BMJ Global Health

BackgroundInfectious disease modelling (IDM) is increasingly being used to understand disease transmission and inform public health policy. However, its growth and policy influence has never been quantified, possibly because of the volume of literature involved. The development of large language model (LLM)-assisted reviewing allowed us to quantify the expansion of IDM publications over time, trends in policy citations of IDM research, and regional disparities in research contributions and citations in policy documents. MethodsAn LLM-assisted bibliometric review was conducted using Embase, Medline, and Web of Science, identifying IDM publications from database inception to December 2024 using GPT-4o. Inclusion criteria encompassed peer-reviewed studies employing mathematical, statistical, or mechanistic models for infectious disease outcomes. LLM accuracy was iteratively refined by human review. We extracted publication metadata, geographic scope, and policy citations using Overton, a global database of policy documents. Growth trends were analysed using negative binomial regression models, and geographic disparities were assessed based on World Bank income classifications. ResultsA total of 33,255 IDM publications were identified over 44 years, with distinct growth phases. The LLM selection and data extraction achieved 98% and 100% accuracy respectively, compared to human search. Publication volume increased from the time of HIV/AIDS emergence, experiencing steady expansion through multiple outbreaks (Ebola, SARS, H1N1, MERS, Zika), and surged sharply just before the COVID-19 pandemic before declining post-2021. Recorded policy citations accounted for 1.7% of IDM publications, closely following the overall publication trend, peaking during periods of heightened public health attention. Policy citations largely reflected national research outputs, with notable cross-regional adoption of IDM evidence in some settings. ConclusionStrengthening the integration of IDM evidence into policymaking processes may require addressing geographic disparities in research output (and its recording in international databases), enhancing cross-regional collaboration, and improving mechanisms for policy uptake. Following the COVID-19 pandemic, policy citations declined despite continued growth in IDM literature, suggesting a potential lag or shift in policymaking priorities.

Current Gaza mortality estimates systematically undercount deaths by failing to account for zero-survivor households. We argue that adjusting for this factor and multi-family cohabitation yields significantly higher figures than previously reported. If we assume 3% zero-survivor households with 75% multi-family cohabitation, mortality estimates increase to 152,395-179,555 direct and indirect deaths (6.92-8.16% of pre-war population).

BackgroundProduct Development Partnerships (PDPs) are non-profit organizations that bridge the gap between the need for new treatments for poverty-related diseases and the resources available to develop them, leveraging a mix of public, philanthropic, multilateral, and private sector funding. This paper describes how two financial metrics were used to estimate the return on investments of drugs developed by the PDP Medicines for Malaria Venture (MMV) as a case study. MethodsThe internal rate of return (IRR) and benefit-cost ratio (BCR) were used to estimate the economic return on investment for the PDP. IRR was based on total investments from 2000 to 2023 and health gains derived from PDP-supported drugs, measured as monetized disability-adjusted life years (DALYs) minus the delivery cost of the products. BCR was calculated by dividing the present value of monetized DALYs by the present value of cost, indicating the overall efficiency and impact of the investments received by MMV. FindingsTotal investment received was $2{middle dot}3 billion over the study period, and the antimalarial drugs developed and launched with the support of MMV averted an estimated 1{middle dot}6 million deaths and 87 million DALYs for a cost of delivery estimated at $785 million. The IRR for the base scenario was 52{middle dot}13% (CI: 52{middle dot}11% - 52{middle dot}16%) and the BCR 12{middle dot}99 (CI: 12{middle dot}92 - 13{middle dot}06). InterpretationThe substantial IRR and BCR generated by investment in antimalarial drug development suggest that the PDP model has a potentially pivotal role to play in global health. FundingNo funding to declare.

ObjectiveThe purpose of this analysis was to describe national critical care capacity shortages for 52 African countries and to outline needs for each country to adequately respond to the COVID-19 pandemic. MethodsA modified SECIR compartment model was used to estimate the number of severe COVID-19 cases at the peak of the outbreak. Projections of the number of hospital beds, ICU beds, and ventilators needed at outbreak peak were generated for four scenarios - if 30, 50, 70, or 100% of patients with severe COVID-19 symptoms seek health services--assuming that all people with severe infections would require hospitalization, that 4.72% would require ICU admission, and that 2.3% would require mechanical ventilation. FindingsAcross the 52 countries included in this analysis, the average number of severe COVID-19 cases projected at outbreak peak was 138 per 100,000 (SD: 9.6). Comparing current national capacities to estimated needs at outbreak peak, we found that 31of 50 countries (62%) do not have a sufficient number of hospital beds per 100,000 people if 100% of patients with severe infections seek out health services and assuming that all hospital beds are empty and available for use by patients with COVID-19. If only 30% of patients seek out health services then 10 of 50 countries (20%) do not have sufficient hospital bed capacity. The average number of ICU beds needed at outbreak peak across the 52 included countries ranged from 2 per 100,000 people (SD: 0.1) when 30% of people with severe COVID-19 infections access health services to 6.5 per 100,000 (SD: 0.5) assuming 100% of people seek out health services. Even if only 30% of severely infected patients seek health services at outbreak peak, then 34 of 48 countries (71%) do not have a sufficient number of ICU beds per 100,000 people to handle projected need. Only four countries (Cabo Verde, Egypt, Gabon, and South Africa) have a sufficient number of ventilators to meet projected national needs if 100% of severely infected individuals seek health services assuming all ventilators are functioning and available for COVID-19 patients, while 35 other countries require two or more additional ventilators per 100,000 people. ConclusionThe majority of countries lack sufficient ICU bed and ventilator capacity to care for the projected number of patients with severe COVID-19 infections at outbreak peak even if only 30% of severely infected patients seek health services. This analysis reveals there is an urgent need to allocate resources and increase critical care capacity in these countries.

