The first COVID-19 case in a healthcare worker in Kenya was reported on March 30, 2020, in Nairobi, leading to a 41-day closure of the health facility where he had worked. We assessed infection prevention and control (IPC) activities and implemented recommendations to re-open and operate the facility. We conducted a risk assessment of the facility in April 2020 using a modified World Health Organization, six-element IPC facility risk assessment tool. IPC recommendations were made, and a follow-up assessment of their implementation was conducted in July 2020. Breaches in IPC measures included poor ventilation in most service delivery areas; lack of physical distancing between patients; inadequate COVID-19 information, education, and communication materials; lack of standard operating procedures on cleaning and disinfecting high-touch areas; insufficient IPC training; inadequate hand hygiene facilities; insufficient personal protective equipment supplies; and an inactive IPC committee. Strengthening IPC measures is critical to prevent healthcare facility closures.

Hand hygiene (HH) in school settings can reduce the spread of infectious diseases and student absenteeism due to illness. During the COVID-19 pandemic, the World Health Organization recommended HH as a public health measure to prevent disease transmission. Understanding school staff's experiences with school-based programs is important for future program development and improvement. As part of a mixed-methods study, we conducted in-depth interviews in March 2022 with school administrators and teachers at 12 primary schools in Belize, selected based on high gaps in HH resources, to understand HH responsibilities, supplies, and challenges. An intervention was implemented to increase HH knowledge and practices among students, which included environmental nudges, supplemental provision of soap, and HH lesson implementation. Follow-up interviews were conducted in June 2023 among school administrators to garner feedback on the intervention. School staff described roles in teaching and managing HH supplies at both timepoints. The environmental nudges and HH lessons were perceived as helpful, but there were gaps remaining in HH practices, which may be partially influenced by practices and beliefs outside of school. Procurement of HH supplies remained a challenge at some schools due to financial constraints. The feedback from school staff will be valuable for the implementation of future hand hygiene programs in schools.

Hand hygiene (HH) can prevent the spread of infectious diseases and school absenteeism. However, limited data exist on HH practices at schools. Our study assesses the impact of a pilot HH intervention in 12 schools in Belize during the coronavirus disease 2019 (COVID-19) pandemic. After a national assessment of existing water, sanitation, and hygiene resources (December 2021-January 2022), 12 pilot schools were selected to evaluate an HH intervention, which included environmental nudges and HH education. Baseline assessments occurred in March 2022, the HH intervention was implemented during October 2022-May 2023, and follow-up assessments were conducted in June 2023. Student knowledge, attitudes, practices (KAP), and hand dirtiness were assessed at baseline and follow-up. There were no changes in overall KAP median scores between the baseline and the follow-up surveys (knowledge: 3 of 4; attitudes: 11 of 12; practices: 8 of 8). There was an increase in the proportion of students who reported cleaning hands during critical moments, such as before eating and after using the restroom. Observations showed that 83% of students at baseline and 71% of students at follow-up washed their hands with soap after using the restroom. The median hand dirtiness score was seven at baseline and five at follow-up (lower score corresponds to dirtier hands). We did not observe improvements in HH after the intervention. It is possible that the decrease in perceived risk of infection as COVID-19 protocols from baseline to follow-up were reduced in schools contributed to the decrease in HH practices.

Healthcare workers and patients are at continual risk for healthcare-associated infections due to poor hand hygiene. Programs that support appropriate hand hygiene practices may mitigate this risk, although implementation is challenged by several barriers, including limited availability of hand hygiene products at the point of care, as described by the world health organization (WHO). In this study, we used mixed methodologies, including in-depth interviews and surveys to assess the knowledge, attitudes, practices, and barriers to appropriate hand hygiene practices among healthcare workers from 19 public primary and secondary healthcare facilities in Quetzaltenango, Guatemala. The qualitative data analyzed by thematic axes and quantitative data are described. We found that healthcare workers have a strong understanding of the importance of hand hygiene and how it contributes to patient health. We encountered knowledge gaps about the route of transmission of pathogens and how to prevent spread. Nevertheless, healthcare workers acknowledged the importance of training programs to strengthen hand hygiene practices. Potential barriers to improving hand hygiene practices included a lack of adequate infrastructure and resources for practicing hand hygiene with alcohol hand sanitizer, soap, and water. The results of this evaluation provide useful information for supporting hand hygiene practices in participant healthcare facilities and contributes to efforts to reduce the risks of healthcare-associated infections. Our findings likely apply to local healthcare facilities in other low- and middle-income countries and may be used to design hand hygiene educational materials for healthcare workers.

Access to hand hygiene (HH) resources in clinical settings is important to prevent healthcare-associated infections, including COVID-19. However, many countries, including Belize, have limited national data on the availability of HH resources and healthcare worker (HCW) hand hygiene adherence (HHA) in healthcare facilities (HCFs). We conducted a study in the 11 largest public HCFs across Belize to evaluate access to HH resources and HHA before and after an intervention (provision of alcohol-based hand rub (ABHR) wall mounts and HH training). Descriptive statistics and multilevel logistic regressions were used to assess changes in HH resources and HHA from baseline to follow-up and explore factors associated with HHA. There was a 19 percent increase in rooms with functional wall-mounted ABHR dispensers (44% to 63%) post-intervention. HHA did not improve from baseline (52%) to follow-up (50%). Combining baseline and follow-up data, HHA was higher when ABHR and soap and water were present (aOR = 4.19, 95% CI = 2.11, 8.32) and when only ABHR was present (aOR = 3.85, 95% CI = 1.92, 7.72) compared with when soap and water were present alone. The decreased perceived risk of COVID-19 at follow-up may explain the null HHA findings. However, our assessment of HH resources and practices provides a useful foundation for future HH programs in HCFs.

