Emerging Infectious Diseases

Using a commercially available H5 serology assay, we identified a 7.4% (n=5/68) anti-H5 seroreactivity rate among hunters in Northern Canada. All participants reported close contact with wild birds.

Many studies have identified antibiotic resistant (ABR) Escherichia coli on meat. Appropriate hand hygiene and cooking practices should minimise the risk of gastrointestinal colonisation with ABR E. coli found on meat, and the subsequent chance of causing resistant opportunistic extraintestinal infection. There are large gaps in our understanding of the prevalence, origins and zoonotic potential of ABR E. coli found on meat, however, and particularly for meat reared in extensive farming systems. Wales is a devolved nation within the United Kingdom having large populations of extensively-reared sheep and beef cattle. To help address knowledge gaps around ABR E. coli on extensively reared meat, therefore, beef mince and lamb loin/leg steaks/chops were purchased from 50 (beef) and 46 (lamb) independent butchers across Wales. Following enrichment culture, 200 g meat samples were found to be positive for E. coli resistant to amoxicillin (31% positivity), streptomycin (28%), spectinomycin (29%), amoxicillin-clavulanate (11%), 3rd generation cephalosporins (2%) and fluoroquinolones (5%). Phylogenetic analysis confirmed that Welsh lamb meat ABR E. coli isolates (n=79) are more closely related to those found in faecal samples collected around sheep (n=352) than around beef cattle (n=361) on Welsh farms. This suggests that faecal contamination at or around slaughter is their primary origin. We found no closely related meat/infection clones (<20 SNPs distant and the same antibiotic resistance genes) when comparing ABR E. coli from Welsh meat (n=92) and those causing extraintestinal infections in people (n=2387) in an English region bordering Wales. We conclude, therefore, that the wider zoonotic implications of finding ABR E coli on beef and lamb meat sold at independent butchers in Wales are small.

Across the United States, backyard poultry (BYP) are becoming increasingly popular as a food source as well as pets. Unfortunately, they have also been a source of annual human salmonellosis outbreaks for over a decade. Previous CDC analyses suggest baby poultry are the main source of live poultry-associated outbreaks as opposed to adult birds. However, there are few data on the frequency of pathogens, such as Salmonella enterica, in baby poultry sold to the BYP market. Further, there is a lack of data on the serovars and antimicrobial resistance (AMR) rates in these baby poultry. We collected 643 soiled bedding and shipping box samples from agricultural supply stores primarily located in Vermont. S. enterica was detected in 23.5% (151/643) of samples, with the highest rates of detection in 2021-2022. Rates of S. enterica varied by species. Turkey poult bedding samples had the highest rates of S. enterica (44.4%; 8/18), while laying chick bedding samples had the lowest (19.4%; 68/350). Meat chick bedding samples had an intermediate rate, at 36% (32/89). The most common serovar detected was Salmonella Enteritidis, which represented 51.2% (64/125) of sequenced isolates. AMR genes or AMR-associated point mutations were detected in 21.6% (27/125) of samples, but only in non-Enteritidis serovars. These data indicate that baby poultry intended for the BYP market pose a substantial risk of salmonellosis to consumers.

Dromedary camels are the main reservoir for Middle East respiratory syndrome coronavirus (MERS-CoV), a re-emerging infectious disease with pandemic potential. Somalia harbours approximately 32% of dromedary camels globally. We investigated current and past MERS-CoV infections among occupationally-exposed workers in slaughterhouses, dairy farms, livestock markets and a quarantine station. Sera and nasopharyngeal/oropharyngeal swabs from 770 workers were analysed for MERS-CoV antibodies by Enzyme-Linked Immunosorbent Assay (ELISA) and virus neutralization and for viral RNA by Real Star(R) MERS-CoV Reverse Transcription Polymerase Chain Reaction (RT-PCR). One farm worker with no travel history in the Qardo district, Karkar region, Puntland was sero-positive by ELISA and virus neutralization, providing the first-ever evidence of zoonotic spillover of MERS-CoV to humans in Somalia. This finding highlights the need to strengthen MERS-CoV surveillance across Somalia, along with an urgent need to strengthen national laboratory capacity and integrate MERS into diagnostic algorithms to generate accurate and reliable infection data and studies to understand the socio-cultural and potential risk factors for MERS-CoV.

