Assessment of vector microfilarial uptake as a comparatively non-invasive technique for monitoring onchocerciasis treatment campaigns in the Americas

Summary Since 1992, efforts have been made to combat onchocerciasis in Guatemala through mass distribution of ivermectin. The impact of the campaign is assessed by taking skin-snips from sentinel groups within selected communities. This method gives an estimate of the prevalence and intensity of infection, and thus the efficacy of the treatment. In some communities people are becoming reluctant to volunteer for skin-snipping, and so there is a need for an alternative technique that will give quantitative results. In most hyperendemic communities in Guatemala, biting blackflies are so ubiquitous that few people object to allowing 10 to 20 flies to engorge upon them. We examined data on the quantitative uptake of microfilariae by Simulium ochraceum before and after ivermectin distribution to see whether results similar to skin-snip data could be obtained. Counts of microfilariae ingested by S. ochraceum are compared to the numbers found in skin-snips from the same volunteers. In a group of 31 untreated infected persons, a skin-snip survey detected 64.5% positive, while feeding flies (vector microfilarial uptake, VmfU) detected 96.8%. Post-treatment, in a sample of 58 of whom 52 (89.7%) had a history of infection, both skin-snips and VmfU detected 54.2%. Vector blood meals contained more microfilariae than a mg of skin before treatment, but both recorded about equal numbers after treatment. When the data set was subdivided to compare samples taken at 2–3, 6–8 and 14–17 months post-treatment, the effect of ivermectin was still apparent at 6–8 months, but had virtually disappeared by 14 months post-treatment. A surprising observation was that the flies ingested fewer microfilariae from treated persons than was expected from the skin densities as estimated by skin-snip. This effect lasted for over 8 months, and could indicate that ivermectin has a greater effect on transmission than previously suspected. We conclude that VmfU could be used as an alternative to skin-snipping, and discuss the ethical implications.     

Blood retinol and β-carotene levels in rural Guatemalan preschool children

Plasma retinol and -carotene levels were measured in 502 preschool Guatemalan children from five rural hamlets. Their ages ranged from 6 to 78 months (mean: 42.9±19.2 months); 45% males and 55% females. The mean retinol value in the whole group was 0.9±0.4 µmol/1 (range: 0.1 to 8.4 µmol/1). There was no significant difference between sexes in retinol mean values nor in the incidence of retinol values less than 0.7 µmol/1 (22% in males, 18% in females). When grouped by age and community, significant low retinol mean values were found in two hamlets in the youngest age group (12 to 23 months) as compared to the other age-groups (p<0.05). In the other two hamlets, there were no significant differences among retinol means by age-group. The highest prevalence of deficient retinol values by age-group was in the 12 to 23 months group (40%), and decreased as age increased. The mean value for -carotene in the whole group was 0.13±0.18 µmol/1 (range: 0.01 to 2.23 µmol/1). There were no significant differences in -carotene means between sexes in the whole group. Stratifying the -carotene data by age-groups and community, values were significantly higher in the 48–59 months and 72–83 months groups, as compared with the other age groups in two of the communities (p<0.05). Significant differences across communities for -carotene were found only in the 12 to 23 months group.     

Knowledge,attitudes, and practices regarding seasonal influenza vaccination during pregnancy in Costa Rica: A mixed-methods study

BackgroundInfluenza increases stillbirth risk, morbidity and mortality in pregnant women. Vaccination protects pregnant women against severe disease and indirectly protects their infants, but coverage among pregnant women remains low worldwide. We aimed to describe knowledge, attitudes, and practices (KAP) regarding seasonal influenza vaccination among postpartum women and prenatal care physicians in Costa Rica.MethodsWe conducted cross-sectional KAP surveys to women one to three days after childbirth at Costa Rican Social Security Fund maternity hospitals, and obstetricians and general practitioners who provided prenatal care in 2017. Principal components analysis, multiple imputation, and logistic regression were used to examine associations between influenza vaccination and demographics, prenatal care, and sources of information—separately for postpartum women and physicians. We also held two focus groups of six healthcare workers each to further describe vaccination KAP.ResultsWe surveyed 642 postpartum women and 146 physicians in maternity hospitals in five Costa Rican provinces of whom 85.5 % (95 % CI: 82.6 %-88.0 %) and 57.9 % (95 % CI: 49.6 %-65.7 %) were vaccinated for influenza, respectively. Factors associated with influenza vaccination for postpartum women included tetanus vaccination (aOR: 3.62, 95 % CI: 1.89–6.92); received vaccination recommendations from clinicians during prenatal check-ups (aOR: 3.39, 95 % CI: 2.06–5.59); had other children in household vaccinated for influenza (aOR: 2.25, 95 % CI: 1.08–4.68); and secondary/university education (aOR: 0.15–0.31) with no formal education as reference. For postpartum women, reasons for vaccination were perceived benefits for mother and infant, whereas not being offered vaccines was most cited for non-vaccination. Most prenatal care physicians recommended influenza vaccines during prenatal check-ups but believed vaccination causes flu-like symptoms.ConclusionVaccination campaigns and provisions of free vaccines effectively increased knowledge and coverage among women in Costa Rica. To improve access, women should be offered vaccines during prenatal care appointments. Educating healthcare workers about vaccine benefits for themselves and patients is needed to mitigate safety concerns.     

Population-Based Study of Trachoma in Guatemala

Abstract

Purpose: A prevalence survey for active trachoma in children aged under 10 years and trichiasis in women aged 40 years and older was carried out in four districts in the Sololá region in Guatemala, which is suspected of still having a trachoma problem.

