Geographic areas with the highest concentration of traffic accidents in San Salvador, El Salvador: a spatial analysis of the 2014-2018 period

OBJECTIVE.

This study aimed to identify the areas with the highest concentration of traffic accidents and injuries in the San Salvador Metropolitan Area (SSMA).

MATERIALS AND METHODS.

Traffic accidents were analyzed spatially by point location and by the sum of events in areas of 200 m2. The point location was analyzed by "nearest neighbor analysis", while the areas with the sum of traffic accidents were analyzed by Getis-Ord Gi* to obtain the hot spots. The resulting hot spots with the highest concentration of traffic accidents in the SSMA were evaluated in the field using an observation form to collect data on infrastructure and road safety characteristics.

RESULTS.

Five areas with the highest number of traffic accidents and injuries, mainly containing primary roads, were identified by analyzing 8191 traffic accidents reported between 2014-2018.

CONCLUSION.

The sites with the highest concentration of traffic accidents and injuries were characterized by considerably damaged road infrastructure and the lack of safety systems for drivers and pedestrians. The spatial analysis of traffic accidents and injuries can contribute to improve surveillance and road safety in the SSMA.

Symptoms of depression and anxiety in young people in El Salvador: Associations with peer and family relationships, artistic activities and health behaviours during the COVID-19 pandemic

BACKGROUND

Little is known regarding the correlates of mental health, during the COVID-19 pandemic, in lower income countries. Using data from almost the entire population of graduating high school students in El Salvador, we examine the associations between depression and anxiety symptoms and potentially protective factors including peer and family relationships, health behaviours and artistic leisure activities.

METHODS

Data comes from the AVANZO survey conducted in El Salvador with 42,314 graduating high school students aged 15-21 in November 2020. Participants completed the Revised Child Anxiety and Depression Scale and Socioemotional Skills Scale. Using a structural equation modelling framework, we tested the associations between these variables and whether these associations varied by sex.

RESULTS

Participants who experienced more positive family relationships reported fewer symptoms of depression (β = -0.304, p < .001) and anxiety (β = -0.103, p < .001). Similar results were found between health behaviours and symptoms of depression (β = -0.398, p < .001), and anxiety (β = -0.312, p < .001). Peer relationships were non-significantly associated with depression and anxiety symptoms. Associations were similar for boys and girls.

LIMITATIONS

Students undertook the mental health survey as part of an academic test, which might have increased mental stress. The Socioemotional Skills Scales is newly developed, and results are cross-sectional.

CONCLUSIONS

Our findings provide insight into the experiences of an understudied population during the pandemic and identify positive family relationships and health behaviours as important correlates of mental health during this time.

Ticks and tick-borne rickettsiae from dogs in El Salvador, with report of the human pathogen Rickettsia parkeri

Twelve tick species have been reported in El Salvador; however, information regarding ticks infesting domestic dogs is lacking, and pathogenic tick-borne Rickettsia species have never been reported in El Salvador. This work evaluated ticks infesting 230 dogs from ten municipalities in El Salvador from July 2019 to August 2020. A total of 1,264 ticks were collected and identified into five species: Rhipicephalus sanguineus sensu lato (s.l.), Rhipicephalus microplus, Amblyomma mixtum, Amblyomma ovale, and Amblyoma cf. parvum. The tick R. sanguineus s.l. was the most frequent species in all localities (81.3% of sampled dogs), followed by Amblyomma mixtum (13.0%), Amblyomma ovale (10.9%) and Amblyomma cf. parvum (10.4%). The overall mean intensity of tick infestation was 5.5 ticks/dog. The highest specific mean intensity value was for R. sanguineus s.l. (4.8 ticks/dog), varying from 1.6 to 2.7 ticks/dog for the three Amblyomma species. From a random sample of 288 tick specimens tested molecularly for the presence of rickettsial agents, three spotted fever group Rickettsia were detected: Rickettsia amblyommatis in 90% (36/40) A. mixtum, 46% (11/24) A. cf. parvum, 4% (7/186) R. sanguineus s.l., and 17% Amblyomma spp.; Rickettsia parkeri strain Atlantic rainforest in 4% (1/25) A. ovale; and an unnamed rickettsia agent, designated as 'Rickettsia sp. ES-A.cf.parvum', in 4% (1/24) A. cf. parvum. Our finding of R. parkeri strain Atlantic rainforest in A. ovale is highly relevant because this agent has been associated to spotted fever illness in other Latin American countries, where A. ovale is implicated as its main vector. These findings suggest that spotted fever cases caused by R. parkeri strain Atlantic rainforest could be occurring in El Salvador.

Chagas disease prevalence among migrants from El Salvador in Milan: a cross- sectional study of an often-overlooked population

BACKGROUND

Chagas disease (CD) is considered to be highly endemic in El Salvador, where its prevalence is estimated to be 1.3-3.7%. Although more than 40,000 migrants from El Salvador are currently living in Europe (particularly in Spain and Italy), there are few data regarding the prevalence of CD in this population. The aim of this study was to evaluate the prevalence of CD among Salvadorans living in Italy.

METHODS

A cross-sectional serological survey of CD among Salvadorans living in the metropolitan area of Milan was carried out between October 2017 and December 2019. The participants' blood samples were tested for Trypanosoma cruzi antibodies using two different serological assays. The collected demographic data included their biological sex, province of origin, the type of housing in their country of origin, and family history of CD.

RESULTS

Of the 384 subjects who voluntarily participated in the study, five (1.3%, most coming from La Paz) were positive to both serological assays and therefore conclusively diagnosed as having CD. Five other subjects had discrepant serological results but were not positive to a third assay. Three of the five subjects with a diagnosis of CD completed medical staging, one of whom had chronic disease (digestive and cardiac involvement).

CONCLUSIONS

The prevalence of CD among Salvadorans living in Milan is similar to that estimated by the WHO in 2010. Although they are often overlooked in CD surveys, Salvadoran migrants should be included in CD control programs in countries in which the disease is not endemic.

Intensive competency-based training strategy in a National Hospital in times of Pandemic

COVID-19 has revealed the lack of capacity to respond to a pandemic. This article aims to 1. Describe the training of healthcare workers from “Hospital Nacional El Salvador” using intensive training based on competencies and 2. Share the results of the course evaluation, hoping that this training methodology will be helpful to other countries. Given the large group of professionals to train (Physicians and Paramedics), a compact course based on competencies was designed and executed. In order to optimize instruction times and the need for assistance care, the course was scheduled for a total duration of 4 hours and was imparted by selected instructors from August 17 to 21, August 24 to 28, and September 7 to 11, 2020 (15 working days in total). The Research Ethics Committee of Hospital Nacional El Salvador approved the study. The effectiveness of the educational intervention was evaluated by a pre–post-survey of knowledge perception on 4 domains with 10 areas of skills in intensive care. 100% (n: 981) of the participants were trained in hands-on care of COVID-19 patients; 66.3% female–33.7% male, with an average age of 29.92 ± 5.82 years. The course achieved an increased perception of knowledge in the 10 areas evaluated with a mean of 5.72 ± 0.59 to 8.60 ± 0.19 (P < .0001). The short intensive training in competencies carried out at Hospital Nacional El Salvador proved to be effective in improving the knowledge of healthcare workers engaged in patient care.

Exposure to violence, polyvictimization and youth's mental health and alcohol use in El Salvador

BACKGROUND

Community and family violence are major global health problems. Approximately 1.3 million deaths around the world and 2.5% of global mortality are due to violence. In El Salvador, youth are exposed to multiple levels of physical and emotional violence, abuse, and crime.

OBJECTIVE

The objective of this study was to investigate the various sources of violence against youth and determine the associations with mental distress symptoms, suicidal ideation, and alcohol use outcomes.

PARTICIPANTS AND SETTING

We use information gathered in 2017 from a representative sample of 13- to 24-year-old adolescents and young adults from El Salvador.

