Assessing the relationship between multimorbidity, NCD configurations, frailty phenotypes, and mortality risk in older adults.

BACKGROUND: Older adults are increasingly susceptible to prolonged illness, multiple chronic diseases, and disabilities, which can lead to the coexistence of multimorbidity and frailty. Multimorbidity may result in various noncommunicable disease (NCD) patterns or configurations that could be associated with frailty and death. Mortality risk may vary depending on the presence of specific chronic diseases configurations or frailty. METHODS: The aim was to examine the impact of NCD configurations on mortality risk among older adults with distinct frailty phenotypes. The population was analyzed from the Costa Rican Longevity and Healthy Aging Study Cohort (CRELES). A total of 2,662 adults aged 60 or older were included and followed for 5 years. Exploratory factor analysis and various clustering techniques were utilized to identify NCD configurations. The frequency of NCD accumulation was also assessed for a multimorbidity definition. Frailty phenotypes were set according to Fried et al. criteria. Kaplan‒Meier survival analyses, mortality rates, and Cox proportional hazards models were estimated. RESULTS: Four different types of patterns were identified: 'Neuro-psychiatric', 'Metabolic', 'Cardiovascular', and 'Mixt' configurations. These configurations showed a higher mortality risk than the mere accumulation of NCDs [Cardiovascular HR:1.65 (1.07-2.57); 'Mixt' HR:1.49 (1.00-2.22); ≥3 NCDs HR:1.31 (1.09-1.58)]. Frailty exhibited a high and constant mortality risk, irrespective of the presence of any NCD configuration or multimorbidity definition. However, HRs decreased and lost statistical significance when phenotypes were considered in the Cox models [frailty + 'Cardiovascular' HR:1.56 (1.00-2.42); frailty + 'Mixt':1.42 (0.95-2.11); and frailty + ≥ 3 NCDs HR:1.23 (1.02-1.49)]. CONCLUSIONS: Frailty accompanying multimorbidity emerges as a more crucial indicator of mortality risk than multimorbidity alone. Therefore, studying NCD configurations is worthwhile as they may offer improved risk profiles for mortality as alternatives to straightforward counts.

Design and implementation of an intensive panel survey with refugees and other migrants in need of protection in Costa Rica.

Over the last decade, the global population of refugees and other migrants in need of international protection (MNP) has more than doubled. Despite their rapid growth, panel data collection among MNP remains rare, leaving scholars with few data sources to draw on to understand dynamic changes in their social, economic, legal, or health circumstances. With that paucity in mind, we developed and piloted the Encuesta de Refugiados: Experiencias Sociales y Salud (ERESS), a weekly panel survey conducted with MNP living in Costa Rica. To our knowledge, this panel constitutes one of the first weekly surveys with MNP anywhere in the world. Here, we describe the overall study design, sample recruitment and retention, and key descriptive findings. We show that retaining demographically and socioeconomically diverse MNP in intensive panel surveys is possible and that doing so reveals valuable insights into dynamic changes in their incorporation, family dynamics, and health and wellbeing. By offering a summary of our field experiences and central methodological findings, we highlight the potential benefits and challenges of collecting intensive panel data with MNP, as scholars increasingly seek to understand their pre- and post-migration trajectories and relationships between the two.

A 6-year retrospective study of clinical features, microbiology, and genomics of Shiga toxin-producing Escherichia coli in children who presented to a tertiary referral hospital in Costa Rica.