BackgroundThe Covid-19 pandemic led to widespread changes to health and social institutions. The effects of the pandemic on neonatal and infant health outcomes in low- and middle-income countries (LMICs) are poorly understood, and nationally representative data characterizing changes to health care and outcomes is only now emerging. MethodsWe used nationally representative survey data with vital status and perinatal care information on 2,959,203 children born in India, Madagascar, Cambodia, Nepal, and the Philippines. Using interrupted time series models, we estimated the change in neonatal mortality (death in first 30 days of life) and infant mortality (death in first year of life) following the start of the Covid-19 pandemic, controlling for granular location fixed-effects and seasonality. FindingsWe analyzed 2,935,052 births (146,820 deaths) before March 2020 and 24,151 births (799 deaths) after March 2020. We estimated that infant mortality increased by 9.9 deaths per 1,000 live births after March 2020 (95% CI 5.0, 15.0; p<0.01; 22% increase) and neonatal mortality increased by 6.7 deaths per 1,000 live births (95% CI 2.4, 11.1; p<0.01; 27% increase). We observe increased mortality in all study countries. We also estimated a 3.8 percentage point reduction in antenatal care use (95% CI -4.9, -2.7; p<0.01) and a 5.6 percentage point reduction in facility deliveries (95% CI -7.2, -4.0; p<0.01) during the pandemic. InterpretationSince the start of the Covid-19 pandemic, neonatal and infant mortality are higher than expected in five LMICs. Helping LMICs resume pre-pandemic declines in neonatal and infant mortality should be a major global priority. FundingNational Institute of Child Health and Development (R01HD104835 PI Wagner) Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThe impact of the Covid-19 pandemic on infant and neonatal mortality in low- and middle-income countries (LMICs) is not well-understood. We searched PubMed using the terms "COVID" AND (("child" OR "infant" OR "neonatal") AND "mortality")) AND ("low- and middle-income countries" OR "developing countries") on May 10, 2023, without language restrictions. The existing evidence is mixed. Increased mortality rates have been documented in Ghana, Nigeria, Uganda, and Nepal while decreased rates documented in South Africa and Guinea. Prior analyses were mainly based on clinic and hospital administrative data and were often confined to a selection of facilities or geographic areas, hampering the generalizability of the existing evidence. We found no published article that leveraged nationally representative data sources to provide a general assessment of infant or neonatal mortality in LMICs following the start of the Covid-19 pandemic. Added value of this studyTo our knowledge, this study provides the most comprehensive and generalizable investigation of the impact of the Covid-19 pandemic on infant and neonatal mortality in LMICs to date. Using nationally representative survey data from five LMICs that were recently released, we estimated an increase of 9.9 and 6.7 deaths per 1,000 live births in infant and neonatal mortality, respectively, during the Covid-19 pandemic. We also found significant reductions in antenatal care use and facility deliveries, which could partly explain the changes in mortality we document. Implications of the available evidenceOur study highlights significant increases in infant and neonatal mortality rates in five LMICs following the start of the Covid-19 pandemic, which sets back about a decades worth of progress. The decline in antenatal care services and facility births documented in our study suggests mortality increases were partly driven by disruptions in health service access induced by Covid-19 control measures. Helping to get reductions in neonatal and infant mortality back on track in LMICs should be a major global priority.