METHODS

Data used in this analysis came from a nationally cross-sectional household survey called Violence Against Children Survey (VACS) in El Salvador. We used logistic regression models to determine the associations between lifetime witnessing violence, exposure to physical, sexual, emotional violence, and youth mental health outcomes.

RESULTS

Polyvictimization was associated with greater odds of each mental health outcome after adjusting for confounders. The strongest relative association was observed between emotional violence and mental distress. Sexual violence and emotional violence were predictors of suicidal ideation. Finally, physical violence and sexual violence were associated with alcohol use. The greatest associations were observed between sexual violence perpetrated by a parent, peer, or another adult in the community and suicidal ideation, at a magnitude of approximately six times higher odds.

CONCLUSIONS

Preventing violence against youth is likely to improve mental health and wellbeing in El Salvador and other similar contexts worldwide.

Inference of malaria reproduction numbers in three elimination settings by combining temporal data and distance metrics

Individual-level geographic information about malaria cases, such as the GPS coordinates of residence or health facility, is often collected as part of surveillance in near-elimination settings, but could be more effectively utilised to infer transmission dynamics, in conjunction with additional information such as symptom onset time and genetic distance. However, in the absence of data about the flow of parasites between populations, the spatial scale of malaria transmission is often not clear. As a result, it is important to understand the impact of varying assumptions about the spatial scale of transmission on key metrics of malaria transmission, such as reproduction numbers. We developed a method which allows the flexible integration of distance metrics (such as Euclidian distance, genetic distance or accessibility matrices) with temporal information into a single inference framework to infer malaria reproduction numbers. Twelve scenarios were defined, representing different assumptions about the likelihood of transmission occurring over different geographic distances and likelihood of missing infections (as well as high and low amounts of uncertainty in this estimate). These scenarios were applied to four individual level datasets from malaria eliminating contexts to estimate individual reproduction numbers and how they varied over space and time. Model comparison suggested that including spatial information improved models as measured by second order AIC (ΔAICc), compared to time only results. Across scenarios and across datasets, including spatial information tended to increase the seasonality of temporal patterns in reproduction numbers and reduced noise in the temporal distribution of reproduction numbers. The best performing parameterisations assumed long-range transmission (> 200 km) was possible. Our approach is flexible and provides the potential to incorporate other sources of information which can be converted into distance or adjacency matrices such as travel times or molecular markers.

Prevalence and Sociodemographic Predictors of Intimate Partner Violence Against Women in El Salvador

Violence against women is currently one of the major problems in El Salvador. However, the country lacks existing data to address this issue. The recent coming into effect of the Ley Especial Integral para una Vida Libre de Violencia para las Mujeres (LEIV) [Comprehensive Law for a Life Free of Violence Against Women] urgently calls for the dimensions of the problem to be understood. The aim of this study is to determine the prevalence of physical, sexual, emotional, and controlling violence, which Salvadoran women aged 15 to 64 years suffer at the hands of their current partners or ex-partners, and the association of such violence with sociodemographic factors. The target population of the study is composed of Salvadoran women aged 15 to 64, from which a representative sample of 1,274 women was obtained. The results reveal that 54.4% of Salvadoran women reported having suffered some type of physical, sexual, or psychological violence during their lives. Psychological control (41.2%) was the most frequent form of violence, followed by emotional violence (39%), physical violence (22.5%), and sexual violence (13.3%). Women's number of children, marital status, and age were the main factors associated with violence. This study provides information needed to develop victim care measures and training programs for professionals. The study also provides evidence of the impact of public policies and prevention programs already in place.

Sugary Liquids in the Baby Bottle: Risk for Child Undernutrition and Severe Tooth Decay in Rural El Salvador

As communities worldwide shift from consuming traditional diets to more processed snacks and sugar-sweetened beverages (SSBs), increases in child obesity and tooth decay and persistence of undernutrition are particularly apparent in Latin American countries. Further evidence of shared risk factors between child undernutrition and poor oral health outcomes is needed to structure more effective health interventions for children’s nutrition. This study aims to identify dietary, oral health, and sociodemographic risk factors for child undernutrition and severe early childhood caries (sECC) among a convenience sample of 797 caregiver–child pairs from rural Salvadoran communities. Caregiver interviews on child dietary and oral health practices were conducted, and their children’s height, weight, and dental exam data were collected. Multivariable regression analyses were performed using RStudio (version 1.0.143). Caregiver use of SSBs in the baby bottle was identified as a common significant risk factor for child undernutrition (p = 0.011) and sECC (p = 0.047). Early childhood caries (p = 0.023) was also a risk factor for developing undernutrition. Future maternal–child health and nutrition programs should coordinate with oral health interventions to discourage feeding children SSBs in the baby bottle and to advocate for policies limiting SSB marketing to young children and their families.

Epidemic of Chronic Kidney Disease of Nontraditional Etiology in El Salvador: Integrated Health Sector Action and South-South Cooperation

In El Salvador, chronic kidney disease had reached epidemic propor-tions towards the end of this century's first decade. In 2011-2012, the Ministry of Health reported it was the leading cause of hospital deaths in men, the fifth in women, and the third overall in adult hospital fa-talities. Farming was the most common occupation among men in dialysis (50.7%). By 2017, chronic kidney disease admissions had overwhelmed hospital capacity.In 2009, El Salvador's Ministry of Health, Cuba's Ministry of Public Health and PAHO launched a cooperative effort to comprehensively tackle the epidemic. The joint investigations revealed a total prevalence of chronic kidney disease in the adult population of farming communities higher than that reported internationally (18% vs.11%-14.8%), higher in men than in women (23.9% vs 13.9%) and higher in men who were farmers/farmworkers than in men who were not (31.3% vs. 14.8%). The disease was also detected in children. An association was found between chronic kidney disease and exposure to agrochemicals (OR 1.4-2.5). In 51.9% of all chronic kidney disease cases, traditional causes (diabetes, hyperten-sion, glomerulopathies, obstructive nephropathies and cystic diseases) were ruled out and the existence of a particular form of chronic kidney disease of nontraditional etiology was confirmed (whose initial cases were reported as early as 2002). In the patients studied, functional altera-tions and histopathologic diagnosis confirmed a chronic tubulointerstitial nephritis; most presented with neurosensory hearing loss, altered tendon refiexes and tibial artery damage. The main results of this cooperation were the epidemiologic, physio-pathologic, clinical and histopathologic characterization of chronic kid-ney disease of nontraditional etiology. This characterization facilitated case definition for the epidemic and led to the hypothesis of systemic toxicity from agrochemicals (e.g., paraquat, glyphosate), which par-ticularly affect the kidneys and to which farmers/farmworkers (who may also become dehydrated in the fields) are most exposed. The research thus also laid the foundations for design of comprehensive intersectoral government actions to reduce cases and put an end to the epidemic. KEYWORDS Chronic kidney disease; chronic renal failure; tubuloint-erstitial nephritis; epidemiology; histopathology; international coopera-tion; agrochemicals; environmental pollutants, noxae, and pesticides; occupational health; PAHO; El Salvador; Cuba.

Physical Fighting among School-Attending Adolescents in El Salvador: An Examination of the 2013 Global School-Based Health Survey

Background: Violence among school-attending adolescents is an important public health problem worldwide. The present study examined demographic correlates for physical fighting behavior among a nationally representative sample of school-attending adolescents in El Salvador. Methods: Initial cross-tabulations to screen for correlations was then followed by logistic regression to understand the direction and the strength of selected demographic variables for physical fighting behavior, which occurred within a 12 month period of recall. Results: Out of a sample of 1910 school-attending adolescents in El Salvador, 11.5% reported having been involved in two or more physical fights during the recall period. Regression analyses indicated that being male (OR = 3.55; 95% CI = 2.11-6.00); having experienced bullying (OR = 2.16; 95% CI = 1.44-3.24); physical activity (OR 0.61; 95% CI 0.46-0.80); a sedentary lifestyle (OR 1.54; 95% CI 1.05-2.27), suicide planning (OR 2.28; 95% CI 1.46-3.56), and having non-understanding parents (OR = 1.45; 95% CI 1.06-1.98) were significantly associated with physical fighting among the sampled adolescents. Conclusion: Within the limitations of cross-sectional surveys conducted in school settings, the results of the present study suggest that giving attention to preventing bullying behavior among males and involving parents should be components of a multi-pronged strategy to preventing physical fighting in schools in El Salvador.

