{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T18:53:36Z","timestamp":1789239216013,"version":"build-2803163510"},"reference-count":92,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"2","license":[{"start":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T00:00:00Z","timestamp":1770163200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,2,4]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>\n                    Acute febrile illness (AFI) surveillance networks can play a key role in identifying emerging pathogens and promoting global health security, especially for vulnerable populations in low- and middle-income countries. In January 2020, the Belize AFI Surveillance network was formed, and 5,643 participants were enrolled over the first 3-year period across 11 participating public hospitals. Using real-time polymerase chain reaction testing for vector-borne pathogen detection and BioFire\u00ae diagnostic testing for respiratory and gastrointestinal pathogens, the causes of illness were examined in relation to 54 pathogens in these participants. In response to the coronavirus disease 2019 pandemic, surveillance was expanded to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Overall, one or more pathogens were successfully identified in 51% of participants, with 43 different pathogens detected. Many important discoveries were made, including the first reported case of acute Chagas disease in Belize and eight cases of\n                    <jats:italic>Vibrio cholerae<\/jats:italic>\n                    . The most common identified vector-borne disease was dengue, with all four serotypes detected. The most common respiratory pathogens detected were SARS-CoV-2 and human rhinovirus\/enterovirus. The most common gastrointestinal pathogens detected were different strains of diarrheagenic\n                    <jats:italic>Escherichia coli<\/jats:italic>\n                    and norovirus. These and other results obtained via AFI surveillance enabled in-country and academic partners to respond to disease outbreaks rapidly and to monitor disease activity across the country more effectively.\n                  <\/jats:p>","DOI":"10.4269\/ajtmh.25-0328","type":"journal-article","created":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T18:57:27Z","timestamp":1764874647000},"page":"224-236","source":"Crossref","is-referenced-by-count":1,"title":["Infectious Causes of Acute Febrile Illness in Belize, 2020\u20132022"],"prefix":"10.4269","volume":"114","author":[{"given":"Adrianna","family":"Maliga","sequence":"first","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shannon E.","family":"Ronca","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Russell","family":"Manzanero","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Melendez","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah M.","family":"Gunter","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Lino","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joy","family":"Mackey","sequence":"additional","affiliation":[{"name":"Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andres","family":"Espinosa-Bode","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention\u2014Central America, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beatriz","family":"Lopez","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention\u2014Central America, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rafael","family":"Chacon-Fuentes","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention\u2014Central America, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Freedom M.","family":"Green","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oluwadara","family":"Okeremi","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Strobel","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel P.","family":"Rehm","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"William T. Shearer Center for Human Immunobiology, Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Flor M.","family":"Mu\u00f1oz","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Loren","family":"Cadena","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention\u2014Central America, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa","family":"Diaz-Musa","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francis","family":"Morey","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Zielinski-Gutierrez","sequence":"additional","affiliation":[{"name":"Centers for Disease Control and Prevention\u2014Central America, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerhaldine","family":"Morazan","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristy O.","family":"Murray","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Emory University School of Medicine and Children\u2019s Healthcare of Atlanta, Atlanta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2795","reference":[{"key":"b1","series-title":"PLoS