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Guatemala: maternal mortality in Guatemala: assessing the gap, beginning to bridge it.

Developing countries which have somewhat reliable vital statistics but poor or incomplete information about maternal mortality must make the most of the data available. Such data may require modification for maternal mortality analyses. What is important, however, is the decision to use available information and to analyse it properly. The analysis of maternal mortality in Guatemala, using data from 1986 birth and death certificates, identified particular areas, health regions, and particular ethnic groups that had significantly higher maternal mortality ratios than others. Small but disproportionately affected populations that had no available maternal health assistance were identified-a problem found in many developing countries. These groups urgently need the services of traditional birth attendants or other forms of assistance before, during and after delivery. The analysis of vital statistics led to the beginning of operative research and the collection of background information for establishing an epidemiologic surveillance programme for maternal mortality.

Adolescent

[Leprosy in Guatemala 1982].

Leprosy is an endemic disease in Guatemala. The author presents a brief account of the Leprosy situation, from the year of 1527 to January first, 1982. During the early years of the Guatemala's colonial epoch, Leprosy was also named "Lazarus illness". From the years of 1530 to 1874, the leprosy patients, were successively attended in the following hospitals: 1) "The Mercy Hospital" in 1530; 2) "The Saint Lazarus Hospital" in 1638; 3) "The Piety Asylum" in 1874; and 4) "The Ramiro Galvez Leprosarium" in 1972. In 1973, was founded the "Guatemala Leprosy Patronage" and also, it created the the INSTITUTE OF DERMATOLOGY, also named INDERMA. From January first of 1973 to January first of 1982, INDERMA taked care and and treated, in its Guatemala city hospital and out patients clinics, the following cases: I. Patients with diseases of the skin, 79,241, II. New leprosy patients plus periodical consults (every 3 months) of old and known leprosy patients, during 9 consecutive years, 3,685, III. Clinical controls and consults of suspicious contacts, 6,188, IV. The INDERMA's rural anti leprosy campaign and their mobil units, take care and clinically examined healthy persons, 12,096, Among this group, were discovered 137 new leprosy patients. The total amount of INDERMA's health services, til I/82, 101,206. The rural anti leprosy campaign, has confirmed that the north oriental zone is the endemic area of Guatemala (Photo 7). Until today (I/1982) there are 410 verified cases of Leprosy in Guatemala. Among them, the predominant leprosy type, is the lepromatous one, with 49,04%. 62,43% of the leprosy patients are male. Of the age group, the 30 to 39 year old, predominates with 19,24%. The prevalence and density leprosy index, were verified only in the endemic zone with 24 257 square kilometers and 0,564% and 1 441 290 population = 0,345%. Actually, as the endemic leprosy area is controlled, INDERMA has continued the study and care of the leprosy patients in the rest of the Guatemala republic.

Adolescent

Epidemic cholera in Guatemala, 1993: transmission of a newly introduced epidemic strain by street vendors.

Epidemic cholera reached Guatemala in July 1991. By mid-1993, Guatemala ranked third in the hemisphere in reported cases of cholera. We conducted a case-control study with two age-, sex-, and neighbourhood-matched controls per patient in periurban Guatemala City. Twenty-six patients hospitalized for cholera and 52 controls were enrolled. Seven (47%) of 15 stool cultures obtained after admission yielded toxigenic Vibrio cholerae O1. All seven were resistant to furazolidone, sulfisoxazole, and streptomycin, and differed substantially by pulsed-field gel electrophoresis from the Latin American epidemic strain dominant in the hemisphere since 1991. In univariate analysis, illness was associated with consumption of left-over rice (odds ratio [OR] = 7.0, 95% confidence interval [CI] = 1.4-36), flavored ices (-helados') (OR = 3.6, CI = 1.1 - 12), and street-vended non-carbonated beverages (OR = 3.8, CI = 1.2-12) and food items (OR = 11.0, CI = 2.3-54). Street-vended food items remained significantly associated with illness in multivariate analysis (OR = 6.5, CI = 1.4-31). Illness was not associated with drinking municipal tap water. Maintaining water safety is important, but slowing the epidemic in Guatemala City and elsewhere may also require improvement in street vendor food handling and hygiene.

