New light on the use of Theobroma cacao by Late Classic Maya.

Cacao seeds, Theobroma cacao, provide the basis for a ceremonially important Mesoamerican food. Past efforts to identify cacao in ceramics focused on highly decorative vessel forms associated with elite ceremonial contexts, creating assumptions as to how cacao was distributed and who could access it. This study examines 54 archaeological ceramic sherds from El Pilar (Belize/Guatemala) of Late Classic (600 to 900 CE) residential and civic contexts representing a cross-section of ancient Maya inhabitants. Identification of cacao in ancient sherds has depended on the general presence of theobromine; we used the discrete presence of theophylline, a unique key biomarker for cacao in the region. Analysis was done by grinding off all outside surfaces to reduce contamination, pulverizing the inner clay matrix, extracting absorbed molecules, and concentrating the extractions. In order to obtain especially high selectivity and low limits of detection, our study utilized the technique of resonance-enhanced multiphoton ionization coupled with laser-desorption jet-cooling mass spectrometry. This technique isolates molecules in the cold gas phase where they can be selectively ionized through a resonant two-photon process. Of the sherds analyzed, 30 samples (56%) were found to contain significant amounts of theophylline and thus test positive for cacao. Importantly, cacao is present in all contexts, common to all Maya residents near and far from centers.

Cancer Demographics and Time-to-Care in Belize.

BACKGROUND: Belize is a middle-income Caribbean country with poorly described cancer epidemiology and no comprehensive cancer care capacity. In 2018, GO, Inc., a US-based NGO, partnered with the Ministry of Health and the national hospital in Belize City to create the first public oncology clinic in the country. Here, we report demographics from the clinic and describe time intervals to care milestones to allow for public health targeting of gaps. PATIENTS AND METHODS: Using paper charts and a mobile health platform, we performed a retrospective chart review at the Karl Heusner Memorial Hospital (KHMH) clinic from 2018 to 2022. RESULTS: During this time period, 465 patients with cancer presented to the clinic. Breast cancer (28%) and cervical cancer (12%) were most common. Most patients (68%) presented with stage 3 or 4 disease and were uninsured (78%) and unemployed (79%). Only 21% of patients ever started curative intent treatment. Median time from patient-reported symptoms to a biopsy or treatment was 130 and 189 days. For the most common cancer, breast, similar times were seen at 140 and 178 days. Time intervals at the clinic: <30 days from initial visit to biopsy (if not previously performed) and <30 days to starting chemotherapy. CONCLUSION: This study reports the first clinic-based cancer statistics for Belize. Many patients have months between symptom onset and treatment. In this setting, the clinic has built infrastructure allowing for minimal delays in care despite an underserved population. This further affirms the need for infrastructure investment and early detection programs to improve outcomes in Belize.

Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis.

PURPOSE: Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services. METHODS: Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model. RESULTS: We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening. CONCLUSION: Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.

Voices of those living with type 2 diabetes in Belize: barriers to care before and during the COVID-19 pandemic.

Belize has the highest national prevalence of type 2 diabetes (T2D) of Central and South America, and fifth direst in the world. T2D is the leading cause of death in Belize, a country facing burdens of increasing prevalence with few resources. Since March of 2020, the COVID-19 pandemic has exacerbated the difficulties of those living with T2D in Belize. To address T2D issues in Belize, our interdisciplinary research team explored the barriers to care and self-management for adult patients with T2D in Belize prior to and during the COVID-19 pandemic.Research relationships between Canadian (ARH) and Belizean (LE) authors have been ongoing since 2016. Together we used a qualitative Constructivist Grounded Theory design generating knowledge through 35 semi-structured patient interviews, 25 key informant discussions, and participant observation with field notes between February 2020 to September 2021. We used Dedoose analysis software for a systematized thematic coding process, as well as iterative verification activities. Findings revealed several barriers to care and self-management, including: 1) the tiered health and social care system with major gaps in coverage; 2) the unfulfilled demand for accurate health information and innovative dissemination methods; and 3) the compounding of loss of community supports, physical exercise, and health services due to COVID-19 restrictions. In the post-pandemic period, it is necessary to invest in physical, nutritional, economic, and psychosocial health through organized activities adaptable to changeable public health restrictions. Recommendations for activities include sending patients informational and motivational text messages, providing recipes with accessibly sourced T2D foods, televising educational workshops, making online tools more accessible, and mobilising community and peer support networks.