The Chronic Kidney Disease Epidemic in El Salvador: A Cross-Sectional Study

INTRODUCTION Chronic kidney disease has reached epidemic levels in several Central American countries since the early years of this century. In El Salvador, it is the second cause of death in men, the fifth in persons over 18 years old and the third cause of hospital deaths in the adult population. Its features, especially those of a subtype unassociated with traditional risk factors such as diabetes and high blood pressure, are only partially understood. OBJECTIVE Estimate the magnitude of chronic kidney disease in the adult population of El Salvador, considering both prevalence of the disease in its diverse forms as well as presence of potential risk factors nationally and in major subpopulations. METHODS A descriptive, cross-sectional analysis was conducted on data obtained from the Survey of Chronic Non-communicable Diseases in Adults in El Salvador, completed in 2015. The original data (interviews and measurements) were collected between October 2014 and March 2015 from 4817 adults employing a two-stage probabilistic cluster sample, with stratification of primary sampling units. Our analysis, using 20 of the 118 primary variables included in the original survey, focused on point estimation of prevalence rates and means, related to both traditional biological risk factors and nontraditional ones, such as insufficient hydration, strenuous working conditions and exposure to toxic agents. A separate analysis was performed to estimate prevalence of chronic kidney disease from nontraditional causes. Corresponding confidence intervals were calculated with proper weighting. RESULTS The general prevalence of chronic kidney disease in El Salvador was 12.8% (men 18.0%; women 8.7%). Of the chronically ill kidney patients, 13.1% were between 20 and 40 years of age. Among biological risk factors, the most frequent was high blood pressure (37.0%). Among nontraditional risk factors, high levels of sugary drink consumption (81.0%), insufficient hydration (65.9%) and high levels of exposure to agrochemicals in the work environment (12.6%) were also observed. Prevalence of chronic kidney disease from nontraditional causes was 3.9% (men 6.1%; women 2.2%). CONCLUSIONS Chronic kidney disease has reached epidemic proportions in El Salvador. The data confirm a health tragedy that, although especially striking older men, also takes a severe toll on young men and women. The results confirm findings of previous research in several Salvadoran agricultural communities. The relatively high level of population exposure to agrochemicals is important and alarming, especially in rural areas, meriting health-impact studies that include and go beyond possible impact on chronic kidney disease. KEYWORDS Kidney, renal insufficiency, chronic, risk factors, epidemics, El Salvador.

Leisure activities and alcohol consumption among adolescents from Peru and El Salvador

INTRODUCTION

Structured and unstructured leisure are known protective and risk factors, respectively, for alcohol consumption during adolescence. However, little is known about the interaction between the two leisure types and alcohol consumption.

METHOD

A cross-sectional study was performed among high-school students in El Salvador and Peru. Schooled adolescents, aged 13-18 (N = 5640), completed a self-administered questionnaire about risk behaviors, including their leisure activities and whether they had consumed alcoholic beverages. They were classified into tertiles of the amount of time of both structured and unstructured activities. A non-conditional multivariate logistic regression was conducted to evaluate the association of both types of leisure with alcohol consumption. We also used a likelihood ratio test to assess the potential interaction of structured and unstructured leisure time in alcohol consumption.

RESULTS

Alcohol consumption was much more frequent among adolescents in the highest tertile of unstructured leisure time compared to the lowest one (Adjusted OR: 5.52; 95% CI: 4.49-6.78), and less frequent among those from the highest tertile of structured leisure time compared to the lowest one (Adjusted OR: 0.66; 95% CI: 0.55-0.80). We did not find an interaction effect between structured and unstructured leisure time with regard to initiation of alcohol consumption.

DISCUSSION

The study suggests that structured leisure is not enough to compensate for the possible harmful effect of unstructured leisure. Parents, educators and policy makers might be advised to discourage unstructured leisure among adolescents, and not simply to encourage structured leisure.

Intervention Reach and Sexual Risk Reduction of a Multi-level, Community-Based HIV Prevention Intervention for Crack Users in San Salvador, El Salvador

This article examines the effects of a multi-level, community-based HIV prevention intervention for crack users residing in low-income neighborhoods in San Salvador, El Salvador conducted between August 2011 and June 2016. The intervention consisted of three components introduced sequentially: (1) rapid HIV testing in community settings; (2) a social network HIV testing intervention; and (3) small group interventions with crack users who were members of the same social network. The intervention was evaluated with an interrupted time series design in which we used respondent-driven sampling to conduct 7 cross-sectional surveys with crack users along a 3-4 month period for each assessment (total n = 1597). Results revealed a significant increase in exposure to the intervention over time with 50% of the participants reporting exposure to one or more of the three components. Getting an HIV test at the community site was associated with reductions in total times each individual had sex without a condom (p < 0.05) compared to those who had been exposed to no intervention components. Being referred by another crack user through the Social Network HIV intervention was also associated with reductions in total numbers of condomless sex (p < 0.05) The cumulative effect of being exposed to more than one intervention component was associated with reductions in total number of times individuals had condomless sex (p < 0.05). In spite of the high level of intervention reach and that self-reported exposure to intervention components was associated with lower sexual risk, reductions in sexual risk over time were not observed in the full sample, indicating that the penetration of HIV prevention components was not sufficient to produce population level change.

Spatiotemporal analysis of canine rabies in El Salvador: Violence and poverty as social factors of canine rabies

BACKGROUND

The incidence of canine rabies cases in El Salvador has decreased in the last decade since the establishment of intense control programs, such as massive vaccination campaigns implemented by the Ministry of Health. Socioeconomic crises in recent years have limited the access to certain areas across the country and have impacted surveillance and prevention campaigns, which places the country at risk for a resurgence of canine rabies.We aimedto describe the spatiotemporal patterns of canine rabies and its association with critical social factors in El Salvador from 2005 to 2014.

METHOD

We included 459 cases of canine rabies. Several socioeconomic, demographic, and surveillance variables were modeled using a Poisson regression to evaluate their associations with the incidence of canine rabies. Spatial scan statistics were adjusted or unadjusted with covariates and applied to identify statistically significant clusters of canine rabies. Finally, a canine rabies risk map was created.

RESULTS

A positive association and higher risk of canine rabies were found for low poverty zones, where it is suspected that urban slums contribute to ongoing rabies transmission (RR = 7.74). Violence had a negative association with rabies (RR = 0.663), which is likely due to reporting bias. Significant clusters were identified in all five epidemiological regions, and the Eastern region had the highest risk (RR = 50.62). The influences of the selected variables in cluster detection were confirmed by the adjusted analysis. Higher-risk townships were distributed from the Western to the Eastern regions of the country.

CONCLUSION

Social factors are determinants of rabies in El Salvador and play a major role in national spatial patterns of the disease. There are high-risk areas for canine rabies across the country, and there were two persistent rabies foci during the study period. Examining the role of social factors can provide better insight into rabies in vulnerable countries, and socioeconomic factors can be key elements in developing better policies and interventions for rabies control.