Adolescent

Genotype-specific in vitro amplification of sequences of the wild type 3 polioviruses from Mexico and Guatemala.

The extensive nucleotide sequence heterogeneity among independent genotypes of wild polioviruses permits the systematic design of genotype-specific molecular reagents. We have prepared two sets of polymerase chain reaction (PCR) primer pairs specific for the genotype of wild poliovirus type 3 recently endemic to Mexico and Guatemala. Nucleotide sequences of a representative wild type 3 virus isolated in Mexico in 1989 differed from the corresponding Sabin 3 (Leon 12 a1b) sequences at 167 of 900 positions within the VP1 region. From the sequence data, wild virus-specific primer pairs were designed to complement regions of high mismatch (greater than 33%) with Sabin 3 templates. Primer binding sites were spaced along the genome so that the predicted amplification products (142 bp and 163 bp) could be easily resolved electrophoretically from the products generated with our Sabin strain-specific primers (Sabin 1: 97 bp; Sabin 2: 71 bp; Sabin 3: 53 bp). RNAs of all wild type 3 poliovirus isolates from Mexico and Guatemala obtained over a 13-year period (1977-1990) served as efficient templates for amplification of the 142-bp and 163-bp products. Genomic templates derived from vaccine-related polioviruses and most heterologous wild polioviruses were inactive under equivalent reaction conditions. Amplifications generating a 114-bp product with a broadly reacting primer pair, matching highly conserved sequences in the 5'-noncoding region, provided a positive control for the presence in samples of poliovirus (or enterovirus) RNAs. Selective amplification of wild Mexico-Guatemala type 3 poliovirus sequences was obtained with either primer set in reactions containing large stoichiometric excesses (up to 10(6)-fold) of vaccine-related RNAs. We have used wild genotype-specific PCR primer sets to facilitate identification of wild polioviruses present in both clinical and environmental samples.

Amino Acid Sequence

The costs and effectiveness of three vitamin A interventions in Guatemala.

The purpose of the study presented in this paper was to estimate, using secondary sources of data, the cost and effectiveness of three programs to combat vitamin A deficiency in Guatemala-the national sugar fortification program, a targeted capsules distribution program and the promotion of home food production combined with nutrition education and to draw conclusions concerning priorities for Guatemala. Data on the costs and coverage were collected from implementing agencies in Guatemala. Coverage data were converted into a common set of impact indicators. Sensitivity analyses were conducted on variables whose precise value was uncertain. Potential impacts of improvements in program performance operations were also explored. The analysis found the cost per high-risk person achieving adequate vitamin A to be US $0.98 for fortification, US $1.68-1.86 for capsule distribution and US $3.10-4.16 for food production/education. Fortification is the most efficient option if vitamin A levels in sugar are maintained at reasonable levels. Where fortified sugar is not consumed and vitamin A deficiency is highly prevalent, small-scale, targeted, complementary interventions such as capsules and food production education may be appropriate for sustained broader impacts.

Cost-Benefit Analysis

Disease-surveillance and decision-making after the 1976 Guatemala earthquake.

In the first 3 weeks after the 1976 earthquake in Guatemala a system for collecting, analysing, and disseminating information of medical importance was instituted in the disaster area. Data on cases of selected diseases, number of available hospital beds, and medical supplies were collected, and reported epidemics were investigated. The system functioned well despite the limited numbers of trained personnel. Collection and analysis were quick enough for data to be used immediately in decision-making. No epidemics of communicable diseases were observed in the affected area. The number of dog bites in Guatemala City increased but no cases of rabies were reported. The success of the surveillance system in Guatemala suggests that immediate use of epidemiological methods should be an integral part of disaster relief.

