Mask wearing is a critical mitigation strategy in preventing the introduction and spread of SARS-CoV-2, the virus that causes coronavirus 2019 (COVID-19), within school settings. In October 2020, a sample of 3,953 middle and high school students aged 13–21 years who were attending in-person classes were asked about mask use by fellow students in several settings. Approximately 65% of students reported that fellow students wore a mask “all the time” in the classroom and in hallways or stairwells. However, reported use of masks all the time was lower in other indoor locations, including school buses (42%), restrooms (40%), and the cafeteria (when not eating) (36%). Reported observed mask use all the time was lowest during sports or extracurricular activities (28%) and outside on school property (25%).

CONTEXT: A trained and diverse public health workforce is needed to respond to public health threats. The Epidemic Intelligence Service (EIS) is an applied epidemiology training program. Most EIS officers are from the United States, but some are from other countries and bring unique perspectives and skills. OBJECTIVES/EVALUATION: To characterize international officers who participated in the EIS program and describe their employment settings after training completion. DESIGN: International officers were people who participated in EIS and who were not US citizens or permanent residents. We analyzed data from EIS's application database during 2009-2017 to describe officers' characteristics. We used data from the Centers for Disease Control and Prevention's (CDC's) workforce database for civil servants and EIS exit surveys to describe jobs taken after program completion. MAIN OUTCOME MEASURES: We described the characteristics of the international officers, jobs taken immediately after program completion, and duration of employment at CDC. RESULTS: Among 715 officers accepted in EIS classes of 2009-2017, 85 (12%) were international applicants, with citizenships from 40 different countries. Forty (47%) had 1 or more US postgraduate degrees, and 65 (76%) were physicians. Of 78 (92%) international officers with available employment data, 65 (83%) reported taking a job at CDC after program completion. The remaining took a public health job with an international entity (6%), academia (5%), or other jobs (5%). Among 65 international officers who remained working at CDC after graduation, the median employment duration was 5.2 years, including their 2 years in EIS. CONCLUSIONS: Most international EIS graduates remain at CDC after program completion, which strengthens the diversity and capacity of CDC's epidemiological workforce. Further evaluations are needed to determine the effects of pulling away crucial talent from other countries needing experienced epidemiologists and to what extent retaining those persons can benefit public health globally.

Since 1951, the Epidemic Intelligence Service (EIS) of the U.S. Centers for Disease Control and Prevention (CDC) has trained physicians, nurses, scientists, veterinarians, and other allied health professionals in applied epidemiology. To understand the program's effect on graduates' leadership outcomes, we examined the EIS alumni representation in five select leadership positions. These positions were staffed by 353 individuals, of which 185 (52%) were EIS alumni. Among 12 CDC directors, four (33%) were EIS alumni. EIS alumni accounted for 29 (58%) of the 50 CDC center directors, 61 (35%) of the 175 state epidemiologists, 27 (56%) of the 48 Field Epidemiology Training Program resident advisors, and 70 (90%) of the 78 Career Epidemiology Field Officers. Of the 185 EIS alumni in leadership positions, 136 (74%) were physicians, 22 (12%) were scientists, 21 (11%) were veterinarians, 6 (3%) were nurses, and 94 (51%) were assigned to a state or local health department. Among the 61 EIS alumni who served as state epidemiologists, 40 (66%) of them were assigned to a state or local health department during EIS. Our evaluation suggests that epidemiology training programs can serve as a vital resource for the public health workforce, particularly given the capacity strains brought to light by the COVID-19 pandemic.

Soil-transmitted helminth (STH) infections and diarrheal illness affect billions of people yearly. We conducted a cross-sectional survey in Nueva Santa Rosa, Guatemala to identify factors associated with STH infections and diarrhea using univariable and multivariable logistic regression models. On multivariable analyses, we found associations between STH infections and two factors: school-aged children (odds ratio (OR) vs. adults: 2.35, 95% CI 1.10–4.99) and household drinking water supply classified as ‘other improved’ (OR vs. ‘improved’: 7.00, CI 1.22–40.14). Finished floors in the household vs. natural floors were highly protective (OR 0.16, CI 0.05–0.50) for STH infection. In crowded households (>2.5 people/bedroom), observing water present at handwashing stations was also protective (OR 0.32, CI 0.11–0.98). When adjusted for drying hands, diarrhea was associated with preschool-age children (OR vs. adults: 3.33, CI 1.83–6.04), spending >10 min per round trip collecting water (OR 1.90, CI 1.02–3.56), and having a handwashing station ≤10 m near a sanitation facility (OR 3.69, CI 1.33–10.21). Our study indicates that familiar WASH interventions, such as increasing drinking water quantity and water at handwashing stations in crowded homes, coupled with a hygiene intervention like finished flooring may hold promise for STH and diarrhea control programs. © 2021 The Authors.