Methods: Population-based surveys were undertaken in three districts, within 15 randomly selected communities in each district. In addition, in a fourth district that borders the third district chosen, we surveyed the small northern sub-district, by randomly selecting three communities in each community, 100 children aged under 10 years were randomly selected, and all females over 40 years. Five survey teams were trained and standardized. Trachoma was graded using the World Health Organization simplified grading scheme and ocular swabs were taken in cases of clinical follicular or inflammatory trachoma. Prevalence estimates were calculated at district and sub-district level.

Results: Trachoma rates at district level varied from 0–5.1%. There were only two sub-districts where active trachoma approached 10% (Nahualá Costa, 8.1%, and Santa Catarina Costa, 7.3%). Trichiasis rates in females aged 40 years and older varied from 0–3%. Trachoma was likely a problem in the past.

Conclusions: Trachoma is disappearing in the Sololá region in Guatemala. Health leadership may consider further mapping of villages around the areas with an especially high rate of trachoma and infection, and instituting trichiasis surgery and active trachoma intervention where needed.     

Ethnicity and HIV risk behaviour,testing and knowledge in Guatemala

Objectives. To describe levels of risky sexual behaviour, HIV testing and HIV knowledge among men and women in Guatemala by ethnic group and to identify adjusted associations between ethnicity and these outcomes.

Design. Data on 16,205 women aged 15–49 and 6822 men aged 15–59 from the 2008–2009 Encuesta Nacional de Salud Materno Infantil were used to describe ethnic group differences in sexual behaviour, HIV knowledge and testing. We then controlled for age, education, wealth and other socio-demographic factors in a multivariate logistic regression model to examine the effects of ethnicity on outcomes related to age at sexual debut, number of lifetime sex partners, comprehensive HIV knowledge, HIV testing and lifetime sex worker patronage (men only).

Results. The data show low levels of risky sexual behaviour and low levels of HIV knowledge among indigenous women and men, compared to other respondents. Controlling for demographic factors, indigenous women were more likely than other women never to have been tested for HIV and to lack comprehensive HIV knowledge. They were less likely to report early sexual debut and three or more lifetime sexual partners. Indigenous men were more likely than other men to lack comprehensive HIV knowledge and demonstrated lower odds of early sexual debut, 10 or more lifetime sexual partners and sex worker patronage.

Conclusions. The Mayan indigenous population in Guatemala, while broadly socially vulnerable, does not appear to be at elevated risk for HIV based on this analysis of selected risk factors. Nonetheless, low rates of HIV knowledge and testing may be cause for concern. Programmes working in indigenous communities should focus on HIV education and reducing barriers to testing. Further research into the factors that underlie ethnic self-identity and perceived ethnicity could help clarify the relative significance of these measures for HIV risk and other health outcomes.     

Cutaneous leishmaniasis control in Alta Verapaz (northern Guatemala): evaluating current efforts through stakeholders’ experiences

Background::Cutaneous leishmaniasis (CL), endemic in Guatemala, mostly affects poor people living in the northern region. A national control program that includ...     

Relationships that Heal: Beyond the Patient-Healer Dyad in Mayan Therapy

Biomedicine fosters particular styles of interaction and behaviors, with the therapeutic relationship seen as occurring between a doctor and patient. In contrast, where alternative modalities of healing are practiced, relationships go beyond a dyadic interaction and include wider social networks. In this article, we propose the existence of a ‘therapeutic unit’ in Maya healing practices in Guatemala that binds healer, wellness seeker, family, and community members, along with the spiritual and natural realms, into a coherent system requiring all of these elements to achieve success. Drawing on interviews with 67 Maya healers, we describe healers’ understanding of raxnaq’il nuk’aslemal (well-being), and show how these interactions activate wider networks that play crucial roles during treatments. We highlight how holism is expressed in relationships typical of indigenous healing systems, and how an appreciation of this is important for developing culturally appropriate health care provision systems.     

Understanding ethnic variation in pregnancy-related care in rural Guatemala

Objectives. This study examines the relatively low use of modern pregnancy-related care in Guatemala, especially among indigenous women, and explores the role of socioeconomic status, social and cultural variables, and access to biomedical health facilities in accounting for ethnic differences in care. Methods. The data for the analysis come from the Guatemalan Survey of Family Healtha population-based survey of rural women that contains detailed data on care received during pregnancy and delivery along with extensive background information. Binomial and multinomial logit models are used to identify the variables that affect the likelihood of receiving different types of care during pregnancy and delivering in a medical facility and the extent to which sociocultural factors and measures of access account for the observed ethnic differences. Results: The estimates not only confirm previous findings of a large ethnic difference in the use of modern pregnancy-related care, but also extend them by identifying a gradient within the indigenous population. The analysis demonstrates that, in general, sociocultural variables are more strongly associated with modern pregnancy-related care than are measures of access and that the former variables explain more of the ethnic variation in care than the latter. The results also demonstrate that pregnant women, especially indigenous women, are more likely to seek biomedical care in conjunction with traditional midwifery care rather than to rely solely on the former. Conclusion. The findings suggest that midwives are likely to continue to be key providers of pregnancy-related care in the future, even as access to modern health facilities improves. Current efforts directed toward the training and integration of midwives into the formal health system are likely to be much more effective at improving pregnancy-related care than the replacement of midwives with biomedical providers.