The main purpose of the Guatemalan Program of Primary Health Care (SINAPS) is to increase the effective coverage of primary health care services in rural populations of Guatemala. The Rural Health Promoter (RHP) provides services such as community census and maps vaccinations detection and distribution of food supplements to pregnant women and preschool children at high risk of malnutrition oral rehydration to children with diarrhea primary curative care encouragement of longterm breastfeeding and promotion of health and environmental sanitation. The traditional birth attendant (TBA) provides care of normal pregnancy birth and puerperium detection of high nutritional risk newborns and referral of high risk pregnant women to health services. SINAPS external evaluation is performed through baseline and endline surveys carried out in a random sample of families in 3 control and 6 experimental Health Districts. Results indicate that both groups control and experimental were very similar before program implementation in terms of malnutrition infant mortality vaccinations and contraceptive usage. As of December 31 1981: 1) 100% of malnourished children were participating in the food supplementation program 2) 84% of households received oral rehydration salts and 3) prevalence of contraceptive usage increased from 10.7-15% after 3 months of the program. Personnel training is carried out in-service and as of 30 December 1981 405 RHPs and 228 TBAs were being trained. Several methods developed in SINAPS are currently being adopted at the national level in Guatemala and other Latin American countries.

Pseudoperonospora humuli populations from Oregon and Washington were analyzed for genetic variation using random amplified polymorphic DNA (RAPD) and DNA amplification fingerprinting (DAF) markers. The genetic structure of the Oregon and Washington populations differed considerably. There was little genetic diversity in Washington, with only five RAPD and six DAF groups detected among 40 isolates tested. One genotype was predominant in Washing-ton. In contrast, 18 RAPD and 34 DAF groups were found among the 40 isolates tested from Oregon. No unique band profile associated with host cultivar was observed. It is suggested that the distinct difference in population structure between the two geographic regions might be due to climatic differences resulting in a higher frequency of sexual reproduction of P. humuli in Oregon than in Washington.

Most of today’s 1.7 million women veterans obtain all or most of their medical care outside the VA health care system, where their veteran status is rarely recognized or acknowledged. Several aspects of women’s military service have been associated with adverse psychologic and physical outcomes, and failure to assess women’s veteran status, their deployment status, and military trauma history could delay identifying or treating such conditions. Yet few clinicians know of women’s military history—or of military service’s impact on women’s subsequent health and well being. Because an individual’s military service may be best understood within the historical context in which it occurred, we provide a focused historical overview of women’s military contributions and their steady integration into the Armed Forces since the War for Independence. We then describe some of the medical and psychiatric conditions associated with military service.

ISEE-257 Introduction: Low birth weight (LBW, < 2500 grams) is used to delimit populations at risk for adverse health outcomes in infancy. Recent studies have found associations between LBW and common airborne pollutants, including ETS and biofuel smoke. In Guatemala, low birth weight is estimated at 13%. Aim: We examined indoor air pollution (IAP) as a risk factor for LBW among pregnant women participating in the Randomized Stove Intervention Trial, conducted in the western Guatemalan highlands between October 2002 and December 2004. Methods: 535 households of indigenous Mayans participated in the study, which examined the impact of IAP on acute lower respiratory infection incidence among children <18 months. Pregnant women, or households with children younger than 4 months, were randomly assigned to either receive a vented stove called a “plancha”, or continue cooking over their open fire until the end of the study (at which time they received a plancha). 283 singleton births were monitored by project staff. All women delivered in their homes, and fieldworkers attempted to visit the home as soon as possible to measure birth weight. Results: 191 (67.5%) newborns were measured within 48 hours of delivery and 45 (23.5%) weighed less than 2,500 grams. Newborn weight measurements (mean ± SD) were: 2.78 ± 0.42 kilograms (n=99) among intervention (“plancha ”) households and 2.73 ± 0.38 kilograms (n=92) among control (open fire) households, 48 grams (95% CI: -163, 66 grams) higher among plancha households. This difference was not statistically significant: p-value = 0.41 (pooled variances, t = -0.83, α=.95, 2-tailed, d.f.=189). Of the 225 infants measured within 7 days of delivery, 50 (22.2%) weighed less than 2,500 grams. Among this group, infant weights (mean ± SD) were: 2.83 ± 0.45 kilograms (n=120) among intervention, and 2.76 ± 0.43 kilograms (n=105) among control households, representing an insignificant difference between the two groups: p-value = 0.23 (pooled variances, t = -1.20, α=.95, 2-tailed, d.f.=223). The mean ± SD days between birth and initial measurement were the same for both intervention and control groups. Results indicated significant differences in kitchen IAP levels to particulate matter (PM1,plancha: 92 μg/m3; open fire: 1440 μg/m3), although all pregnant women in the study averaged only 59 days (range:1-165 days) with the plancha stove prior to delivery, thus limiting differential exposure mostly to the third trimester. Discussion: The Guatemalan Stove Intervention Trial offered a unique opportunity to monitor the health of pregnant women and subsequent perinatal outcomes residing in one of the poorest regions in Guatemala. Plancha stoves were able to reduce kitchen air pollution by 94%. LBW was a secondary measure of the study and methodological limitations include lack of information about gestational age, and inability to arrive at all home births within 48 hours, which may bias the findings toward the null. Despite these limitations, current results demonstrate a weak, but consistent, relationship between IAP and increased LBW, among this very vulnerable population.