BACKGROUND: Split-hand/foot malformation (SHFM) is a rare, genetically heterogeneous, congenital limb defect. Some but not all associated genes are known; therefore, the aim was to identify genes underlying SHFM. METHODS: Buccal cell-derived DNA from 26 children with SHFM and their parents who participated in the National Birth Defects Prevention Study was exome sequenced. Family-based trio analyzes prioritized rare coding variants by inheritance patterns, predicted pathogenicity, and location within putative limb development genes. Copy-number variants in SHFM candidate genomic regions were also examined. Case-control analyzes compared coding variants between case children and 1191 controls (parents of children with non-limb birth defects). Variant validation was by Sanger sequencing or droplet digital polymerase chain reaction. RESULTS: In family-based analyzes, the prioritized and validated variants (each in a single family) included likely damaging variants that were heterozygous and de novo in speckle type BTB/POZ protein (SPOP) and ubiquitin-like modifier activating enzyme 2 (UBA2), X-linked recessive in fibroblast growth factor 13 (FGF13) and RNA binding motif protein 10 (RBM10), and compound heterozygous in interleukin enhancer binding factor 3 (ILF3). Validation assays did not confirm predicted de novo copy-number gains at chromosomes 10q24 and 19p13.11. Case-control analyzes did not identify statistically significant associations. CONCLUSION: Exome analysis nominated new susceptibility genes (FGF13, ILF3, RBM10, SPOP) and detected a variant in a known candidate gene (UBA2). Follow-up investigation is needed to ascertain damaging variants in these genes in additional cases with SHFM and evaluate the impact of the variants on gene expression, protein function, and limb development.

Survey research relies on cooperation and coordination between researchers and respondents. Survey-literate respondents possess a level of understanding of the survey process that facilitates their participation. Non-survey-literate respondents, on the other hand, are less equipped to provide accurate responses, which can lead to increased survey error. In this article, we present findings from a cognitive interview project conducted in Brazil to illustrate potential barriers to respondent participation and demonstrate how these barriers contribute to response error. To test questions on inclusive education, researchers from the Collaborating Center for Questionnaire Design and Evaluation Research at the National Center for Health Statistics facilitated the collection of data through 80 cognitive interviews conducted in various neighborhoods in Rio de Janeiro, Brazil. Recruitment targeted caregivers of children with and without disabilities, and respondents were predominantly female with low literacy levels. The results indicated that respondents with limited familiarity with the survey process (non-survey-literate) struggled to orient themselves to the survey task. They faced challenges in choosing response options, understanding scale relationships, and interpreting vocabulary. Additionally, many respondents expressed a need to share salient details of their lives, which the survey was not designed to capture. Understanding these barriers to participation and identifying ways to mitigate them can help reduce survey error, particularly in vulnerable populations.

IMPORTANCE: Clostridioides difficile is among the most prevalent health care-associated pathogens worldwide. Controlling it remains a critical challenge, due in part to spore viability on surfaces. OBJECTIVE: To quantify transmission of C difficile within health care facilities and evaluate the roles of environmental surfaces and health care personnel (HCP) hands in C difficile movement. DESIGN, SETTING, AND PARTICIPANTS: In 2018, a 13-week longitudinal, observational study was conducted in 2 intensive care units (ICUs) in Utah with daily culture-based sampling of patient body sites, room environmental surfaces, HCP hands, and shared environmental surfaces. Both toxigenic and nontoxigenic C difficile strains were selected for whole genome sequencing and included in the analysis. Data were analyzed from September 2021 to September 2024. MAIN OUTCOMES AND MEASURES: The primary outcome was the identification of transmission clusters based on genomic relatedness between isolates from patients, environmental surfaces, and HCP hands. Clusters were defined as isolates with 2 or fewer single nucleotide variants between them. RESULTS: Of the 278 unique ICU admissions, 177 patients consented to body site sampling and were sampled. Along with these, environment surfaces and HCP hands were sampled daily for all occupied rooms, leading to 7000 total samples. Sampling patients, their environment, and HCP hands revealed that nearly 8% of all patients had C difficile linked to other admissions and 57% of transmission clusters bridged nonoverlapping patient-stays. Including environmental surfaces and HCP hands, a 3.6-fold higher C difficile movement was identified than with patient sampling alone, highlighting environmental surfaces as reservoirs. CONCLUSIONS AND RELEVANCE: These results challenge the idea that nosocomial transmission is not a primary source of acquisition and underscore the importance of hand hygiene and environmental decontamination. This study reinforces the need to include environmental surfaces and HCP hands in future work characterizing the burden of nosocomial transmission. Understanding the transmission pathways of C difficile within health care facilities, particularly the roles of environmental surfaces and HCP hands, is critical to improving infection control measures.