BACKGROUND: Diarrhea is a major cause of morbidity and mortality, yet incidence and etiology data are limited. We conducted laboratory-based diarrhea surveillance in Guatemala. METHODS: A diarrhea case was defined as >/=3 loose stools in a 24-h period in a person presenting to the surveillance facilities. Epidemiologic data and stool specimens were collected. Specimens were tested for bacterial, parasitic, and viral pathogens. Yearly incidence was adjusted for healthcare seeking behaviors determined from a household survey conducted in the surveillance catchment area. RESULTS: From November 2008 to December 2012, the surveillance system captured 5331 diarrhea cases; among these 1381 (26%) had specimens tested for all enteric pathogens of interest. The adjusted incidence averaged 659 diarrhea cases per 10,000 persons per year, and was highest among children aged < 5 years, averaging 1584 cases per 10,000 children per year. Among 1381 (26%) specimens tested for all the pathogens of interest, 235 (17%) had a viral etiology, 275 (20%) had a bacterial, 50 (4%) had parasites, and 86 (6%) had co-infections. Among 827 (60%) specimens from children aged < 5 years, a virus was identified in 196 (23%) patients; 165 (20%) had norovirus and 99 (12%) rotavirus, including co-infections. Among 554 patients aged >/=5 years, 103 (19%) had a bacterial etiology, including diarrheagenic Escherichia coli in 94 (17%) cases, Shigella spp. in 31 (6%), Campylobacter spp. in 5 (1%), and Salmonella spp. in 4 (1%) cases. Detection of Giardia and Cryptosporidium was infrequent (73 cases; 5%). CONCLUSIONS: There was a substantial burden of viral and bacterial diarrheal diseases in Guatemala, highlighting the importance of strengthening laboratory capacity for rapid detection and control and for evaluation of public health interventions.

CONTEXT: Public health has a responsibility to ensure the ability of its workforce to deliver essential services, including mastering the core public health competencies. PROGRAM: The Division of Scientific Education and Professional Development (DSEPD) of the Centers for Disease Control and Prevention has a mission to improve health outcomes through a competent, sustainable, and empowered public health workforce. The DSEPD programs offer fellowships and other training opportunities, develop and disseminate quality public health training, and advance public health workforce development science. EVALUATION: The DSEPD developed a unified division logic model to describe the combined activities and intended outcomes of all DSEPD programs and their intended contribution to a robust public health workforce and to support ongoing program planning and evaluation. The logic model has 4 streams of work that include (1) producing and disseminating quality learning products; (2) implementing and managing fellowship programs that support learning; (3) providing public health service through fellows; and (4) advancing workforce development science through collaboration with other public health leaders.The underlying program theory is that a robust workforce has sufficient workforce, organizational, and systems capacity to deliver public health essential services and, therefore, to protect the public's health. Three scientific theories support the program theory: the quality of learning; the accepted practice of competency-based programs and the service-learning model; and use of evidence-guided decision making in workforce development programs. DISCUSSION: A unified division logic model allows DSEPD to describe its combined approaches to workforce development as a coherent portfolio with well-defined goals and measureable outcomes. The logic model effectively communicates the relationship among division programs, their shared outcomes, and their combined contributions to developing and maintaining a robust public health workforce. A unified logic model can serve as effective frame of reference for division evaluation and as evidence in public health workforce development science.

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Background: We describe the epidemiology and antimicrobial susceptibility patterns of culture-confirmed Shigella infections in facility-based surveillance sites in Guatemala. Current studies using quantitative molecular diagnostics suggest Shigella may contribute most to the global diarrheal disease burden. Since identification of Shigella requires culturing techniques using stool specimens and few laboratories in Guatemala routinely culture for this pathogen, little is known about the true burden of Shigella in Guatemala or, importantly, the antimicrobial resistance patterns. Methods: Clinical, epidemiological, and laboratory data were collected on 5399 patients with acute diarrhea (≥3 loose stools in 24 h) from June 2007-August 2012. Multidrug resistance (MDR) was defined as resistance to ampicillin and trimethoprim/sulfamethoxazole. Results: Five percent (261) of stool specimens yielded Shigella spp. The annual incidence of laboratory-confirmed infections ranged from 5.0 to 24.1 per 100,000 persons in Santa Rosa and 0.3 to 6.2 per 100,000 in Quetzaltenango; 58% of cases occurred in children < 5 years of age. Thirty patients were hospitalized; one patient died. Oral rehydration or intravenous solution was used to treat 72% of hospitalized and 15% of ambulatory cases. Fifty-nine percent of cases were S. flexneri and 51% of cases were MDR. Conclusions: Shigella is an important cause of bacterial diarrhea in children and prevalence of MDR highlights the importance of appropriate treatment regimens. This study demonstrates that strengthening laboratory capacity in Guatemala can help determine causes which can lead to prevention of diarrheal diseases, particularly in children. Such capacity building is also critical for rapid detection and control of public health threats at their source and therefore for global health security.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Improved water quality reduces diarrhea, but the impact of improved water quality on Ascaris and Trichuris, soil-transmitted helminths (STH) conveyed by the fecal-oral route, is less well described. To assess water quality associations with diarrhea and STH, we conducted a cross-sectional survey in households of south-eastern Guatemala. Diarrhea was self-reported in the past week and month. STH was diagnosed by stool testing using a fecal parasite concentrator method. We explored associations between Escherichia coli-positive source water (water quality) and disease outcomes using survey logistic regression models. Overall, 732 persons lived in 167 households where water was tested. Of these, 79.4% (581/732) had E. coli-positive water, 7.9% (58/732) had diarrhea within the week, 14.1% (103/732) had diarrhea within the month, and 6.6% (36/545) tested positive for Ascaris or Trichuris, including 1% (6/536) who also reported diarrhea. Univariable analysis found a statistically significant association between water quality and STH (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.1-24.5) but no association between water quality and diarrhea. Waterborne transmission and effects of water treatment on STH prevalence should be investigated further. If a causal relationship is found, practices such as household water treatment including filtration might be useful adjuncts to sanitation, hygiene, and deworming in STH control programs.