Trends and factors associated with HIV testing among women aged 15-49 years in Belize: an analysis using the Multiple Indicator Cluster Survey 2006, 2011, and 2015-2016.

BACKGROUND: Belize has one of the highest human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome prevalence rates in Central America, with women of reproductive age being particularly vulnerable to HIV. Therefore, this study examined the factors associated with HIV testing among women of reproductive age in Belize and trends in HIV testing in 2006, 2011, and 2015-2016. METHODS: Cross-sectional data were analyzed using three Belize Multiple Indicator Cluster Surveys. The number of participants were 1,675, 4,096, and 4,699 women aged 15-49 years in 2006, 2011, and 2015-2016, respectively. We used variance-weighted least-squares regression to estimate annual changes. Multivariate logistic regression analysis was performed to evaluate the associated factors. Analyses were conducted using Stata version 15, and weights were applied for generalization to the population. RESULTS: HIV testing rates increased from 47.7% in 2006 to 66.5% in 2015, with an average annual change of 0.082 (95% confidence interval: 0.07-0.09). Logistic regression models showed that women aged 15-24 years were less likely to have been tested for HIV compared to women aged 25-34 years. Women from the Mayan ethnic group were less likely to have been tested than those from other ethnic groups. Compared to women who spoke Spanish, those who spoke English/Creole were more likely to have been tested for HIV; additionally, those who spoke minority languages were less likely to have been tested. Being married and having given birth were associated with increased odds of HIV testing. Living in rural areas and households with the poorest wealth indices were associated with decreased odds of being tested for HIV. Women with good HIV knowledge and accepting attitudes towards people living with HIV were more likely to be tested. CONCLUSIONS: From 2006 to 2015, HIV testing in women of reproductive age showed an increasing trend in Belize. We recommend interventions to expand HIV testing for women of reproductive age in Belize, particularly those aged 15-24 years, speaking minority languages, living in rural areas, and having a low socioeconomic status.

Does "Susto" Really Exist? Indigenous Knowledge and Fright Disorders Among Q'eqchi' Maya in Belize.

Susto is one of the most common disorders referenced in the medical anthropological and cultural psychiatric literature. This article questions if "susto" as understood in cultural psychiatric terms, especially in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), is in fact a single "cultural concept of distress." There is extensive cross-cultural and intracultural variability regarding fright-related disorders in the ethnographic literature. What is often labeled "susto" may be in reality a variety of distinct disorders, or lacking in the two signature components found in the cultural psychiatric literature: the existence of a "fright," and subsequent soul loss. There has been significant polysemic and geographical drift in the idiom label, the result of colonialism in Mesoamerica, which has overlayed but not necessarily supplanted local knowledge. Using data from fifteen years of research with Q'eqchi' (Maya) healers and their patients, we demonstrate how important variability in signs, symptoms, diagnosis, treatment, and prognosis of fright-related disorders renders any simple declaration that this is a singular "susto" problematic. We argue for a careful consideration of the knowledge of Indigenous medical specialists charged with treating fright-related disorders and against the inclination to view variability as insignificant. Such consideration suggests that Indigenous forms of fright-related disorder are not susto as presented commonly in the DSM and cultural psychiatric literature.

The adoption of climate-smart agriculture to address wildfires in the Maya Golden Landscape of Belize: Smallholder farmers' perceptions.