IntroductionNon-communicable diseases (NCDs) represent a significant global health burden in sub-Saharan Africa (SSA). However, most SSA countries such as Senegal lack reliable data despite the need for surveillance of NCD trends to inform targeted preventive strategies. MethodsWe used publicly available data from the Global Burden of Disease Study (World Health Organizations Health Inequality Data Repository). We used age-standardised regression to analyze the trends of NCDs (cancers, cardiovascular diseases, chronic respiratory diseases, diabetes, and chronic kidney diseases) incidence among adults in Senegal. Statistical analysis was performed using the Joinpoint Regression Program, Version 5.3.0.0 and data visualization was performed using R, version 4.4.0 ResultsNCD incidence rates in females were consistently higher than in males. Rates in females increased from 190,857 to 194,620 cases per 100,000 population between 2000 and 2019 (p-value 0.007) as compared to 160,623 to 163,800 cases per 100,000 population in males (p-value 0.002). Incidence rates were higher in females for neoplasm (p-value 0.03), chronic respiratory diseases (p-value 0.07), and diabetes and chronic kidney diseases (p-value 0.04), while cardiovascular disease incidence was higher in males (p-value 0.02). ConclusionThere was a significant increase in age-standardized NCD incidence among adults in Senegal. When considering subtypes, all had increased incidence rates, except cardiovascular diseases which showed a significant decrease over time. A national NCD registry and targeted risk factor prevention programs are crucial to help tackle the NCD burden in Senegal. KEY MESSAGESO_ST_ABSWhat is already known?C_ST_ABSO_LISenegal is experiencing a shift towards a higher burden of NCD, with a probability of dying from NCD as high as 20% [95% CI: 11.9-28.8%] in 2019 according to WHO. C_LIO_LIUnfortunately, reliable epidemiological data and surveillance systems are lacking to inform appropriate prevention and resource allocation strategies. C_LI What does this study add?O_LIOverall, we observed a significant increasing trend in the age-standardized incidence of NCD during the study period, 2000-2019. C_LIO_LIThere were differences between NCD subtypes, with neoplasm rates remaining constant throughout the study period while diabetes, chronic kidney disease and chronic respiratory disease were increasing. C_LIO_LIIncidence rates were consistently higher in females compared to males, especially for chronic respiratory disease, diabetes, and chronic kidney disease. C_LI What do the new findings imply?O_LIThe overall non-significant increasing trend of NCD incidence rates in Senegal calls for the critical need to invest in robust surveillance systems such as NCD national registry and targeted risk factors prevention programs to tackle this growing burden. C_LIO_LIDiscrepancies in the trends of some NCD subtypes may reflect reporting bias, which needs to be addressed by well-designed longitudinal cohort studies. C_LI

Tuberculosis (TB) is the leading global cause of death from a single infectious agent, with more than 10 million new cases annually. As a part of its efforts to control TB, the World Health Organisation (WHO) adopted the End TB Strategy in 2014 to reduce TB incidence by 90% between 2015 and 2035, with intermediate targets every five years. We examined TB incidence data from 2000 to 2018 for 40 high burden countries (HBCs) from the WHO published statistics, contextualized and assessed their trends over time, and projected the incidence to 2035 for each country. Two recurrent patterns accounted for 26 of the 40 HBCs: linear decrease (n = 14) or a peak in the 2000s followed by decline (n = 12). As uncontrolled HIV is the greatest risk factor for TB, trends in HIV infected and uninfected people were analysed separately for 15 Sub-Saharan African HBCs with high HIV prevalence. The projections of current trends were compared against the reductions required to meet the WHO End TB targets. Of the 25 countries without a high burden of HIV, only 5 are on track to meet the End TB targets: Ethiopia, Laos, Myanmar, Russia, and South Korea. Of the 15 high HIV burden countries, 6 are on track: Eswatini, Kenya, Lesotho, South Africa, Tanzania, and Zimbabwe. Three high HIV burden countries, Botswana, Namibia, and Zambia will miss the End TB targets due to the diminishing returns of indirectly decreasing TB incidence by controlling the HIV epidemic. Overall, we predict 62 million excess cases of TB between 2020 and 2035 in the 29 HBCs projected to miss the WHO End TB targets. In high HIV burden countries, new programs aimed directly at TB will be required to maintain momentum. Moreover, our projections are based on data prior to the COVID-19 pandemic; the disruption of the pandemic is overwhelmingly likely to interrupt vital TB services and increase TB incidence. We anticipate that these findings will help orientate countries to their progress towards the End TB goals and inform the level of investment required to meet these important targets for a TB-free world. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed and Google Scholar with the terms "End TB assessment," "End TB Strategy," or "WHO End TB" between June 2019 and September 2020 to identify studies in English reporting on progress towards meeting the End TB targets. We only identified two studies that carried out a quantitative assessment of current estimates against the End TB targets. One study limited its analyses to current estimates, rather than using statistical methods to produce projections based on current trends, while the other study and the WHO Global TB Report 2019 presented projections to 2020 only. No report provided a per-country estimate of the progress toward the End TB targets through 2035. Added value of this studyThis study presents projections of TB incidence from 2020 to 2035 for 40 high TB burden countries. We benchmark the progress of each country against the reductions necessary to meet the WHO End TB targets. We provide per country (rather than per WHO region) breakdowns of these numbers and place the results into broader global health and socio-political contexts. Additionally, we separately model incidence trends in HIV infected and uninfected populations to account for different trajectories in the two populations. Implications of all the available evidenceOnly 11 of the 40 countries assessed are on track to meet the 2035 End TB targets, leading to a total of 62 million excess cases of TB compared with if the targets were met. This is consistent with previous reports such as the WHO Global TB Report 2019, which found that only 11 of 30 high burden countries were on track to meet targets for 2020. We additionally demonstrate that TB specific programs should be developed in most high HIV burden countries, as reductions in TB in HIV uninfected people are declining much more slowly than in HIV infected people.

