Central American (Guatemalan, Honduran, Salvadoran) Minor Refugees

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Priority Health Conditions
A list of priority health conditions to consider when caring for or assisting Central American refugees.


Background
Geography, History and Cultural Origins, Ethnic Groups, Language and Literacy, Religious Beliefs, Family and Kinship


Healthcare Access and Conditions in Guatemala, Honduras, and El Salvador
Primary Healthcare, Immunizations, Reproductive Health, Women’s Health Issues, Sexual-and Gender-Based Violence.

Medical Screening of US-Bound Refugees
Overseas Medical Examination, Pre-Departure Medical Screening, Post-Arrival Medical Screening


Health Information
Infectious and Communicable Diseases, Parasitic Infections, Non-Communicable Diseases, Mental Health, Nutrition

Priority Health Conditions

Based on available data, the issues listed below are prevalent priority health conditions that healthcare providers should consider when caring for refugees from El Salvador, Guatemala, and Honduras.

Background

El Salvador, Guatemala, and Honduras are three of the northernmost countries of Central America, making up the Northern Triangle, situated just south of Mexico on the isthmus linking North and South America 1. The Northern Triangle has a population of roughly 29.8 million. Guatemala is the most populous country, having a population of approximately 14.9 million 2, while El Salvador and Honduras have populations of roughly 6.1 million and 8.7 million, respectively 34. Each country is mountainous and has narrow coastal belts along the Pacific Ocean and/or the Caribbean Sea 2, 3, 4. The region is vulnerable to hurricanes, active volcanoes, and earthquakes 1.

Figure 1: Location of El Salvador, Guatemala, and Honduras

This shows a map of El Salvador, Guatemala, and Honduras highlighted.

Source: Division of Global Migration and Quarantine (DGMQ), CDC

History and Cultural Origins

Like the rest of Mesoamerica, Guatemalans, Hondurans, and Salvadorans share a common pre-Columbian history, originating from the Lenca, Olmec, and Maya civilizations. These ancient indigenous cultures left behind an extensive legacy of art, architecture, and traditions, many of which are still present throughout Central America. Indigenous Central Americans first came into contact with Spanish explorers and colonists in the early 1500s and endured three centuries of colonial rule. In 1821, a united battle for independence led to the establishment of the Federal Republic of Central America. The republic dissolved in 1838, and the countries of El Salvador, Guatemala, and Honduras were formed 1. However, post-colonial independence brought instability, violence, and war, which persisted throughout the 20th century along with shifting civil and military governance, uneven economic development, and social unrest 1.

Ethnic Groups

El Salvador

Approximately 86.3% of Salvadorans are mestizo (mixed race). Whites account for 12.7%, while Amerindian (including Lenca, Kakawira, and Nahua-Pipil), black, and other ethnicities account for a small minority 3.

Guatemala

Roughly 60% of Guatemalans are of mestizo or European descent. The remaining 40% of the population is K’iche (9.1%), Kaqchikel (8.4%), Mam (7.9%), Q’egchi (6.3%), other Mayan (8.6%), and indigenous non-Mayan (0.2%) 2.

Honduras

Mestizos account for approximately 90% of the population, while Amerindians represent 7% of Hondurans. The remaining 3% of the population is either black or white 4.

Language and Literacy

El Salvador

Spanish is the official and most widely spoken language in El Salvador 3. Some indigenous Salvadorans speak Nahua, an Amerindian language. However, such speakers are few, as indigenous persons account for less than 1% of El Salvador’s population 3. Approximately 88% of the Salvadoran population is literate, defined as being at least 15 years old and able to read and write. Among Salvadoran men, 90.4% are literate, while literacy for women is estimated at 86% 3.

Guatemala

Although Spanish is the official language of Guatemala, only 60% of the population communicates primarily in Spanish. Forty percent communicate in one of many Amerindian languages. There are 23 officially recognized Amerindian languages, including Quiche, Cakchiquel, Kekchi, Mam, Garifuna, and Xinca 2. Approximately 81.5% of the Guatemalan population is literate. Overall, 87.4% of men are literate, and 76.3% of women2.

