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.

Access to water, sanitation, and hygiene (WASH) resources in schools is critical for disease prevention and control, especially during public health emergencies. In Belize, systematic, national data on WASH in schools are needed to inform public health decisions and interventions. From December 2021 to January 2022, a national survey was sent electronically to government and government-aided primary and secondary schools in Belize (N = 308) to gather information on WASH services. From the survey, 12 pilot schools were selected based on the highest self-reported need for WASH resources to participate in additional evaluation and intervention, which included environmental nudges, supplemental supply provision, and hand hygiene education. To understand how the progression of the COVID-19 pandemic may have influenced hand hygiene, facility assessments to evaluate access to hand hygiene resources were conducted in person when most schools reopened for face-to-face learning during the pandemic (March 2022) and 15 months later (June 2023). Among the schools participating in the national survey (N = 221), 55% reported times when water was not available at the schools. Almost 9 in 10 schools (89%) had a functional handwashing station, and 47% reported always having soap for handwashing. Between baseline and follow-up at the 12 pilot schools, we observed decreases in the proportion of functional handwashing access points (-11%), functional handwashing access points accessible for individuals with disabilities (-17%) and small children (-29%), and functional alcohol-based hand rub dispensers (-13%). Despite the ongoing COVID-19 pandemic, we observed gaps in WASH resources in schools in Belize during the onsite assessments at the pilot schools. Schools should be encouraged and provided with WASH resources to maintain vigilance for disease control measures.

Chagas disease is a leading cause of non-ischemic cardiomyopathy in endemic regions of Central and South America. In Belize, Triatoma dimidiata sensu lato has been identified as the predominate taxon but vectorial transmission of Chagas disease is considered to be rare in the country. We recently identified an acute case of vector-borne Chagas disease in the northern region of Belize. Here we present a subsequent investigation of triatomines collected around the case-patient's home. We identified yet undescribed species, closely related to Triatoma huehuetenanguensis vector by molecular systematics methods occurring in the peridomestic environment. The identification of a T. cruzi-positive, novel species of Triatoma in Belize indicates an increased risk of transmission to humans in the region and warrants expanded surveillance and further investigation.

Existing acute febrile illness (AFI) surveillance systems can be leveraged to identify and characterize emerging pathogens, such as SARS-CoV-2, which causes COVID-19. The US Centers for Disease Control and Prevention collaborated with ministries of health and implementing partners in Belize, Ethiopia, Kenya, Liberia, and Peru to adapt AFI surveillance systems to generate COVID-19 response information. Staff at sentinel sites collected epidemiologic data from persons meeting AFI criteria and specimens for SARS-CoV-2 testing. A total of 5,501 patients with AFI were enrolled during March 2020-October 2021; >69% underwent SARS-CoV-2 testing. Percentage positivity for SARS-CoV-2 ranged from 4% (87/2,151, Kenya) to 19% (22/115, Ethiopia). We show SARS-CoV-2 testing was successfully integrated into AFI surveillance in 5 low- to middle-income countries to detect COVID-19 within AFI care-seeking populations. AFI surveillance systems can be used to build capacity to detect and respond to both emerging and endemic infectious disease threats.

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices-for example, hand hygiene-are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

In January 2020, we instituted acute febrile illness surveillance in 11 hospitals and clinics across Belize. Within 3 months, we diagnosed an acute case of Chagas disease by polymerase chain reaction in a 7-year-old child in the northern part of the country. Phylogenetic analyses of the parasite from the acute blood specimen revealed a multiclonal Trypanosoma cruzi infection, including parasites from the TcII (25.0% of haplotypes), TcIV (2.5% of haplotypes), and TcV (72.5% of haplotypes) discrete typing units. The family reported no history of travel, and three Triatoma species vectors were found within the home. The child's mother was seronegative for antibodies to T. cruzi, ruling out congenital transmission. Convalescent blood samples documented seroconversion and confirmed acute infection. The child was successfully treated with nifurtimox. This is the first known diagnosed case of acute Chagas infection in Belize, highlighting the need for further investigation and public health prevention measures.