Though much has been written about the importance of decolonising global health, there is a lack of consensus around how it should be defined, conceptualised and actioned, and who has responsibility to do so. In accordance with PRISMA guidelines, we undertook a scoping review of the decolonising global health literature to explore the meaning of decolonising global health, to identify examples of best practice, and to find out how those writing about the issue see the future of the movement. We searched databases for peer-reviewed and grey literature with titles and abstracts, and then full texts double-screened by authors to identify papers for inclusion. Our search strategy focussed on opinions and discourse using terms broadly linked to decolonising global health. Papers published in either the peer reviewed and grey literature were eligible for inclusion. Data, including conclusions and recommendations, were extracted and results presented as a narrative synthesis of included papers to provide a contemporary account of the decolonising global health agenda. Included papers (n=129) were predominantly commentary or opinion pieces (n=95). Authors of the included papers were affiliated with institutions predominantly from high income countries including the USA (n=53) and UK (n=30). Included papers presented a broad range of definitions for decolonising global health, describe the historical, colonial influence on global health, explore power imbalances in current global health structures, and make a number of suggestions as to how to address these imbalances. Despite the clear imperative in the literature to take action, there is no clear consensus on where to start. Drawing from the findings of our review, we conclude with a set of recommended approaches and next steps for decolonising global health, focussing on epistemic injustice, partnership working, the structure of global health, and individual duty.

Sub-Saharan Africa (SSA) continues to bear a disproportionate global disease burden while also facing significant disparities in research productivity and impact. As such, strengthening the research capacity in SSA is an urgent priority, necessitating a multifaceted assessment of the current landscape, the role of international collaboration, and the alignment of research efforts with health needs. In this study, we conducted a macro-level bibliometric analysis to assess research capacity, thematic alignment, and structural autonomy in SSA. We found that SSA accounted for approximately 15% of the global population and 21% of the global disease burden, yet it received only 2.7% of global citations in 2021. Despite increasing the research output over time, academic impact and leadership remain limited. Higher international collaboration rates were positively associated with a higher research impact, but also with a markedly greater proportion of publications without SSA researchers in key authorship positions, indicating persistent structural dependency. Researcher autonomy in SSA was substantially lower than in other regions, though slight improvements were observed during the COVID-19 period. Meanwhile, the Burden-Adjusted Research Intensity analysis showed a disproportionate concentration of research on HIV/AIDS, tuberculosis, and malaria, a focus that was sustained--and even intensified--in SSA during the pandemic, while many other high-burden diseases, including neglected tropical diseases, remained severely under-researched. In conclusion, this study provides quantitative evidence of persistent academic dependency and misaligned research priorities in SSA, with our analyses revealing how structural inequities in international collaborations and externally driven research agendas limit local research leadership and potentially hinder effective responses to regional health needs. Achieving a more just global research ecosystem demands active decolonization efforts centered on empowering Global South ownership, necessitating the fostering of genuinely equitable partnerships, reforming of funding mechanisms to prioritize locally led research, and sustained investment in developing the local research and leadership capacity. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LISub-Saharan Africa (SSA) bears a disproportionate share of the global disease burden but has historically lagged in research output and scientific capacity. C_LIO_LIStructural and systemic barriers have long hindered the development of robust research ecosystems in SSA. C_LI What this study addsO_LISSA faces a critical mismatch between its high disease burden and its limited capacity to generate scientific research needed to address local health challenges. C_LIO_LIHigher international collaboration in SSA is correlated with both greater citation impact and diminished local leadership. C_LIO_LIThere are persistent inequities in research in SSA in relation to the COVID-19 pandemic. C_LI How this study might affect research, practice or policyO_LIOur results underscore the need to focus on structural equity, in addition to the quantity and quality, in global health research. C_LIO_LITo decolonize knowledge production, international partnerships must prioritize local leadership, long-term investment, and alignment with regional health needs. RSI and BARI offer practical tools to monitor these goals and guide policy reform. C_LIO_LIEquitable research ecosystems will require both capacity building in SSA and behavioral shifts in high-income country funders and institutions. C_LI

BACKGROUND: Undernutrition is the leading risk factor for tuberculosis (TB), yet evidence on programmatic nutritional support during treatment is limited. Benin and Togo are neighboring West African counties. Benin provides in-kind food support to all people with drug-susceptible TB; neighbouring Togo does not. This created the opportunity for a natural experiment. METHODS: We conducted a prospective cohort study at 13 sites in Benin and Togo (September 2023-June 2024). We compared recipients of nutritional support with non-recipients, using Beninese non-recipients as an internal comparison. Primary outcomes were [&ge;]5% weight gain at month 2, change in 6-minute walk test (6MWT) distance, and pill-count adherence. We used multivariable regression adjusted for pre-specified covariates. RESULTS: Of 769 participants, 450 received nutritional support and 319 did not. Recipients had higher odds of [&ge;]5% weight gain at month 2 (adjusted odds ratio [aOR] 1.57, 95% CI 1.13-2.19) and [&ge;]10% at month 6 (aOR 1.92, 1.35-2.74), greater 6MWT improvement (adjusted {beta} 40.6 m, 26.5-54.6), and higher adherence (aOR 3.43, 1.81-6.51). Mortality was lower among recipients (aOR 0.32, 0.11-0.93). Sputum conversion and treatment success did not differ. Beninese non-recipients resembled Togolese participants across outcomes. CONCLUSION: Programmatic nutritional support was associated with improved weight gain, functional recovery, adherence, and lower mortality during TB treatment, supporting its integration into national TB programmes.