ISEE-189 Introduction: Several reports have described the risk of burns to children from open wood fires in poor countries, but there is little information available on community incidence and none describing the impact of preventative interventions. A randomised controlled trial currently underway in Guatemala designed to assess impacts of an improved stove on pneumonia and other health outcomes provides an opportunity to study this issue. Methods: The study sample includes 507 homes using an open fire, recruited from a rural area of western Guatemala. Eligible homes had a child under 4 months or a pregnant woman (providing the index children for respiratory illness outcomes). Health surveillance for the index child is by weekly home visits until 18 months of age, with episodes of burns/scalds recorded. Household interview includes questions on burns/scalds in older siblings of the index child, repeated 6 monthly. Homes were randomly allocated to receive a plancha chimney wood stove immediately, or when the index child reaches 18 months. Results: Index children being very young and closely supervised initially had a very low rate of burns/scalds. Preliminary analysis of 34 cases in these children after 11 months of follow-up showed similar numbers of burns in plancha and control groups (although due to OF in 2 plancha homes), with a trend towards burns in open fire homes being in older children (9.7 vs 7.1 months, p=0.1). Among 1040 siblings aged up to 8 years in study homes, 22 reported a burn/scald in the 6 months prior to baseline (42 per 1,000 per year), all under 6 years. Eight resulted from falling into the fire, eight from scalds, and six from a hot object, pot or other cause. Fifteen left scars, seven larger than 2 cm diameter, one 3x14 cm. A further 40 episodes were recalled as having occurred prior to the last 6 months with similar causes, five leaving scars at least 5 cm in diameter. Discussion: An improved stove has the potential to prevent the majority of burns/scalds, particularly the most severe episodes resulting from falling into an open fire. Initial findings indicate that burns still occur with the plancha, but this could be in part lack of experience with young children near an unfamiliar, new type of stove, and a clearer picture may emerge as they get older. This study will provide information on incidence, severity and causes, and evidence on intervention effectiveness over 18 months in children up to around 10 years. Education in the safe use of improved stoves may well be required, as is the case for home accident prevention in any society.