School-aged children are vulnerable to infectious diseases due to their developing immune systems and frequent social interactions. The COVID-19 pandemic underscored the importance of non-pharmaceutical interventions, like hand hygiene (HH). This study evaluated the changes achieved through a school-based intervention to Guatemalan primary school students’ HH knowledge, attitudes, and self-reported practices while collecting teacher feedback to inform future efforts. The intervention included handwashing festivals, environmental nudges, and the regular delivery of soap and alcohol-based hand rub (ABHR). Knowledge, attitudes, and practices (KAP) surveys were conducted pre- and post-intervention with 109 and 144 students, respectively. Six teachers participated in interviews to provide perspectives. Significant improvements were observed in students’ knowledge of HH’s role in preventing disease (pre: 84.4%; post: 96.5; p < 0.01) and recognition of critical moments (pre: 84.4%; post: 92.4%; p < 0.05). Self-reported practices also improved, with more students reporting washing their hands for 20 s or more (pre: 68.8%; post: 79.9%; p < 0.05). Fewer students reported liking ABHR after the intervention (pre: 89%; post: 78.5%; p < 0.05). Teachers reported increased HH practices and provided feedback to enhance interventions. These findings highlight the effectiveness of school-based interventions and emphasize the importance of addressing knowledge gaps and incorporating teacher insights for sustained public health benefits. © 2025 by the authors.

Work-related injuries from overexertion, particularly lifting, are a major concern in occupational safety. Traditional assessment tools, such as the Revised NIOSH Lifting Equation (RNLE), require significant training and practice for deployment. This study presents an approach that integrates tactile gloves with computer vision (CV) to enhance the assessment of lifting-related injury risks, addressing the limitations of existing single-modality methods. Thirty-one participants performed 2747 lifting tasks across three lifting risk categories (LI < 1, 1 ≤ LI ≤ 2, LI > 2). Features including hand pressure measured by tactile gloves during each lift and 3D body poses estimated using CV algorithms from video recordings were combined and used to develop prediction models. The Convolutional Neural Network (CNN) model achieved an overall accuracy of 89 % in predicting the three lifting risk categories. The results highlight the potential for a real-time, non-intrusive risk assessment tool to assist ergonomic practitioners in mitigating musculoskeletal injury risks in workplace environments.

Background: The tick-borne pathogens, Bourbon virus (BRBV) and Heartland virus (HRTV) are the cause of febrile illnesses that may progress to severe and fatal diseases. Materials and Methods: As a preliminary effort to determine if these viruses were enzootic in Texas, ticks and blood samples were collected from feral swine (Sus scrofa) and white-tailed deer (Odocoileus virginianus) (WTD) killed by gunning as part of an abatement program during 2019-2021 in Travis County, Texas. Ticks were collected from these animals by hand and blood samples were obtained by cardiac puncture using 22-gauge needles and 5 mL syringes. Information was recorded for each animal, including date, sex, and location. The species of ticks were identified morphologically using a taxonomic key, and serum samples were tested for neutralizing antibodies to BRBV and HRTV. Results: A total of 83 Ixodes scapularis and 58 Amblyomma americanum ticks were collected from feral swine, and 196 I. scapularis and 11 Dermacentor albipictus from WTD. Although A. americanum, the implicated vector of both viruses was collected from feral swine, neutralizing antibody was not detected to BRBV, but 12% (9/75) had antibody to HRTV as evidence of a previous infection. Of the serum samples obtained from WTD, all were negative for BRBV neutralizing antibody, but 6.6%% (5/75) were positive for HRTV antibody. Conclusion: These preliminary results indicated that HRTV was enzootic in Travis, County, Texas and further studies are warranted to determine the specific tick vectors and the possible role of WTD and feral swine in the maintenance and transmission cycle of this virus.