Infectious disease research is essential for disease prevention and management within refugee camps and informal settlements. We aim to assess the state of infectious disease research with displaced communities in the top ten refugee-hosting low- and middle-income countries. We searched three journal databases for primary research that explicitly included refugees or was conducted in a refugee camp, informal settlement, or displaced people-serving hospital and focused directly on an infectious disease following PRISMA guidelines. Forty studies (out of 1,179) met the inclusion criteria. Common research challenges included population mobility, limited external validity, and low recruitment. No studies included the community in the initial study conception or investigated the research impact on the community. Community involvement was often through community health workers (45%). Of the 18 studies that studied a resource-based intervention, 20% explicitly noted that the intervention was unsustainable. Such context-specific considerations are vital in research with displaced communities.

The COVID-19 pandemic is an emerging threat across the African continent where critical care capacity is underdeveloped or unknown. In this paper, we describe national critical care capacity including number of ICU beds, number of ventilators, and number of physician and non-physician anesthesia providers for 54 African countries. Data was compiled from a variety of resources including World Bank databases, local and international news media, government reports, local healthcare workers, and published scientific literature. Overall, data on number of physicians, hospital beds, and ICU beds were available for over 90% of countries. Data on number of ventilators, number of physician anesthesia providers (PAP) and non-PAP were available for 46 (85%), 47 (87%) and 37 (69%) countries, respectively. Across all 54 countries included in the analysis, there was an average of 3.10 ICU beds and 0.97 ventilators per 100,000 people, and an average of 2.42 total (physician and non-physician) anesthesia providers per 100,000 people. The purpose of this analysis was to fill in knowledge gaps around current critical care capacity across the African continent and to inform national, regional, and international pandemic preparation and response efforts.

BackgroundArmed conflict, compounded by displacement and food insecurity, has affected Adamawa, Borno and Yobe states of northeast Nigeria (population {approx} 12 million) since 2009. The crisis escalated in 2013-2014 and featured a delayed humanitarian response. We wished to estimate the death rate and toll attributable to the crisis. Data availability constraints restricted estimation to the period 2016 to 2019. MethodsWe did a small-area estimation statistical analysis of previously collected data, stratified by local government area and month. We fitted a mixed effects model to household mortality data collected as part of 70 ground surveys implemented by humanitarian actors within the study area and period. Model predictors, selected from a wider candidate list, included livelihood typology, the price of staple cereal, vaccination geo-coverage and the presence of humanitarian actors. To project accurate death tolls, we adjusted population denominators based on internal and refugee displacements. We used the model and population estimates to project mortality under observed conditions and under different assumptions of counterfactual conditions, had there been no crisis, with the difference between observed and counterfactual providing excess mortality. ResultsCrude and under 5 years death rates were highly elevated across most ground surveys, with net negative household migration. Between April 2016 and December 2019, we projected that 490,000 deaths (230,000 children under 5y) died in excess of the counterfactual non-crisis level; this death toll ranged from medians of 90,000 to 550,000 depending on the counterfactual assumptions chosen, specifically whether to consider a Nigeria-wide price inflation phase as inherently part of the crisis in the north-east. Crude and under 5 years death rates were two to three times higher than counterfactual levels, and highest in 2016-2017. DiscussionThis may be the first crisis-wide estimate of mortality attributable to the crisis in north-east Nigeria. Our findings do not reflect acute emergency periods before 2016 and the situation in neighbouring countries affected by the conflict. Sensitivity analysis suggests that results for Borno state, where conflict has been most intense, are subject to under-estimation due to data not representing hard-to-access areas. Further studies to document mortality in this and other crises are needed to guide decision-making and memorialise their human toll.

IntroductionIt is estimated that there were 263 million malaria cases and 597,000 deaths in 2023 globally, a substantial proportion of which are attributable to inadequate access to good-quality and efficacious antimalarials. Africa bears the highest malaria burden. Yet despite the high prevalence of substandard and falsified (SF) antimalarials in some African regions, their prevalence across space and time remains poorly understood. MethodsWe extracted data from the Infectious Disease Data Observatory (IDDO) Medicine Quality Scientific Literature Surveyor database on the prevalence of SF antimalarials. We used spatiotemporal modelling to estimate the proportion of antimalarials that were SF in each country and each year covered by the data. We constructed three different models; each included identical spatial structures and covariates but different specifications of the temporal trends. We modelled spatial effects using the Besag-York-Mollie model (BYM). We fitted the models using integrated nested Laplace approximation (INLA) and compared models predictive ability using the widely applicable information criterion (WAIC). ResultsWe extracted data from 76 random and convenience surveys conducted between 1996 and 2019, including 8213 antimalarial samples in total. The model with the best predictive performance included an interaction between space and time (WAIC=499.430), suggesting that the highest prevalence of SF antimalarials occurred between 1996 and 2003, with higher predictions in West and Central Africa regions. Most countries had no clear temporal patterns, but we estimated a notable decline in reported SF prevalence in Kenya, Uganda, Tanzania, and Madagascar beginning around 2003. ConclusionThis study provides estimates of the prevalence of SF antimalarials in Africa at country level throughout time, improving our understanding of the heterogeneity in the burden of SF antimalarials across Africa. These estimates can inform targeted interventions to reduce the public health impact of SF medicines. However, we observed high levels of uncertainty throughout the study period in most countries, reflecting the sparsity of antimalarial quality surveillance data in Africa and implying that estimates should be interpreted with caution.