Negl Trop Dis","first-page":"e0007962","article-title":"Central Latin America: Two decades of challenges in neglected tropical disease control","volume":"14","author":"Hotez","year":"2020"},{"key":"b2","article-title":"Belize","year":"2022"},{"key":"b3","article-title":"Statistics.","year":"2024"},{"key":"b4","series-title":"Am J Trop Med Hyg","first-page":"584","article-title":"The history of dengue outbreaks in the Americas","volume":"87","author":"Dick","year":"2012"},{"key":"b5","series-title":"J Infect Dis","first-page":"S436","article-title":"Chikungunya: Its history in Africa and Asia and its spread to new regions in 2013\u20132014","volume":"214","author":"Zeller","year":"2016"},{"key":"b6","article-title":"Half the Population of the Americas is at Risk of Diseases Carried by Small Insects.","author":"Mitchell","year":"2014"},{"key":"b7","series-title":"N Engl J Med","first-page":"1552","article-title":"Zika virus","volume":"374","author":"Petersen","year":"2016"},{"key":"b8","series-title":"Antiviral Res","first-page":"223","article-title":"Zika in the Americas, year 2: What have we learned? What gaps remain? A report from the Global Virus Network","volume":"144","author":"Aliota","year":"2017"},{"key":"b9","series-title":"Science","first-page":"2333","article-title":"Origin of the West Nile virus responsible for an outbreak of encephalitis in the northeastern United States","volume":"286","author":"Lanciotti","year":"1999"},{"key":"b10","series-title":"Rev Panam Salud Publica","first-page":"112","article-title":"West Nile virus activity in Latin America and the Caribbean","volume":"19","author":"Komar","year":"2006"},{"key":"b11","series-title":"Int J Infect Dis","first-page":"320","article-title":"Molecular ecology of Triatoma dimidiata in southern Belize reveals risk for human infection and the local differentiation of Trypanosoma cruzi parasites","volume":"108","author":"Polonio","year":"2021"},{"key":"b12","series-title":"Lancet","first-page":"1917","article-title":"Global burden of respiratory infections due to seasonal influenza in young children: A systematic review and meta-analysis","volume":"378","author":"Nair","year":"2011"},{"key":"b13","series-title":"Lancet","first-page":"946","article-title":"Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: A systematic review and modelling study","volume":"390","author":"Shi","year":"2017"},{"key":"b14","series-title":"Am J Trop Med Hyg","first-page":"912","article-title":"Population density, poor sanitation, and enteric infections in Nueva Santa Rosa, Guatemala","volume":"94","author":"Jarquin","year":"2016"},{"key":"b15","series-title":"Trop Dis Travel Med Vaccines","first-page":"9","article-title":"Review: Chronic and persistent diarrhea with a focus in the returning traveler","volume":"3","author":"Duplessis","year":"2017"},{"key":"b16","series-title":"J Clin Microbiol","first-page":"1673","article-title":"Noroviruses as a cause of diarrhea in travelers to Guatemala, India, and Mexico","volume":"48","author":"Koo","year":"2010"},{"key":"b17","article-title":"CDC Leverages Acute Febrile Illness Surveillance System to Respond to COVID-19.","year":"2022"},{"key":"b18","series-title":"Emerg Infect Dis","first-page":"1232","article-title":"Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007","volume":"14","author":"Lanciotti","year":"2008"},{"key":"b19","series-title":"Virol J","first-page":"10","article-title":"Development of real time PCR for detection and quantitation of dengue viruses","volume":"6","author":"Gurukumar","year":"2009"},{"key":"b20","series-title":"Emerg Infect Dis","first-page":"764","article-title":"Chikungunya virus in US travelers returning from India, 2006","volume":"13","author":"Lanciotti","year":"2007"},{"key":"b21","series-title":"J Clin Microbiol","first-page":"314","article-title":"Assessment of real-time PCR assay for detection of Rickettsia spp. and Rickettsia rickettsii in banked clinical samples","volume":"51","author":"Kato","year":"2013"},{"key":"b22","series-title":"J Clin Microbiol","first-page":"1477","article-title":"Detection of Trypanosoma cruzi by DNA amplification using the polymerase chain reaction","volume":"27","author":"Moser","year":"1989"},{"key":"b23","series-title":"Iran J Parasitol","first-page":"463","article-title":"Simplified Pan-species real-time PCR-based detection of Plasmodium Spp. in blood smear","volume":"11","author":"Hassanpour","year":"2016"},{"key":"b24","series-title":"PLoS Negl Trop Dis","first-page":"e2311","article-title":"Analytical and clinical performance of the CDC real time RT-PCR assay for detection and typing of dengue virus","volume":"7","author":"Santiago","year":"2013"},{"key":"b25","series-title":"Euro Surveill","first-page":"2000045","article-title":"Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR","volume":"25","author":"Corman","year":"2020"},{"key":"b26","article-title":"Belize \u2013 COVID-19 Overview.","year":"2023"},{"key":"b27","series-title":"Viruses","first-page":"768","article-title":"Epidemiological and clinical characteristics of acute dengue virus infections detected through acute febrile illness surveillance, Belize 2020","volume":"14","author":"Ly","year":"2022"},{"key":"b28","series-title":"Am J Trop Med Hyg","first-page":"992","article-title":"Diagnosis of acute chagas disease in a Belizean child with evidence of a multiclonal Trypanosoma cruzi infection","volume":"107","author":"Murray","year":"2022"},{"key":"b29","series-title":"BMC Public Health","first-page":"1196","article-title":"The impact of COVID-19 pandemic on the health-seeking behaviour of an Asian population with acute respiratory infections in a densely populated community","volume":"21","author":"Tan","year":"2021"},{"key":"b30","series-title":"Int J Environ Res Public Health","first-page":"4274","article-title":"Factors associated with the implementation of non-pharmaceutical interventions for reducing coronavirus disease 2019 (COVID-19): A systematic review","volume":"18","author":"Regmi","year":"2021"},{"key":"b31","series-title":"Acta Trop","first-page":"106286","article-title":"Opportunities and challenges to accurate diagnosis and management of acute febrile illness in adults and adolescents: A review","volume":"227","author":"Grundy","year":"2022"},{"key":"b32","series-title":"Indian J Pediatr","first-page":"945","article-title":"\u201cRationalization of empiric antibiotic therapy\u201d \u2013 A move towards preventing emergence of resistant infections","volume":"87","author":"Singhal","year":"2020"},{"key":"b33","series-title":"Drug Discov Ther","first-page":"282","article-title":"Approach to acute febrile illness during the COVID-19 pandemic","volume":"14","author":"Bhatt","year":"2021"},{"key":"b34","series-title":"Clin Infect Dis","first-page":"523","article-title":"Patterns of illness in travelers visiting Mexico and Central America: The GeoSentinel experience","volume":"53","author":"Flores-Figueroa","year":"2011"},{"key":"b35","series-title":"Am J Gastroenterol","first-page":"1774","article-title":"Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico","volume":"99","author":"Okhuysen","year":"2004"},{"key":"b36","series-title":"BMC Res Notes","first-page":"297","article-title":"Diarrheagenic Escherichia coli in Costa Rican children: A 9-year retrospective study","volume":"12","author":"P\u00e9rez-Corrales","year":"2019"},{"key":"b37","series-title":"Trop Med Int Health","first-page":"408","article-title":"Burden of diarrhoeagenic Escherichia coli in Santa Rosa, Guatemala in active health-services surveillance during 2008\u20132009 and 2014\u20132015","volume":"27","author":"Jarquin","year":"2022"},{"key":"b38","series-title":"Medicine (Baltimore)","first-page":"e8139","article-title":"A systematic review and meta-analysis of the prevalence of norovirus in cases of gastroenteritis in developing countries","volume":"96","author":"Nguyen","year":"2017"},{"key":"b39","series-title":"Hum Vaccin Immunother","first-page":"2281","article-title":"Global rotavirus vaccine introductions and coverage: 2006 \u2013 2016","volume":"14","author":"Abou-Nader","year":"2018"},{"key":"b40","article-title":"EPI Country Report: Belize.","year":"2019"},{"key":"b41","series-title":"PLoS Negl Trop Dis","first-page":"e787","article-title":"Arboviral etiologies of acute febrile illnesses in Western South America, 2000-2007","volume":"4","author":"Forshey","year":"2010"},{"key":"b42","series-title":"PLoS Negl Trop Dis","first-page":"e0005859","article-title":"Clinical and epidemiologic characteristics of dengue and other etiologic agents among patients with acute febrile illness, Puerto Rico, 2012\u20132015","volume":"11","author":"Tomashek","year":"2017"},{"key":"b43","series-title":"PLoS Negl Trop Dis","first-page":"e0010069","article-title":"The global epidemiology of chikungunya from 1999 to 2020: A systematic literature review to inform the development and introduction of vaccines","volume":"16","author":"Bettis","year":"2022"},{"key":"b44","series-title":"Am J Trop Med Hyg","first-page":"642","article-title":"Seroprevalence of seven zoonotic pathogens in pregnant women from the Caribbean","volume":"91","author":"Wood","year":"2014"},{"key":"b45","article-title":"PAHO\/WHO Data \u2013 Dengue Cases.","author":"Guti\u00e9rrez","year":"2015"},{"key":"b46","article-title":"PAHO\/WHO Data \u2013 PLISA.","year":"2022"},{"key":"b1","series-title":"PLoS Negl Trop Dis","first-page":"e0007962","article-title":"Central Latin America: Two decades of challenges in neglected tropical disease control","volume":"14","author":"Hotez","year":"2020"},{"key":"b2","article-title":"Belize","year":"2022"},{"key":"b3","article-title":"Statistics.","year":"2024"},{"key":"b4","series-title":"Am J Trop Med Hyg","first-page":"584","article-title":"The