Animals

Comparison of active and passive case detection of cutaneous leishmaniasis in Guatemala.

To estimate the degree to which passive case detection underestimates the true incidence of cutaneous leishmaniasis in Guatemala, we compared data from the passive surveillance system of the Guatemalan Ministry of Health with a cross-sectional population-based survey of cutaneous leishmaniasis in Guatemala. Of the 2,938 persons interviewed, 143 (5%) reported having had cutaneous leishmaniasis at some time in the past, 37 (1.3%) reported the onset of infection in the 12 months before the survey, 31 (1.1%) had active infections, and 16 (0.5%) had parasitologically confirmed infections. Calculated on the basis of these reports and the estimated population of the endemic area, the total number of new cases in the leishmaniasis-endemic area in the 12 months before the survey was approximately 2,574; during the same 12 month period, Ministry of Health data based on passive surveillance listed 64 cases of cutaneous leishmaniasis. In Guatemala, incidence estimates based on passive surveillance may underestimate the occurrence of cutaneous leishmaniasis by as much as a factor of 40.

Adolescent

Social inequality and children's growth in Guatemala.

This paper is an investigation of the effects of social inequality in Guatemala on children's health and nutritional status as measured by attained height. Guatemala remains a highly stratified and poor society. We examine the association of land distribution, land tenure, occupation, and other aspects of family social and economic status with children's height between the ages of three months and 36 months, using data from a cross-sectional survey. An important consequence of the poverty and poor living conditions of the majority of the Guatemalan population is substantial deficits in children's growth. Our results suggest that children's growth is affected by ethnicity, their father's occupation, land distribution in the area where they live, and maternal education. Substantial growth deficits are observed among children living at altitudes above 1500 metres; we hypothesize that this is because, in Guatemala, higher altitude is associated with land scarcity, poorer agricultural conditions, and greater remoteness from transport networks and other public services.

Adolescent

Plasticity, political economy, and physical growth status of Guatemala Maya children living in the United States.

Migration of Maya refugees to the United States since the late 1970s affords the opportunity to study the consequences of life in a new environment on the growth of Maya children. The children of this study live in Indiantown, Florida, and Los Angeles, California. Maya children between 4 and 14 years old (n = 240) were measured for height, weight, fatness, and muscularity. Overall, compared with reference data for the United States, the Maya children are, on average, healthy and well nourished. They are taller and heavier and carry more fat and muscle mass than Maya children living in a village in Guatemala. However, they are shorter, on average, than children of black, Mexican-American, and white ethnicity living in Indiantown. Children of Maya immigrants born in the United States tend to be taller than immigrant children born in Guatemala or Mexico. Families that invest economic and social resources in their children have taller children. More economic successful families have taller children. Migration theory and political economy theory from the social sciences are combined with plasticity theory and life history theory (parental investment) from biology to interpret these data.

Black or African American

Knowledge, attitudes and perceptions (KAP) of onchocerciasis: a survey among residents in an endemic area in Guatemala targeted for mass chemotherapy with ivermectin.

If ivermectin distribution programs are to have maximum impact on the morbidity and transmission of human onchocerciasis there must be broad and sustained acceptance within the endemic communities. Educational activities, developed with careful consideration of community attitudes, should promote positive treatment seeking behavior while simultaneously addressing local reservations about the control effort. To better understand the ambient knowledge, attitudes, and practices concerning onchocerciasis in the context of ivermectin use in Guatemala, we conducted a survey among 145 heads of households in five endemic communities. Given the country's long-standing nodulectomy program, it was not surprising that 100% of persons interviewed had heard of the disease 'la filaria', which they defined as a skin nodule that could cause blindness. Ninety-five percent of respondents identified surgery as the only cure for the condition. Relatively few (39%) knew that la filaria was caused by a worm, although slightly more (50%) knew that the condition was acquired by the bite of an insect. The term microfilaria was not broadly recognized. We also determined that onchocerciasis was not perceived as a serious health problem: few persons (12%) mentioned la filaria when requested to provide a complete list of illnesses that occurred in the community, and the gravity of infection (based on rank ordering of common illnesses) was similar to that of a bad cold. Recommendations were made which might assist long-term acceptance of a national chemotherapy initiative against onchocerciasis in Guatemala.