Globally, there is a lack of consolidation and thus sharing of critical mortality estimates which can serve as an early warning of the severity of a humanitarian crisis. This lack of a comprehensive view may mask critical situations, and impact on which crises are more measured and visible to the humanitarian community. This ultimately affects the allocation of scarce humanitarian resources. Somalia is a country marked by recurrent drought, armed conflict, food insecurity and malnutrition. To facilitate real-time investigation of mortality rates, we developed the open-source, publicly available Somalia Mortality Estimation Database (S-MED) to visualise mortality estimates from retrospective surveys and surveillance systems in Somalia in real-time. This enables improved awareness through visualization of mortality estimates as well as the capacity to facilitate multisectoral analysis of determinants of mortality (i.e., drought, displacement, disease outbreaks) and higher-level analysis (i.e., crisis-wide analysis of mortality estimates and mortality forecasting). In this paper, we describe the mortality, morbidity, food insecurity, and environmental data contained in S-MED. We show how its mortality data can be used for improved detection of early warning signals and a more comprehensive public health interpretation of drought and armed conflict-driven health crises in 2018 and 2022. Similar mortality surveillance initiatives could be adapted to crisis-affected settings globally.

IntroductionGlobal health research (GHR) requires transparent practices and stakeholder engagement to maximize impact. While monitoring systems exist for clinical research transparency in high-income countries, there is limited systematic assessment of these practices in global health research. This study evaluated methods for monitoring GHR transparency and engagement practices using established indicators. MethodsWe analyzed three samples: (1) 200 interventional trials from ClinicalTrials.gov (2008-2019) focused on tuberculosis and maternal health, with two-thirds from low-and-middle-income countries; (2) 200 trial publications from global health journals (2011-2023); and (3) research outputs from global health funder websites. We assessed registration timing, result reporting, open access status, and stakeholder engagement using standardized indicators. ResultsAmong registry trials, 37% were prospectively registered, 65% published results in journals, and 15% reported summary results in ClinicalTrials.gov. Only 34% reported results in any format within 24 months of completion. For journal publications, 72% were freely accessible, and among a subsample of 100 articles, 23% included stakeholder engagement statements. The funder website sample yielded insufficient metadata for systematic analysis. ConclusionOur findings demonstrate that monitoring GHR transparency and engagement is feasible using trial registries and journal publications, though funder websites currently lack adequate tracking data. While open access rates are encouraging, timely result reporting and stakeholder engagement documentation need improvement. These results highlight opportunities for developing GHR-specific monitoring approaches through collaborative efforts among global stakeholders. FundingBerlin University Alliance What is already known on this topicPrevious studies have highlighted gaps in transparency and patient engagement in clinical trials. To address these, various tools, such as national and university dashboards, have been developed to monitor practices. In global health research (GHR), this monitoring has been primarily led by intergovernmental agencies; however, academic research can complement these efforts by enhancing rigor and driving actionable change. This study proposes a methodological approach to identify global health studies for analysis with established research indicators and aims to suggest complementary strategies for analyzing GHR. What this study addsThis study introduces a methodology suitable for assessing GHR studies with transparency and engagement indicators. We sourced data from trial registry, global health journals, and funder websites, providing accompanying code and data to facilitate reproducibility for other researchers in the field. Unlike prior analyses in global health context that often emphasize LMICs, our approach incorporates both LMIC and HIC studies, recognizing the collaborative foundation of GHR and encouraging shared contextualized findings. Our findings offer empirical data while underscoring the need for expanded collaboration to refine indicators and methodologies, enhancing the contextual relevance of GHR monitoring. How this study might affect research, practice or policyCollaborative efforts among researchers, funders, and communities are essential to develop new methodologies and indicators that focus on actionable change highlighted by continuous monitoring. While often led by large organizations, GHR monitoring can be enriched by academic research, making it more contextualized and accessible to global health researchers. By proposing initial methodologies, we provide a foundation that can be refined along with indicators that can be contextualized, both of which are essential for driving effective global health research.