The Acute Febrile Illness (AFI) Surveillance Network in Belize is a country-wide active surveillance program aimed at diagnosing vector-borne, respiratory, and enteric pathogens among patients presenting to 11 participating hospitals and clinics with new onset fever. This study describes the epidemiology of dengue virus (DENV) infections in Belize diagnosed through AFI surveillance in 2020. Of the 894 patients enrolled and PCR-tested for DENV in this period, 44 DENV-positive cases (5%) were identified. All four DENV serotypes were detected, with two cases testing positive for DENV serotype 4, which is the first report of this serotype in Belize since 2004. The majority of DENV cases (66%) were diagnosed in the Belize District, which contains the largest urban center in the country (Belize City). Positive cases were detected between January 2020 and September 2020, with the majority (89%) diagnosed during the dry season between January and April, unlike years prior when cases were more often diagnosed during the wet season. Clinical signs and symptoms varied slightly between DENV serotypes. Active surveillance of DENV among AFI cases provides insight into the epidemiologic and clinical characteristics of DENV in Belize. This information is important for informing public health interventions to mitigate DENV transmission.

On August 16, 2021, the Oregon Health Authority Public Health Division (OPHD) was notified of two pediatric cases of Shiga toxigenic Escherichia coli among members of the same household. Each of the patients received a positive polymerase chain reaction test result for Shiga toxin in a stool specimen. E. coli O157:H7 was subsequently isolated from stool culture from both patients. During routine case investigation, the local health department determined that one patient, aged 2 years, had attended an in-home child care center. OPHD visited the child care center on August 18 to conduct case ascertainment among staff members and children, share recommendations for rapid isolation and exclusion of those ill, observe infection prevention practices during diaper changing, and educate staff members on infection prevention measures for toys and high-touch surfaces. The investigation team requested parental consent and attempted to collect clinical information on gastrointestinal symptoms during July 30–August 18 and stool specimens from all staff members and children on the day of the visit. A child care center staff member followed up with other staff members and children who were not present on the day of the visit to obtain clinical information and provide them with specimen collection kits and instructions. Stool specimens were placed in Cary-Blair transport medium, transported to OPHD, and tested for 22 enteric pathogens using the BioFire FilmArray Gastrointestinal Panel (BioFire Diagnostics, LLC).

In August 2018, two Oregon patients with diagnosed Salmonella infection were interviewed using a standard enteric illness questionnaire; both patients reported having eaten raw cake mix. Standardized interview questionnaire data collected from 207 Oregon patients with salmonellosis in 2017 indicated a 5% rate of consumption of raw “cake mix or cornbread mix” (Oregon Health Authority, unpublished data, 2017). The binomial probability that both 2018 patients were exposed to raw cake mix by chance was determined to be 0.003, prompting the Oregon Health Authority (OHA) to collect and test the contents of 43 boxes of unopened cake mix of various brands from six retail locations. OHA sent samples to the Institute for Environmental Health Laboratories in Lake Forest Park, Washington, for pathogen testing. Salmonella Agbeni was isolated from an unopened box of white cake mix from manufacturer A, and whole genome sequencing (WGS) data describing the isolate were uploaded to the U.S. National Library of Medicine’s National Center for Biotechnology Information (NCBI) website (https://www.ncbi.nlm.nih.gov/pathogensexternal icon). OHA used the NCBI database to compare sequence data with the cake mix isolate (PNUSAS056022) and then consulted CDC’s System for Enteric Disease Response, Investigation, and Coordination (SEDRIC), a web-based, outbreak investigation tool designed for collaborative, multistate investigations of enteric disease outbreaks.* On October 19, OHA determined that clinical isolates from four patients from Maryland, Ohio, and Wisconsin, with specimen isolation dates ranging from June to September 2018, were genetically related to the Salmonella Agbeni isolate from the unopened box of white cake mix, within four single nucleotide polymorphisms (SNPs).

Lack of maintenance on vacant neighborhood lots is associated with higher levels of depression, anxiety, and stress for nearby residents. Overgrown grasses and dense brush provide hiding spots for criminals and space to conduct illicit activities. This study builds upon previous research by investigating greening programs that engage community members to conduct routine maintenance on vacant lots within their neighborhoods. The Clean & Green program is a community-based solution that facilitates resident-driven routine maintenance of vacant lots in a midsized, Midwestern city. We use mixed effects regression to compare assault and violent crime counts on streets where vacant lot(s) are maintained by community members (N = 216) versus streets where vacant lots were left alone (N = 446) over a 5-year timeframe (2009-2013). Street segments with vacant lots maintained through the Clean & Green program had nearly 40% fewer assaults and violent crimes than street segments with vacant, abandoned lots, which held across 4 years with a large sample and efforts to test counterfactual explanations. Community-engaged greening programs may not only provide a solution to vacant lot maintenance, but also work as a crime prevention or reduction strategy. Engaging the community to maintain vacant lots in their neighborhood reduces costs and may increase the sustainability of the program.