Prevalence of Self-Reported Gluten-Related Disorders and Adherence to a Gluten-Free Diet in Salvadoran Adult Population

Gluten-related disorders are not considered of relevance at public health level in Central America. The prevalence of gluten-related disorders, and adherence to a gluten-free diet, remain unknown in the Central American region. We conducted a cross-sectional survey of the Central American population from San Salvador, El Salvador, to estimate the prevalence rates of self-reported gluten-related disorders and adherence to a gluten-free diet. 1326 individuals were surveyed. Self-reported prevalence rates were (95% Confidence Interval): gluten sensitivity 3.1% (2.3–4.2); physician-diagnosed celiac disease 0.15% (0.04–0.5); wheat allergy 0.75% (0.4–1.3); non-celiac gluten sensitivity 0.98% (0.5–1.6). The prevalence rate of adherence to a gluten-free diet was 7.0% (5.7–8.5). Seven self-reported physician diagnosed gluten-sensitive cases informed the co-existence of non-celiac gluten sensitivity with celiac disease and/or wheat allergy. Among the non-self-reported gluten sensitivity individuals following a gluten-free diet, 50% reported that they were seeing a health professional for gluten-free dietary advice. Gluten sensitivity is commonly reported in Salvadoran population, but some health professionals acknowledge the coexistence of wheat allergy, celiac disease, and non-celiac gluten sensitivity. Among studies at population level, the prevalence of adherence to a gluten-free diet in Salvadoran population is the highest reported until now. However, just a few of the gluten-free diet followers were doing it for health-related benefits; the others reported weight control and the perception that the diet is healthier as the main motivation for adopting such a diet.

[Irritable bowel syndrome subtypes and characteristics in children from Panama, Ecuador,El Salvador, Nicaragua and Mexico]

INTRODUCTION

Few pediatric studies classify the irritable bowel syndrome (IBS) subtypes.

OBJECTIVE

To describe the characteristics and subtypes of IBS in children from Panama, Ecuador, El Salvador, Nicaragua and Mexico.

MATERIAL AND METHODS

Prevalence study performed in children between 8 and 18 years of age with a diagnosis of IBS. The children answered the Questionnaire for Pediatric Gastrointestinal Symptoms Roma III for Schoolchildren and Adolescents (QPGS-III) to identify functional gastrointestinal disorders. Variables such as age and sex were taken into account. The subtypes of IBS were classified in IBS with constipation (IBS-c), with diarrhea (IBS-d), mixed (IBS-m) and without subtype (IBS-ss). Statistical analysis included measures of central tendency, two-tailed student t-test, chi-square test, and Fisher's exact test, with a significant p<0.05.

RESULTS

We included 79 children (54.4% female, 12.1±2.1 years) presenting IBS-ss in 55.7%, IBS-c in 15.2%, IBS-m in 15.2% and SII-d in 13.9%. Severe pain predominated most of the day and with mucous stools; possible associations for IBS-d school and sex.

CONCLUSION

After IBS-ss, the IBS-e, IBS-d and IBS-m are similar, being the possible risk factors for IBS-d, the public school and the female gender.

Chagas disease knocks on our door: a cross-sectional study among Latin American immigrants in Milan, Italy

OBJECTIVES

We aimed to assess the prevalence and risk factors for Chagas disease (CD) in Latin American immigrants and to evaluate the accuracy of diagnostic tests. Moreover, we offered to all positive subjects a complete free-of-charge clinical/instrumental evaluation as well as benznidazole treatment in order to stage the disease and verify drug tolerability.

METHODS

A cross-sectional survey of CD among Latin Americans living in Milan and its metropolitan area was conducted between July 2013 and July 2014. Blood samples were tested for serologic evidence of CD together with a questionnaire covering demographic and clinical-epidemiological information.

RESULTS

Forty-eight (9.6%) of the 501 tested subjects were conclusively diagnosed as having CD. The highest prevalence of CD was among those from Bolivia (43/169, 25.4%) and El Salvador (4/68, 5.9%). Older age (adjusted odds ratio (aOR)] 1.05, p =0.004), a Bolivian origin (aOR 8.80; p =0.003), being born in the department of Santa Cruz (aOR 3.72, p =0.047), having lived in mud houses (aOR 2.68; p =0.019), and having an affected relative (aOR 12.77, p =0.001) were independently associated with CD. The ARCHITECT Chagas test showed the highest sensitivity (100%) and specificity (99.8%). Twenty-nine of the subjects with CD (60.4%) underwent disease staging, 10 of whom (35.7%) showed cardiac and/or digestive involvement. Benznidazole treatment was associated with high frequency of adverse reactions (19/27, 70.4%) and permanent discontinuation (8/27, 29.6%).

CONCLUSIONS

CD is highly prevalent among Bolivians and Salvadorans living in Milan. Regions with a large Latin American immigrant population should implement programmes of active detection and treatment.

Chronic kidney disease of nontraditional etiology in Central America: a provisional epidemiologic case definition for surveillance and epidemiologic studies

SYNOPSIS Over the last two decades, experts have reported a rising number of deaths caused by chronic kidney disease (CKD) along the Pacific coast of Central America, from southern Mexico to Costa Rica. However, this specific disease is not associated with traditional causes of CKD, such as aging, diabetes, or hypertension. Rather, this disease is a chronic interstitial nephritis termed chronic kidney disease of nontraditional etiology (CKDnT). According to the Pan American Health Organization (PAHO) mortality database, there are elevated rates of deaths related to kidney disease in many of these countries, with the highest rates being reported in El Salvador and Nicaragua. This condition has been identified in certain agricultural communities, predominantly among male farmworkers. Since CKD surveillance systems in Central America are under development or nonexistent, experts and governmental bodies have recommended creating standardized case definitions for surveillance purposes to monitor and characterize this epidemiological situation. A group of experts from Central American ministries of health, the U.S. Centers for Disease Control and Prevention (CDC), and PAHO held a workshop in Guatemala to discuss CKDnT epidemiologic case definitions. In this paper, we propose that CKD in general be identified by the standard definition internationally accepted and that a suspect case of CKDnT be defined as a person age < 60 years with CKD, without type 1 diabetes mellitus, hypertensive diseases, and other well-known causes of CKD. A probable case of CKDnT is defined as a suspect case with the same findings confirmed three or more months later.

A multi-country, cross-sectional observational study of retinopathy of prematurity in Latin America and the Caribbean

Objective To consolidate available information from the Latin American and Caribbean (LAC) region on 1) national incidence of retinopathy of prematurity (ROP) and 2) national-level government inputs on ROP (existing national policies, guidelines, programs, and financing for ROP prevention, detection, and treatment, including ROP screening) in 2014. Methods In March and April 2015, a multi-country online survey was distributed to 56 medical and public health experts working on ROP in LAC countries. Respondents were instructed to provide quantitative and qualitative information representative of the national situation in 2014 for ROP incidence and national-level government inputs (existing national policies, guidelines, programs, and financing for ROP prevention, detection, and treatment, including ROP screening) in their country. Results The survey was completed in full by a total of 11 experts from 10 LAC countries (Argentina, Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, El Salvador, Mexico, Nicaragua, and Panama). According to the survey results, six countries had a national policy that includes ROP prevention, detection, and treatment, with screening and treatment covered by national/federal funding. Eight countries had national guidelines for ROP. Four countries had legislation mandating eye examination of preterm infants. Most countries had Level 3 and 4 neonatal intensive care units with ROP programs in public sector health care facilities. Five countries had a data collection or monitoring system to track the number of newborn babies screened for ROP within hospital settings. On average, countries with three or four of the above-mentioned ROP elements screened 95% of eligible newborns in 2014, while those with only one or two of the ROP elements screened 35% of eligible newborns. Conclusions National government buy-in and involvement in ROP screening and treatment legislation is related to a higher proportion of eligible premature newborns being screened and treated for ROP. Further research should include more countries and assess national-level engagement with ROP, including ROP screening and treatment.

Prevalence of chronic kidney disease of non-traditional causes in patients on hemodialysis in southwest Guatemala

Objective To document the prevalence of patients on hemodialysis in southwestern Guatemala who have chronic kidney disease (CKD) of non-traditional causes (CKDnt). Methods This cross-sectional descriptive study interviewed patients on hemodialysis at the Instituto Guatemalteco de Seguridad Social on their health and occupational history. Laboratory serum, urine and vital sign data at the initiation of hemodialysis were obtained from chart reviews. Patients were classified according to whether they had hypertension or obesity or neither. The proportion of patients with and without these traditional CKD risk factors was recorded and the association between demographic and occupational factors and a lack of traditional CKD risk factors analyzed using multivariate logistic regression. Results Of 242 total patients (including 171 non-diabetics) enrolled in hemodialysis in southwestern Guatemala, 45 (18.6% of total patients and 26.3% of non-diabetics) lacked traditional CKD risk factors. While agricultural work history was common, only travel time greater than 30 minutes and age less than 50 years old were significantly associated with CKD in the absence of traditional risk factors. Individuals without such risk factors lived throughout southwestern Guatemala's five departments. Conclusions The prevalence of CKDnT appears to be much lower in this sample of patients receiving hemodialysis in Southwestern Guatemala than in hospitalized patients in El Salvador. It has yet to be determined whether the prevalence is higher in the general population and in patients on peritoneal dialysis.