Shiga-toxin-producing Escherichia coli (STEC) is associated with diarrhea and hemolytic uremic syndrome (HUS). STEC infections in Costa Rica are rarely reported in children. We gathered all the records of STEC infections in children documented at the National Children's Hospital, a tertiary referral hospital, from 2015 to 2020. Clinical, microbiological, and genomic information were analyzed and summarized. A total of 3,768 diarrheal episodes were reviewed. Among them, 31 STEC were characterized (29 fecal, 1 urine, and 1 bloodstream infection). The prevalence of diarrheal disease due to STEC was estimated at 0.8% (n = 29/3,768), and HUS development was 6.4% (n = 2/31). The stx1 gene was found in 77% (n = 24/31) of STEC strains. In silico genomic predictions revealed a predominant prevalence of serotype O118/O152:H2, accompanied by a cluster exhibiting allele differences ranging from 33 to 8, using a core-genome multilocus sequence typing (cgMLST) approach. This is the first study using a genomic approach for STEC infections in Costa Rica.IMPORTANCEThis study provides a comprehensive description of clinical, microbiological, genomic, and demographic data from patients who attended the only pediatric hospital in Costa Rica with Shiga-toxin-producing Escherichia coli (STEC) infections. Despite the low prevalence of STEC infections, we found a predominant serotype O118/O152:H2, highlighting the pivotal role of genomics in understanding the epidemiology of public health threats such as STEC. Employing a genomic approach for this pathogen for the first time in Costa Rica, we identified a higher prevalence of STEC in children under 2 years old, especially those with gastrointestinal comorbidities, residing in densely populated regions. Limitations such as potential geographic bias and lack of strains due to direct molecular diagnostics are acknowledged, emphasizing the need for continued surveillance to uncover the true extent of circulating serotypes and potential outbreaks in Costa Rica.

The effect of primary healthcare on mortality: Evidence from Costa Rica.

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study.

OBJECTIVE: The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica. METHODS: A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'. RESULTS: Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU. CONCLUSIONS: This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Genomic Diversity and Zoonotic Potential of Brucella neotomae.

After reports in 2017 of Brucella neotomae infections among humans in Costa Rica, we sequenced 12 strains isolated from rodents during 1955-1964 from Utah, USA. We observed an exact strain match between the human isolates and 1 Utah isolate. Independent confirmation is required to clarify B. neotomae zoonotic potential.

Cohort profile: evaluation of immune response and household transmission of SARS-CoV-2 in Costa Rica: the RESPIRA study.

PURPOSE: The RESPIRA cohort aims to describe the nature, magnitude, time course and efficacy of the immune response to SARS-CoV-2 infection and vaccination, population prevalence, and household transmission of COVID-19. PARTICIPANTS: From November 2020, we selected age-stratified random samples of COVID-19 cases from Costa Rica confirmed by PCR. For each case, two population-based controls, matched on age, sex and census tract were recruited, supplemented with hospitalised cases and household contacts. Participants were interviewed and blood and saliva collected for antibodies and PCR tests. Participants will be followed for 2 years to assess antibody response and infection incidence. FINDINGS TO DATE: Recruitment included 3860 individuals: 1150 COVID-19 cases, 1999 population controls and 719 household contacts from 304 index cases. The age and regional distribution of cases was as planned, including four age strata, 30% rural and 70% urban. The control cohort had similar sex, age and regional distribution as the cases according to the study design. Among the 1999 controls recruited, 6.8% reported at enrolment having had COVID-19 and an additional 12.5% had antibodies against SARS-CoV-2. Compliance with visits and specimens has been close to 70% during the first 18 months of follow-up. During the study, national vaccination was implemented and nearly 90% of our cohort participants were vaccinated during follow-up. FUTURE PLANS: RESPIRA will enable multiple analyses, including population prevalence of infection, clinical, behavioural, immunological and genetic risk factors for SARS-CoV-2 acquisition and severity, and determinants of household transmission. We are conducting retrospective and prospective assessment of antibody levels, their determinants and their protective efficacy after infection and vaccination, the impact of long-COVID and a series of ancillary studies. Follow-up continues with bimonthly saliva collection for PCR testing and biannual blood collection for immune response analyses. Follow-up will be completed in early 2024. TRIAL REGISTRATION NUMBER: NCT04537338.

Reducing dietary intake of added sugars could affect the nutritional adequacy of vitamin A in adolescents: the Costa Rica case.

BACKGROUND: In countries where sugar fortification with vitamin A is mandatory, strategies to reduce the prevalence of overweight/obesity in adolescents that involve lowering added sugar intake could lead to vitamin A inadequate intakes, since vitamin A-fortified sugar for home consumption contributes to a high proportion of this vitamin intake in the adolescent diet. METHODS: The study employed a hierarchical linear model to perform a mediation analysis on a cross-sectional sample of adolescents (13-18 years old) in the province of San José, Costa Rica. RESULTS: Lowering the total energy intake derived from added sugars to less than 10% significantly increases the prevalence of vitamin A inadequate intake in adolescents by 12.1% (from 29.6% to 41.7%). This is explained by the mediation model in which, the reduced adequacy of vitamin A intake is mediated by a reduction in total energy intake derived from added sugars fortified with vitamin A. CONCLUSIONS: The vitamin A fortification of sugar for household consumption should be reassessed according to the current epidemiological profile in Costa Rica to promote strategies that reduce the prevalence of overweight/obesity in adolescents by lowering the consumption of added sugars without affecting vitamin A intake.