BackgroundRecent shifts in the global health funding landscape--most notably the dismantling of the United States Agency for International Development (USAID) and possible reduced contributions to the Global Fund to Fight AIDS, TB and Malaria (Global Fund)-- threaten essential tuberculosis (TB) services in low- and middle-income countries (LMICs). We quantified the potential impact on the household economic burden of TB. MethodsWe used linked epidemiological and economic models, calibrated to 79 LMICs, to estimate future TB patient costs under four scenarios: continuation of 2024 funding levels (baseline), termination of USAID, termination of USAID plus announced reductions in Global Fund contributions, and full elimination of external funding for TB. Outcomes included total TB-attributable household costs and numbers of households experiencing catastrophic costs (disease-related costs >20% of annual income). FindingsUSAID termination was projected to produce US$7.5 (95% uncertainty interval: $6.1-8.9) billion in additional patient-incurred costs and 3.9 (3.1-4.6) million additional households experiencing catastrophic costs over 2025-2050. The worst-case scenario (elimination of all external funding) resulted in $79.7 ($60.0-99.2) billion in additional patient-incurred costs and 40.5 (30.9-50.7) million additional households experiencing catastrophic costs--a 32% increase over baseline. Impacts were greatest for poorer households, with over 50% of additional catastrophic costs occurring in the poorest 20% of households. InterpretationAbrupt reductions in international donor funding for TB may reverse recent progress toward financial risk protection and health equity in LMICs. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSSeveral prior studies have examined the potential impact of cuts in international health funding from the United States of America. We searched PubMed and medRxiv for studies quantifying the effects of reductions in international donor funding on the economic burden of tuberculosis, published between January 1 and August 7, 2025, using search terms related to funding ("funding", "donor", "aid", "assistance"), tuberculosis ("tuberculosis", "TB"), patients or households (patient*, household*), and economic burden (cost*, econ*). The identified studies described a range of potential health consequences that could result from funding cuts. To our knowledge, no studies have considered the impact of funding cuts on the household economic burden of disease. Added value of this studyOur modelling suggested that termination of United States Agency for International Development (USAID) funding could lead to US$7.5 (95% uncertainty interval: $6.1-8.9) billion in additional patient-incurred costs and 3.9 (3.1-4.6) million additional households experiencing catastrophic costs over 2025-2050. Further reductions in funding to the Global Fund to Fight AIDS, TB and Malaria (Global Fund) in line with current announcements from donor countries could lead to a further $21.2 ($16.6-25.6) billion in patient-incurred costs and 10.7 (8.4-13.0) million households experiencing catastrophic costs. If all external TB funding were terminated, a projected $72.2 ($53.9-90.4) billion in patient-incurred costs could accrue and 36.6 (27.7-46.1) million households could experience catastrophic costs, compared with the impact of the funding cuts to USAID alone. Implications of all the available evidenceDisruptions to TB services resulting from reductions in international donor funding could result in increased tuberculosis-associated morbidity and mortality, which in turn could result in increased economic burden on resource-constrained households in the worlds poorest countries. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed.

BackgroundTuberculosis services in many settings rely heavily on international donor funding. In 2025, the United States Agency for International Development (USAID) was dismantled, and other countries also announced cuts to overseas development assistance. We quantified potential epidemiological impacts attributable to these reductions in international donor funding. MethodsWe calibrated a deterministic tuberculosis model to epidemiological indicators in low- and middle-income countries. We projected three future scenarios assuming: a) levels of funding in 2024 continue through 2035, b) termination of USAID funding from 2025, and c) additional reductions in funding through The Global Fund in line with current donor announcements from 2025. We assumed a reduction in tuberculosis treatment initiation rates proportional to budget reductions for each scenario, estimating cumulative excess incident episodes of symptomatic tuberculosis and tuberculosis deaths. FindingsWe modelled 79 countries, representing 91% of global tuberculosis incidence and 90% of global tuberculosis mortality in 2023. Our modelling suggested that the termination of USAID funding may lead to 420 500 excess tuberculosis deaths by 2035. Further reductions in funding in line with current announcements by the United States, France, the United Kingdom, and Germany may lead to an additional 699 200, 63 100, 50 500, and 30 500 TB deaths, respectively. Impacts would be greatest in low-income countries. InterpretationWe estimate substantial potential impacts on tuberculosis morbidity and mortality due to reductions in international donor funding. Expanded support from domestic and international donors is essential to address immediate gaps in prevention, diagnosis, and treatment. FundingThis work was unfunded.