Adolescent

Plants used in Guatemala for the treatment of gastrointestinal disorders. 1. Screening of 84 plants against enterobacteria.

Gastrointestinal disorders are important causes of morbidity in developing countries. Natural healing is the traditional way of treating these diseases in Guatemala. Ethnobotanical surveys and literature reviews showed that 385 plants from 95 families are used in Guatemala for the treatment of gastrointestinal disorders. The activity of 84 of the most commonly used plants was screened in vitro against five enterobacteria pathogenic to man (enteropathogenic Escherichia coli, Salmonella enteritidis, Salmonella typhi, Shigella dysenteriae and Shigella flexneri). Results indicate that 34 (40.48%) plants inhibit one or more of the enterobacteria tested. The most commonly inhibited bacterium was S. typhi (33.73%) and the most resistant was E. coli (7.35%). The plants of American origin which exhibited the best antibacterial activity were: Byrsonima crassifolia, Diphysa robinioides, Gnaphalium stramineum, Guazuma ulmifolia, Psidium guajava, Sambucus mexicana, Simarouba glauca, Smilax lundelii, Spondias purpurea and Tagetes lucida. These results indicate a scientific basis for use of these medicinal plants for attacking enterobacterial infections in man.

Anti-Bacterial Agents

Ethnobotanical survey of the medicinal flora used by the Caribs of Guatemala.

An ethnobotanical survey was conducted among the Carib population of Guatemala in 1988-1989. In general terms, the sample surveyed possessed a relatively good standard of living. Results indicated that health services were utilized by the population, and that domestic medicine, mainly plants (96.9%) was used by 15% of the population. One hundred and nineteen plants used for medicinal purposes were collected, of which 102 (85.7%) could be identified; a list of these together with the information provided for each plant is presented. The most frequently reported plants used as medicine are: Acalypha arvensis, Cassia alata, Cymbopogon citratus, Melampodium divaricatum. Momordica charantia, Neurolaena lobata, Ocimum basilicum, Petiveria alliacea and Solanum nigrescens. Most of these plants are found in the region, but some are brought from the Highlands or outside of the country, such as Malva parviflora, Matricaria chamomilla, Peumus boldus, Pimpinella anisum, Rosmarinus officinalis and Tagetes lucida. This survey demonstrated that the Carib population of Guatemala has survived in a transcultural environment of African and native Amerindian beliefs.

Female

Differential immune response to Onchocerca volvulus: IgG4 antibody responses differ in onchocerciasis patients from Guatemala and Ghana.

Geographical differences exist in the clinical features of onchocerciasis in Central America and West Africa, which could be due in part from variations in the antigenic composition of the infecting organism. In an attempt to address this question, adult female worms of Onchocerca volvulus derived from nodules of patients from Guatemala and Ghana were compared in terms of polypeptide composition and the IgG4 antibody responses induced in patients. It was shown that a Tris-buffer soluble extract from the worms obtained in the two regions differ in polypeptide composition. Furthermore, the diagnostic polypeptides were found to be in the 30 kDa region but the recognition of these antigens was less intense and less frequently observed in the sera of microfilaria (mf) positive patients from Ghana than equivalent age and sex matched patients from Guatemala.

Adolescent

Evaluation of a standardized leishmanin skin test in Guatemala.