Honduras

The official language of Honduras is Spanish, which is widely spoken. Hondurans may also speak Amerindian dialects 4. Approximately 88.5% of the Honduran population is literate. Rates of literacy among men and women are comparable: 88.4% of male Hondurans and 88.6% of female Hondurans are literate 4.

Religious Beliefs

El Salvador

El Salvador is overwhelmingly Christian. Roman Catholicism is practiced by 57.1% of the population. Protestants account for 21.2% of the population, while small minorities are Jehovah’s Witnesses (1.9%) or Mormon (0.7%). Additionally, 16.8% of the population does not identify as religious, and the remaining 2.3% practice other religions 3.

Guatemala

Roman Catholicism is the predominant religion in Guatemala, with 65-70% of Guatemalans identifying as Catholic 5. However, among the indigenous Maya, Catholic practices and traditions are often infused with beliefs of pre-Columbian origin. Evangelical Protestantism has become increasingly popular since the mid-20th century, particularly among lower-income households. As a result, Protestants now account for about 40% of the population6.

Honduras

Roughly 80% of the Honduran population is Roman Catholic. Growth in Protestant churches has swelled in recent years, making Protestantism the second most popular religion in Honduras 7.

Family and Kinship

Familismo is an integral part of Latin American culture, in which women play a critical role. Women are often responsible for the organization and maintenance of family life and tradition, a role that may afford them significant influence in the home. Many Central American nations are patriarchal, with men often providing the primary income for the family, and women serving as caregivers for the children and family 8.

For additional information regarding minors from Central America, please visit the Cultural Orientation Resource Exchange pdf icon[PDF – 16 pages]external icon.

Healthcare Access and Conditions in Guatemala, Honduras, and El Salvador

Even though minors from El Salvador, Guatemala, and Honduras may be designated as refugees, they have not been living in refugee camps, and usually come from their hometown or village.

Primary Care

Compared to the United States and other high-income nations, physician density in El Salvador, Guatemala, and Honduras is quite low. According to recent data, there are approximately 1.6 physicians per 1,000 population in El Salvador. Physician population density is markedly lower in both Guatemala and Honduras, with 0.93 and 0.37 physicians per 1,000 population, respectively 14. The World Health Organization estimates that countries with fewer than 23 healthcare workers (including physicians, nurses, and midwives) per 10,000 population will likely fail to achieve adequate coverage rates for primary healthcare, as defined by the Millennium Development goals 15. Therefore, the number of doctors in El Salvador, Guatemala, and Honduras is likely insufficient to achieve adequate coverage for primary healthcare needs.

Access to basic healthcare in Central America largely depends on socioeconomic status and environment (urban or rural). El Salvador, Guatemala, and Honduras have worked to improve access and quality of care, particularly in rural settings. Despite improvements to health services and systems, rural populations still have difficulty accessing basic health services. In Guatemala, it is estimated that basic health and nutrition services meet only 54% of the needs of the rural population 16. Similarly, in Honduras, 88.3% of the total population receives care from the Ministry of Health. However, the majority of health services are located in the most developed cities, not easily accessible for rural and indigenous populations 17. Minors from rural and often underserved regions may also seek care from traditional healers, such as curanderos or folk healers 18. Curanderismo exists throughout Latin America, and practitioners treat a wide range of ailments including illnesses recognized by modern medicine as well as “folk illness” specific to the local population 18.

Immunizations

Despite challenges in accessing basic primary care services in El Salvador, Guatemala, and Honduras, each country reports high immunization coverage among children. Vaccination coverage in El Salvador varies from 90% to 93%, depending on the vaccine, while vaccination coverage ranges from 93% to 98% and 88% to 93% in Guatemala and Honduras, respectively 19. El Salvador, Guatemala, and Honduras administer vaccines in accordance with the World Health Organization’s (WHO) Expanded Program on Immunization.

Women’s Health Issues

Select reproductive health indicators for El Salvador, Guatemala, and Honduras are presented in Table 1. In many cases, access to reproductive healthcare is likely limited for indigenous populations throughout Central America.