Johnes disease (JD), caused by Mycobacterium avium subsp. paratuberculosis (MAP), is an important livestock disease in Japan. We typed 48 field isolates from cattle feces collected on 13 farms in Kushiro Subprefecture during 2024-2025 and 62 MAP-positive cattle fecal samples collected in the same region during 2025-2026 using a real-time PCR assay targeting the Type S-specific arylsulfatase gene. No Type S strains were detected among the cultured isolates or fecal samples examined in this study, suggesting that the cattle cases analyzed were more consistent with Type C than with Type S strains. Broader surveys are needed to define MAP strain diversity in Japan and improve control strategies.

Powassan virus (POWV) is an emerging tick-borne flavivirus that can cause severe encephalitis in humans. Currently no vaccines or therapeutics are approved to treat POWV. POWV is spread by the deer tick, Ixodes scapularis, which is ubiquitous across the Northeastern United States. To better understand POWV prevalence in high-risk populations, we examined POWV seroprevalence in Cadets at United States Military Academy (USMA) in West Point, New York. Cadets at USMA, located in a heavily wooded area, are at high risk for tick exposure during outdoor military training. 1,051 serum samples from the Cadet class of 2017 were screened for POWV seropositivity using a POWV Envelope (E) DIII ELISA. A seropositivity rate of 1.3% was determined. Several ELISA-positive samples were also able to neutralize both reporter virus particles bearing the POWV E protein and authentic POWV. This study demonstrates populations at risk for tick exposure may have significant seroprevalence of POWV.

Hantavirids, specifically the members within the genus Orthohantavirus, represent a significant global public health threat, with bat-associated lineages challenging traditional reservoir paradigms. To investigate the genetic diversity of hantavirids in Southeast Asia, we conducted an expanded surveillance program in Lao PDR from May 2023 to October 2025 in bat populations and wild animals from local wet markets. Using molecular screening and deep sequencing to characterize hantavirids from bat populations and wild animals from local wet markets, we identified 20 positive samples across four bat species, recovering coding-complete genomes for multiple novel variants. Phylogenetic analysis confirmed that these viruses form a monophyletic group within Mobatvirus, resolving into two major subclades. The first subclade clustered with Quezon and Robina viruses found in fruit-eating bats. The second subclade further split into two lineages corresponding to Thakrong and Xuan Son viruses, which are associated with trident and leaf-nosed bats, respectively. Despite the strong host specificity observed, the detection of these viruses in a wet market, a critical interface for human-wildlife contact, indicates a potential zoonotic risk. These findings significantly expand the known diversity of mobatviruses in Laos and highlight the urgent need for serological surveillance in at-risk human populations to assess the potential for spillover.

The panzootic caused by high pathogenicity avian influenza (HPAI) H5N1 clade 2.3.4.4b has been devastating for animals, globally. Despite global spread, the virus remains absent in Oceania. Herein we report the results of our fourth year of enhanced migratory bird surveillance, coinciding with the spring migration of wild birds in 2025; none of the 847 migratory wild birds or 38 marine mammals were positive for HPAI H5N1, although we did detect LPAI. Surveillance remains a critical tool for HPAI H5N1 response, with early detection and rapid response being critical to mitigate the impacts of this virus on animal, environment and human health.

Coronaviruses (CoVs) are diverse RNA viruses infecting a wide range of hosts, with significant implications for public health, animal production and welfare. Bats are key reservoirs of mammalian CoVs and have contributed to the emergence and circulation of several zoonotic viruses in a wildlife context, while mustelids represent important hosts at the human-animal interface, as highlighted by SARS-CoV-2 outbreaks in farmed mink. Using metagenomic next-generation sequencing, we screened bats and wild mustelids and recovered and characterized full-length CoV genomes. Building on previous findings in Danish wildlife, including alpha-CoVs and a MERS-related beta-CoV in bats, this study expands current knowledge of coronavirus diversity and evolution in wildlife, emphasizing their relevance for zoonotic emergence.