Background. Lead exposure is linked to intellectual disability and anemia in children. The United States Centers for Disease Control and Prevention (CDC) recommends biomonitoring of blood lead levels (BLLs) in children with BLL ≥5 μg/dL and chelation therapy for those with BLL ≥45 μg/dL. Objectives. This study aimed to determine blood and environmental lead levels and risk factors associated with elevated BLL among children from Owino Uhuru and Bangladesh settlements in Mombasa County, Kenya. Methods. The present study is a population-based, cross-sectional study of children aged 12-59 months randomly selected from households in two neighboring settlements, Owino Uhuru, which has a lead smelter, and Bangladesh settlement (no smelter). Structured questionnaires were administered to parents and 1-3 ml venous blood drawn from each child was tested for lead using a LeadCare ® II portable analyzer. Environmental samples collected from half of the sampled households were tested for lead using graphite furnace atomic absorption spectroscopy. Results: We enrolled 130 children, 65 from each settlement. Fifty-nine (45%) were males and the median age was 39 months (interquartile range (IQR): 30-52 months). BLLs ranged from 1 μg/dL to 31 μg/dL, with 45 (69%) children from Owino Uhuru and 18 (28%) children from Bangladesh settlement with BLLs > 5 μg/dL. For Owino Uhuru, the geometric mean BLL in children was 7.4 μg/dL (geometric standard deviation (GSD); 1.9) compared to 3.7 μg/ dL (GSD: 1.9) in Bangladesh settlement (p < 0.05). The geometric mean lead concentration of soil samples from Owino Uhuru was 146.5 mg/Kg (GSD: 5.2) and 11.5 mg/Kg (GSD: 3.9) (p < 0.001) in Bangladesh settlement. Children who resided < 200 m from the lead smelter were more likely to have a BLL ≧5 μg/dL than children residing ≥200 m from the lead smelter (adjusted odds ratio (aOR): 33.6 (95% confidence interval (CI): 7.4-153.3). Males were also more likely than females to have a BLL ≧5 μg/dL (39, 62%) compared to a BLL < 5 μg/dL [aOR: 2.4 (95% CI: 1.0-5.5)]. Conclusions. Children in Owino Uhuru had significantly higher BLLs compared with children in Bangladesh settlement. Interventions to diminish continued exposure to lead in the settlement should be undertaken. Continued monitoring of levels in children with detectable levels can evaluate whether interventions to reduce exposure are effective. Participant Consent. Obtained Ethics Approval. Scientific approval for the study was obtained from the Ministry of Health, lead poisoning technical working group. Since this investigation was considered a public health response of immediate concern, expedited ethical approval was obtained from the Kenya Medical Research Institute and further approval from the Mombasa County Department of Health Services. The investigation was considered a non-research public health response activity by the CDC. Competing Interests. The authors declare no competing financial interests.

Background: Acute gastroenteritis (AGE) is a leading infectious cause of morbidity worldwide, particularly among children in developing countries. With the decline of rotavirus disease rates following introduction of rotavirus vaccines, the relative importance of norovirus will likely increase. The objectives of this study were to determine the incidence and clinical profile of norovirus disease in Guatemala. Methods: We analyzed data from a population-based surveillance study conducted in Guatemala from 2008-2013. Demographics information, clinical data, and stool samples were collected from patients presenting with AGE (>/=3 liquid stools within 24-hours that initiated 7 days before presentation). Estimated incidence of hospitalized, outpatient, and total community norovirus disease was calculated using surveillance data and household surveys of healthcare utilization. Results: We included 999 AGE hospitalizations and 3,189 AGE outpatient visits at facilities, of which 164 (16%) and 370 (12%), respectively, were positive for norovirus. Severity of norovirus was milder than rotavirus. Community incidence of norovirus ranged between 2068-4954 per 100,000 person-years (py) in children <5 years of age. Children <5 years also had higher incidence of norovirus-associated hospitalization (51-105 per 100,000 py) compared with patients aged >/=5 years (0-1.6 per 100,000 py and 49-80 per 100,000 py, respectively). Conclusion: This study highlights the burden of norovirus disease in Guatemala, especially among young children. These data can help prioritize development of control strategies, including the potential use of vaccines, and provide a baseline to evaluate the impact of such interventions.