Table 1. Reproductive Health Indicators for El Salvador, Guatemala, and Honduras

Table 1. Reproductive Health Indicators for El Salvador, Guatemala, and Honduras
Country Prevalence of contraceptive use (%) Fertility rate# Adolescent fertility rate Infant mortality rate Maternal mortality ratio§ Prevalence of pregnant women receiving prenatal care (%)ǁ Births attended by skilled birthing attendant (%)
El Salvador 72 1.9 66 14 54 96 98
Guatemala 54* 3.2 81 24 88 93* 63
Honduras 73 2.4 66 17 129 97 83

#Total fertility rate represents the average number of children born to a woman during her childbearing years
Number of births per 1,000 women ages 15-19
Number of infant deaths per 1,000 live births
§Number of maternal deaths per 100,000 live births
ǁPercentage of all pregnant women receiving prenatal care at least once during pregnancy by skilled health personnel

Source: World Bank HealthStats Databank 20, unless otherwise cited.
*UNICEF21

Sexual- and Gender-Based Violence

Sexual- and gender-based violence has been increasing throughout Central America and Mexico. El Salvador, Guatemala, and Honduras report extremely high rates of femicide, with rates up to five times higher than overall homicide rates in the majority of Northern, Western, and Southern European countries 22. Gangs and other armed criminal groups often perpetrate violence against women, and domestic violence throughout Central America is widespread 23. In Honduras, 16,000 allegations of violence against women were registered in 2012, with 74% relating to domestic or interfamily violence, and 20% relating to sex crimes 24.

Medical Screening of US-Bound Refugees

Overseas Medical Examination

As overseas medical examination is mandatory for all refugees coming to the United States and must be performed according to the CDC’s Technical Instructions for overseas medical examinations. The overseas medical examination is performed by panel physicians selected by the U.S. Department of State. CDC provides the regulatory and technical oversight and training for all panel physicians. The purpose of the medical examination is to identify applicants with inadmissible health-related conditions.

Central American refugees and parolees admitted through the CAM program receive medical assessments from panel physicians before arrival in the United States (Figure 3). As this program is relatively new, additional components of the medical screening may be added as more individuals are approved for resettlement. Those entering under different mechanisms do not receive medical assessments by panel physicians before entry.

Information collected during the overseas medical examination is reported to the Electronic Disease Notification system (EDN) and is available to state refugee health programs in the states where the refugees are resettled. Refugees are not required to receive any vaccines before they are admitted into the United States.

Figure 3: Medical Assessment of United States-bound Central American Refugees

* Class B1 TB refers to tuberculosis fully treated by directly observed therapy, or abnormal chest x-ray with negative sputum smears and cultures, or extrapulmonary TB.

* Class B1 TB refers to tuberculosis fully treated by directly observed therapy, or abnormal chest x-ray with negative sputum smears and cultures, or extrapulmonary TB.

Pre-departure Medical Screening

If previously diagnosed with Class B1 TB (tuberculosis fully treated using directly observed therapy, or abnormal chest x-ray with negative sputum smears and cultures, or extrapulmonary TB), Central American refugees receive a pre-departure medical screening approximately 3 weeks before leaving for the United States.

Post-Arrival Medical Screening

CDC recommends that refugees receive a post-arrival medical screening (domestic medical examination) within 30 days of arrival in the United States. The Department of Health and Human Services’ Office of Refugee Resettlement (ORR) supports medical screening for those who have been granted refugee status. The purpose of these comprehensive examinations is to identify conditions for which refugees may not have been screened during their overseas medical examinations and to introduce refugees to the U.S. healthcare system. CDC provides guidelines and recommendations for the domestic medical examination of newly arrived refugees, which state health departments oversee and administer. State refugee health programs determine who conducts the examinations within their jurisdictions; these may be performed by health department personnel, private physicians, or federally qualified health centers (FQHCs). Most state health departments collect data from the screenings.

Health Information

Tension, fear, and uncertainty that can be triggered by chronic violence have lasting effects on physical and psychological health. Chronic distress, mental health conditions, hypertension, and depressed immune system can all stem from exposure to protracted violence 25. Additionally, fear and concerns regarding crime often deters people from using healthcare and other critical services, which are largely concentrated in urban areas and difficult to access for rural populations 16, 26.