Despite the existence of an effective vaccine, the United States continues to experience outbreaks of hepatitis A, including in Massachusetts (MA) and New Hampshire (NH) in 2018 and again in MA in 2023. To clarify the relationship between these outbreaks and better understand their drivers, we generated hepatitis A virus whole genome sequences from reported cases and analyzed them using open-source genotyping tools developed and released as part of this study. We found that the 2018 and 2023 outbreaks were caused by distinct viral strains, despite affecting individuals with similar demographic characteristics and reported risk factors. Detailed analysis of genomic and epidemiologic data further resolved transmission patterns within and across outbreaks, showing that experiencing homelessness and prior use of drugs were associated with increased transmission while also revealing transmission between individuals with and without these risk factors, as well as spread across state borders. Together, these findings demonstrate the value of broadly accessible genomic tools for understanding hepatitis A outbreaks and illustrate how whole genome analysis can complement epidemiological investigation by resolving transmission patterns and outbreak drivers that can inform public health interventions.

Background Rifampicin-resistant tuberculosis (RR-TB) is a major threat to public health in Viet Nam, with nearly 10,000 incident cases estimated annually. It is uncertain whether these cases are driven by transmission of resistant strains or de novo resistance acquisition during treatment. Methods We undertook dense, city-wide sampling of adults newly diagnosed with pulmonary RR-TB in Ho Chi Minh City, Viet Nam's largest city, between March 2020 and April 2024. Participants provided sputum for culture and whole-genome sequencing (WGS), and demographic and clinical data were collected at enrolment. Phylogenetic analyses were combined with clinical histories to infer transmitted versus acquired rifampicin resistance. Estimates were corrected for sampling coverage using simulation-extrapolation (SIMEX). Temporal emergence of rifampicin resistance was reconstructed by lineage using Bayesian phylogenetic dating, and the geographic and demographic structure of transmission networks was assessed using geocoded residential data and commute time-based analyses. Findings Among 2,319 RR-TB cases diagnosed during the study period, 1,491 (64%) isolates were successfully sequenced. After accounting for sampling and phylogenetic uncertainty, we estimated that between 72% and 87% of all RR-TB arose through transmission of already-resistant strains with the remainder due to de novo acquired resistance. Bayesian dating analyses revealed that resistance emergence events occurred repeatedly from the 1980s to the present, with early events seeding long-lived, city-wide transmission networks. Transmission networks were geographically dispersed across the city, with limited household clustering, and only weakly structured by host demographics, consistent with diffuse, city-wide transmission rather than localised or assortative spread. Interpretation RR-TB in Ho Chi Minh City is driven predominantly by ongoing transmission, but a substantial minority of cases arise from newly acquired resistance. Alongside promoting early diagnosis and treatment to interrupt transmission, the main drivers of acquired resistance need to be identified to control RR-TB.