Before recommending the skin-test use at national level in Guatemala of an antigen prepared from Leishmania major (a Leishmania species not found in the New World), we conducted a study in 100 Guatemalans to determine its sensitivity and specificity. The antigen consisted of 0.1 mL of a solution that contained 5 x 10(6) promastigotes of L. major (MRHO/IR/75/VAX). Positive leishmanin skin test (LST) reactions at 48 h were observed in 16 (80%) of 20 patients with proven active cutaneous leishmaniasis (CL), 18 (90%) of 20 with previously treated proven CL, and in 18 (90%) of 20 with a history and compatible scan of previously suspected but unconfirmed CL. None of 20 healthy controls or 20 patients with skin lesions due to causes other than CL had positive reactions to the LST, giving a sensitivity of 85% and specificity of 100%. There were no statistically significant differences in ethnic group, age, duration of the lesion, lesion size or Leishmania species between the 34 persons with true positive reactions. Even though it will be necessary to test this antigen on a larger number of patients, these preliminary results show that this antigen is specific and reasonably sensitive in identifying current or past CL and that it is a reasonable choice for epidemiological studies on CL in Guatemala.

Adolescent

Extranodal head and neck lymphomas in Guatemala: high frequency of Epstein-Barr virus-associated sinonasal lymphomas.

Sinonasal lymphomas of T cell or natural killer cell (T/NK cell) phenotype represent a subset of extranodal head and neck lymphomas. T/NK cell sinonasal lymphomas have been described in diverse geographic settings, including China, Japan, Peru, Northern Europe, and North America. The frequency of these lymphomas is highly dependent on the geographic location in which they occur, their incidence being low in Europe and North America and relatively high in Asian countries and in Peru. Regardless of their geographic location, they are typically associated with the Epstein-Barr virus (EBV). Few studies have addressed the relative frequency of sinonasal lymphoma within the group of extranodal head and neck lymphomas. We investigated the anatomic distribution, immunophenotypical profile, and EBV status of 33 cases of extranodal head and neck lymphoma from patients in Guatemala. The anatomic distribution of these lymphomas is similar to that seen in Asian countries: 17 (52%) in the sinonasal area, five (15%) in the palate, and 11 (33%) in other locations. Fifteen (88%) of the 17 sinonasal lymphomas showed a T or null cell phenotype with a strong association with EBV by in situ hybridization. Most Guatemalan patients with these lymphomas were of Mayan descent. In Guatemala, the relative frequency of sinonasal lymphomas within the group of head and neck lymphomas is significantly higher than that reported for Western countries. In addition, the relative frequency of T/NK versus B cell sinonasal lymphomas is higher than that described in North America and similar to that observed in Asian countries and Peru.

Adolescent

NGOs in community health insurance schemes: examples from Guatemala and the Philippines.

In poor rural communities, access to basic health care is often severely limited by inadequate supply as well as financial barriers to seeking care. National policies may introduce social health insurance, but these are likely to begin with the salaried public and private sector workers while the informal sector population may be the last to be covered. Community initiatives to generate health care financing require a complex development process. This paper covers attempts to develop such schemes in rural populations in Guatemala and the Philippines through non-government organizations and notes the major factors which have contributed to unequal progress in the two schemes. The scheme of the Association por Salud de Barillas (ASSABA) in Guatemala was not sufficiently established as an administrative body at the conceptual stage and there was no clear national policy on health care financing. By the time the necessary action was taken, local conflicts hindered progress. In the Philippines, the ORT Health Plus Scheme (OHPS) was implemented during the period of legislation of a national health insurance act. The appraisal after three years of operation shows that OPHS has made health care affordable and accessible to the target population, composed mainly of low and often unstable income families in rural areas. The major success factors are probably the administrative structure provided by a cooperative and controls in the delivery system and in expenditures, through the salaried primary health care team, referral process and the capitation agreement for hospital-based services. The proliferation of such schemes could benefit from national guidelines, a formal accreditation process and an umbrella organization to provide assistance in design, training and information services, involving government, non-government and academic institutions as an integral part of the development process.

Accreditation