PROBLEM/CONDITION: Approximately 800 foodborne illness outbreaks occur in the United States each year. These outbreaks include approximately 15,000 illnesses, 800 hospitalizations, and 20 deaths. Although illnesses from outbreaks account for a small portion of all foodborne illnesses, outbreak investigations reveal how these illnesses originate by offering crucial data through epidemiologic, environmental health, and laboratory analyses and aid in outbreak mitigation and prevention. PERIOD COVERED: 2014-2022. DESCRIPTION OF SYSTEM: The Foodborne Disease Outbreak Surveillance System (FDOSS), via the National Outbreak Reporting System (NORS), captures data from foodborne enteric illness outbreak investigations in the United States. Epidemiology or communicable disease control and environmental health programs of state and local health departments collect and voluntarily report the data to NORS, which is managed by CDC. These data include information about cases (e.g., case counts, symptoms, duration of illness, and health care-seeking behaviors), laboratory specimens, settings of exposure, implicated food items, and contributing factors (i.e., how the outbreak occurred). A foodborne illness outbreak is defined as two or more cases of a similar illness associated with a common exposure (e.g., shared food, venue, or experience). Data collected from an outbreak investigation help the investigator identify contributing factors to the outbreak. Contributing factors are food preparation practices, behaviors, and environmental conditions that lead to pathogens getting into food, growing in food, or surviving in food and are grouped into three categories: contamination (when pathogens and other hazards get into food), proliferation (when pathogens that are already present in food grow), and survival (when pathogens survive a process intended to kill or reduce them). RESULTS: A total of 2,677 (40.5%) foodborne illness outbreaks reported during 2014-2022 with information on contributing factors were included in this analysis. Foodborne outbreak periods were categorized into three time frames: 2014-2016 (first), 2017-2019 (second), and 2020-2022 (third). Of the 2,677 outbreaks, 1,142 (42.7%) occurred during the first time frame, 1,130 outbreaks (42.2%) during the second time frame, and 405 outbreaks (15.1%) during the third time frame. The proportion of bacterial outbreaks increased from the first (41.9%) to the third time frame (48.4%), and the proportion of viral outbreaks decreased (33.3% to 23.2%). Over the three time frames, the proportion of outbreaks with a contamination contributing factor decreased (85.6%, 83.6%, and 81.0%, respectively). The proportion of outbreaks with a proliferation contributing factor category decreased from the first (40.3%) to the second time frame (35.0%), then increased during the third time frame (35.1%), and the proportion of outbreaks with a survival contributing factor category decreased from the first (25.7%) to the second time frame (21.9%), then increased during the third time frame (25.7%). The proportion of outbreaks with aquatic animals as an implicated food item increased from the first (12.0%) to the second time frame (18.5%), then decreased during the third time frame (18.3%). The proportion of outbreaks with land animals as an implicated food item decreased from the first (16.7%) to the second time frame (14.2%), then increased during the third time frame (15.1%).For outbreaks with a contamination contributing factor, the proportion of food contaminated by an animal or environmental source before arriving at the point of final preparation increased over the three time frames (22.2%, 27.7%, and 32.3%, respectively), and the proportion of outbreaks with contamination from an infectious food worker through barehand contact with food decreased (20.5%, 15.2%, and 8.9%, respectively). For the proliferation category, the proportions of outbreaks associated with allowing foods to remain out of temperature control for a prolonged period during preparation and during food service or display decreased over the three time frames (15.2%, 12.2%, and 9.9%, respectively; and 13.6%, 10.4%, and 8.9%, respectively), and the proportion of improper cooling of food decreased from the first (9.4%) to the second time frame (8.8%), then increased during the third time frame (10.9%). For the survival category, the proportion of outbreaks associated with inadequate time and temperature control during initial cooking/thermal processing of food decreased from the first (12.1%) to the second time frame (9.6%) and increased during the third time frame (12.1%).For bacterial outbreaks, cross-contamination of foods was among the top five contributing factors during the first (22.0%) and second time frames (20.8%) but not during the third time frame. Inadequate time and temperature control during initial cooking of food was among the top five contributing factors during all three time frames (23.8%, 20.4% and 20.9%, respectively). Improper cooling was not among the top five contributing factors during the first and second time frames but was during the third time frame (17.3%). For viral outbreaks, contamination from an infectious food worker through barehand contact with food was among the most common contributing factors during the first (47.1%) and second time frames (37.7%) and decreased to the third most common contributing factor during the third time frame (28.7%). Contamination from an infectious food worker through gloved-hand contact with food was among the top five contributing factors during the first (32.1%) and second time frame (25.5%) and was the most common contributing factor during the third time frame (42.5%). INTERPRETATION: Many foodborne illness outbreaks occur because of contamination of food by an animal or environmental source before arriving at the point of final preparation. Most viral outbreaks are caused by contamination from ill food workers. The decrease in the proportion of viral outbreaks and the proportion of outbreaks with a contamination contributing factor during 2020-2022 might be attributed to effects from the COVID-19 pandemic. Nonpharmaceutical interventions (e.g., increased glove use, cleaning and disinfection, and closure of restaurant dining areas) implemented during the COVID-19 pandemic likely led to a reduction in norovirus, which is typically spread by infectious food workers. Two common contributing factors to bacterial outbreaks are allowing foods to remain out of temperature control for a prolonged period and inadequate time and temperature control during cooking. Proper time and temperature controls are needed to effectively eliminate bacterial pathogens from contaminated foods and ensure safe food operations. PUBLIC HEALTH ACTION: Retail food establishments can follow science-based food safety guidelines such as the Food and Drug Administration Food Code and Hazard Analysis and Critical Control Points (HACCP) plans. Restaurant managers can mitigate contamination by ill food workers by implementing written policies concerning ill worker management, developing contingency plans for staffing during worker exclusions, and addressing reasons why employees work while sick. Health department staff members who investigate outbreaks and conduct routine inspections can encourage restaurants to follow their HACCP plans and other verified food safety practices, such as cooling, to prevent outbreaks.

With the increasing demand of power and energy, more and more cells are packed into battery modules. Consequently, the electromagnetic (EM) emissions from batteries also intensify. These emissions have been observed to interfere with nearby electronic safety and health devices, causing malfunctions. While conventional methods, such as shielding, filtering, and distance separation, are commonly used to mitigate the interference issue, each has its own limitations and may not be applicable in all situations. On the other hand, magnetic field cancellation methods found in certain applications offer distinct advantages in addressing challenging magnetic field shielding or compensation issues. In this article, we introduce a novel approach to mitigate EM emissions from batteries consisting of common cylindrical form cells. The new approach leverages the coherent nature of battery cell currents when powering external load and the paired structure present in the battery pack, and then rearranges the cells so that the magnetic fields of the loops of paired cells are canceling one another. We demonstrate the validity of our approach in addressing the EM interference issue that exists in an electronic device currently used in underground coal mines. The results show a significant reduction in EM emission from the battery, highlighting the effectiveness of our approach in real applications. U.S. Government work not protected by U.S. copyright.