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.

When food handlers become ill with hepatitis A virus (HAV) infection, state and local health departments must assess the risk of HAV transmission through prepared food and recommend or provide postexposure prophylaxis (PEP) for those at risk for HAV infection. Providing PEP (eg, hepatitis A [HepA] vaccine or immunoglobulin), however, is costly. To describe the burden of these responses on state and local health departments, we determined the number of public health responses to HAV infections among food handlers by reviewing public internet sources of media articles. We then contacted each health department to collect data on whether PEP was recommended to food handlers or restaurant patrons, the number of PEP doses given, the number of HepA vaccine or immunoglobulin doses given as PEP, and the mean number of health department person-hours required for the response. Of 32 public health responses identified from Twitter, HealthMap, and Google alerts from January 1, 2012, to December 31, 2014, a total of 27 (84%) recommended PEP for other food handlers or restaurant patrons or both. Per public health response, the mean cost per dose of the HepA vaccine or immunoglobulin was $34 139; the mean personnel cost per response was $7329; and the total mean cost of each response was $41 468. PEP is expensive. Less aggressive approaches to PEP, such as limiting PEP to fellow food handlers in nonoutbreak situations, should be considered in the postvaccination era. HepA vaccine for PEP provides long-term immunity and can be used when immunoglobulin is unavailable or cannot be administered within 14 days of exposure to HAV.

Most studies of immigrant health are cross-sectional and fail to collect information prior to migration, leading to potential bias and confounding. The present pilot study examines the feasibility of studying migrants prospectively, with baseline data collected before migration. The study followed two cohorts of Filipinos for one year, a migrant cohort (n=27) that emigrated to the U.S. and a second non-migrant cohort (n=26) that remained in the Philippines. The one-year retention rate was 96%. The migrant cohort arrived in the U.S. within two months of their baseline assessment. Migrants and non-migrants did not differ with regard to body mass index, waist circumference, or waist to hip ratio at baseline or at follow-up. It is feasible to conduct a transnational, longitudinal study of two cohorts of Filipinos. This design provides important pre-migration information, is analogous to a natural experiment, can be upscaled, and allows for a rigorous examination of immigrant health.

Ninety-seven animal, human, and dairy Streptococcus porcinus or Streptococcus pseudoporcinus isolates in the CDC Streptococcus strain collection were evaluated based on DNA-DNA reassociation, 16S rRNA and rpoB gene sequencing, conventional biochemical and rapid ID 32 STREP identification methods, and antimicrobial susceptibility testing to determine their taxonomic status, characteristics for species differentiation, antimicrobial susceptibility and relevance of clinical source. Nineteen of the 97 isolates (1 human, 18 swine) were identified as S. porcinus. The remaining 72 human isolates and 6 dairy isolates were identified as S. pseudoporcinus. The use of 16S rRNA or rpoB gene sequencing was required to differentiate S. porcinus from S. pseudoporcinus. The human and dairy S. pseudoporcinus isolates were biochemically distinct from each other as well as distinct by 16S rRNA and rpoB gene sequencing. Therefore, we propose the subspecies denominations S. pseudoporcinus subsp. hominis subsp. nov. for the human isolates and S. pseudoporcinus subsp. lactis subsp. nov. for the dairy isolates. Most strains were susceptible to the antimicrobials tested, with the exception of tetracycline. Two strains of each species were also resistant to clindamycin and erythromycin and carried the erm(A) (S. pseudoporcinus) or the erm(B) (S. porcinus) genes. S. porcinus was identified from a single human isolate recovered from a wound in an abattoir worker. S. pseudoporcinus was primarily isolated from the genitourinary tract of women, but was also associated with blood, placental, and wound infections. Isolates reacting with group B antiserum and demonstrating wide beta hemolysis should be suspected of being S. pseudoporcinus and not S. agalactiae.