Ecosystems around the globe are enduring wildfires with greater frequency, intensity, and severity and this trend is projected to continue as a result of climate change. Climate-smart agriculture (CSA) has been proposed as a strategy to prevent wildfires and mitigate climate change impacts; however, it remains poorly understood as a strategy to prevent wildfires. Therefore, the authors propose a multimethod approach that combines mapping of wildfire susceptibility and social surveys to identify priority areas, main factors influencing the adoption of CSA practices, barriers to their implementation, and the best CSA practices that can be implemented to mitigate wildfires in Belize's Maya Golden Landscape (MGL). Farmers ranked slash and mulch, crop diversification, and agroforestry as the main CSA practices that can be implemented to address wildfires caused by agriculture in the MGL. In order to reduce wildfire risk, these practices should, be implemented in agricultural areas near wildlands with high wildfire susceptibility and during the fire season (February-May), in the case of slash and mulch. However, socio-demographic and economic characteristics, together with a lack of training and extension services support, inadequate consultation by agencies, and limited financial resources, hinder the broader adoption of CSA practices in the MGL. Our research produced actionable and valuable information that can be used to design policies and programs to mitigate the impacts of climate change and wildfire risk in the MGL. This approach can also be used in other regions where wildfires are caused by agricultural practices to identify priority areas, barriers and suitable CSA practices that can be implemented to mitigate wildfires.

HEMATOLOGIC AND BIOCHEMICAL VALUES OF FREE-RANGING HAWKSBILL SEA TURTLES (ERETMOCHELYS IMBRICATA) IN GLOVER'S REEF, BELIZE.

Blood samples were obtained from the dorsal cervical sinus of free-ranging hawksbill sea turtles (Eretmochelys imbricata) collected at Glover's Reef Marine Reserve, 42 km east of the coast of Belize, for hematology and plasma biochemistry analysis. Unknown sex, subadult turtles (N = 32) were sampled in 2013 (n = 22) and 2017 (n = 10). To provide a more robust data set, parameters that did not have statistically significant differences were pooled and treated as a single population. Eleven hematologic parameters were evaluated; of these, five were pooled. Twenty-three plasma biochemical parameters were evaluated; of these, 15 were pooled. The PCV observed in this study (mean 33.44%) was double that observed in two studies of juvenile hawksbills in Dubai (means 17% and 16%), whereas the total WBC count was half that observed in immature and adult hawksbills sampled in the Galápagos (mean 2.91 × 103 versus 5.3 × 103/µl). Total protein and albumin were lower than regionally similar, adult female hawksbills in Brazil (means 3.36 versus 5.45 g/dl and 0.93 versus 2.11 g/dl, respectively). Globulins were higher (mean 2.43 versus 1.06 and 0.5 g/dl), driving the albumin:globulin ratio lower than that observed in two studies of juvenile hawksbills in Dubai (0.4:1 versus 1.1:1 and 1:1, respectively). These findings represent a geographically distinct population from previous reports, highlight the variability in blood parameters from disparate populations, and reaffirm the vital importance of considering a multitude of variables when interpreting reptilian blood values. The similarities in the majority of values observed in 2013 and 2017 provide confidence in the stability of these parameters in this population.

Shifts in predator behaviour following climate induced disturbance on coral reefs.

Coral reefs are increasingly ecologically destabilized across the globe due to climate change. Behavioural plasticity in corallivore behaviour and short-term trophic ecology in response to bleaching events may influence the extent and severity of coral bleaching and subsequent recovery potential, yet our understanding of these interactions in situ remains unclear. Here, we investigated interactions between corallivory and coral bleaching during a severe high thermal event (10.3-degree heating weeks) in Belize. We found that parrotfish changed their grazing behaviour in response to bleaching by selectively avoiding bleached Orbicella spp. colonies regardless of bleaching severity or coral size. For bleached corals, we hypothesize that this short-term respite from corallivory may temporarily buffer coral energy budgets by not redirecting energetic resources to wound healing, and may therefore enable compensatory nutrient acquisition. However, colonies that had previously been heavily grazed were also more susceptible to bleaching, which is likely to increase mortality risk. Thus, short-term respite from corallivory during bleaching may not be sufficient to functionally rescue corals during prolonged bleaching. Such pairwise interactions and behavioural shifts in response to disturbance may appear small scale and short term, but have the potential to fundamentally alter ecological outcomes, especially in already-degraded ecosystems that are vulnerable and sensitive to change.