ISEE-170 Introduction: There is accumulating evidence that indoor air pollution from household use of biomass fuels increases the risk of developing chronic obstructive pulmonary disease (COPD). Women receive the greatest exposures due to their activities in the home and kitchen. We will, in the first randomized control trial ever with air pollution, investigate the effect of reducing indoor air pollution (with improved stoves) on women’s lung health. Here we present preliminary results from the baseline assessment. This gives a picture of the lung health among women who experience indoor air pollution at the expected high end of the dose-response curve. Methods: This study is conducted in a Mayan Indian community in the Guatemalan highlands and includes only households using an open woodfire for cooking and spaceheating. It comprises 504 women of child-bearing age visited in their homes by trained fieldworkers who speak the local language. They were asked questions about chronic airway symptoms based on standard questions (MRC/IUATLD). The original format of key cough and phlegm questions were, however, not usable, and they were modified through extensive local piloting to versions for which the time patterns of symptoms were understood by the women. The women underwent spirometry testing and had their carbon monoxide (CO) levels in exhaled breath measured as a proxy for recent air pollution exposure. Measurements of CO from kitchens and personal monitors will also be available as will evidence of the relationship between CO and particle pollution in these households. Results: Prevalence of selected airway symptoms is presented in Table 1 and crude spirometry results in Table 2. Obstructive airway symptoms were frequently reported; 9.3% had persistent cough or phlegm for at least 3 months consecutively. Frequent phlegm experienced for at least three months was associated with a decrease in FEV1/ FVC ratio of 4.7% (p<0.001). Neither passive smoking (23.6%) nor pregnancy (32.5%) influenced lung function results. Only one woman smoked and two were ex-smokers, hence smoking was not included in the analyses. Adjusting for height and age, CO in exhaled breath was negatively associated with FEV1/FVC; one ppm increase in CO corresponded to a 0.15 unit fall in FEV1/FVC (p=0.021). The mean concentration of CO in exhaled breath was 7.5 ppm (sd 4.1).Table 1: Prevalence of selected airway symptoms among women in highland Guatemala using biomass fuels for cooking and spaceheating.Table 2: Age, height and lung function among the study women.Conclusion: Obstructive airway symptoms are frequent in this highly-exposed female population, and exposure to CO in indoor air is associated with a decrease in lung function.

ISEE-168 Introduction: Indoor air pollution from biomass combustion in open fires affects rural populations in developing countries all over the world. We will, in the first randomised control trial for air pollution ever done with healthy populations, study the effect of installing improved chimney stoves (planchas) on women’s health. The plancha significantly reduces indoor air pollution levels. A positive side effect for the women may be the change in working posture from use of an open fire on the floor to an upright position while cooking. Here we present preliminary results from the baseline assessment of self-reported eye discomfort, headaches, and back pain. Methods: This study is conducted in a Mayan Indian community in the Guatemalan highlands and includes only households using an open woodfire for cooking and spaceheating. It comprises 504 women [mean age 27.7 years (sd 7.5), 32.5% pregnant] visited in their homes by trained native-speaking fieldworkers. As part of a more comprehensive interview, questions were asked about eye discomfort, headache and back pain. In addition, the women had their carbon monoxide (CO) levels in exhaled breath determined as a proxy for recent air pollution exposure. Results: In total 63.3% of the women had experienced headache during the last month. Of these, 29.6% had symptoms every day, and 32.3% reported their headache to be strong (Table 1). Sore or watery eyes during the last month was reported by 41% of the women, and 56% of these were bothered every day (Table 2). The risk of eye discomfort increased with increasing levels of CO in exhaled breath, while no such relation was found for headache (Table 3). Back pain during the last month was reported by 48.6% of the women (Table 4), pregnant women having higher prevalence (OR 1.5, 95% CI 1.0–2.2). Of those with back pain, 30 (12.3%) could not perform daily duties due to the pain. A number of factors were reported to make back pain worse, most important being washing clothes (55.9%) and cooking (28.6%) (Table 4).Table 1: Self-reported headache during the last month.Table 2: Self-reported prevalence of eye discomfort during the last month.Table 3: Determinants of eye discomfort and headache.Table 4: Self-reported prevalence of back pain during the last month.Discussion: Headache and eye discomfort were common symptoms in this female population exposed to high levels of indoor air pollution. Our results suggest that eye discomfort was linked to personal exposure levels. Back pain was common and reported to be associated with cooking by more than a quarter of the affected women. An improved stove has the potential to prevent back pain in these women.