A novel Legionella species was identified based on 16S rRNA and mip (macrophage infectivity potentiator) gene sequencing analysis, cellular fatty acids, isoprenoid quinones, biochemical reactions, antigens, and quantitative DNA-DNA hybridization. The strain CDC-1796-JAP-E(T) was isolated from well water at the Nagassaki Municipal Medical Center, Japan. Two strains, CDC-3041-AUS-E and CDC-3558-AUS-E, were isolated from water samples during an outbreak of legionellosis in South Australia. The strain CDC-5427-OH-H was isolated from a 66-year-old female patient diagnosed with Legionnaires' disease in the U.S. The cells from these four strains were gram-negative, non-fluorescent, rod-shaped, and positive for alkaline phosphatase, esterase, leucine arylamidase, catalase, gelatinase, beta-lactamase, and tyrosine browning assay. Phylogenetic analysis of 16S rRNA and mip genes revealed that the four strains formed a distinct cluster within the genus Legionella. The bacteria contained branched-chain fatty acids and quinones that are typical of the genus Legionella. Slide agglutination tests demonstrated no cross-reaction with 52 previously described Legionellaceae. DNA hybridization studies indicated DNAs from the four strains were highly related (78-84%) but showed 29% relatedness to L. oakridgensis (ATCC 33761(T)) and less than 10% to other Legionella species tested. These characterizations suggest that the isolates represent a novel species, for which the name Legionella nagasakiensis sp. nov is proposed, for the type strain CDC-1796-JAP-E(T) (=ATCC BAA-1557(T)=JCM 15315(T)).

Eight isolates submitted to CDC from 1989 to 2006 from clinical specimens were initially identified as members of the genus Burkholderia based on preliminary cellular fatty acid analysis and/or 16S rRNA gene sequencing. With the recent descriptions of the new species B. rhizoxinica and B. endofungorum, which are considered endosymbiotic bacteria in Rhizopus microsporus fungi, we now identify seven of these clinical isolates as B. rhizoxinica and one as B. endofungorum based on biochemical testing, 16s rRNA, and DNA-DNA hybridization results. We also further characterize these isolates by assessing toxin production and/or by multiple locus sequence typing.

During January to April 2007, hospital staff reported 3 patients with Rhodococcus equi bloodstream infections. Isolates were analyzed at the Centers for Disease Control and Prevention, Atlanta, GA, to confirm identification and to assess strain relatedness; 2 were R. equi but genetically distinct, and 1 was identified as Gordonia polyisoprenivorans. Rapid reference laboratory support prevented an unnecessary outbreak investigation.

Four isolates (FSL S4-120T, FSL S4-696, FSL S4-710, and FSL S4-965) of Gram-positive, motile, facultatively anaerobic, non-sporeforming bacilli that were phenotypically similar to Listeria spp. were isolated from soil, standing water, and flowing water samples obtained from the natural environment in the Finger Lakes National Forest, New York, USA. The four isolates were closely related to one another and were determined to be the same species by whole genome DNA-DNA hybridization studies (>82% relatedness at 55 degrees C and >76% relatedness at 70 degrees C with 0.0-0.5% divergence). 16S ribosomal RNA sequence analysis confirmed their close phylogenetic relatedness to L. monocytogenes and L. innocua and more distant relatedness to L. welshimeri, L. seeligeri, L. ivanovii, and L. grayi. Phylogenetic analysis of partial sequences for sigB, gap, and prs showed that these isolates form a well-supported sistergroup to L. monocytogenes. The four isolates were sufficiently different from L. monocytogenes and L. innocua by DNA-DNA hybridization to warrant their designation as a new Listeria species. The four isolates yielded positive reactions in the AccuProbe(R) test that is purported to be specific for L. monocytogenes, did not ferment L-rhamnose, were non-hemolytic on blood agar media, and did not contain a homologue of the L. monocytogenes virulence gene island. On the basis of their phenotypic characteristics and their genotypic distinctiveness from L. monocytogenes and L. innocua, the four isolates should be classified as a new species within the genus Listeria, for which the name Listeria marthii sp. nov. is proposed. The type strain of L. marthii is FSL S4-120T (=ATCC BAA 1595T =BEIR NR 9579T =CCUG 56148T). L. marthii has not been associated with human or animal disease at this time.