BACKGROUND: Malaria accounts for ~21% of outpatient visits annually in Kenya; prompt and accurate malaria diagnosis is critical to ensure proper treatment. In 2013, formal malaria microscopy refresher training for microscopists and a pilot quality-assurance (QA) programme for malaria diagnostics were independently implemented to improve malaria microscopy diagnosis in malaria low-transmission areas of Kenya. A study was conducted to identify factors associated with malaria microscopy performance in the same areas. METHODS: From March to April 2014, a cross-sectional survey was conducted in 42 public health facilities; 21 were QA-pilot facilities. In each facility, 18 malaria thick blood slides archived during January-February 2014 were selected by simple random sampling. Each malaria slide was re-examined by two expert microscopists masked to health-facility results. Expert results were used as the reference for microscopy performance measures. Logistic regression with specific random effects modelling was performed to identify factors associated with accurate malaria microscopy diagnosis. RESULTS: Of 756 malaria slides collected, 204 (27%) were read as positive by health-facility microscopists and 103 (14%) as positive by experts. Overall, 93% of slide results from QA-pilot facilities were concordant with expert reference compared to 77% in non-QA pilot facilities (p < 0.001). Recently trained microscopists in QA-pilot facilities performed better on microscopy performance measures with 97% sensitivity and 100% specificity compared to those in non-QA pilot facilities (69% sensitivity; 93% specificity; p < 0.01). The overall inter-reader agreement between QA-pilot facilities and experts was kappa = 0.80 (95% CI 0.74-0.88) compared to kappa = 0.35 (95% CI 0.24-0.46) between non-QA pilot facilities and experts (p < 0.001). In adjusted multivariable logistic regression analysis, recent microscopy refresher training (prevalence ratio [PR] = 13.8; 95% CI 4.6-41.4), ≥5 years of work experience (PR = 3.8; 95% CI 1.5-9.9), and pilot QA programme participation (PR = 4.3; 95% CI 1.0-11.0) were significantly associated with accurate malaria diagnosis. CONCLUSIONS: Microscopists who had recently completed refresher training and worked in a QA-pilot facility performed the best overall. The QA programme and formal microscopy refresher training should be systematically implemented together to improve parasitological diagnosis of malaria by microscopy in Kenya.

BACKGROUND: Globally, vaccine preventable diseases are responsible for nearly 20% of deaths annually among children <5 years old. Worldwide, many children dropout from the vaccination program, are vaccinated late, or incompletely vaccinated. We evaluated the impact of text messaging and sticker reminders to reduce dropouts from the vaccination program. METHODS: The evaluation was conducted in three selected districts in Kenya: Machakos, Langata and Njoro. Three health facilities were selected in each district, and randomly allocated to send text messages or provide stickers reminding parents to bring their children for second and third dose of pentavalent vaccine, or to the control group (routine reminder) with next appointment date indicated on the well-child booklet. Children aged <12 months presenting for their first dose of pentavalent vaccine were enrolled. A dropout was defined as not returning for vaccination ≥ 2 weeks after scheduled date for third dose of pentavalent vaccine. We calculated dropout rate as a percentage of the difference between first and third pentavalent dose. RESULTS: We enrolled 1,116 children; 372 in each intervention and 372 controls between February and October 2014. Median age was 45 days old (range: 31-99 days), and 574 (51%) were male. There were 136 (12%) dropouts. Thirteen (4%) children dropped out among those who received text messages, 60 (16%) among who received sticker reminders, and 63 (17%) among the controls. Having a caregiver with below secondary education [Odds Ratio (OR) 1.8, 95% Confidence Interval (CI) 1.1-3.2], and residing >5 km from health facility (OR 1.6, CI 1.0-2.7) were associated with higher odds of dropping out. Those who received text messages were less likely to drop out compared to controls (OR 0.2, CI 0.04-0.8). There was no statistical difference between those who received stickers and controls (OR 0.9, CI 0.5-1.6). CONCLUSION: Text message reminders can reduce vaccination dropout rates in Kenya. We recommend the extended implementation of text message reminders in routine vaccination services.

INTRODUCTION: Kenya adopted the Integrated Disease Surveillance and Response (IDSR) strategy in 1998 to strengthen disease surveillance and epidemic response. However, the goal of weekly surveillance reporting among health facilities has not been achieved. We conducted a cross-sectional study to determine the prevalence of adequate reporting and factors associated with IDSR reporting among health facilities in one Kenyan County. METHODS: Health facilities (public and private) were enrolled using stratified random sampling from 348 facilities prioritized for routine surveillance reporting. Adequately-reporting facilities were defined as those which submitted >10 weekly reports during a twelve-week period and a poor reporting facilities were those which submitted <10 weekly reports. Multivariate logistic regression with backward selection was used to identify risk factors associated with adequate reporting. RESULTS: From September 2 through November 30, 2013, we enrolled 175 health facilities; 130(74%) were private and 45(26%) were public. Of the 175 health facilities, 77 (44%) facilities classified as adequate reporting and 98 (56%) were reporting poorly. Multivariate analysis identified three factors to be independently associated with weekly adequate reporting: having weekly reporting forms at visit (AOR19, 95% CI: 6-65], having posters showing IDSR functions (AOR8, 95% CI: 2-12) and having a designated surveillance focal person (AOR7, 95% CI: 2-20). CONCLUSION: The majority of health facilities in Nairobi County were reporting poorly to IDSR and we recommend that the Ministry of Health provide all health facilities in Nairobi County with weekly reporting tools and offer specific trainings on IDSR which will help designate a focal surveillance person.