Background Respiratory infections remain the leading infectious cause of death among children and adolescents, yet the share of these deaths that could be averted with currently feasible care is not routinely quantified. Existing amenable-mortality frameworks rely on cause lists and population-level mortality benchmarks and do not exploit information on how many episodes occur. We propose an episode-fatality-ratio (EFR) frontier approach and apply it to lower respiratory infections (LRI), whooping cough (pertussis) and upper respiratory infections (URI) in 204 countries, 1990-2023. Methods For each cause, country and year we computed EFR = deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. The frontier was defined as the 10th-percentile country EFR within each GBD super-region, cause and year; avoidable deaths = max(0, deaths - episodes x frontier EFR). Primary estimates are deterministic; 95% uncertainty intervals (UIs) come from 2,000 Monte Carlo draws. Sensitivity analyses varied the frontier percentile, applied an aspirational global frontier, constructed pertussis counterfactuals, and recomputed all estimates within the single under-5 age band. Results In 2023, 333,803 childhood deaths from lower respiratory infections (95% UI 289,123-417,460; 46.9% of LRI deaths) were avoidable. Summing the three causes deterministically gives 391,034 avoidable deaths (46.5% of 840,444); the combined figure is a deterministic sum, and a UI is available for the LRI component only. The pertussis (43,958; 39.0%) and URI (13,273; 81.0%) estimates are secondary: their deterministic point values fall below their own Monte Carlo intervals and the underlying death estimates carry very wide uncertainty (global pertussis UI 12,545-321,874). Avoidable deaths fell from 1,050,468 (44.9%) in 1990, but between 2019 and 2023 the avoidable share for LRI+URI barely moved (48.7% to 47.7%) while absolute avoidable deaths fell 14.5%, a pattern consistent with stalled convergence to the frontier. Sub-Saharan Africa plus South Asia held 73.1% of avoidable deaths in 2023 versus 41.8% in 1990; ten countries accounted for 59.1%. Conclusion Nearly half of childhood respiratory-infection deaths remain avoidable relative to within-region best practice, and the residual burden is increasingly concentrated in low-income settings. In the pertussis counterfactual, most countries kept pace with their regional frontier, so further gains require advancing the frontier itself through quality-of-care improvements.

BackgroundStaff shortages, limited training, and inadequate hospital equipment often delay responses to patient deterioration in low-resource settings. The IMPALA continuous monitoring system was developed to support proactive care for critically ill children in such settings. This study evaluated IMPALA cost-effectiveness compared with current practice manual intermittent monitoring from provider and societal perspectives. MethodsWe conducted an economic evaluation based on a before-and-after cohort of children (0 to 180 months) admitted to Zomba Central Hospital (ZCH) and St. Lukes Hospital (SLH), Malawi (2022 to 2024), where IMPALA was implemented in high-dependency units (HDUs). Targeted maximum likelihood estimation assessed percentage point (pp) differences in mortality, critical illness events (CIEs), disability-adjusted life years (DALYs), and costs (medical, non-medical, indirect). Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness probabilities were calculated for different willingness-to-pay thresholds. FindingsAt ZCH paediatric ward, 1 840 pre- and 6 255 post-IMPALA children were included; 248 and 736 were admitted to the HDU. Ward mortality decreased (3.7% to 2.8%), with an adjusted 1.9pp reduction (95%CI: - 3.8;-0.6). At ZCH-HDU, mortality slightly increased (8.1% to 9.0%), but IMPALA was associated with an adjusted 9.8pp reduction (95%CI: -26.5;5.0), a 47.1pp decrease in CIEs (95%CI: -52.9;-41.8), and 5.4 DALYs averted (95%CI: -14.2;3.1). At SLH paediatric ward, mortality decreased (4.0% to 2.1%), with an adjusted 1.6pp reduction (95%CI: -3.2;-0.2), a 25.5pp decrease in CIEs (95% CI: -30.1;-20.9), and 1.0 DALYs averted (95% CI: -1.9;-0.1). Provider and societal costs decreased in both wards, but not in the HDU. IMPALA was dominant in wards and slightly more costly but more effective in the HDU (ICERs -$22.5 to $0.4 per life saved). Cost-effectiveness probabilities ranged from 0.8 to 1.0 in wards and 0.3 to 1.0 in the HDU. InterpretationIMPALA was highly cost-effective, reducing mortality by >40%, morbidity by >50%, increasing DALYs averted, shortening hospital stays, and lowering costs, with spillover benefits from HDUs to wards. FundingThis project is part of the EDCTP2 programme (grant number RIA2020I-3294 IMPALA) supported by the European Union and Founders Pledge through GOAL3. Evidence before the studyContinuous monitoring reduces mortality in high-resource settings, but its effectiveness in low-resource contexts remains uncertain. Systems designed for well-resourced environments may not suit settings with high patient-to-staff ratios, power instability, and limited supplies. In Malawi, qualitative findings suggest that the IMPALA monitoring system - including battery-supported automated digital continuous monitoring devices and local server, a tablet decision support app, and staff training - is feasible and potentially beneficial. However, evidence on the potential impact and cost-effectiveness are lacking. Added value of this studyThis study provides empirical evidence that the IMPALA monitoring system is a cost- and life-saving alternative to standard care, which relies on manual intermittent monitoring in low-resource settings. The findings indicate benefits, including saving lives, preventing critical illness events, and reducing disease burden, while lowering inpatient and societal costs by shortening hospital stays on paediatric wards as a spillover effect. Implications of all the available evidenceThis study implies that robust, well-implemented continuous patient monitoring systems can enhance childrens health outcomes and quality of care while reducing costs in a low-resource setting, highlighting the need for its broader implementation to improve paediatric care worldwide.