This section describes health conditions, with a focus on infectious diseases, for which Central American children from El Salvador, Guatemala, and Honduras are at significant risk. Where applicable and available, screening or pre-departure interventions are described.

The American Academy of Pediatrics (AAP) Immigrant Toolkit, Section on Clinical Care reviews diseases and conditions that are prevalent in immigrant populations. The AAP Immigrant Toolkit also provides medical screening and treatment recommendations for immigrants and refugees from resource-poor areas of developing countries, including countries in Central America 27. For more information please see AAP.external icon

Infectious and Communicable Diseases

Arboviruses: Dengue, Chikungunya, and Zika Viruses

Dengue, chikungunya, and Zika viruses cause mosquito-borne infections of increasing concern in El Salvador, Guatemala, and Honduras. Dengue fever is endemic throughout much of Central and South America. However, chikungunya first arrived in this region in 2014 after appearing in the Caribbean in 2013. Currently, local chikungunya transmission is occurring in more than 45 countries and territories in the Americas, including El Salvador, Guatemala, and Honduras 28, 29. Active Zika virus transmission has been reported throughout Central America, including El Salvador, Guatemala, and Honduras 30.

Acute dengue, chikungunya, and Zika infections have similar presentations and may be clinically indistinguishable. Common symptoms include fever, headache, severe myalgia, arthralgia, joint swelling, and rash. Chikungunya is unique in that it may cause persistent joint inflammation for months, and sometimes years, even after acute symptoms have resolved. Chikungunya should be considered in those with chronic rheumatologic symptoms from areas of local transmission. Dengue is unique because reinfection with another dengue virus can cause a condition called severe dengue. Severe dengue can be fatal if not properly treated in a timely manner. With good medical management, mortality due to severe dengue can be less than 1%. Severe dengue is more likely when an individual returns to a disease-endemic area and unlikely in a newly arriving refugee. Zika may be associated with conjunctivitis and other symptoms that are generally less severe than dengue and chikungunya. Zika virus infection is frequently asymptomaticexternal icon . Despite the relatively benign nature of acute infection, Zika has recently been associated with an increased risk of Guillain-Barré syndrome, and birth defects (e.g., microcephaly) when acquired during pregnancy 31, 32. CDC has posted interim screening guidelines for infants with microcephaly and possible Zika infection. Clinical presentation of these infections during the domestic screening visit is unlikely since the incubation period is generally short, with symptoms often resolving within 10 days of exposure.

Hepatitis B Virus Infection

The prevalence of chronic hepatitis B virus infection in Central American children arriving in the United States is unknown. However, recent data suggest that the general prevalence in El Salvador, Honduras, and Guatemala is low (<2%). In addition, all three countries include a birth dose of hepatitis B vaccine in their national immunization schedules. Therefore, it is reasonable to conduct targeted screening for chronic hepatitis B virus infection in at-risk individuals including:

  • Known or suspected IV drug users
  • Men who have sex with men
  • People with tattoos
  • Pregnant women
  • Children of mothers with known hepatitis B virus infection
  • Household contacts of infected individuals
  • HIV- or hepatitis C-infected individuals
  • Children who received whole blood products or blood components before immigration
  • Children with a history of known or possible sexual exploitation

Children should complete the 3-dose hepatitis B vaccine series if no official documentation of prior completion is available.

For further information, see the domestic hepatitis B screening guidance for refugees.

Sexually Transmitted Infections (HIV, Syphilis, Gonorrhea, etc.)

HIV screening is not required for refugees before resettlement to the United States. However, HIV screening should be offered to all refugees, in accordance with existing domestic refugee screening guidance for HIV developed by CDC. Although HIV prevalence is relatively low in Central America, minors arriving from El Salvador, Guatemala, and Honduras should be screened, as maternal HIV status is likely unknown and vertical transmission is possible. No data are available regarding the prevalence of syphilis, gonorrhea, and chlamydia. Syphilis and gonorrhea screening is done per current CDC technical instructions on all refugees 15 years or older. Any patient, regardless of age, should be tested for syphilis, gonorrhea, or chlamydia if symptomatic or if there is a history of or concern about possible sexual activity or exploitation.