Genome-Based Characterization of Listeria monocytogenes, Costa Rica.

Genomic data on the foodborne pathogen Listeria monocytogenes from Central America are scarce. We analyzed 92 isolates collected during 2009-2019 from different regions in Costa Rica, compared those to publicly available genomes, and identified unrecognized outbreaks. Our findings suggest mandatory reporting of listeriosis in Costa Rica would improve pathogen surveillance.

Severe Rickettsia typhi Infections, Costa Rica.

Murine typhus is a febrile, fleaborne disease caused by infection with Rickettsia typhi bacteria. Cases can range from mild and nonspecific to fatal. We report 2 cases of murine typhus in Costa Rica, confirming the presence and circulation of R. typhi causing severe disease in the country.

Frailty as a predictor of mortality: a comparative cohort study of older adults in Costa Rica and the United States.

BACKGROUND: Frailty is a common condition among older adults that results from aging-related declines in multiple systems. Frailty increases older adults' vulnerability to negative health outcomes, including loss of mobility, falls, hospitalizations, and mortality. The aim of this study is to examine the association between frailty and mortality in older adults from Costa Rica and the United States. METHODS: This prospective cohort study uses secondary nationally-representative data of community-dwelling older adults from the Costa Rican Longevity and Healthy Aging Study (CRELES, n = 1,790) and the National Health & Aging Trends Study (NHATS, n = 6,680). Frailty status was assessed using Physical Frailty Phenotype, which includes the following five criteria: shrinking, exhaustion, low physical activity, muscle weakness, and slow gait. We used Cox proportional hazard models to examine the association between frailty and all-cause mortality, including sociodemographic characteristics and health behaviors as covariates in the models. Mortality follow-up time was right censored at 8 years from the date at baseline interview. RESULTS: The death hazard for frail compared to non-frail older adults was three-fold in Costa Rica (HR = 3.14, 95% CI: 2.13-4.62) and four-fold in the White US (HR = 4.02, 95% CI: 3.04-5.32). Older age, being male, and smoking increased mortality risk in both countries. High education was a protective factor in the US, whereas being married/in union was a protective factor in Costa Rica. In the US, White older adults had a lower risk of death compared to all other races and ethnicities. CONCLUSIONS: Results indicate that frailty can have a differential impact on mortality depending on the country. Access to universal health care across the life course in Costa Rica and higher levels of stress and social isolation in the US may explain differences observed in end-of-life trajectories among frail older adults.

Seroprevalence and detection of bovine leukosis virus in semen from breeding bulls in Costa Rica.

Bovine leukemia virus (BLV) causes enzootic bovine leukosis, a persistent infection and the most important neoplastic disease in cattle. It is spread primarily by transferring infected lymphocytes through blood from carriers to healthy animals. The present study is aimed at determining the seropositivity of BLV in breeding bulls from Costa Rica and at detecting for the first time in the country BLV DNA in bull semen. Between May 2011 and August 2018, 379 blood and 133 semen samples were collected from bulls distributed in 118 farms. The serum was analyzed by an enzymatic immunoassay and the semen by polymerase chain reaction and sequencing. BLV seropositivity was 43.5% (165/379), while 64.4% (76/118) of the farms had positive reactors. Holstein (75.7%) and Jersey (73.0%) breeds showed the highest seropositivity. In addition, Bos taurus bulls (68.1%), older than seven years (50.0%), and those belonging to dairy farms (75.5%) had higher seropositivity compared to Bos indicus (17.7%), younger than seven years (42.2%), and those from beef farms (15.5%), respectively. Moreover, Bos taurus bulls had a higher risk of being seropositive than Bos indicus (OR = 3.4; 95% CI: 1.7-6.8). BLV DNA was found in one semen sample (2.5%; 1/40) from a seropositive bull. The importance of serum and molecular BLV screening in semen samples and the potential role of some risk factors associated with the disease, such as the bull's age, genotype, and type of livestock productive system, is argued in the present report.