High Prevalence of Nausea among School Children in Latin America

OBJECTIVES

To evaluate the prevalence of nausea and its association with functional gastrointestinal disorders (FGIDs) in a large-scale, population-based study of Latin American school children.

STUDY DESIGN

This cross-sectional study collected data from children in 3 Latin American countries. A Spanish version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-III) was administered to school children in Central and South America. Subjects were classified into FGIDs based on Rome criteria (QPGS-III). Students from 4 public and 4 private schools in the countries of El Salvador, Panama, and Ecuador participated in this epidemiologic study.

RESULTS

A total of 1137 school children with mean age 11.5 (SD 1.9, range 8-15) years completed the QPGS-III (El Salvador n = 399; Panama n = 321; Ecuador n = 417). Nausea was present in 15.9% of all school children. Two hundred sixty-eight (24%) children met criteria for at least 1 FGID. Nausea was significantly more common in children with FGIDs compared with those without: El Salvador 38% vs 15% (P < .001); Panama 22% vs 7% (P < .001); Ecuador 25% vs 13% (P = .004). Among children with FGIDs, those with functional constipation had a high prevalence of nausea. Nausea was significantly more common in girls and children attending private schools.

CONCLUSIONS

Nausea is commonly present in Latin American school children. FGIDs are frequently associated with nausea.

HIV Treatment for Alcohol and Non-Injection Drug Users in El Salvador

Since the mid-1990 s, many developing countries have introduced and expanded the availability of combination antiretroviral therapy (cART) to persons living with HIV (PLH). However, AIDS-related mortality continues to be high particularly among drug users. In this article, we present results from in-depth interviews with 13 HIV medical providers and 29 crack cocaine and alcohol using PLH in El Salvador. Providers endorsed negative attitudes toward substance using PLH and warned PLH that combining cART with drugs and alcohol would damage their livers and kidneys resulting in death. Upon diagnosis, PLH received little information about HIV treatment and many suffered depression and escalated their drug use. PLH reported suspending cART when they drank or used drugs because of providers' warnings. Substance using PLH were given few strategies and resources to quit using drugs. Messages from medical providers discourage drug users from initiating or adhering to antiretroviral therapy (ART) and may contribute to treatment abandonment.

Interventions targeting absences increase adherence and reduce abandonment of childhood cancer treatment in El Salvador

BACKGROUND

In El Salvador, about 200 new cases of pediatric cancer are diagnosed each year, and survival rates approach 70%. Although treatment is available at no cost, abandonment of therapy has remained at a steady yearly rate of 13% during the past decade. A time sensitive adherence tracking procedure (TS-ATP) was recently implemented to detect missed appointments, identify their causes, and intervene promptly. Procedure The study team was informed daily of patient/family failure to attend medical appointments in the pediatric oncology unit; the families were contacted and interviewed to ascertain and address the reasons. Patients who did not return after this initial contact were contacted again through local health clinics and municipalities. Law enforcement was a last resort for patients undergoing frontline treatment with a good prognosis., The system was adapted to clinical urgency: families of patients undergoing induction therapy were contacted within 24 hr, those in other therapy phases, within 48 hr, and those who had completed treatment, within one week. Reasons for absence were obtained by telephone or in person.

RESULTS

The annual rate of abandonment was reduced from 13-3% during the 2 years period. There were 1,111 absences reported and 1,472 contacts with caregivers and institutions. The three main reasons for absences were financial needs (165, 23%), unforeseen barriers (116, 16%), and domestic needs (86, 12%).

CONCLUSIONS

Use of the treatment adherence tracking system to locate and communicate with patients/families after missed appointments and the allocated aid stemming from these interviews substantially reduced abandonment and non-adherence.

Determinants of Health Service Responsiveness in Community-Based Vector Surveillance for Chagas Disease in Guatemala, El Salvador, and Honduras

BACKGROUND

Central American countries face a major challenge in the control of Triatoma dimidiata, a widespread vector of Chagas disease that cannot be eliminated. The key to maintaining the risk of transmission of Trypanosoma cruzi at lowest levels is to sustain surveillance throughout endemic areas. Guatemala, El Salvador, and Honduras integrated community-based vector surveillance into local health systems. Community participation was effective in detection of the vector, but some health services had difficulty sustaining their response to reports of vectors from the population. To date, no research has investigated how best to maintain and reinforce health service responsiveness, especially in resource-limited settings.

METHODOLOGY/PRINCIPAL FINDINGS

We reviewed surveillance and response records of 12 health centers in Guatemala, El Salvador, and Honduras from 2008 to 2012 and analyzed the data in relation to the volume of reports of vector infestation, local geography, demography, human resources, managerial approach, and results of interviews with health workers. Health service responsiveness was defined as the percentage of households that reported vector infestation for which the local health service provided indoor residual spraying of insecticide or educational advice. Eight potential determinants of responsiveness were evaluated by linear and mixed-effects multi-linear regression. Health service responsiveness (overall 77.4%) was significantly associated with quarterly monitoring by departmental health offices. Other potential determinants of responsiveness were not found to be significant, partly because of short- and long-term strategies, such as temporary adjustments in manpower and redistribution of tasks among local participants in the effort.

CONCLUSIONS/SIGNIFICANCE

Consistent monitoring within the local health system contributes to sustainability of health service responsiveness in community-based vector surveillance of Chagas disease. Even with limited resources, countries can improve health service responsiveness with thoughtful strategies and management practices in the local health systems.

Zinc Deficiency in Latin America and the Caribbean

BACKGROUND

Zinc deficiency affects multiple vital functions in the life cycle, especially growth. Limited information is available on the magnitude of zinc deficiency in Latin America and the Caribbean.

OBJECTIVE

To examine the latest available information on both the prevalence of zinc deficiency and the risk of zinc deficiency in Latin America and the Caribbean.

METHODS

The prevalence of zinc deficiency was identified through a systematic review looking for the latest available data on serum zinc concentrations from surveys or studies with national representativeness conducted in Latin America and the Caribbean. The risk of zinc deficiency in Latin America and the Caribbean was estimated based on dietary zinc inadequacy (according to the 2011 National Food Balance Sheets) and stunting in children under 5 years of age.

RESULTS

Only four countries had available national biochemical data. Mexican, Colombian, Ecuadorian, and Guatemalan children under 6 years of age and women 12 to 49 years of age had a high prevalence of zinc deficiency (19.1% to 56.3%). The countries with the highest risk of zinc deficiency (estimated prevalence of inadequate zinc intake > 25% plus prevalence of stunting > 20%) were Belize, Bolivia, El Salvador, Guatemala, Haiti, Honduras, Nicaragua, and Saint Vincent and the Grenadines. Zinc dietary inadequacy was directly correlated with stunting (r = 0.64, p < .001).

CONCLUSIONS

Prevalence data from the four available Latin America and Caribbean national surveys indicate a high prevalence of zinc deficiency in children under 6 years of age and women 12 to 49 years of age. High rates of both estimated zinc dietary inadequacy and stunting were also reported in most Latin America and Caribbean countries.