Objective: Schools’ ability to implement recommended hygiene-related activities is critical in preventing the spread of gastrointestinal and respiratory illness. We conducted this study to improve understanding of perceived barriers to, and responsibility for implementing recommended activities related to hand hygiene, cleaning, and disinfection. Methods: We recruited a convenience sample of adults affiliated with the National Parent Teacher Association during July-August 2020. Questions focused on barriers to implementing recommended hygiene-related, cleaning, and disinfection activities. Results: Overall, 1173 participants completed the survey. Among caregivers, the main barriers to conducting hand hygiene were educators’ ability to monitor students (72%), lack of time (66%), and limited funding for hygiene supplies (65%). Among educators, the main barriers to conducting hand hygiene were access to needed supplies (75%), ability to monitor students (75%), and lack of time (72%). The top barriers reported by both groups relating to cleaning and disinfection activities were similar, with both groups reporting limited staff capacity (61% vs 75%), lack of time/scheduling difficulties (64% vs 75%), and lack of funds to purchase supplies (64% vs 70%). Conclusions: Our results clarify stakeholder concerns around implementation and main barriers. To implement recommended activities, schools need support (funding, staff, and supplies) and guidance for hygiene-related activities. © 2024, Paris Scholar Publishing. All rights reserved.

Local alcohol-based hand rub (ABHR) production systems in low-resource settings, such as in health care facilities (HCFs) in low- and middle-income countries, frequently reuse containers for storing and dispensing ABHR. Cleaning/disinfection (C/D) of ABHR containers is necessary to safely reuse them and is an integral part of the WHO's guidelines on local ABHR production. However, HCFs may not be aware of the need for C/D; combined with suboptimal implementation, this poses a risk of contamination of ABHR. As part of district-led ABHR production in HCFs in five rural districts in Uganda, we developed a standard operating procedure (SOP) for C/D of reused ABHR containers and provided on-site training for infection prevention and control personnel. Using in-person surveys, we assessed the availability of C/D supplies and equipment and the self-reported C/D practices before and after the training. At baseline, almost all (n = 90/91) HCFs reported reusing ABHR containers; 8% and 12% of HCFs routinely had all of the key C/D materials needed for adequately cleaning and disinfecting containers using chlorine and thermal disinfection methods, respectively. HCFs that reported adequately cleaning containers per the SOP increased from 3% (n = 2) at baseline to 18% (n = 16) after the training, whereas adequate disinfection increased from 0% (n = 0) to 5% (n = 5). All HCFs that performed disinfection reported using chlorine, and none reported using thermal disinfection. Improving access to C/D supplies, providing routine mentorship, and monitoring ABHR container C/D are needed to further improve C/D practices.

PROBLEM: Water, sanitation and waste infrastructure and services in Ukrainian health-care facilities often fail to meet global and national standards, hindering the provision of safe, quality care. The war has worsened existing problems. APPROACH: To incrementally improve water, sanitation, hand hygiene, environmental cleaning and health-care waste practices, the World Health Organization (WHO) is working with the health ministry, the Ukrainian Public Health Centre and regional United States Centers for Disease Prevention and Control (CDC) to implement the Water and Sanitation for Health Facility Improvement Tool (WASH FIT). In December 2022, WHO trained staff from the regional CDC, Ukrainian Public Health Centre and nine priority health-care facilities. Facility teams assessed services, and developed and implemented improvement plans in January 2023. Follow-up assessments were conducted after six months. LOCAL SETTING: About 4300 health-care facilities operate in Ukraine. Funding for new water and sanitation infrastructure, as well as operating and maintaining existing services, is likely inadequate. RELEVANT CHANGES: After implementation, the average WASH FIT score increased from 66 out of a maximum of 100 (range: 57-73) to 83 (range: 69-93). Facilities more effectively managed water-related risks, replaced broken taps, improved waste management practices and installed backup water supply and storage sources. LESSONS LEARNT: WASH FIT can be used to identify gaps in water, sanitation, hygiene and waste services and track progress towards addressing these gaps. Engaged local leaders, health-based national water, sanitation, hygiene standards, regular on-site training and mentoring drive these improvements. Strengthening public health entities is critical to institutionalize the process.