Global efforts to prevent and mitigate the impacts of high pathogenicity avian influenza (HPAI) H5 on domestic animals, humans, and wildlife rely on timely and transparent information that is both accurate and interpretable across countries and sectors. International epidemiological and genomic databases, such as the World Animal Health Information System (WAHIS), the Global Animal Disease Information System (EMPRES-i+), the Global Initiative on Sharing All Influenza Data (GISAID), and the National Center for Technological Bioinformation Virus Portal (NCBI) provide essential information for surveillance, research, and decision-making. To evaluate how well these resources capture recent wildlife impacts, we consolidated information from these databases and complementary public sources including government reports, scientific literature, and news articles, on wildlife mortality associated with HPAI H5 in the Americas from November 2021 to July 2024. The consolidated dataset comprised 615,883 wild birds (287 spp.) and 63,409 wild mammals (39 spp.). In comparison, WAHIS represented 16,902 wild birds (261 spp.) and 6,323 wild mammals (31 spp.) while EMPRES-i+ captured a substantially smaller portion of affected host diversity for both wild birds (105 spp.) and wild mammals (27 spp.). Genomic databases (GISAID and NCBI) represented 7,027 whole genome equivalents of H5 viruses from wild birds (175 spp.) and 371 from wild mammals (26 spp.). These discrepancies indicate that international databases, while essential, provide an incomplete picture of HPAI impacts on wildlife, with significant geographic and taxonomic asymmetries attributable to differences in surveillance capacity, reporting practices, sequencing effort, and data-sharing pathways. Studies and management strategies relying on these resources without complementary validation may therefore mistake data gaps for real-world epidemiological patterns. Strengthening data reporting standards, improving validation procedures, and integrating international databases with national reports, scientific publications, and other sources will enhance the reliability of epidemiological analyses and support more effective One Health surveillance, risk assessment, and conservation action. Author summaryHigh pathogenicity avian influenza (HPAI) H5 viruses, often called bird flu viruses, can cause severe disease in birds and mammals, including humans. Because of their relevance for human health, livestock production, and wildlife conservation, international databases were established to share information on when and where these viruses are detected, which species are affected, and what virus strains are found. These databases are essential tools for governments, scientists, and conservation practitioners working to track outbreaks, understand how these viruses spread and evolve, and guide surveillance and response. In this study, we compiled and compared information on recent HPAI H5 events in wildlife in the Americas available in international databases with information from other public sources, including reports from governments, scientific literature, and news articles. We found important discrepancies in how countries and species affected were represented across sources. As a result, international databases might not fully capture the actual distribution or conservation impact of HPAI H5 on wildlife. Our findings also show why decision-makers and scientists should interpret database-derived patterns carefully. We provide recommendations to improve international databases to address these gaps and better inform One Health risk assessment and wildlife conservation actions.

Objectives: A pooled testing algorithm for tuberculosis (TB), in which sputum specimens from multiple individuals are tested in pools with individual testing of positive pools, can optimise diagnostic resources. This study evaluated the diagnostic accuracy and cartridge savings of pooled testing with the Xpert MTB/RIF Ultra assay (Xpert Ultra) relative to individual Xpert Ultra testing. Methods: We conducted a cross sectional study among 2,396 adults (aged above 15 years) with presumptive TB enrolled between July 2024 and February 2025, through facility based case finding (FBCF) and community based case finding (CBCF). Participants submitted two sputum specimens. The first underwent individual Xpert Ultra testing; remnant specimens were combined into four specimen pools and tested again with Xpert-Ultra. The second specimen was used to inoculate liquid culture (BACTEC MGIT). Data were used to simulate an up-front pooled testing strategy; sensitivity and specificity of this approach was estimated against culture, and cartridge use was compared with individual Xpert-Ultra testing. Results: Of 2,396 participants, 395 (16.5%) had a positive Xpert Ultra and/or culture, including 360/912 (39.5%) in FBCF and 35/1484 (2.4%) in CBCF. The pooled testing approach had sensitivity of 82.4% (95% confidence interval [CI], 77.9; 86.3) and specificity of 98.5% (97.8; 99.0) compared to culture, with lower sensitivity than individual Xpert-Ultra testing (86.5%, 82.4; 89.9) but high specificity (98.1%, 97.4; 98.7). Sensitivity of pooled testing was lower in CBCF (59.1%, 36.4; 79.3) than in FBCF (84.0%, 79.5;87%), whereas cartridge savings were greater in CBCF (69.1% vs 9.6%). The pooling strategy reduced Xpert-Ultra cartridge use by 46.5%, saving USD 14,447. Conclusions: Pooled Xpert-Ultra testing among adults appears resource-efficient for TB screening in Vietnam. As sensitivity is lower compared to individual Xpert Ultra testing, particularly for paucibacillary disease, these losses should be carefully weighed against gains in affordability and expand access to molecular testing. Careful, context-specific implementation is essential to maximise programmatic benefit while minimising missed persons with TB.