Tuberculosis

El Salvador reported 2,206 new and relapsed cases of tuberculosis in 2014, and a prevalence of 49 cases per 100,000 population33. Within El Salvador, six new cases of multidrug-resistant (MDR) tuberculosis were confirmed in 2014 33. Guatemala and Honduras both reported higher numbers of cases and prevalence rates than El Salvador. Guatemala and Honduras reported 3,163 and 2,820 new and relapsed cases, respectively 34, 35. Tuberculosis prevalence was 106 per 100,000 population in Guatemala, and 49 per 100,000 population in Honduras in 2014 34, 35. Additionally, 79 new cases of MDR TB were reported in Guatemala and 38 new cases of MDR TB were reported in Honduras for 2014 34, 35.

Refugee children are screened for TB infection. Any child with known latent tuberculosis infection (LTBI) at the time of arrival should be offered LTBI treatment. In addition, those without documentation of LTBI screening should be tested, with treatment offered to those who test positive.

For additional information regarding tuberculosis, see the World Health Organization Tuberculosis Profileexternal icon.

Parasitic Infections

Chagas Disease

Approximately 10% of Chagas disease cases in the Americas are found in Central America36. El Salvador, Guatemala, and Honduras are uniformly affected, with approximately 200,000 cases per country 37. Chagas disease is caused by the parasite Trypanosoma cruzi and is most commonly transmitted through contact with the feces of an infected triatomine insect (“kissing bug”). Transmission can also occur when humans are bitten by infected triatomines (CDC Chagas Disease). Reports of congenital and post-transplant infections, as well as infection after consumption of contaminated food and drink, although rare, have also been documented.

Chagas disease has an acute and chronic phase. Acute infection may be asymptomatic or may be characterized by nonspecific symptoms such as malaise, fever, and anorexia. Swelling may be observed around the site where the parasite entered the body. If left untreated, acute infection is lifelong and can lead to severe complications in 20-30% of patients. Severe complications may include heart rhythm abnormalities that can lead to sudden death, dilated heart, and dilated esophagus or colon. Chronic Chagas disease is considered to be the most common cause of nonischemic heart disease in Central America and may cause cardiomyopathy years after initial infection 36. However, the majority of people will be asymptomatic and unaware of infection, and few parasites are found in the blood. At this time, routine screening is not recommended for Central American children 38.

Giardiasis

Giardiasis is a common infection in all refugee populations. Routine screening of asymptomatic individuals is not recommended, as there is no evidence that screening and treatment are beneficial in these cases. However, giardia infection can be associated with mild symptoms such as abdominal discomfort, loose stool, flatulence, and eructation. In addition, it has been associated with failure to thrive in children. As young children may not verbalize symptoms or express overt signs of the disease, it is reasonable to screen children, particularly those under 5 years old. When screening is performed, stool antigen testing is the preferred method, as it is more sensitive and convenient than stool ova and parasite examination.

Malaria

Although malaria is endemic to El Salvador, Guatemala, and Honduras, the prevalence is not high enough to justify routine screening or presumptive treatment. The malaria species predominantly found in these countries is Plasmodium vivax, also known as relapsing malaria. This form of malaria may become dormant in the liver and reactivate months and even years after exposure, causing clinical disease. As such, clinicians should consider malaria in the differential diagnosis with a patient with symptoms associated with malaria, such as fever, even if exposure to malaria was not recent. For further and updated information, see the domestic screening guidance for malaria in refugees.

Soil-transmitted Helminths (STH)

People living in extreme poverty, including indigenous populations in El Salvador, Guatemala, and Honduras, are at high risk for neglected tropical diseases, including STH (mainly ascariasis, trichuriasis, and hookworm) 39. Guatemala is known to have the highest rate of STH infections in Central America 40. Children from El Salvador, Guatemala, and Honduras require periodic deworming campaigns due to significant STH endemicity, with 300,000 children treated in El Salvador and 1.1 million children treated in Guatemala and Honduras annually 41. However, STH surveillance data in Central America is limited 42.