Oral susceptibility to ivermectin is over fifty times greater in a wild population of Anopheles albimanus mosquitoes from Belize than the STECLA laboratory reference strain of this mosquito.

BACKGROUND: The STECLA strain of Anopheles albimanus has been in continuous colony for many years and is the reference strain on which genomic studies for the species are based. Recently, the STECLA strain was demonstrated to be much less susceptible to ivermectin ingested in a blood meal (4-day LC50 of 1468 ng/ml) than all other Anopheles species tested to-date (LC50 values range from 7 to 56 ng/ml). The ability of An. albimanus to survive ingestion of ivermectin at concentrations far beyond that typically found in the blood of ivermectin-treated people or livestock (i.e., 30-70 ng/ml) could invalidate the use of ivermectin as a malaria vector control strategy in areas where An. albimanus is a primary vector. METHODS: To investigate this, host-seeking An. albimanus were captured in northern Belize and used in membrane feeding bioassays of ivermectin, employing the same methods as described earlier with the STECLA strain. RESULTS: Field-collected An. albimanus in Belize were 55 times more susceptible to ingested ivermectin than were the STECLA reference strain. Oral susceptibility to ivermectin in wild An. albimanus from Belize (4-day LC50 of 26 ng/ml) was equivalent to that of other Anopheles species tested. CONCLUSIONS: Contrary to initial assessments using a highly inbred strain of mosquito, laboratory studies using a field population indicate that ivermectin treatment of livestock could reduce An. albimanus populations in areas of Central America and the Caribbean where malaria transmission may occur. Toxicity screening of ivermectin and other systemic parasiticides for malaria control should examine wild populations of the vector species being targeted.

A qualitative inquiry of food insecurity in Belize.

OBJECTIVE: To explore and provide contextual meaning around issues surrounding food insecurity, namely factors influencing food access, as one domain of food security. DESIGN: A community-based, qualitative inquiry using semi-structured face-to-face interviews was conducted as part of a larger sequential mixed-methods study. SETTING: Cayo District, Belize, May 2019-August 2019. PARTICIPANTS: Thirty English-speaking individuals (eight males, twenty-two females) between the ages of 18-70, with varying family composition residing within the Cayo District. RESULTS: Participants describe a complex interconnectedness between family- and individual-level barriers to food access. Specifically, family composition, income, education and employment influence individuals' ability to afford and access food for themselves or their families. Participants also cite challenges with transportation and distance to food sources and educational opportunities as barriers to accessing food. CONCLUSION: These findings provide insight around food security and food access barriers in a middle-income country and provide avenues for further study and potential interventions. Increased and sustained investment in primary and secondary education, including programmes to support enrollment, should be a priority to decreasing food insecurity. Attention to building public infrastructure may also ease burdens around accessing foods.

Ancient Maya wetland fields revealed under tropical forest canopy from laser scanning and multiproxy evidence.