BACKGROUND: Measures of diagnostic test accuracy provide evidence of how well a test correctly identifies or rules-out disease. Commonly used diagnostic accuracy measures (DAMs) include sensitivity and specificity, predictive values, likelihood ratios, area under the receiver operator characteristic curve (AUROC), area under precision-recall curves (AUPRC), diagnostic effectiveness (accuracy), disease prevalence, and diagnostic odds ratio (DOR) etc. Most available analysis tools perform accuracy testing for a single diagnostic test using summarized data. We developed a SAS macro for evaluating multiple diagnostic tests using individual-level data that creates a 2 × 2 summary table, AUROC and AUPRC as part of output. METHODS: The SAS macro presented here is automated to reduce analysis time and transcription errors. It is simple to use as the user only needs to specify the input dataset, "standard" and "test" variables and threshold values. It creates a publication-quality output in Microsoft Word and Excel showing more than 15 different accuracy measures together with overlaid AUROC and AUPRC graphics to help the researcher in making decisions to adopt or reject diagnostic tests. Further, it provides for additional variance estimation methods other than the normal distribution approximation. RESULTS: We tested the macro for quality control purposes by reproducing results from published work on evaluation of multiple types of dried blood spots (DBS) as an alternative for human immunodeficiency virus (HIV) viral load (VL) monitoring in resource-limited settings compared to plasma, the gold-standard. Plasma viral load reagents are costly, and blood must be prepared in a reference laboratory setting by a qualified technician. On the other hand, DBS are easy to prepare without these restrictions. This study evaluated the suitability of DBS from venous, microcapillary and direct spotting DBS, hence multiple diagnostic tests which were compared to plasma specimen. We also used the macro to reproduce results of published work on evaluating performance of multiple classification machine learning algorithms for predicting coronary artery disease. CONCLUSION: The SAS macro presented here is a powerful analytic tool for analyzing data from multiple diagnostic tests. The SAS programmer can modify the source code to include other diagnostic measures and variance estimation methods. By automating analysis, the macro adds value by saving analysis time, reducing transcription errors, and producing publication-quality outputs.

OBJECTIVE: To investigate the biodynamics of human-exoskeleton interactions during patient handling tasks using a subject-specific modeling approach. BACKGROUND: Exoskeleton technology holds promise for mitigating musculoskeletal disorders caused by manual handling and most alarmingly by patient handling jobs. A deeper, more unified understanding of the biomechanical effects of exoskeleton use calls for advanced subject-specific models of complex, dynamic human-exoskeleton interactions. METHODS: Twelve sex-balanced healthy participants performed three simulated patient handling tasks along with a reference load-lifting task, with and without wearing the exoskeleton, while their full-body motion and ground reaction forces were measured. Subject-specific models were constructed using motion and force data. Biodynamic response variables derived from the models were analyzed to examine the effects of the exoskeleton. Model validation used load-lifting trials with known hand forces. RESULTS: The use of exoskeleton significantly reduced (19.7%-27.2%) the peak lumbar flexion moment but increased (26.4%-47.8%) the peak lumbar flexion motion, with greater moment percent reduction in more symmetric handling tasks; similarly affected the shoulder joint moments and motions but only during two more symmetric handling tasks; and significantly reduced the peak motions for the rest of the body joints. CONCLUSION: Subject-specific biodynamic models simulating exoskeleton-assisted patient handling were constructed and validated, demonstrating that the exoskeleton effectively lessened the peak loading to the lumbar and shoulder joints as prime movers while redistributing more motions to these joints and less to the remaining joints. APPLICATION: The findings offer new insights into biodynamic responses during exoskeleton-assisted patient handling, benefiting the development of more effective, possibly task- and individual-customized, exoskeletons.

BACKGROUND: Outbreaks of emerging multidrug-resistant organisms (eMDROs), including carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and Candida auris, have been reported among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients. We describe eMDRO clusters in SARS-CoV-2 units and associated infection control (IC) practices early in the SARS-CoV-2 pandemic. METHODS: We conducted a retrospective survey of a convenience sample of health departments in 11 states to describe clusters of eMDROs that began before November 1, 2020 and involved SARS-CoV-2 units. Cluster characteristics and IC practices during the cluster period were assessed using a standardized outbreak report form, and descriptive analyses were performed. RESULTS: Overall, 18 eMDRO clusters (10 carbapenem-resistant Enterobacterales, 6 C auris, 1 carbapenem-resistant Pseudomonas aeruginosa, and 1 carbapenem-resistant A baumannii) in 18 health care facilities involving 397 patients were reported from 10 states. During the cluster period, 60% of facilities reported a shortage of isolation gowns, 69% extended use of gowns, and 67% reported difficulty obtaining preferred disinfectants. Reduced frequency of hand hygiene audits was reported in 85% of acute care hospitals during the cluster period compared with before the pandemic. CONCLUSIONS: Changes in IC practices and supply shortages were identified in facilities with eMDRO outbreaks during the SARS-CoV-2 pandemic and might have contributed to eMDRO transmission.

During the coronavirus disease 2019 pandemic, alcohol-based hand rub (ABHR) availability and use increased as a prevention measure. ABHR is a convenient, effective way to kill microbes on hands but is hampered by the presence of organic material, whereas handwashing with water and soap (HWWS) can physically remove microbes and dirt. Although ABHR is preferred in most health care settings, the suitability of ABHR use in community settings has not been measured. We compared characteristics between community members and health care personnel (HCP) to inform considerations for promoting ABHR in community settings. We included data from community locations and health care facilities in Kenya and Uganda collected between 2021 and 2022. Hand dirtiness swabs were measured using the Quantitative Personal Hygiene Assessment Tool (qPHAT), a visual scale where 0 is very visibly dirty and 10 is no visible dirt. Participants were also asked about the appropriate method to use when hands were visibly dirty. Hand swabs were collected from HCP and community members. Both groups had median qPHAT scores of five. Neither the adjusted odds of having a qPHAT score less than or equal to five (1.4, 95% CI: 0.8-2.2) nor the adjusted odds of responding correctly to the knowledge question (0.8, 95% CI: 0.4-1.4) differed significantly by setting. People in community settings may, therefore, have comparable hand dirtiness and knowledge of appropriate hand hygiene practices to use ABHR as a HWWS complement. Further investigation into guidance and use of supportive messaging should be considered as completed elsewhere.