Acinetobacter baumannii is a major cause of severe hospital-acquired infections, with a steadily increasing global prevalence driven by a few clinically adapted lineages. Animals and natural environments also harbor A. baumannii populations, but assessing their connections to clinical lineages is limited by sparse genomic data and a lack of integrated sampling. We conducted a local One Health genomic epidemiology study, sampling, isolating, sequencing, and characterizing several hundred A. baumannii isolates from clinical, animal, and environmental contexts. Within a geographically restricted area, we recovered several globally distributed clinical lineages (international clones, ICs), as well as livestock- and environment-associated lineages shared across Europe, highlighting widespread dissemination beyond clinical settings. Isolates closely related to the emerging clinical lineage IC11 were found in livestock, but no other clinically associated lineages were detected outside clinical contexts. Among these, the epidemic superlineage IC2 was identified in both human and veterinary clinical settings, indicating that similar practices in human and animal medicine select for closely related opportunistic pathogens. We found that hospitals host distinct, antibiotic-sensitive endemic populations capable of causing infection. These populations belong to a diversifying clade spanning clinical and environmental contexts and carry a high load of insertion sequences. Strong plasmid conservation further suggests frequent horizontal gene transfer across ecological compartments. Overall, A. baumannii comprises diverse, context-adapted lineages with a high potential for global spread. Although intercontext transmission appears limited, plasmids may overcome these ecological barriers. Our findings underscore the need for integrated One Health surveillance to better understand transmission pathways and limit the emergence of clinically adapted strains.

West Nile virus (WNV) and Usutu virus (USUV) are neurotropic Orthoflaviviruses sharing a similar enzootic transmission cycle primarily involving Culex pipiens mosquitoes as vectors and birds as amplifying hosts. First identified in Africa, both viruses established endemicity across Europe over the past two decades, most likely introduced and spread by migratory bird species along Mediterranean flyways. In avian species, infection outcomes range from subclinical to fatal neuroinvasive disease, varying by viral strain, host immunity, and species susceptibility. Southern France emerges as a key hotspot for the circulation of these viruses, supported by diverse avian habitats conducive to year-round viral maintenance. This study investigated the prevalence of WNV and USUV in more than 2500 sedentary and migratory wild birds from these regions during 2024-2025 using molecular surveillance. Samples were collected using mist net and bird boxes, across multiple passerine and non-passerine taxa, spanning wetlands, urban fringes, and agricultural zones. Our analyses revealed widespread viral circulation across diverse species, mainly among passerines such as great tits, house sparrows, and barn swallows with USUV detected at higher rates than WNV in both study years. Overall prevalence was markedly higher in 2024 than in 2025, potentially reflecting climatic or ecological drivers. Migratory individuals likely seed viral introductions during seasonal passages, whereas resident populations sustain local enzootic cycles, facilitating overwintering persistence. These results highlight the pivotal role of mixed avifauna in arbovirus dynamics within Mediterranean Europe and emphasize the necessity for integrated, year-round surveillance targeting high-risk species and habitats. Enhanced monitoring will aid in predicting spillover risks and informing vector control strategies to mitigate zoonotic threats.

