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As the recognition of autism spectrum disorder (ASD) increases, and the prevalence estimates of ASD continue to rise throughout the world, it has become apparent that access to diagnostic and treatment services is highly dependent on geography. Even within countries such as the United States, which has received significant interest and investment in understanding, diagnosing, treating, and providing programs for those with ASD over the last 20+ years, access to information and services is uneven. In poorer countries such as the Dominican Republic (DR), where >40% of citizens live below the poverty level and access to quality healthcare overall continues to be a challenge, issues associated with ASD are not yet being adequately addressed. The objective of this review is to provide a realistic synopsis of the resources currently available to Dominicans who have a family member or loved one with ASD. We examine the challenges these families face in finding care, the stigma associated with ASD, and programs available for people with ASD. We conclude that while the DR is making progress in its efforts to address ASD, there is still much work to be done.

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Nicaragua is one of the lowest income countries in Latin America, where there is a shortage of data on women living homeless. This paper analyses the types, timing and perceived causality of stressful life events (SLE) suffered both during childhood and adolescence and throughout life by women living homeless (n = 30). A structured interview was used to collect the data. Findings showed that women living homeless in Nicaragua suffered a very high number of SLEs, and that these were extremely severe and from very early ages. Most of the SLEs took place before the women became homeless. The SLEs suffered by the women interviewed in Nicaragua were largely similar to those seen in women living homeless in other cultural contexts with higher incomes, although it should be noted that those interviewed in Nicaragua had suffered a higher number of SLE during their childhood and adolescence. The women interviewed mainly attributed finding themselves homeless to having suffered SLEs in the family environment. The suffering of multiple and severe SLEs, largely leading to living in socioeconomically disadvantaged situations, seem to present a significant vulnerability factor both for becoming homeless and remaining homeless over time.

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OBJECTIVES: Health-related quality of life (HRQL) in type 1 diabetes is a critical health outcome but has not been studied in many low-income countries. In this study we evaluated the validity of 2 HRQL instruments, measured the HRQL and explored the association between HRQL and glycemic control. METHODS: This was a cross-sectional study of Haitian youth with diabetes between 0 and 25 years of age and living in Haiti. We administered the 51-item Diabetes Quality of Life for Youth (DQOLY) questionnaire and the EuroQol Visual Analogue Scale (EQ-VAS). Psychometric analyses evaluated internal consistency and construct validity of the DQOLY and its 21-item short form, the DQOLY-SF. Linear regression was used to identify predictors of HRQL and glycated hemoglobin (A1C). RESULTS: In 85 youth (59% female; mean age, 17.5 years; mean diabetes duration, 3.7 years; mean A1C, 11.3%), DQOLY and DQOLY-SF had adequate internal consistency with Cronbach's alpha values of 0.86 and 0.84, respectively. Confirmatory factor analysis revealed adequate validity for the DQOLY-SF and DQOLY Satisfaction subscale. HRQL, as measured using the DQOLY-SF, was 62±16 (mean ± standard deviation) out of 100. Mean EQ-VAS score was 78±24 out of 100. Older age (p=0.004), female sex (p=0.02) and lower socioeconomic status (SES) (p=0.03) were risk factors for lower DQOLY score, and older age (p=0.02) and marginally female sex (p=0.06) for lower DQOLY-SF score. No predictors of EQ-VAS were identified. HRQL measures were not associated with glycemic control. CONCLUSIONS: The DQOLY-SF and DQOLY Satisfaction subscale are valid measures of HRQL in Haitian youth with diabetes. HRQL is low and was worse in older, female and low-SES youth, but was not associated with glycemic control.

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OBJECTIVE: Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings. RESULTS: Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers. CONCLUSION: These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.

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BACKGROUND: The immunization of large portions of populations in low/middle-income countries is considered one of the key measures to limit the development of new SARS-CoV-2 variants. However, parental vaccine hesitancy might be an important obstacle to pediatric vaccination. The aim of this survey was to study the prevalence and extent of COVID-19 vaccine hesitancy among parents of children and adolescents living in Brazil. METHODS: Caregivers of children and adolescents referred to the emergency department of Hospital Estadual de Bauru, São Paulo (Brazil) were invited to fill in a validated questionnaire on vaccine hesitancy and to report their willingness for themselves and their offspring to receive a COVID-19 vaccine. RESULTS: A total of 501 consecutive caregivers filled in the survey. Response rate was 100%. A minority (N = 14, 2.8%) of caregivers were hesitant about vaccines. Despite this, half of them declared they were willing to vaccinate their offspring against COVID-19. CONCLUSIONS: This survey identifies that vaccine hesitancy is very low among caregivers living in Brazil and that even many of the hesitant caregivers are willing to vaccinate their offspring against COVID-19. This study highlights the importance of offering the COVID-19 vaccination to the whole population, including subjects that present uncertainty about other vaccines.