Children from El Salvador, Guatemala, and Honduras do not receive presumptive STH treatment before departure. Upon arrival in the United States, these children should be presumptively treated with albendazole, or tested and then treated. It is necessary to check three ova and parasite stool samples collected 12-24 hours apart in order to identify STH infection and treat appropriately.

Strongyloides stercoralis

Available data on Strongyloides prevalence in Central America are limited. Similarly, no data are available on the prevalence of Strongyloides infections in U.S. immigrants and refugees from Central America 43. It is prudent to presumptively treat or screen for Strongyloides according to current CDC guidelines.

Taeniasis

Taeniasis in humans, caused by Taenia solium (pork tapeworm) and Taenia saginata (beef tapeworm), is endemic in Central America; however, surveillance data is limited 44. Infections are spread by ingestion of undercooked beef or pork, or ingestion of cysts directly via oral-fecal contamination. Most infections are asymptomatic; however, some patients may have nausea, anorexia, or epigastric pain. Taenia solium is the cause of cysticercosis and neurocysticercosis 45. In a 2011 house-to-house survey in rural Honduras, neurocysticercosis was the leading cause of seizures, accounting for 13% of cases 46.

Hymenelopis nana tapeworm infection is endemic in Guatemala and is presumed to be present in other Central American countries 47. Although infection is often asymptomatic, it may cause abdominal pain, diarrhea, anorexia, and anal pruritus. Hymenelopis nana is spread is via oral-fecal contamination, and infection is most common in children 48.

Tapeworm infection is diagnosed using stool ova and parasite testing. Testing three stool samples collected 12-24 hours apart increases sensitivity. Tapeworm is treated with praziquantel, with the type of tapeworm dictating the dosage and duration of treatment 49. However, if seizures or neurologic deficits of unknown cause are present, neurocysticercosis must be ruled out using neuroimaging before treatment with praziquantel.

All Central American children should have a complete blood count (CBC) with differential to evaluate for eosinophilia (absolute eosinophil count ≥400). The differential diagnosis for an increased eosinophil count is broad and should include parasitic infections for this population. It should be noted that not all parasitic infections cause eosinophilia. Please refer to CDC guidelines for presumptive treatment options or further evaluation, as clinically indicated.

Neurocysticercosis infection can cause seizures and neurologic deficits. Treatment of a person with neurocysticercosis with albendazole and praziquantel can cause adverse effects such as provoking or worsening seizures. Therefore, any child with a known history of neurologic deficit or seizures should not receive albendazole or praziquantel until neurocysticercosis infection has been ruled out or should be done in consultation with an infectious disease expert.

Non-Communicable Diseases (NCDs)

El Salvador, Guatemala, and Honduras do not maintain national non-communicable disease registries. However, over the past 25 years, chronic illnesses such as cardiovascular disease, cancer, type 2 diabetes, and chronic respiratory diseases have replaced communicable diseases as the most common causes of death. Rates of adult obesity, hypertension, and tobacco use are similar in all three countries. Communicable diseases continue to be the primary cause of mortality for children under 5 years old. Neonatal and maternal mortality are high, with elevated teen pregnancy rates and lack of prenatal and perinatal care as likely contributing factors. Deaths related to road traffic accidents and violence have noticeably increased in recent years 50, 51, 52, 53.

Anemia

Anemia is common in El Salvador, Guatemala, and Honduras. The prevalence in children under 5 years old is 30%, 47%, and 40%, respectively, in these countries 54, 55, 56. Pregnant women also have been noted to have high prevalence of anemia, particularly in Guatemala, where 22% of pregnant women are anemic 57, 58. Iron deficiency due to poor nutrition or chronic parasitic infection (which can cause indolent blood loss) is the chief etiology of anemia. However, many other conditions may contribute to anemia, such as lead exposure, untreated chronic disease, and hemoglobinopathies. Arriving children should be screened for anemia with a complete blood count. Please see the CDC Summary Checklist for the Domestic Medical Examination for Newly Arriving Refugees for further guidance.