Ebola virus disease (EVD), caused by the Ebola virus (EBOV), is characterized by high morbidity and mortality, with 16 distinct EVD outbreaks reported in the Democratic Republic of the Congo (DRC), alone. As part of the formal response to the 2018 outbreaks in Equateur and North Kivu provinces, a recombinant vesicular stomatitis virus-Zaire Ebolavirus envelope glycoprotein vaccine (rVSV-ZEBOV-GP) vaccine was deployed under emergency use. While clinical trials have evaluated vaccine safety and efficacy, there is a paucity of real-world data documenting antibody durability for longer periods post-vaccination. Here, we present serologic data from 1081 individuals in Beni, North Kivu (n = 599) and Mbandaka, Equateur (n = 482) who were vaccinated during the outbreaks--with samples from baseline up to five-years following vaccination. Using a multiplexed immunoassay, we show sustained anti-EBOV GP reactivity: at year-5 collection, 72% of individuals naive at time of vaccination remained seroreactive to EBOV GP. Stratifying by site, antibody titers remained significantly elevated after baseline across all post-vaccination timepoints in both linear and logistic mixed-effects models. Pre-existing EBOV GP reactivity at baseline was the strongest independent predictor of antibody response in Mbandaka, associated with higher titers and greater odds of seropositivity (OR = 3.87, 95% CI: 2.50-6.01, p-value < 0.001), consistent with a boosting effect among previously exposed individuals. However, this was not replicated in Beni (OR: 0.66, 95% CI: 0.27-1.58, p-value = 0.348). In Mbandaka, among those recipients who reported receiving a booster dose, the odds of seroreactivity were 12.75-fold (p-value < 0.001) and 3.68-fold higher (p-value = 0.04) at 4.2 and 5-years post-vaccination, respectively, in comparison to odds of reactivity at three weeks following administration of the initial dose. Occupational groups with zoonotic or community-level exposure had trending lower odds of seroreactivity relative to healthcare workers, most consistently in Beni. Ultimately, these data indicate that five years following administration of the rVSV-ZEBOV-GP vaccine, most vaccinated individuals retain detectable anti-EBOV GP antibodies. While correlates of protection for EVD are not well established, sustained IgG seroreactivity to EBOV GP may serve as a marker for future understandings of the durability of and variation in immune responses to this high-consequence pathogen.

Background: Binary interpretation of Mycobacterium tuberculosis (Mtb) interferon gamma release assay (IGRA) results discards information about recency of exposure and disease risk. We analysed quantitative IGRA responses to Mtb in a community--based survey to investigate associations with response magnitude and inform understanding of transmission dynamics. Methods: We included QuantiFERON--TB Gold Plus (QFT--Plus) results from 2,895 participants (10--40 years old) in Blantyre, Malawi. Bayesian regression models assessed the probability of a positive response ([&ge;]0.35 IU/mL), response magnitude, and associated factors. We also investigated associations with a TB2-TB1 differential >0.6 IU/mL (proposed to reflect recent transmission), and how hypothetical alternative IGRA positivity thresholds affected inference about age-- and sex--specific transmission. Results: 17.4% (503/2,895) of participants had positive TB1 or TB2 responses at the QFT--Plus positivity threshold (0.35 IU/mL). The distributions of TB1 and TB2 responses, among participants with positive QFT--Plus, were similar across age and sex. A TB2-TB1 differential >0.6 IU/mL occurred in 3.8% (109/2,895) of participants and was not associated with age or sex. However, participants with HIV had reduced odds of TB2-TB1>0.6 IU/mL (adjusted odds ratio 0.37 [0.14--0.93]). At higher hypothetical positivity thresholds, the mean predicted Mtb immunoreactivity prevalence among males exceeded that in females at an earlier age: at 19 years, predicted immunoreactivity prevalence ratios were 0.90 (0.83--0.99) and 1.02 (0.89--1.15) at 0.1 IU/mL and 0.5 IU/mL thresholds, respectively. Conclusions: Quantitative IGRA responses offer information about age-- and sex--specific immunoreactivity and transmission risks that dichotomisation obscures. In high-burden settings, quantitative IGRA responses may clarify Mtb transmission patterns and guide targeted public health strategies.