Evidence of the negative effect of sexual minority stigma on HIV testing among MSM and transgender women in San Salvador, El Salvador

A cross sectional survey was administered to 670 men who have sex with men (MSM) and transgender women (TW) in San Salvador through respondent driven sampling to identify determinants of ever testing for HIV using a minority stress framework. A positive association was found between ever testing and older age [adjusted odds ratio (aOR) 2.10], past experience of sexual assault (aOR 2.92), perceiving that most social acquaintances had tested (aOR 1.81), and knowing a PLHIV (aOR 1.94). A negative association was found between homelessness and ever testing (aOR 0.43). Among the MSM sub-sample (n = 506), similar results were found for older age (aOR 2.63), and past experience of sexual assault (aOR 2.56). Internalized homonegativity was negatively associated with ever testing for HIV among MSM (aOR 0.46), and HIV testing stigma and experienced provider discrimination further strengthened this relationship. It is important to mitigate sexual minority stigma in order to increase HIV testing among MSM. Future research should explore this construct among TW.

Prevalence of visual impairment in El Salvador: inequalities in educational level and occupational status

OBJECTIVE

To examine the prevalence of blindness, visual impairment, and related eye diseases and conditions among adults in El Salvador, and to explore socioeconomic inequalities in their prevalence by education level and occupational status, stratified by sex.

METHODS

Based upon the Rapid Assessment of Avoidable Blindness (RAAB) methodology, this nationwide sample comprised 3 800 participants (3 399 examined) ≥ 50 years old from 76 randomly selected clusters of 50 persons each. The prevalence of blindness, visual impairment and related eye diseases and conditions, including uncorrected refractive error (URE), was calculated for categories of education level and occupational status. Multiple logistic regression models were fitted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) and stratified by sex.

RESULTS

Age-adjusted prevalence was 2.4% (95% CI: 2.2-2.6) for blindness (men: 2.8% (95% CI: 2.5-3.1); women: 2.2% (95% CI: 1.9-2.5)) and 11.8% (95% CI: 11.6-12.0) for moderate visual impairment (men: 10.8% (95% CI: 10.5-11.1); women: 12.6% (95% CI: 12.4-12.8)). The proportion of visual impairment due to cataract was 43.8% in men and 33.5% in women. Inverse gradients of socioeconomic inequalities were observed in the prevalence of visual impairment. For example, the age-adjusted OR (AOR) was 3.4 (95% CI: 2.0-6.4) for visual impairment and 4.3 (95% CI: 2.1-10.4) for related URE in illiterate women compared to those with secondary education, and 1.9 (95% CI: 1.1-3.1) in cataract in unemployed men.

CONCLUSIONS

Blindness and visual impairment prevalence is high in the El Salvador adult population. The main associated conditions are cataract and URE, two treatable conditions. As socioeconomic and gender inequalities in ocular health may herald discrimination and important barriers to accessing affordable, good-quality, and timely health care services, prioritization of public eye health care and disability policies should be put in place, particularly among women, the unemployed, and uneducated people.

Sounding the alarm on chronic kidney disease in farming communities: María Isabel Rodríguez MD. Minister of health, El Salvador. Interview by Conner Gorry

In April 2013, a consortium of regional health ministries, nongovernmental organizations, aid agencies, clinical specialists and researchers from diverse sectors convened in San Salvador to discuss the epidemic of chronic kidney disease of unknown or non-traditional causes (CKDu) plaguing agricultural communities in Central America and beyond. The three-day meeting, where presentation of research on the clinical and epidemiological characteristics of CKDu roused significant debate, led the Pan American Health Organization to declare CKDu "a pressing and serious health problem [which] represents a burden for families, communities, health systems and society as a whole."[1] This High-level Meeting on Chronic Kidney Disease of Non-Traditional Causes in Central America (24-26 April) followed several international meetings at which Dr María Isabel Rodríguez, El Salvador's Minister of Health, presented studies on the disease burden in her country, where end-stage renal disease is the leading cause of hospital deaths. She outlined results of original scientific research by Dr Carlos Orantes (first published in MEDICC Review), that described an "elevated prevalence of chronic kidney disease, chronic renal failure and risk factors" among the patients studied, noting that "the most common [form] was chronic kidney disease of unknown cause, associated with neither diabetes nor hypertension."[2] In this interview with MEDICC Review, Dr Rodríguez discussed the gravity of the problem in Salvadoran agricultural communities; the importance of CKDu research in other countries; and the urgent need for intersectoral action and active community participation to confront and control the epidemic.

Performance and comparison of self-reported STI symptoms among high-risk populations - MSM, sex workers, persons living with HIV/AIDS - in El Salvador

Resource-limited countries have limited laboratory capability and rely on syndromic management to diagnose sexually transmitted infections (STIs). We aimed to estimate the sensitivity, specificity and positive predictive value (PPV) of STI syndromic management when used as a screening method within a study setting. Men who have sex with men (MSM), female sex workers (FSWs) and people living with HIV/AIDS (PLWHA) participated in a behavioural surveillance study. Data were obtained on demographics, sexual behaviours, STI history and service utilisation. Biological specimens were tested for genital inflammatory infections (Neisseria gonorrhoeae [GC], Chlamydia trachomatis [CT], Mycoplasma genitalium [MG], Trichomonas vaginalis [TV]) and genital ulcerative infection (syphilis and Herpes simplex virus-2). There was a high prevalence of Herpes simplex virus-2 (MSM 48.1%, FSW 82.0% and PLWHA 84.4%). Most participants reported no ulcerative symptoms and the majority of men reported no inflammatory symptoms. Sensitivity and PPV were poor for inflammatory infections among PLWHA and MSM. Sensitivity in FSWs for inflammatory infections was 75%. For ulcerative infections, sensitivity was poor, but specificity and PPV were high. Reliance on self-reported symptoms may not be an effective screening strategy for these populations. STI prevention studies should focus on symptom recognition and consider routine screening and referral for high-risk populations.

Household-level dietary quality indicator for countries in nutritional transition: application to vulnerable communities in El Salvador

OBJECTIVE

To develop a household-level diet quality indicator (HDQI) using the Salvadorian dietary guidelines to assess the dietary quality of households in vulnerable communities in El Salvador.

DESIGN

The Salvadorian dietary guidelines were reviewed and eighteen HDQI components were identified (nine foods and nine nutrients). The components were evaluated using a proportional scoring system from 0 to 1, penalizing over- and under-consumption, where appropriate. The HDQI was validated in consultations with experts in El Salvador and by statistical analyses of the study sample data. Dietary variety and energy, nutrient and food intakes were compared among households above and below the median HDQI score using Student's t test.

SETTING

Vulnerable, border communities in El Salvador.

SUBJECTS

Households (n 140) provided food consumption information using an FFQ and sociodemographic data.

RESULTS

The mean HDQI score was 63·5, ranging from 43·6 to 90·0. The indicator showed a positive, significant association with the dietary variety components. The statistical associations of the indicator with the energy and nutrient components were as expected.

CONCLUSIONS

Based on the indicator's demonstrated face validity and the results of the expert consultations, the indicator is suggested as a good measure of diet quality for households in El Salvador.

Temporal trends in diarrhea-related hospitalizations and deaths in children under age 5 before and after the introduction of the rotavirus vaccine in four Latin American countries

INTRODUCTION

Rotavirus infection mainly affects children under 5 years of age and causes 453,000 deaths annually throughout the world. Several countries in Latin America have introduced the rotavirus vaccine and the majority have epidemiological data to measure impact following vaccine introduction.

OBJECTIVE

To assess the impact of rotavirus immunization on the number of all-cause diarrhea-related deaths and hospitalizations in children under 1 and 5 years of age in Bolivia, El Salvador, Honduras and Venezuela.

METHODS

Interrupted time-series analyzed with the integral method and the projection method to evaluate the pre and post-vaccine introduction trend in diarrheal disease compared to Argentina as the control country. The analysis period was from 2002 to 2010, including 2 to 4 post-vaccine years depending on the country. Information sources included records from PAHO, the Ministry of Health, public hospitals, social security, the private health system, the Expanded Programme on Immunization and UNPop 2008.