Transient three-dimensional (3D) heat and moisture transfer simulations were conducted to analyze the thermal performances of the entire phase change material (PCM) integrated into firefighters' gloves. PCM was broken down into several segments to cover the back and palm of the hand but to avoid finger joints to keep hand functions. Parametric studies were performed to explore the effects of PCM melting temperatures, PCM locations in the glove and PCM layer thicknesses on the overall thermal performance improvement of firefighters' gloves. The study found that PCM segments could extend the time for hand skin surfaces (areas covered or not covered by PCM) to reach second-degree burn injury (60 °C) by 1.5-2 times compared to conventional firefighters' gloves without PCM. Moreover, PCM segments could help mitigate the temperature increase on hand skin and glove surface after fire exposure.

The World Health Organization recommends healthcare workers (HCWs) practice hand hygiene (HH) while providing care. Making alcohol-based hand rub (ABHR) available at points of care is recommended during times of high patient volume, such as the COVID-19 pandemic. In low-and middle-income countries, such as Belize, there may be limited access to HH materials within healthcare facilities (HCF). This paper examines the motivators and barriers to HH among HCWs in the 11 largest public healthcare facilities in Belize and HCWs’ experiences with an intervention. In 2021, focus group discussions (FGDs) gathered HCWs’ HH perceptions and preferences. An intervention was then implemented to increase ABHR access and HH training for HCWs. Post-intervention endpoint FGDs in 2022 documented HCWs’ experiences with interventions. Baseline FGDs revealed that self-protection and protection of one’s household members from illness were key motivators for HCWs’ HH practice. Insufficient time, inadequate access to HH supplies, and gaps in education were barriers to practicing HH. At endpoint, participants appreciated increased access to ABHR and its convenience but did not like ABHR’s effect on hands. Experiences with the training were mixed. To improve HCWs’ HH practices, HH interventions should be tailored to HCWs’ context and learning preferences. © 2024 The Authors.

Workers regularly using vibrating hand tools may develop a disorder referred to as hand-arm vibration syndrome (HAVS). HAVS is characterized by cold-induced vasospasms in the hands and fingers that result in blanching of the skin, loss of sensory function, pain, and reductions in manual dexterity. Exposure to vibration induces some of these symptoms. However, the soft tissues of the hands and fingers of workers are compressed as a result of the force generated when a worker grips a tool. The compression of these soft tissues might also contribute to the development of HAVS. The goal of this study was to use an established rat tail model to determine the mechanisms by which compression of the tail tissues affects (1) the ventral tail artery (VTA) and ventral tail nerves (VTN), (2) nerves and sensory receptors in the skin, (3) dorsal root ganglia (DRG), and (4) spinal cord. Tissue compression resulted in the following changes (1) circulating pituitary and steroid hormone concentrations, (2) expression of factors that modulate vascular function in the skin and tail artery, and (3) factors associated with nerve damage, DRG, and spinal cord. Some of these observed effects differed from those previously noted with vibration exposure. Based upon these findings, the effects of applied force and vibration are different. Studies examining the combination of these factors might provide data that may potentially be used to improve risk assessment and support revision of standards.

BACKGROUND: Myotonic dystrophy type 1 (DM1) is a multisystem genetic disorder that classically presents with symptoms associated with myotonia, early onset cataracts, and muscular weakness, although the presentation and pattern of disease progression is quite varied. Presenting symptoms are well documented among adults with DM1. However, less is known about the co-occurrence of symptoms over time. We aimed to use factor analysis to explore the correlation pattern of signs and symptoms (S/S) that emerged during the clinical course. RESULTS: Clinical records of 228 individuals with adult onset DM1 were abstracted using the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) from a six-site cohort in the United States during an eight-year study period. Factor analysis was used to group the correlated S/S into latent factors. Three factors were identified. Group 1: 'Facial Weakness/Myotonia' includes the two most common S/S, as indicated by its name. Group 2: 'Skeletal Muscle Weakness' includes eight muscular S/S and is more frequently reported by males and those with older age at onset. Group 3: 'Gastrointestinal distress/Sleepiness' includes four non-muscular S/S and hand stiffness. The abstracted medical records reported that over 63% of individuals had S/S from all three groups. Associations of covariates with factor scores were also examined using linear regression. CTG repeat length was significantly positively associated with higher factor scores for all three factors. CONCLUSIONS: This study identified three latent factors of S/S which accumulated during the clinical course of adult onset DM1.

The antiviral drug tecovirimat* has been used extensively to treat U.S. mpox cases since the start of a global outbreak in 2022. Mutations in the mpox viral protein target (F13 or VP37) that occur during treatment can result in resistance to tecovirimat(†) (1,2). CDC and public health partners have conducted genetic surveillance of monkeypox virus (MPXV) for F13 mutations through sequencing and monitoring of public databases. MPXV F13 mutations associated with resistance have been reported since 2022, typically among severely immunocompromised mpox patients who required prolonged courses of tecovirimat (3-5). A majority of patients with infections caused by MPXV with resistant mutations had a history of tecovirimat treatment; however, spread of tecovirimat-resistant MPXV was reported in California during late 2022 to early 2023 among persons with no previous tecovirimat treatment (3). This report describes a second, unrelated cluster of tecovirimat-resistant MPXV among 18 persons with no previous history of tecovirimat treatment in multiple states.

