assessed by comparing them to ultrasound. RESULTS: By ultrasound, infant mean gestational age at birth was 38.3 weeks (SD = 1.6) with 16% born at less than 37 gestation. LMP was more accurate than NB (mean difference of +0.13 weeks for LMP and +0.61 weeks for NB). However, LMP and NB estimates had low agreement with ultrasound-determined gestational age (Lin's concordance<0.48 for both methods) and preterm birth (κ<0.29 for both methods). By LMP, 18% were judged premature compared with 6% by NB. LMP underestimated gestational age among women presenting later to prenatal care (0.18 weeks for each additional week). Gestational age for preterm infants was overestimated by nearly one week using LMP and nearly two weeks using NB. New Ballard neuromuscular measurements were more predictive of preterm birth than those measuring physical criteria. CONCLUSION: In an indigenous population in highland Guatemala, LMP overestimated prematurity by 2% and NB underestimated prematurity by 10% compared with ultrasound estimates. New, simple and accurate methods are needed to identify preterm birth in resource-limited settings worldwide.

Incidence and Clinical Profile of Norovirus Disease in Guatemala, 2008-2013.

Background: Acute gastroenteritis (AGE) is a leading infectious cause of morbidity worldwide, particularly among children in developing countries. With the decline of rotavirus disease rates following introduction of rotavirus vaccines, the relative importance of norovirus will likely increase. Our objectives in this study were to determine the incidence and clinical profile of norovirus disease in Guatemala. Methods: We analyzed data from a population-based surveillance study conducted in Guatemala from 2008 through 2013. Demographic information, clinical data, and stool samples were collected from patients who presented with AGE (≥3 liquid stools within 24 hours that initiated 7 days before presentation). Estimated incidence of hospitalized, outpatient, and total community norovirus disease was calculated using surveillance data and household surveys of healthcare use. Results: We included 999 AGE hospitalizations and 3189 AGE outpatient visits at facilities, of which 164 (16%) and 370 (12%), respectively, were positive for norovirus. Severity of norovirus was milder than of rotavirus. Community incidence of norovirus ranged from 2068 to 4954 per 100000 person-years (py) in children aged<5 years. Children aged <5 years also had higher incidence of norovirus-associated hospitalization (51-105 per 100000 py) compared with patients aged ≥5 years (0-1.6 per 100000 py and 49-80 per 100000 py, respectively). Conclusions: This study highlights the burden of norovirus disease in Guatemala, especially among young children. These data can help prioritize development of control strategies, including the potential use of vaccines, and provide a baseline to evaluate the impact of such interventions.