BACKGROUND: Streptococcus pneumoniae is a leading cause of pneumonia worldwide. However, the burden of pneumococcal pneumonia among adults in low- and middle-income countries is not well described. METHODS: Data from 2008-2012 was analyzed from two surveillance sites in Guatemala to describe the incidence of pneumococcal pneumonia in adults. A case of hospitalized pneumococcal pneumonia was defined as a positive pneumococcal urinary antigen test or blood culture in persons aged ≥ 18 years hospitalized with an acute respiratory infection (ARI). RESULTS: Among 1595 adults admitted with ARI, 1363 (82%) had either urine testing (n = 1286) or blood culture (n = 338) performed. Of these, 188 (14%) had pneumococcal pneumonia, including 173 detected by urine only, 8 by blood culture only, and 7 by both methods. Incidence rates increased with age, with the lowest rate among 18-24 year-olds (2.75/100,000) and the highest among ≥65 year-olds (31.3/100,000). The adjusted incidence of hospitalized pneumococcal pneumonia was 18.6/100,000 overall, with in-hospital mortality of 5%. CONCLUSIONS: An important burden of hospitalized pneumococcal pneumonia in adults was described, particularly for the elderly. However, even adjusted rates likely underestimate the true burden of pneumococcal pneumonia in the community. These data provide a baseline against which to measure the indirect effects of the 2013 introduction of the pneumococcal conjugate vaccine in children in Guatemala.

BACKGROUND: Bacterial pneumonia is a leading cause of illness and death worldwide, but quantifying its burden is difficult due to insensitive diagnostics. Although World Health Organization (WHO) protocol standardizes pediatric chest radiograph (CXR) interpretation for epidemiologic studies of bacterial pneumonia, its validity in adults is unknown. METHODS: Patients (age ≥15 years) admitted with respiratory infections to two Guatemalan hospitals between November 2007 and March 2012 had urine and nasopharyngeal/oropharyngeal (NP/OP) swabs collected; blood cultures and CXR were also performed at physician clinical discretion. 'Any bacterial infection' was defined as a positive urine pneumococcal antigen test, isolation of a bacterial pneumonia pathogen from blood culture, or detection of an atypical bacterial pathogen by polymerase chain reaction (PCR) of nasopharyngeal/oropharyngeal (NP/OP) specimens. 'Viral infection' was defined as detection of viral pathogens by PCR of NP/OP specimens. CXRs were interpreted according to the WHO protocol as having 'endpoint consolidation', 'other infiltrate', or 'normal' findings. We examined associations between bacterial and viral infections and endpoint consolidation. FINDINGS: Urine antigen and/or blood culture results were available for 721 patients with CXR interpretations; of these, 385 (53%) had endpoint consolidation and 253 (35%) had other infiltrate. Any bacterial infection was detected in 119 (17%) patients, including 106 (89%) pneumococcal infections. Any bacterial infection (Diagnostic Odds Ratio [DOR] = 2.9; 95% confidence Interval (CI): 1.3-7.9) and pneumococcal infection (DOR = 3.4; 95% CI: 1.5-10.0) were associated with 'endpoint consolidation', but not 'other infiltrate' (DOR = 1.7; 95% CI: 0.7-4.9, and 1.7; 95% CI: 0.7-4.9 respectively). Viral infection was not significantly associated with 'endpoint consolidation', 'other infiltrate,' or 'normal' findings. INTERPRETATION: 'Endpoint consolidation' was associated with 'any bacterial infection,' specifically pneumococcal infection. Therefore, endpoint consolidation may be a useful surrogate for studies measuring the impact of interventions, such as conjugate vaccines, against bacterial pneumonia.

Medical students have limited exposure to field epidemiology, even though will assume public health roles after graduation. We established a 10-week elective in field epidemiology during medical school. Students attended one-week didactic sessions on epidemiology, and nine weeks in field placement sites. We administered pre- and post-tests to evaluate the training. We enrolled 34 students in 2011 and 2012. In 2011, we enrolled five of 24 applicants from a class of 280 medical students. In 2012, we enrolled 18 of 81 applicants from a class of 360 students; plus 11 who participated in the didactic sessions only. Among the 34 students who completed the didactic sessions, 74% were male, and their median age was 24 years (range: 22-26). The median pre-test score was 64% (range: 47-88%) and the median post-test score was 82% (range: 72-100%). Successful completion of the field projects was 100%. Six (30%) students were not aware of public health as a career option before this elective, 56% rated the field experience as outstanding, and 100% reported it increased their understanding of epidemiology. Implementing an elective in field epidemiology within the medical training is a highly acceptable strategy to increase awareness for public health among medical students.