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Hepatitis C (HCV) is a global pandemic. The World Health Organization has developed a strategic plan for HCV elimination that focuses on low- and middle-income countries (LMICs) and high-risk populations, including people who inject drugs (PWID). While direct-acting antiviral (DAA) therapies are highly effective at eliminating HCV infections and have few side effects, medical professionals and policymakers remain concerned about the risk of reinfection among PWID. This study is a systematic review of research measuring the rate of HCV reinfection among PWID in LMICs and identifies additional areas for further research. A systematic search strategy was used to identify studies documenting HCV reinfection after sustained virologic response in PWID in LMICs. We refined results to include studies where at least 50% of participants had DAA treatment for primary HCV infection. Pooled reinfection rate was calculated across all studies. Seven studies met eligibility criteria. Most studies were conducted in six upper middle-income countries (Mexico, Romania, Russia, Taiwan, Georgi, and Brazil) and one lower middle-income country (Bangladesh) with a total of 7665 participants. No study included information from PWID in low-income countries. Sample sizes ranged from 200 to 3004 individuals, with demographic data missing for most participants. Four studies used deep gene sequencing, and reflex genotyping procedures to differentiate reinfection (infection by a different HCV genotype/subtype) from virologic relapse (infection by the same strain). The follow-up time of people cured from primary chronic HCV infection ranged from 12 weeks to 6.6 years. The pooled reinfection rate of all seven studies was 2.8 (range: 0.02 to 10.5) cases per 100 person-years (PY). In the five studies that differentiated relapse from reinfection, the incidence of reinfection was 1.0 per 100 PY. To date, research on reinfection rates among PWID in LMICs remains limited. Research focused on PWID in low-income countries is particularly needed to inform clinical decision making and evidence-based programs. While rates of reinfection among PWID who complete DAA treatment in upper and lower middle-income countries were similar or lower than rates observed in PWID in high-income countries, the rates were highly variable and factors may influence the accuracy of these measurements. This systematic review identifies several areas for continued research. Policies concerning access to HCV testing and treatment should be comprehensive and not place restrictions on PWID in these settings.

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Background: Assessing food consumption in adolescents is essential for the determination of an appropriate nutritional status. This study intended to assess dietary patterns and its associated factors in rural Mozambican adolescents. Methods: This was a cross-sectional study of 323 adolescents. A food frequency questionnaire was used and food was grouped into nine groups. An exploratory factorial analysis identified the food patterns. A principal component analysis provided food consumption scores in each factor, split into three groups. An adjustment of multinomial regression models was made. Results: Two diet patterns were identified: pattern 1 (fats, beans, meats and eggs, cereals and sugars) and pattern 2 (vegetables, roots and tubers, fruits, chestnuts and walnuts). The proportional model for pattern 1 indicated highest consumption for adolescents with per capita family income equal to or greater than 78.13 meticais (Mozambique's currency) and for adolescents whose parents had a formal job. For pattern 2, consumption was lower for adolescents whose guardians had high school education or more. The consumption in the first three quartiles was lower for individuals with an income between 1 and 78.12 meticais. Conclusions: For Mozambican adolescents, higher income, education and parents' jobs were predictive variables for consumption of fats, beans, meats and eggs, cereals, and sugars, while higher education and higher income implies lower consumption of vegetables, roots and tubers, fruits, chestnuts, and walnuts.

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OBJECTIVE: To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition. STUDY DESIGN: A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality. RESULTS: Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score. CONCLUSIONS: Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.

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BACKGROUND: The aim of this study was to assess point and period prevalence and incidence of perinatal depression in Mexican women. METHODS: The Structured Clinical Interview for DSM-IV and the Patient Health Questionnaire (PHQ-9) were administered at three points in time to 210 women: during the third trimester of pregnancy, at six weeks and at six months after delivery. RESULTS: Prevalence of prenatal depression was 9.0%, and 13.8% at six weeks and 13.3% at six months postpartum. Incidence of postpartum depression (PPD) was 10.0% at six weeks and 8.2% at six months. Prevalence of prenatal depressive symptoms was 16.6%; and 17.1% at six weeks and 20.0% at six months postpartum. Incidence of postpartum depressive symptoms (PPDS) was 11.4% at six weeks and 9.0% at six months. At six months postpartum, women with depression were younger (OR=2.45, p=0.02), had fewer years׳ schooling (OR=5.61, p=0.00), were unpartnered (OR=3.03, p=0.01), unemployed (OR=3.48, p=0.00) and poorer (OR=4.00, p=0.00) than women without depression. LIMITATIONS: 25% of the initial sample was not retained to complete the three assessments. Non completers were younger, less educated and reported more depressive symptoms. This may have resulted in an underestimation of prevalence. CONCLUSIONS: This is the first longitudinal study in Latin America to assess perinatal depression at three different points in times, reporting point and period prevalence and incidence of clinical depression and depressive symptoms. Most LA countries have yet to recognize the importance of providing mental health care for expectant and postpartum mothers to reduce disability in mothers and infants.

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BACKGROUND: Relapsed childhood acute myeloid leukemia (AML) outcomes have not been documented in resource-limited settings. We examined survival after relapse for children with AML (non-APML) and acute promyelocytic leukemia (APML) in Central America. PROCEDURE: We retrospectively evaluated outcomes of children with first relapse of AML (non-APML) and APML in Guatemala, Honduras, or El Salvador diagnosed between 1997 and 2011. Predictors of subsequent event-free survival (EFS) and overall survival (OS) were examined. RESULTS: We identified 140 children with relapsed AML (non-APML), and 24 with relapsed APML. Two-year subsequent EFS and OS (±SE) were 7.0 ± 2.5% and 9.1 ± 2.8%, respectively. Worse outcomes were associated with Hispanic or Indigenous heritage, white blood cell count at diagnosis ≥50 × 10(9) /L, and time to relapse <18 months. For those with relapsed APML, subsequent 2-year EFS and OS were 36.7 ± 10.8% and 43.4 ± 12.1%, although few patients survived beyond 3 years. 15.2% of all patients were managed solely with palliative intent following first relapse. CONCLUSIONS: Children with relapsed AML in Central America rarely survive, so palliative strategies should be considered following relapse in this population. However, children with late relapse or with APML may have a prolonged period of remission with second treatment, and consideration of re-treatment may be appropriate.

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