RESULTS

Over the period studied, reductions were observed in trends of diarrhea-related deaths and hospitalizations in children under five. In diarrhea-related deaths, under the integral method, the range of reduction was between 15.7% (13.5-17.9) and 56.8% (56.0-57.5) while with the projection method was between 19.9% (4.9-34.8) and 63.7%(56.1-71.4). In diarrhea-related hospitalizations, under the integral method was 5.6% (4.1-6.7) and 17.9% (16.7-19.1)) while with the projection method was between 5.1%(1.7-8.7) and 11.1% (5.8-16.3) CONCLUSIONS: A decrease was observed in the number of diarrhea related deaths and hospitalizations in all countries under study following introduction of the rotavirus vaccine as opposed to the control country. The impact on reduction of deaths was greater than hospitalization.

Perceived access and actual intake of healthy diets among households in vulnerable Salvadoran communities

OBJECTIVE

This study aimed to examine the dietary intake of Salvadoran households according to perceived access to healthy meals (PAHD), and to identify household characteristics associated with diet quality and PAHD.

METHODS

Secondary data analysis with a sample of 139 Salvadoran households from resource-poor communities in El Salvador. Chi-square tests and ANOVA were used to assess differences in dietary intake across households classified according to PAHD.

RESULTS

High-PAHD households had higher women's education, household food security levels, overall diet quality, and variety, and higher intakes of animal products, fats, cholesterol, vitamin C, and sodium (P < .05). Diet quality was not associated with the household characteristics studied.

CONCLUSIONS AND IMPLICATIONS

Overall diet quality was associated with higher levels of PAHD, but some differences in intakes were not as expected, such as higher intakes in foods and nutrients associated with low-quality diets, among high PAHD households.

[Alternating hemiplegia of childhood. The first clinical case reported in El Salvador]

INTRODUCTION

Alternating hemiplegia of childhood (AHC) is a rare disease characterised by repeated episodes of hemiplegia that alternately affect one side of the body. Onset is usually before the age of 18 months, the episodes last anywhere from a few minutes to several days. In some cases these episodes may even render the early infant quadriplegic for some time if one begins before the previous one has finished or if they occur at the same time. The clinical description includes, in addition to these paralysing attacks, other paroxysmal manifestations that are present in practically all the children diagnosed with this condition and which, moreover, appear earlier. Such manifestations consist in tonic attacks, dystonic attacks, abnormal eye movements and autonomic disorders. The fact that these symptoms precede the typical clinical signs and symptoms often leads to delays in the final diagnosis.

CASE REPORT

We report the case of a male, aged one year and nine months, who initially presented a clinical picture of tonic seizures at the age of two weeks, which then went on to episodes of hemiplegia that appeared alternately at the age of 11 months. The patient also presented retarded overall psychomotor development. In the early stages of the symptoms he was diagnosed with epilepsy, failed to respond to multiple antiepileptic drugs, and the electroencephalogram, neuroimaging and complementary blood and urine tests were all normal/negative. The patient responded well to flunarizine.

CONCLUSIONS

This is the first patient with AHC reported in El Salvador. The early and accurate diagnosis of AHC is essential to be able to establish drug therapy and improve the prognosis and the quality of life of patients and their families.

Correlates of bisexual behaviors among men who have sex with men in El Salvador

Bisexual behaviors may increase transmission pathways of HIV and sexually transmitted infections (STIs) from a higher prevalence group to lower prevalence groups in El Salvador. In 2008, men who have sex with men (MSM) were recruited in San Salvador and San Miguel using respondent driven sampling. Participants were interviewed and tested for HIV and STIs. Sixteen seeds and 797 MSM participated; 34.9% in San Salvador and 58.8% in San Miguel reported bisexual behavior. Bisexual behavior was associated with drug use (adjusted odds ratio (AOR) = 2.57, 95% CI: 1.30-5.06) and insertive anal sex (AOR = 5.45, 95% CI: 3.01-9.87), and inversely associated with having a stable male partner (AOR = 0.47, 95% CI: 0.26-0.84) and disclosing MSM behavior to family (AOR = 0.41, 95% CI: 0.22-0.75). Bisexual behavior was associated with risk behaviors with male and female partners that may be associated with HIV and STI transmission. Bisexual men displayed a distinct identity calling for tailored interventions.

Exploring child maltreatment and its relationship to alcohol and cannabis use in selected Latin American and Caribbean countries

OBJECTIVES

Research from developed countries shows that child maltreatment increases the risk for substance use and problems. However, little evidence on this relationship is available from developing countries, and recognition of this relationship may have important implications for substance demand reduction strategies, including efforts to prevent and treat substance use and related problems. Latin America and the Caribbean is a rich and diverse region of the world with a large range of social and cultural influences. A working group constituted by the Inter-American Drug Abuse Control Commission and the Center for Addiction and Mental Health in June, 2010 identified research on this relationship as a priority area for a multinational research partnership.

METHODS

This paper examines the association between self-reported child maltreatment and use in the past 12 months of alcohol and cannabis in 2294 university students in seven participating universities in six participating countries: Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay. The research also considers the possible impact of religiosity and minimal psychological distress as factors contributing to resiliency in these samples.

RESULTS

The results showed that experience of maltreatment was associated with increased use of alcohol and cannabis. However, the effects differed depending on the type of maltreatment experienced. Higher levels of religiosity were consistently associated with lower levels of alcohol and cannabis use, but we found no evidence of an impact of minimal psychological distress on these measures.

CONCLUSIONS

This preliminary study shows that the experience of maltreatment may increase the risk of alcohol and cannabis use among university students in Latin American and Caribbean countries, but that higher levels of religiosity may reduce that risk. More work to determine the nature and significance of these relationships is needed.

Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric fever in El Salvador

Background

Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.

Method

This prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.

Findings

Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62–119.10; P = 0.016).

Interpretation

Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.

The relationship between community structural characteristics, the context of crack use, and HIV risk behaviors in San Salvador, El Salvador

This paper explores community structural factors in different low-income communities in the San Salvador, El Salvador, that account for differences in the social context in which crack is used and HIV risk behaviors among crack users. Results suggest that both more distal (type of low-income community, level of violent crime, and poverty) and proximate structural factors (type of site where drugs are used, and whether drugs are used within or outside of community of residence) influence HIV risk behaviors among drug users. Additionally, our results suggest that community structural factors influence the historical and geographic variation in drug use sites.

Structural factors influencing patterns of drug selling and use and HIV risk in the San Salvador metropolitan area

This article explores differences in the social context in which crack sales and use and HIV risk take place in seven low-income communities in San Salvador, and structural factors that may influence these differences. The organization of drug selling varied among the communities on a number of dimensions including: whether drug sales were open or closed systems; the type of drug-selling site; and the participation of drug users in drug-distribution roles. Drug-use sites also varied according to whether crack was used in private, semiprivate, or public spaces, and whether individuals used drugs alone or with other drug users. Three patterns of drug use and selling were identified based on the dimensions outlined above. Structural factors that influenced these patterns included the geographic location of the communities, their physical layout, gang involvement in drug sales, and police surveillance. Implications for HIV risk and prevention are explored for each pattern.

[Guillain-Barre syndrome in the paediatric age: epidemiological, clinical and therapeutic profile in a hospital in El Salvador]

INTRODUCTION

Guillain-Barre syndrome (GBS) is an acute polyradiculoneuropathy with, in most cases, an autoimmune aetiology. It manifests as a flaccid motor paralysis, of a distal ascending type, accompanied by areflexia with or without sensory alterations.

AIM

To determine the clinical and therapeutic epidemiological profile of patients diagnosed as suffering from GBS who were attended at the Benjamin Bloom Children's Hospital in El Salvador, between 1st January 1997 and 31st December 2004.

PATIENTS AND METHODS

We performed an observation-based, descriptive, cross-sectional study that included 414 cases. The following data were evaluated: age distribution, sex, age, history of infections, clinical manifestations, results of the lumbar puncture, electrophysiological studies and treatment that was received.