We report on a large area of ancient Maya wetland field systems in Belize, Central America, based on airborne lidar survey coupled with multiple proxies and radiocarbon dates that reveal ancient field uses and chronology. The lidar survey indicated four main areas of wetland complexes, including the Birds of Paradise wetland field complex that is five times larger than earlier remote and ground survey had indicated, and revealed a previously unknown wetland field complex that is even larger. The field systems date mainly to the Maya Late and Terminal Classic (∼1,400-1,000 y ago), but with evidence from as early as the Late Preclassic (∼1,800 y ago) and as late as the Early Postclassic (∼900 y ago). Previous study showed that these were polycultural systems that grew typical ancient Maya crops including maize, arrowroot, squash, avocado, and other fruits and harvested fauna. The wetland fields were active at a time of population expansion, landscape alteration, and droughts and could have been adaptations to all of these major shifts in Maya civilization. These wetland-farming systems add to the evidence for early and extensive human impacts on the global tropics. Broader evidence suggests a wide distribution of wetland agroecosystems across the Maya Lowlands and Americas, and we hypothesize the increase of atmospheric carbon dioxide and methane from burning, preparing, and maintaining these field systems contributed to the Early Anthropocene.

Trace element concentrations in caudal scutes from Crocodylus moreletii and Crocodylus acutus in Belize in relation to biological variables and land use.

Crocodylus moreletii (Morelet's crocodile) and Crocodylus acutus (American crocodile) are generalist, apex predators of subtropical aquatic habitats in Central America. As top predators, crocodiles may be exposed to high levels of micro pollutants, such as trace elements via bioaccumulation that enter the food web as a consequence of human activities. As such, the status of their population can be considered indicative of that of the entire ecosystem - i.e., crocodiles constitute as genuine indicator species. In this study, we report on the concentrations of trace elements found in the caudal scutes of 178 specimens of C. acutus and C. moreletii from Belize. Our objectives were three-fold: (1) to assess variation in trace element concentration between species, sexes, age classes and body index; (2) to identify areas with elevated exposure to trace elements by comparing concentrations in the scutes of crocodiles at various sites in Belize; and (3) to explore links between crocodile trace element load and local land use. All elements tested (Hg, Pb, Cd, As, Cu, Zn, Co) could be detected in at least some scutes. Many of the readings of As and Co were under or close to the detection limit and were not further analyzed. Relatively high Hg concentrations were observed in adults from Chiquibul Forest (median 3.170 µg/g) and Ambergris Caye (0.834 µg/g). Concentrations of Hg and Pb tended to be higher in adult animals than in juveniles, especially in C. acutus. On the other hand, concentrations of Cd, Cu and Zn were higher in juveniles than in subadult adult animals. Concentrations of Cu were higher in C. acutus than in C. moreletii, but otherwise no species-effects were found for the other trace elements. We found a negative correlation between Hg and Zn concentrations; correlations among Cd, Pb, Cu and Zn concentrations tended to be positive. In both juveniles and adults, animals with high concentrations of Zn had lower body-indices (a proxy for physiological condition). None of the other element concentrations correlated with the body-index. Specimens of C. acutus were more often sampled at coastal sites, while C. moreletii sampling points were typically closer to agricultural or forested areas. A canonical correlation analysis revealed a significant association between trace element load and habitat characteristics. Animals sampled inland, near submontane forests, contained higher levels of Hg, while animals sampled near agricultural, urban or lowland habitats tended to have higher concentrations of Cd, Pb, Cu and Zn. This study identifies the most prevalent trace element concentrations impacting Belizean watersheds while highlighting the exposure risk to non-essential trace elements in less-urbanised areas or protected areas.

Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize.

BACKGROUND: Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. OBJECTIVE: This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. METHODS: We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. RESULTS: Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. CONCLUSIONS: The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.

Variable tropical moisture and food availability underlie mixed winter space-use strategies in a migratory songbird.

Identifying environmental correlates driving space-use strategies can be critical for predicting population dynamics; however, such information can be difficult to attain for small mobile species such as migratory songbirds. We combined radio-telemetry and high-resolution GPS tracking to examine space-use strategies under different moisture gradients for wood thrush (Hylocichla mustelina). We explored the role moisture plays in driving food abundance and, in turn, space-use strategies at a wintering site in Belize across 3 years. Individuals occupying drier habitats experienced lower food abundance and poorer body condition. Using data from our radio-tracked study population and GPS tracking from across five breeding populations, we detected low rates of overwinter site persistence across the wood thrush wintering range. Contrary to expectations, individuals in wetter habitats were more likely to engage in permanent mid-winter relocations, up to 148 km. We suggest facultative movements are instead a condition-dependent strategy that enables wintering wood thrush to locate alternative habitat as food availability declines throughout the dry season. Increased aridity is predicted across the wintering range of wood thrush, and future research should delve deeper into understanding how moisture impacts within and between season space-use dynamics and its ultimate impact on the population dynamics of this declining species.