Introduction In preparation for a randomized trial in highland Guatemala, a cross sectional survey was conducted in rural communities in the District of San Marcos, Guatemala to determine the distribution and proportion of households using indoor open fires. The randomized trial is designed to measure the effect of indoor air pollution on acute respiratory infections in children, in which improved chimney stoves will be introduced into houses using open fires for cooking. Methods Based on information from health authorities, village informants and staff field visits; we established the highlands of the Department of San Marcos as a suitable area to conduct the survey. Information on elevation, number of households/community, migration during harvest season, household and kitchen characteristics was collected to select potential study sites. Communities in five municipalities in the Department of San Marcos fulfilled criteria as potential study sites. A structured questionnaire, to collect data for final village selection, included the following main conceptual categories: Basic demographics (age of family members, gender, number of children < 7 months and pregnant women living in the house migration during harvest season), kitchen characteristics and cooking practices and family economic status based on households characteristics. Data was collected over a four week period. Frequency tables and histograms were prepared to present both a tabular and a graphic representation of the results. Cross tabulations were generated to obtain chi-square test results and p values. The p < 0.05 level was the criteria used thorough out to define statistical significance. Univariate and multinomial logistic regression were used to explore socioeconomic characteristic of the households to be studied. Results A total of 5,365 households were surveyed in 45 villages in five municipalities of the Department of San Marcos, Guatemala. Demographic characteristics and behaviors. The mean age of the interviewees was 39.27 years, (Sd = 14.86; range = 15–96). The mean number of persons/household was 6.26 (Sd = 2.7); 648 households (12.07%) reported a pregnant woman and 736 (13.71%) reported a child under 7 months of age. When caretakers were asked where they leave their children when cooking, 86.1% responded that they carried their infant on their back, while 8.5% reported they leave their baby outside the kitchen. The reported duration the baby is carried on the mother's back was variable: 31.3% reported up to 12 months, 42.2%, up to 18 months and 25.6% up to 24 months. Household characteristics. Overall, 52% of households use open fires for cooking Most kitchens, (84.0%), were located in a separate structure from the house. Households using open fires, however, were more likely to have the kitchen located inside the house (p = 0.002; 95% CI = 1.09–4.87). Households with open fires as compared with those using improved stoves were statistically significantly poorer, as evidence by living and cooking in the same room, less adequate housing, less likely to have electricity in the home and more frequent work-related migration (p < .0001). Among those using open-fires, households without electricity and with poorer housing conditions were more likely to be migrate laborers, OR = 1.5 (95% CI 1.3–1.8)

Introduction Pneumonia remains the principal cause of death of children under 5 in developing countries. Evidence from nearly 20 studies associates exposure to pollution from biomass fuels with increased risk of acute lower respiratory infections (ALRI). However, all these studies have been observational designs, very few with exposure assessment, and with inconsistent case ascertainment and definition. To strengthen this evidence, a randomised controlled trial (RCT) is currently underway in Guatemala to measure the effect of an improved stove on ALRI incidence. This provides the first opportunity to study health effects of air pollution in a randomised intervention, largely free of confounding which typically complicates interpretation in environmental epidemiology. This paper describes the methods used for standardised case-finding. Method The sample includes 500 children in a poor rural area of north-western Guatemala. At recruitment, children were aged less than 4 months, or in utero. Each child is being followed to age 18 months. Following baseline questionnaires, a random 50% of homes received plancha stoves-a well–accepted local product known to reduce indoor air pollution by up to 80–90%. Case finding is carried out at three levels: (a) household visits, (b) referral to a study physician, and (c) referral to the district hospital. Fieldworkers trained in IMCI case recognition visit each home weekly, using standard questions and examination (including respiratory rate) to identify possible ALRI cases. This process is very sensitive, but not very specific. Anthropological work was undertaken to identify symptom terms in the local (Mam) language with correct meanings. Children meeting ALRI criteria are referred to a physician, based in a community centre: this helps to maintain blindness of the physician to the intervention/control status of each child's home. Physician assessment utilises standardised clinical criteria, based on prior WHO studies and re-enforced through clinical training sessions. Such sessions are also carried out at regular intervals to maintain consistency. All children with signs of ALRI are referred for chest X-ray (CXR), and RSV antigen testing and pulse oximetry (PO) are carried out. The use of CXR and PO provide additional ‘objective’ assessment of each child, and RSV testing will allow comparison of IAP risk in bronchiolitis and pneumonia cases. Severely ill children are admitted to hospital, and additional clinical information collected at discharge. All deaths are being assessed by verbal autopsy. Conclusion Primary case definition is determined by the study physician, combining clinical findings, CXR, and hospital information, with PO providing a measure of severity. Independent, blind assessment of CXRs and verbal autopsy reports will also be available. Experience with this system of case finding will be reported, including numbers of ALRI cases treated at home and admitted, and %RSV positive. Also analysed will be the differences in numbers and characteristics of ALRI cases defined by (a) IMCI criteria at weekly visit, (b) physician examination with CXR, and (c) CXR findings only. Practical issues in maintaining standardised procedures, and referring children for CXR and admission in a rural population fearful of the hospital will also be reported.