RESULTS

A predominance of males was observed, together with a more frequent presentation in school-age children. The number of cases increased in the third quarter of each of the years included in the study. The most prevalent event in the history of infections was acute respiratory infection. And the most frequent clinical presentation was ascending weakness. Albuminocytological dissociation was detected in 88% of patients who had undergone lumbar puncture. Acute inflammatory demyelinating polyneuropathy predominated in 88.3% of cases. Sixty per cent of patients had to be admitted to the intensive care unit. In most cases treatment consisted in intravenous administration of immunoglobulin. Complications occurred in 30.5% of cases and the mortality rate was 2.9%.

CONCLUSIONS

GBS occurs predominantly in the rainiest season of the year, which is related to an increase in the number of infections in the upper respiratory tract and gastroenteric infections that give rise to a predisposition to present secular outbreaks of the disease.

Exploring factors in the decision to choose sterilization vs alternatives in rural El Salvador

CONTEXT

To explore the factors that influence rural Salvadoran women to undergo tubal sterilization versus opting for alternative methods of family planning.

EVIDENCE ACQUISITION

A moderator fluent in English and Spanish conducted eleven 90-minute focus groups consisting of 5-10 women each. Eligible women in the municipality of San Pedro Perulapan, El Salvador, were identified and recruited by local health workers. Participant demographics and information about family planning decisions were collected through detailed notes and tape-recorded sessions. The tapes were transcribed verbatim, and all data were analyzed using grounded theory procedures to identify common themes.

EVIDENCE SYNTHESIS

Eighty women aged 24-45 years who had previously been sterilized participated in the study. Three major themes influenced a woman's decision to undergo sterilization instead of opting for alternative forms of family planning: (1) availability: tubal sterilization is readily available, (2) fears about side effects of other methods: these women associated negative side effects with other forms of family planning, (3) effectiveness: the women in these focus groups thought sterilization was more effective than other forms of family planning.

CONCLUSIONS

This study shows that there is a lack of information, and misinformation, about other effective methods of contraception, especially the intrauterine device and oral contraceptives. Reproductive health education projects, especially those providing services in locations similar to rural El Salvador, should focus on providing accurate information about all forms of contraception, including tubal sterilization.

Dimensions of child sexual abuse before age 15 in three Central American countries: Honduras, El Salvador, and Guatemala

OBJECTIVE

The prevalence of sexual abuse during childhood or adolescence varies depending on the definitions and age categories used. This study examines the first national, population-based data available on child sexual abuse that occurs before age 15 in three countries: El Salvador, Guatemala, and Honduras. This study uses comparable indicators and measures of sexual abuse for the three countries to document the prevalence of abuse, types of perpetrators, and the association of child sexual abuse with recent intimate partner violence.

METHODS

Child sexual abuse was defined as sexual abuse that first occurs before age 15. Nationally representative data from El Salvador, Guatemala, and Honduras were used. In El Salvador, separate questions on forced intercourse and non-penetrative sexual abuse were asked. Bivariate and multivariate analyses were performed using STATA Version 8SE.

RESULTS

The prevalence of child sexual abuse varied from 7.8% in Honduras to 6.4% in El Salvador and 4.7% in Guatemala. In all three countries, the overwhelming majority of women who reported child sexual abuse first experienced the abuse before age 11. Perpetrators tended to be a family member, a neighbor, or an acquaintance. Bivariate and multivariate analyses indicated that women who experienced child sexual abuse in Guatemala and Honduras were about two times more likely to be in violent relationships as women who did not experience abuse. This relationship was not significant in multivariate analyses for El Salvador where the prevalence of intimate partner violence was the lowest.

CONCLUSIONS

Child sexual abuse in Central America is clearly a problem with the prevalence between 5% and 8%. Child sexual abuse can have long-term negative health impacts including exposure to intimate partner violence in adulthood. Programs to prevent abuse and treat victims of child sexual abuse are needed in Central America.

Association between intestinal parasitic infections and type of sanitation system in rural El Salvador

OBJECTIVE

To identify demographic, behavioural and environmental determinants of intestinal parasitic infection, evaluate the impact of a variety of dry sanitation systems on intestinal parasitic infection, and evaluate the safety of using stored biosolids in agriculture in order to guide future sanitation interventions in rural areas of El Salvador.

METHODS

Interviews were conducted with 109 households in eight communities where double-vaulted and solar urine-diverting desiccating latrines, pit latrines or no latrines were used. Faecal samples from 499 individuals were tested for enteric helminths and protozoa.

RESULTS

Users of solar desiccating latrines had the lowest prevalence of enteric parasite infection. Double-vault, urine-diverting desiccating latrines effectively reduced the transmission of some pathogens, but may not achieve the conditions sufficient for the complete destruction of the more environmentally persistent pathogens, Ascaris lumbricoides and Trichuris trichiura. Contact with inadequately treated latrine biosolids was associated with an increased risk of Ascaris infection.

CONCLUSIONS

Solar latrines were associated with the overall lowest prevalence of enteric parasitic infections. Members of households where latrine biosolids were used in agriculture had a higher prevalence of infection than those where biosolids were buried. We therefore recommend the promotion of solar latrines in rural areas of El Salvador over other dry sanitation systems, and recommend that stored biosolids not be used in agriculture.

Prevalence and risk factors for pelvic floor symptoms in women in rural El Salvador

Our aim was to assess the frequency of pelvic floor symptoms among women in rural El Salvador. After written informed consent was obtained, we administered the short form of the urodynamic distress inventory (UDI-6) plus four other pelvic floor questions to 236 women aged 30 to 75 in rural El Salvador attending a general medicine or gynecology clinic. Average (SD) age, parity, and body mass index were 48.0 (8.4) years, 5.9 (3.4), and 26.9 (4.9) kg/m(2), respectively. Ten (4.2%) women had a prior hysterectomy, 16 (6.8%) women were smokers, and 108 (45.8%) women were postmenopausal. Seventy-one percent of women reported urinary incontinence (UI); 49.3 and 61.1% of women reported urge UI and stress UI, respectively. Forty-one percent of women reported fecal incontinence (FI) of solid or liquid stool. Women with UI were significantly more likely to have had a hysterectomy compared to women without UI. Women with FI had significantly fewer years of education when compared to women without FI. In conclusion, pelvic floor symptoms are highly prevalent among women in rural El Salvador.

El Salvador earthquakes: relationships among acute stress disorder symptoms, depression, traumatic event exposure, and resource loss

Four and seven weeks after powerful earthquakes in El Salvador, the authors examined the relationships among demographics, traumatic event exposure, social support, resource loss, acute stress disorder (ASD) symptoms, depression, and posttraumatic growth. Participants were 253 college students (Study 1) and 83 people in the community (Study 2). In Study 1, female gender, traumatic event exposure, low social support, and loss of personal characteristic, condition, and energy resources contributed to ASD symptoms and depression. In Study 2, damage to home and loss of personal characteristic and object resources contributed to ASD symptoms and depression. Posttraumatic growth was not associated with ASD symptoms or depression. Findings support the conservation of resources stress theory (Hobfoll, 1998). Resource loss spirals, excessive demands on coping, and exposure to multiple disasters are discussed.

Wounds caused by firearms in El Salvador, 2003-2004: epidemiological issues

This study presents data from hospital records in El Salvador describing the features of 100 patients admitted to a public hospital with firearm wounds. Wounds caused by Firearms (WFA) account for 70 per cent of homicides; 30 per cent of WFA homicides died in hospital. For every death in hospital there are five admissions who need treatment and survive. The typical victim is a young man with reasonable education but poor earning capacities and some family responsibilities, who lives in an urban setting where drugs, alcohol and firearms are commonplace. Extrapolating from this study, an estimated 2,580 people were treated in El Salvador hospitals during 2003; and of these 2,400 were treated in public hospitals at a cost to the state of 7.4 million USD, just over seven per cent of the health budget. Using further extrapolations, the total social costs for WFA morbidity would amount to around 34 million USD. There needs to be greater controls on firearms, public education on their risks and a more unified surveillance system.