Bovine coronavirus (BCoV) is an important contributor to the respiratory disease complex in cattle; however, integrated genomic and epidemiological data describing currently circulating respiratory BCoV strains in the United States remain limited. The objective of this study was to monitor respiratory BCoV at the genomic level and analyze its epidemiological patterns over a five-year period. A total of 4,505 respiratory samples submitted to a diagnostic laboratory between January 2020 and November 2025 were analyzed, of which 693 (15.38%) tested positive for BCoV. Positivity was highest in young calves (0-40 days; 20.0%) and declined significantly with increasing age based on logistic regression analysis. Temporal trend analysis using LOESS smoothing and the Mann-Kendall test showed no significant monotonic change in BCoV detection during the study period. Co-infection analysis indicated that BCoV was commonly detected with other viral respiratory pathogens, while bacterial pathogens predominated in many samples. Lung tissues from infected cattle were screened by RT-PCR, and selected samples with high viral loads were subjected to next-generation sequencing. Complete genome sequencing identified four respiratory BCoV isolates ([~]31 kb), all clustering within genotype GIIb with recent U.S. strains. Comparative genomic analysis revealed several amino acid substitutions in structural and non-structural proteins that may influence viral attachment, replication, and tissue tropism. These findings provide updated epidemiological and genomic insights into respiratory BCoV circulating in U.S. cattle.

Mpox has historically been endemic in Central and West Africa, driven by recurrent zoonotic spillover events, but recent outbreaks in East Africa underscore its expanding geographic footprint. Despite this shift, genomic data from East Africa remain limited. We performed genomic characterization of the 2024/2025 Mpox outbreak in Uganda using PCR-confirmed monkeypox virus (MPXV) positive samples (n=511) from 44 districts, all achieving [&ge;]70% genome coverage. To provide regional context, we incorporated 895 publicly available clade Ib MPXV genomes from GISAID, Pathoplexus, and NCBI. Phylogenetic analysis revealed two major clusters within clade Ib, each subdivided into two subclusters, indicating substantial viral diversification. Most Ugandan sequences clustered within the most genetically diverse subcluster. Additional Ugandan genomes were distributed across other subclusters, indicating co-circulation of multiple lineages. Cluster 1 was dominated by sequences from the Democratic Republic of Congo, while phylogeographic analysis identified multiple cross-border introductions into Uganda. These findings highlight the role of regional connectivity in shaping MPXV transmission and underscore the importance of integrated genomic surveillance and cross-border data sharing to inform outbreak response in East and Central Africa.

Serological data provide important insights into SARS-CoV-2 transmission and immunity, particularly in regions with limited routine surveillance such as sub-Saharan Africa. However, antibody waning and boosting following reinfection or vaccination remain poorly characterised, complicating interpretation of serological measurements. Improved understanding of these dynamics is critical for accurate epidemiological inference. Modelling longitudinal serological data provides a means to quantify antibody kinetics and reconstruct infection histories. We analysed 15,679 neutralising antibody (nAb) titres from 1,675 unvaccinated, HIV-uninfected participants in urban (Lilongwe) and rural (Karonga) Malawi (February 2021 - April 2022). NAb titres against ancestral B.1, Beta, Delta, and Omicron (BA.1/BA.2) viruses were measured using an HIV-based SARS-CoV-2 pseudotyped virus neutralisation assay. A multi-level Bayesian model was used to reconstruct infection histories and antibody kinetics. The model identified 429 infections (95% credible interval 417-441), including 39 (9{middle dot}1%) that had not been identified by traditional seroconversion-based thresholds. Antibody levels waned rapidly, with 48% (0{middle dot}403-0{middle dot}560) of the acute boost remaining after three months and only 5% (0{middle dot}027-0{middle dot}098) after one year. Pre-Omicron infections generated stronger antibody boosts than Omicron infections. Responses varied, with individuals clustering into low and high responders. Cross-reactive responses extended across substantial antigenic distances - Omicron infections induced broader immunity. Seroincidence was higher in Lilongwe than in Karonga (0{middle dot}41 vs. 0{middle dot}27 infections per person per three months), driven by the early 2022 Omicron wave. Reinfections were common, particularly among adults and urban residents. SARS-CoV-2 nAb responses following infection were heterogeneous and declined rapidly. This rapid waning underscores the importance of vaccination for sustained protection, while cross-reactivity suggests only partial immunity from prior variants. Identifying reinfections is essential for understanding transmission and finding populations at higher repeat infection risk, particularly where routine surveillance is limited.