Analysis of SARS-CoV-2 mutations in Mexico, Belize, and isolated regions of Guatemala and its implication in the diagnosis.

The genomic sequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide are publicly available and are derived from studies due to the increase in the number of cases. The importance of study of mutations is related to the possible virulence and diagnosis of SARS-CoV-2. To identify circulating mutations present in SARS-CoV-2 genomic sequences in Mexico, Belize, and Guatemala to find out if the same strain spread to the south, and analyze the specificity of the primers used for diagnosis in these samples. Twenty three complete SARS-CoV-2 genomic sequences, available in the GISAID database from May 8 to September 11, 2020 were analyzed and aligned versus the genomic sequence reported in Wuhan, China (NC_045512.2), using Clustal Omega. Open reading frames were translated using the ExPASy Translate Tool and UCSF Chimera (v.1.12) for amino acid substitutions analysis. Finally, the sequences were aligned versus primers used in the diagnosis of COVID-19. One hundred and eighty seven distinct variants were identified, of which 102 are missense, 66 synonymous and 19 noncoding. P4715L and P5828L substitutions in replicase polyprotein were found, as well as D614G in spike protein and L84S in ORF8 in Mexico, Belize, and Guatemala. The primers design by CDC of United States showed a positive E value. The genomic sequences of SARS-CoV-2 in Mexico, Belize, and Guatemala present similar mutations related to a virulent strain of greater infectivity, which could mean a greater capacity for inclusion in the host genome and be related to an increased spread of the virus in these countries, furthermore, its diagnosis would be affected.

Performance of passive case detection for malaria surveillance: results from nine countries in Mesoamerica and the Dominican Republic.

BACKGROUND: In malaria elimination settings, available metrics for malaria surveillance have been insufficient to measure the performance of passive case detection adequately. An indicator for malaria suspected cases with malaria test (MSCT) is proposed to measure the rate of testing on persons presenting to health facilities who satisfy the definition of a suspected malaria case. This metric does not rely on prior knowledge of fever prevalence, seasonality, or external denominators, and can be used to compare detection rates in suspected cases within and between countries, including across settings with different levels of transmission. METHODS: To compute the MSCT, an operational definition for suspected malaria cases was established, including clinical and epidemiological criteria. In general, suspected cases included: (1) persons with fever detected in areas with active malaria transmission; (2) persons with fever identified in areas with no active transmission and travel history to, or residence in areas with active transmission (either national or international); and (3) persons presenting with fever, chills and sweating from any area. Data was collected from 9 countries: Belize, Colombia (in areas with active transmission), Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (September-March 2020). A sample of eligible medical records for 2018 was selected from a sample of health facilities in each country. An algorithm was constructed to assess if a malaria test was ordered or performed for cases that met the suspected case definition. RESULTS: A sample of 5873 suspected malaria cases was obtained from 239 health facilities. Except for Nicaragua and Colombia, malaria tests were requested in less than 10% of all cases. More cases were tested in areas with active transmission than areas without cases. Travel history was not systematically recorded in any country. CONCLUSIONS: A statistically comparable, replicable, and standardized metric was proposed to measure suspected malaria cases with a test (microscopy or rapid diagnostic test) that enables assessing the performance of passive case detection. Cross-country findings have important implications for malaria and infectious disease surveillance, which should be promptly addressed as countries progress towards malaria elimination. Local and easy-to-implement tools could be implemented to assess and improve passive case detection.

