John P. McCracken

Household air pollution (HAP) due to solid fuel use during pregnancy is associated with adverse birth outcomes. The real-life effectiveness of clean cooking interventions has been disappointing overall yet variable, but the sociodemographic determinants are not well described. We measured personal 24-h PM_2.5 (particulate matter n = 218) gravimetrically with Teflon filter, impactor, and personal pump setups. To estimate the effectiveness of owning chimney and liquefied petroleum gas (LPG) stoves (i.e., proportion of PM_2.5 exposure that would be prevented) and to predict subject-specific typical exposures, we used linear mixed-effects models with log (PM_2.5) as dependent variable and random intercept for subject. Median (IQR) personal PM_2.5 in µg/m³ was 148 (90–249) for open fire, 78 (51–125) for chimney stove, and 55 (34–79) for LPG stoves. Adjusted effectiveness of LPG stoves was greater in women with ≥6 years of education (49% (95% CI: 34, 60)) versus 3). Although having a cleaner stove alone typically does not lower exposure enough to protect health, understanding sociodemographic determinants of effectiveness may lead to better targeting, implementation, and adoption of interventions.

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

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

Background: Human metapneumovirus (HMPV) is an important cause of acute respiratory infections (ARI), but little is known about how it compares with respiratory syncytial virus (RSV) in Central America.Objectives: In this study, we describe hospitalized cases of HMPV‐ and RSV‐ARI in Guatemala.Methods: We conducted surveillance at three hospitals (November 2007–December 2012) and tested nasopharyngeal and oropharyngeal swab specimens for HMPV and RSV using real‐time reverse transcription‐polymerase chain reaction. We calculated incidence rates, and compared the epidemiology and outcomes of HMPV‐positive versus RSV‐positive and RSV‐HMPV‐negative cases.Results: We enrolled and tested specimens from 6288 ARI cases; 596 (9%) were HMPV‐positive and 1485 (24%) were RSV‐positive. We observed a seasonal pattern of RSV but not HMPV. The proportion HMPV‐positive was low (3%) and RSV‐positive high (41%) for age <1 month, whereas these proportions were similar (~20%) by age 2 years. The annual incidence of hospitalized HMPV‐ARI was 102/100 000 children aged <5 years [95% confidence interval (CI): 75–178], 2·6/100 000 persons aged 5–17 years (95%CI: 1·2–5·0), and 2·6/100 000 persons aged ≥18 years (95%CI: 1·5–4·9). Among children aged <5 years, HMPV‐positive cases were less severe than HMPV‐RSV‐negative cases after adjustment for confounders [odds ratio (OR) for intensive care = 0·63, 95% CI 0·47–0·84]; OR for death = 0·46, 95% CI 0·23–0·92).Conclusions: Human metapneumovirus is a substantial contributor to ARI hospitalization in Guatemala, but HMPV hospitalizations are less frequent than RSV and, in young children, less severe than other etiologies. Preventive interventions should take into account the wide variation in incidence by age and unpredictable timing of incidence peaks.

Background. Respiratory syncytial virus (RSV) is a major cause of acute respiratory illness (ARI). Little is known about RSV disease among older children and adults in Central America. Methods. Prospective surveillance for ARI among hospital patients and clinic patients was conducted in Guatemala during 2007–2012. Nasopharyngeal and oropharyngeal swab specimens were tested for RSV, using real-time reverse-transcription polymerase chain reaction. Results. Of 6287 hospitalizations and 2565 clinic visits for ARI, 24% and 12%, respectively, yielded RSV-positive test results. The incidence of RSV-positive hospitalization for ARI was 5.8 cases/10 000 persons per year and was highest among infants aged P < .001). Conclusions. The incidences of RSV-associated hospitalization and clinic visitation for ARI were highest among young children, but a substantial burden of ARI due to RSV was observed among older children and adults.