We compared epidemiologic characteristics of Cryptosporidium and Cyclospora in surveillance data from outpatient departments in Guatemala. Routinely-submitted stool specimens were screened by microscopy. Age, sex, and symptom data were collected. Cyclospora was detected in 117 (2.1%) and Cryptosporidium in 67 (1.2%) of 5,520 specimens. The prevalence of Cyclospora peaked in the warmer months, while Cryptosporidium was most common in the rainy season. Both affected children more than adults, but Cryptosporidium affected children at a younger age than Cyclospora (median age 2 years versus 5 years; P < 0.001). Cyclospora showed a stronger association with diarrhea than Cryptosporidium, even when data were stratified by age. These contrasts may reflect differences in the relative importance of transmission modes, the frequency of exposure, and the development of immunity.

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan® (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$ 2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999.La decisión tomada en 1987 por la Merck & Co., fabricante de productos farmacéuticos, de proveer Mectizan® (ivermectina) gratuitamente a los programas de control de la oncocercosis ha obligado a la comunidad sanitaria internacional a buscar formas de distribuir el medicamento a las poblaciones rurales que se ven más afectadas por la enfermedad. En las Américas, la OPS respondió al reto con un llamado a eliminar de la Región toda morbilidad por oncocercosis para el año 2007 mediante la distribución de ivermectina al público. Desde 1991, una alianza multinacional de diversas entidades (la OPS, países con oncocercosis endémica, agencias de desarrollo no gubernamentales, los Centros para el Control y la Prevención de Enfermedades en Atlanta, Georgia, instituciones académicas y agencias de financiamiento) ha generado el apoyo político, económico y técnico necesario para tratar de alcanzar esa meta. Esta alianza está representada por el Programa de Eliminación de la Oncocercosis en las Américas (OEPA), subvencionado por la Fundación Ceguera de los Ríos y actualmente por el Centro Carter. El OEPA se creó como iniciativa de alcance regional destinada a eliminar una enfermedad que no merece atención prioritaria. Desde su aparición en 1993, el OEPA ha aportado más de US$2 millones en ayuda económica, administrativa y técnica para fomentar y subvencionar programas en Brasil, Colombia, Ecuador, Guatemala, México y Venezuela, logrando así aprovechar al máximo la donación de la Merck & Co. Ahora que hemos llegado a la mitad de una subvención de 5 años y US$ 4 millones aportada por el Banco Interamericano de Desarrollo, se sabe que el OEPA tiene la capacidad para apoyar la iniciativa regional hasta fines de 1999.

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan® (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$ 2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999.

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.

This study examined the preferred professional treatment approach at a residential treatment center for socially and emotionally maladjusted girls. The dorm child-care workers and the clinical and educational staff responded to a questionnaire composed of statements reflective of three theoretical orientations: psychoanalytic, person-centered, and cognitive-behavioral therapy. No significant differences were found between the three departments (clinical, school, dorm) for each model of therapy. The results also indicated that the professional personnel employed at this treatment facility were all in agreement that the cognitive-behavioral model of therapeutic intervention is the one preferred. Implications of these findings are discussed.