BACKGROUND: Limited information exists regarding healthcare workers' (HCWs) perceptions about infection prevention and control (IPC) in Latin America. METHODS: We conducted an electronic voluntary anonymous survey to assess HCWs' perceptions towards IPC in 30 hospitals in Latin America during August-September 2022. Nurses, physicians, and environmental cleaning (EVC) staff were prioritized for recruitment. RESULTS: Overall, 1,340 HCWs completed the survey. Of these, 28% were physicians, 49% nurses, 8% EVC staff, and 15% had "other" roles. Self-compliance with hand hygiene (HH) and prevention bundles was perceived to be high by 95% and 89% of respondents, respectively; however, ratings were lower when asked about compliance by their peers (reported as high by 81% and 75%, respectively). Regular training on IPC and access to healthcare-associated infections (HAI) rates were more limited among physicians than other HCWs (e.g., 87% of EVC staff and 45% of physicians reported training upon hiring and thereafter, 60% of nurses and 51% of physicians reported regular access to HAI rate reports). CONCLUSIONS: We identified several opportunities to strengthen IPC practices in Latin American hospitals, including improving HCW education and training on IPC and their awareness of HAI rates and compliance with prevention measures.

Over-exposure of the hand-arm system to intense vibration and force over time may cause degeneration of the vascular, neurological, and musculoskeletal systems in the fingers. A novel animal model using rat tails has been developed to understand the health effects on human fingers exposed to vibration and force when operating powered hand tools or workpieces. The biodynamic responses, such as vibration stress, strain, and power absorption density, of the rat tails can be used to help evaluate the health effects related to vibration and force and to establish a dose-effect relationship. While the biodynamic responses of cadaver rat tails have been investigated, the objective of the current study was to determine whether the biodynamic responses of living rat tails are different from those of cadaver rat tails, and whether the biodynamic responses of both living and cadaver tails change with exposure duration. To make direct comparisons, the responses of both cadaver and living rat tails were examined on four different testing stations. The transfer function of each tail under a given contact force (2 N) was measured at each frequency in the one-third octave bands from 20 to 1000 Hz, and used to calculate the mechanical system parameters of the tails. The transfer functions were also measured at different exposure durations to determine the time dependency of the response. Differences were observed in the vibration biodynamic responses between living and cadaver tails, but the general trends were similar. The biodynamic responses of both cadaver and living rat tails varied with exposure duration. © 2024 by the authors.

The diagnosis of paediatric pulmonary tuberculosis is difficult, especially in young infants who cannot expectorate sputum spontaneously. Breath testing has shown promise in diagnosing respiratory tract infections, but data on paediatric tuberculosis are limited. We performed a prospective cross-sectional study in Kenya in children younger than five years with symptoms of tuberculosis. We analysed exhaled breath with a hand-held battery-powered nose device. For data analysis, machine learning was applied using samples classified as positive (microbiologically confirmed) or negative (unlikely tuberculosis) to assess diagnostic accuracy. Breath analysis was performed in 118 children. The area under the curve of the optimal model was 0.73. At a sensitivity of 86 % (CI 62-96 %), this resulted in a specificity of 42 % (95 % CI 30-55 %). Exhaled breath analysis shows promise as a triage test for TB in young children, although the WHO target product characteristics were not met.

Hand hygiene (HH) can reduce transmission of healthcare-associated infections (HAIs) in healthcare facilities and is especially important in low- and middle-income countries where HH infrastructure may be insufficient and the burden of HAIs is highest. At baseline, we assessed HH infrastructure and practices among healthcare workers (HCWs) at two large hospitals in the Dominican Republic during the COVID-19 pandemic. HCWs were observed for HH adherence (HHA) (defined as the use of alcohol-based hand rub (ABHR) or handwashing with soap and water) before and after patient contact and donning new gloves before patient contact. The baseline assessment was repeated following implementation of local production and distribution of ABHR and a HH promotion campaign. Descriptive analyses and regression models evaluated predictors of HHA and glove use. Cumulative HHA was 18.9%. While patient-care areas with a functional HH resource increased from 47% at baseline to 92% after the intervention, HHA declined from 23.0% to 16.7%. HHA was higher after patient contact (aOR = 5.88; 95% CI = 4.17–8.33), during a period of increased COVID-19 risk (aOR = 1.69; 95% CI = 1.05–2.77), during invasive patient contacts (aOR = 1.64; 95% CI = 1.23–2.17) and when gloves were not used (aOR = 1.25; 95% CI = 1.01–1.56). The negative association between glove use and HHA diminished when access to HH resources increased. New gloves were donned before 39.6% of patient contacts. Glove use was higher among nurses (aOR = 7.12; 95% CI = 3.02–16.79) and during invasive contacts (aOR = 4.76; 95% CI = 2.27–10.0). While access to HH resources increased after the interventions, HHA did not increase. HHA was lower when COVID-19 risk was lower. Findings from this study may guide future efforts to increase HHA among HCWs. Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.