Dental Caries

It should be presumed that most children have had little, if any, dental care, preventive or otherwise, before arrival in the United States. Preventive fluoride varnish should be applied in all children from first tooth eruption through 5 years of age (up to four applications per year, depending on state guidelines) 59. Children should be referred for dental care as soon as possible after arrival 60.

Developmental Delays

Access to medical care in Central America is often limited 61, and studies show a lag in diagnosis of developmental delays among non-English speaking children in the United States 62. It is important that children receive appropriate developmental screening at recommended intervals using screening tools that have been validated in Spanish-speaking populations 63. If delays are identified, children should be referred for home-based or school-based early intervention services.

All children should have age-appropriate vision (ages 3 years and over) and hearing (ages 4 years and over—and at any age if the child is noted to have speech or developmental delays) screens to rule out deficits that could significantly impact development and learning 64.

El Salvador, Guatemala, and Honduras do not have national newborn screening programs for life-threatening, treatable medical conditions. U.S. providers should follow state-specific guidelines for newborn screening in immigrant and refugee infants 65. If no state-specific guidelines exist, newborn metabolic screening should be considered for infants <6 months of age. For children between 6 months and 3 years old, thyroid function testing is reasonable.

Lead Exposure

Lead poisoning has been reported among children in Central America as a result of exposure to home remedies, lead-glazed ceramics, and industrial contamination 66. A study in 337 Honduran school-aged children (median age 7.2 years) evaluated blood lead levels. Of these, 19.6% had elevated blood lead levels (>5 ug/dl)67. Additionally, in one El Salvadoran city where lead acid car batteries are manufactured and disposed of, thousands of residents, both children and adults, were chronically exposed to lead 68. Of note, anemia and malnutrition, both common among children in Central America, increase lead absorption.

All infants and children (6 months to 16 years old), as well as pregnant teens, should be screened for elevated lead levels. Elevated lead in pregnant women increases the risk for spontaneous abortion, low birth weight infants, and developmental delays in infants with significant exposures in utero69. Given the risk for persistent lead exposure in the United States, it is recommended to repeat lead testing 3-6 months after arrival for infants and children (6 months to 59 months of age), and for older children with extended exposure history. Please see CDC Refugee Tool Kit for guidelines for lead poisoning prevention among newly arrived refugee children for further information.

Nutrition

El Salvador, Guatemala, and Honduras have reported high rates of low birth weight in infants (birth weight <2,500g), as well as high rates of malnutrition among infants and children. However, there is an increasing prevalence of overweight and obesity among older children, teens, and adults. This paradox of poor nutrition in early childhood followed by obesity in older children and adults has been described as the “double burden” of malnutrition faced in many developing countries.

Malnutrition

Inequalities and extreme poverty directly affect food security and nutrition, particularly in rural areas of El Salvador. It is estimated that 16.3% of rural Salvadoran families are unable to cover the costs of basic food needs 73. Additionally, 18.9% of all children under age 5 experience chronic undernutrition, with 25.6% of children living in rural regions experiencing chronic undernutrition 73. Overall, approximately 21% of Salvadoran children are stunted, while 6% are underweight, and 2% are wasted 54, 74. It is estimated that malnutrition contributes to more than 30% of all childhood deaths, as chronic undernutrition is known to increase severity of disease 54. Micronutrient deficiencies, including vitamin A deficiency, are also common in young children 54.

Rural, indigenous populations in Guatemala are often the impacted by food and economic insecurities. Guatemala has the third-highest rate of stunting, or chronic malnutrition, worldwide 55, 75. Indigenous populations are disproportionately affected and suffer from malnutrition at twice the rate of non-indigenous children 55, 74. Approximately 49.8% of all Guatemalan children are undernourished, while 69.5% of children in rural, indigenous areas are undernourished 76. Micronutrient deficiencies are relatively common in Guatemala. A multiyear study revealed that 16% of preschool children are vitamin A deficient 77. Iodine deficiency has also been observed, and it is reported that less than 50% of families use iodized salt 55.