Bird rookery nutrient over-enrichment as a potential accelerant of mangrove cay decline in Belize.

Coastal eutrophication is an issue of serious global concern and although nutrient subsidies can enhance primary productivity of coastal wetlands, they can be detrimental to their long-term maintenance. By supplying nutrients to coastal ecosystems at levels comparable to intensive agriculture practices, roosting colonial waterbirds provide a natural experimental design to examine the impacts of anthropogenic nutrient enrichment in these systems. We tested the hypothesis that long-term nutrient enrichment from bird guano deposition is linked to declines in island size, which may subsequently decrease the stability and resilience of mangrove cays in Belize. We combined remote sensing analysis with field- and lab-based measurements of forest structure, sediment nutrients, and porewater nutrients on three pairs of rookery and control cays in northern, central, and southern Belize. Our results indicate that rookery cays are disappearing approximately 13 times faster than cays without seasonal or resident seabird populations. Rookery cays were associated with a significantly higher concentration of nitrogen (N) in mangrove leaves and greater aboveground biomass, suggesting that eutrophication from bird guano contributes to increased aboveground productivity. Sediments of rookery cays also had lower percentages of soil organic matter and total N and carbon (C) than control islands, which suggests that eutrophication accelerates organic matter decomposition resulting in lower total C stocks on rookery cays. Our results indicate that coastal eutrophication can reduce ecosystem stability by contributing to accelerated cay loss, with potential consequences for mangrove resilience to environmental variability under contemporary and future climatic scenarios.

Salt and marine products in the Classic Maya economy from use-wear study of stone tools.

Microscopic study of the edges of Late to Terminal Classic Maya (AD 600-900) chert stone tools from the Paynes Creek Salt Works, Belize, indicates most tools were used for cutting fish or meat or working hide, which was unexpected, given the virtual absence of fish or other animal remains at this large salt-production complex. Use-wear study shows that a minority of stone tools have edge-wear from woodworking. Our study suggests that salting fish was a significant activity at the salt works, which corresponds to Roman, Chinese, and other East Asian civilizations, where salt and salted fish were critical components of food storage, trade, and state finance. Based on analogy with modern Maya salt producers at Sacapulas, Guatemala, we provide estimates of the amounts of salt and salted fish produced at the Paynes Creek Salt Works and the implications for the Classic Maya economy. Salt cakes and salted fish were preserved commodities that could be stored and traded in the marketplace.

Generating indicator species for bird monitoring within the humid forests of northeast Central America.

The use of indicator species can simplify bird monitoring by reducing the level of specialized skills needed, which increases the potential pool of participants and reduces training costs and complexity. To facilitate monitoring in the humid forests of northeast Central America, we conducted point count surveys for birds across gradients of disturbance in the Cockscomb Basin Wildlife Sanctuary, Belize, and analyzed the association of bird species with remotely sensed metrics of forest condition and anthropogenic disturbance using indicator species analysis. Twenty species exhibited significant associations with one or more of these metrics. We propose six species as indicators for anthropogenic disturbance based on our criteria of being associated with anthropogenically disturbed sites, or anthropogenically disturbed and riparian sites with no explicit mention in the literature of an obligate association with riparian habitats, or association of remotely sensed metrics that appeared to reflect disturbance: yellow-olive flycatcher, red-legged honeycreeper, dusky antbird, blue ground dove, buff-throated saltator, and brown jay. We propose the keel-billed motmot as an indicator of undisturbed forest based on its association with forested sites in our analyses. Green shrike vireo, collard trogon, rufous-tailed jacamar, and rufous piha were associated with a specific elevational range but not associated with disturbance, so upward shifts in elevation that might indicate response to climate change would not be confounded with habitat disturbance or degradation. This exercise yielded a much-reduced list of monitoring targets, which will greatly reduce the cost and complexity of forest bird monitoring in the region, as well as reducing barriers to participation.