history of dengue 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meta-analysis","volume":"378","author":"Nair","year":"2011"},{"key":"b13","series-title":"Lancet","first-page":"946","article-title":"Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: A systematic review and modelling study","volume":"390","author":"Shi","year":"2017"},{"key":"b14","series-title":"Am J Trop Med Hyg","first-page":"912","article-title":"Population density, poor sanitation, and enteric infections in Nueva Santa Rosa, Guatemala","volume":"94","author":"Jarquin","year":"2016"},{"key":"b15","series-title":"Trop Dis Travel Med Vaccines","first-page":"9","article-title":"Review: Chronic and persistent diarrhea with a focus in the returning traveler","volume":"3","author":"Duplessis","year":"2017"},{"key":"b16","series-title":"J Clin Microbiol","first-page":"1673","article-title":"Noroviruses as a cause of diarrhea in travelers to Guatemala, India, and Mexico","volume":"48","author":"Koo","year":"2010"},{"key":"b17","article-title":"CDC Leverages Acute Febrile Illness Surveillance System to Respond to COVID-19.","year":"2022"},{"key":"b18","series-title":"Emerg Infect Dis","first-page":"1232","article-title":"Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007","volume":"14","author":"Lanciotti","year":"2008"},{"key":"b19","series-title":"Virol J","first-page":"10","article-title":"Development of real time PCR for detection and quantitation of dengue viruses","volume":"6","author":"Gurukumar","year":"2009"},{"key":"b20","series-title":"Emerg Infect Dis","first-page":"764","article-title":"Chikungunya virus in US travelers returning from India, 2006","volume":"13","author":"Lanciotti","year":"2007"},{"key":"b21","series-title":"J Clin Microbiol","first-page":"314","article-title":"Assessment of real-time PCR assay for detection of Rickettsia spp. and Rickettsia rickettsii in banked clinical samples","volume":"51","author":"Kato","year":"2013"},{"key":"b22","series-title":"J Clin Microbiol","first-page":"1477","article-title":"Detection of Trypanosoma cruzi by DNA amplification using the polymerase chain reaction","volume":"27","author":"Moser","year":"1989"},{"key":"b23","series-title":"Iran J Parasitol","first-page":"463","article-title":"Simplified Pan-species real-time PCR-based detection of Plasmodium Spp. in blood smear","volume":"11","author":"Hassanpour","year":"2016"},{"key":"b24","series-title":"PLoS Negl Trop Dis","first-page":"e2311","article-title":"Analytical and clinical performance of the CDC real time RT-PCR assay for detection and typing of dengue virus","volume":"7","author":"Santiago","year":"2013"},{"key":"b25","series-title":"Euro Surveill","first-page":"2000045","article-title":"Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR","volume":"25","author":"Corman","year":"2020"},{"key":"b26","article-title":"Belize \u2013 COVID-19 Overview.","year":"2023"},{"key":"b27","series-title":"Viruses","first-page":"768","article-title":"Epidemiological and clinical characteristics of acute dengue virus infections detected through acute febrile illness surveillance, Belize 2020","volume":"14","author":"Ly","year":"2022"},{"key":"b28","series-title":"Am J Trop Med Hyg","first-page":"992","article-title":"Diagnosis of acute chagas disease in a Belizean child with evidence of a multiclonal Trypanosoma cruzi infection","volume":"107","author":"Murray","year":"2022"},{"key":"b29","series-title":"BMC Public Health","first-page":"1196","article-title":"The impact of COVID-19 pandemic on the health-seeking behaviour of an Asian population with acute respiratory infections in a densely populated community","volume":"21","author":"Tan","year":"2021"},{"key":"b30","series-title":"Int J Environ Res Public Health","first-page":"4274","article-title":"Factors associated with the implementation of non-pharmaceutical interventions for reducing coronavirus disease 2019 (COVID-19): A systematic review","volume":"18","author":"Regmi","year":"2021"},{"key":"b31","series-title":"Acta Trop","first-page":"106286","article-title":"Opportunities and challenges to accurate diagnosis and management of acute febrile illness in adults and adolescents: A review","volume":"227","author":"Grundy","year":"2022"},{"key":"b32","series-title":"Indian J Pediatr","first-page":"945","article-title":"\u201cRationalization of empiric antibiotic therapy\u201d \u2013 A move towards preventing emergence of resistant infections","volume":"87","author":"Singhal","year":"2020"},{"key":"b33","series-title":"Drug Discov Ther","first-page":"282","article-title":"Approach to acute febrile illness during the COVID-19 pandemic","volume":"14","author":"Bhatt","year":"2021"},{"key":"b34","series-title":"Clin Infect Dis","first-page":"523","article-title":"Patterns of illness in travelers visiting Mexico and Central America: The 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