The First Population-Level Description of Women Diagnosed With Invasive Breast Cancer in Costa Rica From 2008 to 2012: A Cross-Sectional Study.

INTRODUCTION: Breast cancer is the leading cause of cancer-related deaths among women worldwide. In Costa Rica, it ranks first in incidence and fourth in terms of mortality. However, there is a lack of comprehensive information on treatment patterns and outcomes for breast cancer patients in Costa Rica. METHODS: This study utilized data from the National Tumor Registry, which was merged with the Costa Rica Social Security Fund (CCSS) to ensure comprehensive access to clinical information. The study is prospective and focused on patients diagnosed with breast cancer between January 2008 and December 2012. This combined dataset allowed for a more comprehensive analysis of patient characteristics, treatment patterns, and outcomes related to breast cancer in Costa Rica. RESULTS: Among the 4775 patients diagnosed during this period, 3160 met the inclusion criteria for our study. The average age at diagnosis was 59.1 years, with 32.5% of patients being over the age of 65. Most of the patients (55.4%) identified themselves as homemakers, while 46.5% underwent core needle biopsy for diagnosis. Approximately 60% of women were diagnosed with early-stage disease (IA, IIA, and IIB), while 1.7% had metastatic disease, mainly affecting the bone. The mean interval between diagnosis and surgery was 72 days. Most patients (88.7%) received surgery as their initial treatment, and over half (54.4%) received some form of adjuvant therapy. Additionally, 85.6% of patients completed their prescribed treatment. CONCLUSION: This study provides a comprehensive and detailed description of the characteristics and treatment patterns among breast cancer patients in Costa Rica. The findings contribute to our understanding of the disease in this population and can serve as a foundation for further research and improvement in breast cancer management and care.

[Relationship between the oxidative profile and the diet diversity index in older adults in an urban-marginal area of Costa Rica]. / Relación entre el perfil oxidativo y el índice de diversidad de la dieta en adultos mayores de una zona urbano-marginal de Costa Rica.

BACKGROUND AND OBJECTIVE: The older we get, the greater the production of reactive oxygen species and therefore the greater the oxidative stress, which is related to the deterioration of the health of older adults. This study analyzed the relationship between the oxidative profile and the dietary diversity index in an urban-marginal population of older adults in Costa Rica. METHODS: Eighty-eight older adults were studied and various markers of oxidative stress, serum glucose levels, lipid profile, and some micronutrients were determined. In addition, the body mass index (BMI) was calculated and the dietary diversity index (DDI) was determined. RESULTS: Lipid peroxidation and DNA oxidation, a mean plasma antioxidant capacity percentage of 39.54±10.67%, which decreased with age, were evidenced. 67% of the participants had alterations in glycemia, 73% had one or more alterations in blood lipid levels, 55% had insufficient vitamin D levels, and 68.6% were overweight. The average IDD was 4.91 points, indicating that the diet was not very diverse. No relationship was found between IDD and nutritional status, between nutritional status and oxidative stress, nor between biochemical variables and oxidative stress. CONCLUSION: The adults studied presented high oxidative stress, a high percentage of overweight, and a low IDD. A higher IDD was associated with a lower blood concentration of MDA and a higher % PAC.

Experimental infection of Artibeus lituratus bats and no detection of Zika virus in neotropical bats from French Guiana, Peru, and Costa Rica suggests a limited role of bats in Zika transmission.