INTRODUCTION: Neural tube defects such as anencephaly, spina bifida, and encephalocele are congenital anomalies of the central nervous system. Data on the prevalence of neural tube defects in Kenya are limited. This study characterizes and estimates the prevalence of spina bifida and encephalocele reported in a referral hospital in Kenya from 2005-2010. METHODS: Cases were defined as a diagnosis of spina bifida or encephalocele. Prevalence was calculated as the number of cases by year and province of residence divided by the total number of live-births per province. RESULTS: From a total of 6,041 surgical records; 1,184 (93%) had reported diagnosis of spina bifida and 88 (7%) of encephalocele. Estimated prevalence of spina bifida and encephalocele from 2005-2010 was 3.3 [95% Confidence Interval (CI): 3.1-3.5] cases per 10,000 live-births. The highest prevalence of cases were reported in 2007 with 4.4 (95% CI: 3.9-5.0) cases per 10,000 live-births. Rift Valley province had the highest prevalence of spina bifida and encephalocele at 6.9 (95% CI: 6.3-7.5) cases per 10,000 live-births from 2005-2010. CONCLUSION: Prevalence of spina bifida and encephalocele is likely underestimated, as only patients seeking care at the hospital were included. Variations in regional prevalence could be due to referral patterns and healthcare access. Implementation of a neural tube defects surveillance system would provide a more thorough assessment of the burden of neural tube defects in Kenya.

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.

INTRODUCTION: Campylobacteriosis is one of the leading causes of gastroenteritis worldwide. This study describes the epidemiology of laboratory-confirmed Campylobacter diarrheal infections in two facility-based surveillance sites in Guatemala. METHODS: Clinical, epidemiologic, and laboratory data were collected on patients presenting with acute diarrhea from select healthcare facilities in the departments of Santa Rosa and Quetzaltenango, Guatemala, from January 2008 through August 2012. Stool specimens were cultured for Campylobacter and antimicrobial susceptibility testing was performed on a subset of isolates. Multidrug resistance (MDR) was defined as resistance to 3 antimicrobial classes. RESULTS: Campylobacter was isolated from 306 (6.0%) of 5137 stool specimens collected. For children <5years of age, annual incidence was as high as 1288.8 per 100,000 children in Santa Rosa and 185.5 per 100,000 children in Quetzaltenango. Among 224 ambulatory care patients with Campylobacter, 169 (75.5%) received metronidazole or trimethoprim-sulfamethoxazole, and 152 (66.7%) received or were prescribed oral rehydration therapy. Antimicrobial susceptibilities were tested in 96 isolates; 57 (59.4%) were resistant to ciprofloxacin and 12 (12.5%) were MDR. CONCLUSION: Campylobacter was a major cause of diarrhea in children in two departments in Guatemala; antimicrobial resistance was high, and treatment regimens in the ambulatory setting which included metronidazole and trimethoprim-sulfamethoxazole and lacked oral rehydration were sub-optimal.

Acute respiratory infections (ARI) are an important cause of illness and death worldwide, yet data on the etiology of ARI and the population-level burden in developing countries are limited. Surveillance for ARI was conducted at two hospitals in Guatemala. Patients admitted with at least one sign of acute infection and one sign or symptom of respiratory illness met the criteria for a case of hospitalized ARI. Nasopharyngeal/oropharyngeal swabs were collected and tested by polymerase chain reaction for adenovirus, parainfluenza virus types 1,2 and 3, respiratory syncytial virus, influenza A and B viruses, human metapneumovirus, Chlamydia pneumioniae, and Mycoplasma pneumoniae. Urine specimens were tested for Streptococcus pneumoniae antigen. Blood culture and chest radiograph were done at the discretion of the treating physician. Between November 2007 and December 2011, 3,964 case-patients were enrolled. While cases occurred among all age groups, 2,396 (60.4%) cases occurred in children <5 years old and 463 (11.7%) among adults ≥65 years old. Viruses were found in 52.6% of all case-patients and 71.8% of those aged <1 year old; the most frequently detected was respiratory syncytial virus, affecting 26.4% of case-patients. Urine antigen testing for Streptococcus pneumoniae performed for case-patients ≥15 years old was positive in 15.1% of those tested. Among 2,364 (59.6%) of case-patients with a radiograph, 907 (40.0%) had findings suggestive of bacterial pneumonia. Overall, 230 (5.9%) case-patients died during the hospitalization. Using population denominators, the observed hospitalized ARI incidence was 128 cases per 100,000, with the highest rates seen among children <1 year old (1,703 per 100,000), followed by adults ≥65 years old (292 per 100,000). These data, which demonstrate a substantial burden of hospitalized ARI in Guatemala due to a variety of pathogens, can help guide public health policies aimed at reducing the burden of illness and death due to respiratory infections.