Poverty is widespread in Honduras, with 75% of the population living in extreme poverty and 12% of households being food-insecure 78, 79. As in other Central American nations, stunting and malnutrition remain major concerns, particularly for children living in rural areas. Up to 50% of children in some regions are stunted, and children living in rural areas are 2.5 times more at risk for growth faltering than children who live in urban areas 56. Additionally, children in the poorest households are eight times more likely to be stunted than children born to wealthy families 56. Chronic malnutrition can be as high as 48.5% in some rural areas 78. Micronutrient deficiencies, including vitamin A and iron deficiencies, are common in Honduras and are often observed in young children and pregnant women 56

All children between 6 months and 59 months old should be prescribed multivitamins with iron. Older children who are malnourished should also take multivitamins for presumed micronutrient deficiency.

Overweight and Obesity

Although stunting and malnutrition affect large numbers of children in El Salvador, Guatemala, and Honduras, overweight and obesity are growing problems. In Latin America, it is estimated that between 42.5 and 51.8 million children aged 0-18 years are overweight or obese 80. Studies indicate that 5% to 6.5%, 13%, and 7.1% of children under 5 years old are overweight or obese in El Salvador, Guatemala, and Honduras, respectively 81. To date, few countries have implemented national programs or policies to combat the obesity epidemic in Latin America 80.

Overweight and obesity are also increasing among adults, with up to 60% of adults in some Latin American countries classified as overweight or obese 82. Furthermore, models predict increases in overweight and obesity in Latin American females and males by 2050 82. Recent studies indicate that 67% of Guatemalans over 15 years old are overweight, of which 29% of those overweight are obese 55, 83. In Honduras, 46% of all people 15 years and over are either overweight or obese 56, 83, while 49% of adults in El Salvador are either overweight or obese 54, 84. Overweight and obesity, for both children and adults, are largely due to rapid urbanization, adoption of modern Western diets high in refined carbohydrates, saturated fats, and sugars, and increasingly sedentary lifestyles. Additionally, slow progress in improving community infrastructure and public health systems have contributed to overweight and obesity epidemics 54, 55, 56, 85.

Children who are overweight (BMI 85th-95th percentile) or obese (BMI >95 percentile) should be followed closely. Overweight or obese children, as well as their family members, should be offered dietary counseling and support 86. All children, regardless of nutrition status, should have blood pressure checked starting at 3 years old and followed annually 87. Fact sheets and other health promotional materials for healthy eating and physical activity should be shared with all newly arrived patients and family members, regardless of nutritional status upon arrival.

See CDC nutrition-growth guidance for further recommendations and guidelines regarding nutritional assessment and management among newly arrived refugee children.

Mental Health

It can be assumed that the vast majority of children arriving through the CAM program will have experienced some form of significant trauma in their lifetime. These children come from Central American countries with homicide rates ranking among the top five worldwide, high poverty rates, and widespread gang violence. Violence toward women, often perpetuated by gangs and armed criminal groups, has been widely documented. In a 2013 United Nations study, 400 unaccompanied children from El Salvador, Guatemala, Honduras, and Mexico were interviewed. When asked why they had decided to migrate to the United States alone, nearly half (48%) said they left their home country due to escalating violence. Additionally, 81% cited family or opportunities available, 21% reported abuse in the home, and 16% cited situations of deprivation as factors that contributed to their migration 70.

Access to inpatient and outpatient mental health services is very limited. A report from the Pan American Health Organization (PAHO) found that only 363 Guatemalan patients were able to access national outpatient mental health facilities, of whom 58% were women, and 14% were children or teens. Of those treated, anxiety disorders were the most common diagnoses 71. Due to limited access to outpatient and inpatient psychiatric treatment in El Salvador, Guatemala, and Honduras, it is difficult to determine the prevalence and types of mental health issues among children and adults.

Once in the United States, these refugee children must adapt to a new physical environment and culture. Leaving behind family and loved ones in their home country and adapting to life in the United States, coupled with the stress associated with being alone and potentially reuniting with unfamiliar or unknown relatives, can have severe consequences. These factors increase the risk for depression, anxiety, PTSD, substance abuse, and homelessness 72. Therefore, it is important to evaluate these children for mental health issues at initial screening and on an ongoing basis through frequent visits with appropriately trained mental health and primary care providers.