Bats are important natural reservoir hosts of a diverse range of viruses that can be transmitted to humans and have been suggested to play an important role in the Zika virus (ZIKV) transmission cycle. However, the exact role of these animals as reservoirs for flaviviruses is still controversial. To further expand our understanding of the role of bats in the ZIKV transmission cycle in Latin America, we carried out an experimental infection in wild-caught Artibeus lituratus bats and sampled several free-living neotropical bats across three countries of the region. Experimental ZIKV infection was performed in wild-caught adult bats (4 females and 5 males). The most relevant findings were hemorrhages in the bladder, stomach and patagium. Significant histological findings included inflammatory infiltrate consisting of a predominance of neutrophils and lymphocytes, in addition to degeneration in the reproductive tract of males and females. This suggests that bat reproduction might be at some level affected by ZIKV. Leukopenia was also observed in some inoculated animals. Hemorrhages, genital alterations, and leukopenia are suggested to be caused by ZIKV; however, since these were wild-caught bats, we cannot exclude other agents. Detection of ZIKV by qPCR was observed at low concentrations in only two urine samples in two inoculated animals. All other animals and tissues tested were negative. Finally, no virus-neutralizing antibodies were found in any animal. To determine ZIKV infection in nature, the blood of a total of 2056 bats was sampled for ZIKV detection by qPCR. Most of the sampled individuals belonged to the genus Pteronotus sp. (23%), followed by the species Carollia sp. (17%), Anoura sp. (14%), and Molossus sp. (13.7%). No sample of any tested species was positive for ZIKV by qPCR. These results together suggest that bats are not efficient amplifiers or reservoirs of ZIKV and may not have an important role in ZIKV transmission dynamics.

First Report of Campylobacter hepaticus Isolation in Laying Hens and Broiler Breeders with Spotty Liver Disease in Costa Rica.

Poultry producers in Costa Rica have informally reported a spotty liver disease-like syndrome for more than 20 yr. However, despite many attempts, the infectious agent responsible for this syndrome had not been identified. Therefore, following current knowledge of spotty liver disease diagnosis, we invited veterinarians and poultry producers to submit samples to the diagnostic laboratories of the Veterinary Medicine School, Universidad Nacional, to identify the infectious agent of this syndrome. Veterinarians and poultry producers were instructed to collect gallbladders and livers aseptically and send them for pathology examinations and bacterial cultures in less than 24 hr after collection. Samples were processed for standard histopathologic studies and cultured under aerophilic, anaerobic, and microaerophilic conditions. Campylobacter-like colonies were isolated and identified by biochemical and PCR tests. Here we report for the first time the isolation, biochemical characterization, and molecular confirmation of Campylobacter hepaticus in laying hens and broiler breeders with spotty liver disease in Costa Rica.

Nota de investigación- Primer reporte de aislamiento de Campylobacter hepaticus en gallinas de postura y reproductoras pesadas con necrosis hepática focal en Costa Rica. Los productores avícolas en Costa Rica han reportado extraoficialmente un síndrome similar a la necrosis hepática focal durante más de 20 años. Sin embargo, a pesar de muchos intentos, el agente infeccioso responsable de este síndrome no había sido identificado. Por ello, siguiendo los conocimientos actuales relacionados con la necrosis hepática focal, se invitó a los veterinarios y a los productores avícolas a enviar muestras a los laboratorios de diagnóstico de la Facultad de Medicina Veterinaria de la Universidad Nacional, para identificar el agente infeccioso de este síndrome. Se instruyó a los veterinarios y productores avícolas para recolectar vesículas biliares e hígados asépticamente y enviarlos para exámenes patológicos y para cultivos bacterianos en menos de 24 horas después de la recolección. Las muestras se procesaron para estudios histopatológicos estándar y se cultivaron en condiciones aerófilas, anaeróbicas y microaerófilas. Las colonias sugestivas de Campylobacter se aislaron e identificaron mediante pruebas bioquímicas y por PCR. Aquí se reporta por primera vez el aislamiento, caracterización bioquímica y confirmación molecular de Campylobacter hepaticus en gallinas de postura y reproductoras pesadas con la necrosis hepática focal en Costa Rica.

Mycobacterium marinum Infection after Iguana Bite in Costa Rica.

Infections after reptile bites are uncommon, and microbial etiologies are not well defined. We describe a case of Mycobacterium marinum soft-tissue infection after an iguana bite in Costa Rica that was diagnosed through 16S rRNA sequencing and mycobacterial culture. This case informs providers of potential etiologies of infection after iguana bites.

Estimating human papillomavirus vaccine efficacy from a single-arm trial: proof-of-principle in the Costa Rica Vaccine Trial.