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 <6 months (208 cases/10 000 persons per year); among adults, the greatest incidence was observed among those aged ≥65 years (2.9 cases/10 000 persons per year). The incidence of RSV-positive clinic visitation for ARI was 32 cases/10 000 persons per year and was highest among infants aged 6-23 months (186 cases/10 000 persons per year). Among RSV-positive hospital patients with ARI, underlying cardiovascular disease was associated with death, moribund discharge, intensive care unit admission, or mechanical ventilation (odds ratio, 4.1; 95% confidence interval, 1.9-8.8). The case-fatality proportion among RSV-positive hospital patients with ARI was higher for those aged ≥5 years than for those aged <5 years (13% vs 3%; 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.

BACKGROUND: In January of 2008, during the peak of the rotavirus season in Guatemala, a gastroenteritis outbreak with high mortality among infants was reported in Guatemala. Despite extensive efforts, the investigation was limited by the lack of bulk stool specimens collected, particularly from the more severely dehydrated or deceased children. OBJECTIVES: We evaluated the diagnostic performance of rectal swab specimens compared with bulk stool for the detection of rotavirus and norovirus. STUDY DESIGN: Patients with diarrhea (≥3 loose stools in 24h) were enrolled through an ongoing surveillance system in Guatemala. From January through March 2009, we attempted to enroll 100 patients <5 years old captured by the diarrhea surveillance, and collected paired bulk stool and rectal swabs specimens from them. Specimens were tested for norovirus using real-time reverse transcription-polymerase chain reaction and for rotavirus via enzyme immunoassay. RESULTS: We enrolled 102 patients with paired specimens; 91% of 100 paired specimens tested for rotavirus yielded concordant results positive for rotavirus with a negativity rate of 83%. Among 100 paired specimens tested for norovirus, 86% were concordant norovirus detection and the negativity rate was 85%. The diagnostic performance for rotavirus and norovirus detection did not differ significantly between the two specimen types. CONCLUSIONS: Testing of properly collected fecal specimens using rectal swabs may be a viable alternative to bulk stool for detection of rotavirus and norovirus, particularly during outbreaks where collection of bulk stool may be difficult.

Noroviruses (NoVs) are a leading cause of acute gastroenteritis outbreaks and sporadic cases of diarrhea in industrialized countries. To study the prevalence and genetic diversity of NoVs in Guatemala, stool specimens were collected from hospitalized and ambulatory patients presenting with diarrhea (≥3 loose or liquid stools in a 24-hr period) who were enrolled in a prospective surveillance system in the Departments of Santa Rosa (October 2007 to August 2010) and Quetzaltenango (August 2009 to August 2010), Guatemala. Specimens were tested for rotavirus, enteric bacteria, and parasites by routine methods and for genogroups I and II NoV by real-time reverse transcription-PCR. A total of 2,403 stool specimens were collected from hospitalized (n = 528) and ambulatory patients (n = 1,875). Overall, 341 (14%) samples tested positive for NoVs including 114 (22%) hospitalized and 227 (12%) ambulatory patients. NoVs disease peaked during the winter (November-January) months. Among the 341 NoVs-positive patients, 32 (9%) were also positive for rotavirus, 32 (9%) for bacteria, and 9 (3%) for protozoa. Nucleotide sequences were obtained from 84 samples collected from hospitalized children aged <5 years of age, which could be grouped into nine GII and three GI genotypes with GII.4 (74%) and GI.8 (10%) being the most common. This is the first study on the prevalence of NoVs among hospitalized and ambulatory patients with diarrhea in Guatemala. The findings highlight the need to implement laboratory diagnostics for NoVs to improve appropriate clinical management of diarrheal diseases and guide vaccine development. (J. Med. Virol. (c) 2013 Wiley Periodicals, Inc.)

BACKGROUND: Knowing the national disease burden of severe influenza in low-income countries can inform policy decisions around influenza treatment and prevention. We present a novel methodology using locally generated data for estimating this burden. METHODS AND FINDINGS: This method begins with calculating the hospitalized severe acute respiratory illness (SARI) incidence for children <5 years old and persons >=5 years old from population-based surveillance in one province. This base rate of SARI is then adjusted for each province based on the prevalence of risk factors and healthcare-seeking behavior. The percentage of SARI with influenza virus detected is determined from provincial-level sentinel surveillance and applied to the adjusted provincial rates of hospitalized SARI. Healthcare-seeking data from healthcare utilization surveys is used to estimate non-hospitalized influenza-associated SARI. Rates of hospitalized and non-hospitalized influenza-associated SARI are applied to census data to calculate the national number of cases. The method was field-tested in Kenya, and validated in Guatemala, using data from August 2009-July 2011. In Kenya (2009 population 38.6 million persons), the annual number of hospitalized influenza-associated SARI cases ranged from 17,129-27,659 for children <5 years old (2.9-4.7 per 1,000 persons) and 6,882-7,836 for persons >=5 years old (0.21-0.24 per 1,000 persons), depending on year and base rate used. In Guatemala (2011 population 14.7 million persons), the annual number of hospitalized cases of influenza-associated pneumonia ranged from 1,065-2,259 (0.5-1.0 per 1,000 persons) among children <5 years old and 779-2,252 cases (0.1-0.2 per 1,000 persons) for persons >=5 years old, depending on year and base rate used. In both countries, the number of non-hospitalized influenza-associated cases was several-fold higher than the hospitalized cases. CONCLUSIONS: Influenza virus was associated with a substantial amount of severe disease in Kenya and Guatemala. This method can be performed in most low and lower-middle income countries.

BACKGROUND: There have been few population-based studies from Central America on respiratory syncytial virus (RSV) infections in young children. We report population-based incidence rates and describe epidemiological and clinical characteristics of children < 5 years old hospitalized with RSV infections in Guatemala. METHODS: Prospective, active hospital-based surveillance for acute respiratory infections in children <5 years old was conducted at three hospitals in Guatemala from November 2007 through July 2010. RSV hospitalization rates were calculated for areas where the catchment population could be defined. Comparisons were made between children who were RSV-positive and RSV-negative. RESULTS: RSV was detected in 549 (25%) of enrolled children. Overall, annual rates of RSV hospitalizations ranged from 5.9 to 45.9 and 2.0 to 13.7 per 1000 children <1 year old and <5 years old, respectively, but varied by location and calendar year. Rates generally decreased with age-children <6 months had rates up to 30 times higher than older children, but children >12 months old still had rates up to 5.5 per 1000 per year and accounted for 42% of deaths. Children with RSV infections were more likely to have signs of respiratory distress (85% vs. 63%, p<0.001) compared to those without RSV infections, but case fatality ratios were similar (3-4%). CONCLUSIONS: The large burden and severity of RSV infections in young Guatemalan children is similar in magnitude and age distribution to RSV disease burdens found in other developing countries and suggests that this population would benefit from prevention strategies, including vaccines against RSV that are currently under development.

BACKGROUND: Gram-negative bloodstream infections are an important cause of neonatal mortality. In October 2009, we investigated a Klebsiella spp outbreak in a neonatal intensive care unit in Guatemala. METHODS: Probable cases were defined as a Klebsiella spp isolated from blood in neonates aged <28 days in the neonatal intensive care unit between October 1 and November 10, 2009; confirmed cases were identified as Klebsiella pneumoniae. Clinical data were abstracted from medical charts. K pneumoniae isolates were genotyped by pulsed-field gel electrophoresis (PFGE) and tested for antimicrobial susceptibility. Infection control practices were inspected. RESULTS: There were 14 confirmed cases. The median age at onset of infection was 3 days (range, 2-8 days). Nine patients died (64%). K pneumoniae isolates were resistant to multiple antimicrobials. PFGE revealed 2 distinct clusters. Breaches in infection control procedures included inappropriate intravenous solution use and inadequate hand hygiene and contact precautions. CONCLUSIONS: We report a K pneumoniae outbreak with high neonatal mortality in Guatemala. PFGE clustering suggested a common source possibly related to reuse of a single-use intravenous medication or solution. The risk for K pneumoniae bloodstream infections in neonates in low-resource settings where sharing of solutions is common needs to be emphasized.

BACKGROUND: In February 2009, a group of Guatemalan school children developed acute gastroenteritis (AGE) after participating in a school excursion. OBJECTIVES: We conducted a retrospective cohort investigation to characterize the outbreak and guide control measures. STUDY DESIGN: A case was defined as an illness with onset of diarrhea or vomiting during February 25-March 5, 2009. Participants were interviewed using a standardized questionnaire, and stool specimens were collected. We inspected the excursion site and tested water samples for total coliforms and Escherichia coli. RESULTS: We identified 119 excursion participants, of which 92 (77%) had been ill. Fifty-six (62%) patients sought care for their illness, and three (3%) were hospitalized. Eighteen (90%) of the 20 specimens from ill children tested positive for norovirus. Among these, 16 (89%) were of the genogroup I (GI.7) and two (11%) were genogroup II (GII.12 and GII.17). One (8%) of the 12 food handlers had norovirus (GI.7). Drinking water samples had 146 most probable numbers (MPN)/100ml of total coliforms and five MPN/100ml of E. coli. CONCLUSION: We describe the first laboratory-confirmed norovirus outbreak in Guatemala. The high illness attack rate, detection of multiple norovirus strains in sick persons, and presence of fecal contamination of drinking water indicate likely waterborne transmission.

TO THE EDITOR: Rabies is an acute progressive encephalitis caused by infection with a lyssavirus (genus Lyssavirus, family Rhabdoviridae). Most human infections are caused by bites from rabid animals, but the virus also can be transmitted by contact of open wounds or mucous membranes with animal saliva. Prompt administration of postexposure prophylaxis (PEP) is recommended to prevent rabies. Canids are common sources of human exposures in many regions of Africa, Asia, and Latin America. However, all mammals are susceptible, including herbivores such as horses, cattle, and antelope.