BACKGROUND: The World Health Organization recommends a 1- or 2-dose human papillomavirus (HPV) vaccination schedule for females aged 9 to 20 years. Studies confirming the efficacy of a single dose and vaccine modifications are needed, but randomized controlled trials are costly and face logistical and ethical challenges. We propose a resource-efficient single-arm trial design that uses untargeted and unaffected HPV types as controls. METHODS: We estimated HPV vaccine efficacy (VE) from a single arm by comparing 2 ratios: the ratio of the rate of persistent incident infection with vaccine-targeted HPV 16 and 18 (HPV 16/18) and cross-protected types HPV 31, 33, and 45 (HPV 31/33/45) to vaccine-unaffected types HPV 35, 39, 51, 52, 56, 58, 59, and 66 (HPV 35/39/51/52/56/58/59/66) vs the ratio of prevalence of these types at the time of trial enrollment. We compare VE estimates using only data from the bivalent HPV 16/18 vaccine arm of the Costa Rica Vaccine Trial with published VE estimates that used both the vaccine and control arms. RESULTS: Our single-arm approach among 3727 women yielded VE estimates against persistent HPV 16/18 infections similar to published 2-arm estimates from the trial (according-to-protocol cohort: 91.0% , 95% CI = 82.9% to 95.3% [single-arm] vs 90.9% , 95% CI = 82.0% to 95.9% [2-arm]; intention-to-treat cohort: 41.7%, 95% CI = 32.4% to 49.8% [single-arm] vs 49.0% , 95% CI = 38.1% to 58.1% [2-arm]). VE estimates were also similar in analytic subgroups (number of doses received; baseline HPV serology status). CONCLUSIONS: We demonstrate that a single-arm design yields valid VE estimates with similar precision to a randomized controlled trial. Single-arm studies can reduce the sample size and costs of future HPV vaccine trials while avoiding concerns related to unvaccinated control groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00128661.

Bayesian spatial modeling of childhood overweight and obesity prevalence in Costa Rica.

BACKGROUND: Childhood overweight and obesity levels are rising and becoming a concern globally. In Costa Rica, the prevalence of these conditions has reached alarming values. Spatial analyses can identify risk factors and geographical patterns to develop tailored and effective public health actions in this context. METHODS: A Bayesian spatial mixed model was built to understand the geographic patterns of childhood overweight and obesity prevalence in Costa Rica and their association with some socioeconomic factors. Data was obtained from the 2016 Weight and Size Census (6 - 12 years old children) and 2011 National Census. RESULTS: Average years of schooling increase the levels of overweight and obesity until reaching an approximate value of 8 years, then they start to decrease. Moreover, for every 10-point increment in the percentage of homes with difficulties to cover their basic needs and in the percentage of population under 14 years old, there is a decrease of 7.7 and 14.0 points, respectively, in the odds of obesity. Spatial patterns show higher values of prevalence in the center area of the country, touristic destinations, head of province districts and in the borders with Panama. CONCLUSIONS: Especially for childhood obesity, the average years of schooling is a non-linear factor, describing a U-inverted curve. Lower percentages of households in poverty and population under 14 years old are slightly associated with higher levels of obesity. Districts with high commercial and touristic activity present higher prevalence risk.

Estimation of the economic benefits for the public health system related to salt reduction in Costa Rica.

Excessive salt and sodium intake are strongly associated with high blood pressure and increased risk of cardiovascular disease. High blood pressure in turn is the main risk factor for the global burden of morbidity and mortality. The prevalence of this disease in the adult population of Costa Rica in 2018 was 37.2%. Costa Rica has limited information on the economic costs for the public health system and related of the prevalence of this type of disease mediated by dietary factors such as salt intake. OBJECTIVE: to estimate the economic benefits for the public health system related to salt reduction in Costa Rica for the year 2018. METHODOLOGY: estimation of the economic benefits for the public healthcare costs and productivity losses associated to reducing the per capita salt consumption of Costa Ricans to 5g/day, including the estimation of the Years of Life Productive Lost and of the direct costs on consultations, hospitalizations, and medications for the Costa Rica Social Security System. RESULTS: The total annual costs of hospitalization, consultations, and medications attributable to excessive salt intake in the population older than 15 years of age for the year 2018, were estimated at USD $15.1 million. The highest were in hospitalizations (53%), followed by consultations and medications (32% and 15%, respectively). CONCLUSION: NCDs caused by excessive salt intake represent important economic losses for the country, not only in terms of direct health costs, but also indirect due to the increase in years of potential life lost due to premature deaths because of CVD, which causes significant losses of human capital and, therefore, to the economy and the development of Costa Rica.