Journal of Infection and Public Health

The A(H1N1)pdm09 virus remains a major global health threat. This study examined the burden of ICU admission, mortality, and associated predictors among patients with A(H1N1)pdm09 pneumonia in a leading center for infectious diseases in Vietnam. Information on demographic, clinical, and laboratory characteristics, and outcomes was retrieved from medical records of adults admitted with influenza A(H1N1)pdm09 during 2009-2019. Among 729 cases, 21.7% (158/729) developed pneumonia. Among 158 pneumonia cases, 36.7% (58/158) developed moderate-to-severe acute respiratory distress syndrome (ARDS), and 15.2% (24/158) received invasive ventilation. ICU admission and mortality rates were 48.7% (77/158, 95%CI 41.1-56.5%) and 8.2% (13/158, 95%CI 4.9-13.6%), respectively. Predictors of ICU admission included being >60 years old (adjusted OR [AOR] 13.864, 95%CI 2.185-87.956, P=0.005), comorbidities (AOR 6.527, 95%CI 1.710-24.915, P=0.006), AST (AOR 1.013, 95%CI 1.001-1.025, P=0.029), and moderate-to-severe ARDS (AOR 14.027, 95%CI 4.220-46.627, P<0.001). Predictors of mortality were invasive ventilation (AOR 55.355, 95%CI 1.486-2062.375, P=0.030) and double-dose oseltamivir or combination therapy (AOR 32.625, 95%CI 1.594-667.661, P=0.024). In conclusion, mortality is not rare in A(H1N1)pdm09 infection. Monitoring of older patients and those with comorbidities, liver enzyme elevation, or moderate-to-severe ARDS is essential for the timely detection of complications requiring intensive care.

ABSTRACT Background Before obtaining professional medical care, many people in peri-urban and rural Pakistan contact herbalists, spiritual healers, and unlicensed caregivers. This study examined the social, economic, and cultural factors influencing the use of informal care by analysing the health-seeking behaviours of individuals in the Faisalabad District. Methods An exploratory mixed-methods study was conducted in Makkuana and the surrounding villages of Faisalabad District, Punjab. The quantitative component involved a cross-sectional survey of 69 adults using a structured questionnaire adapted from the I-CAM-Q. The qualitative component comprised twelve in-depth interviews and two focus group discussions. Descriptive statistics and chi-square analysis were used for quantitative data. Thematic analysis, guided by the Health Belief Model and Andersen's Behavioural Model, was applied to qualitative data. Results The mean age of participants was 40.4 years; 62.3% were female, and 79.7% had monthly household incomes below PKR 60,000. Of the 69 participants, 68 (98.6%) sought care from an informal provider first, most commonly an unqualified practitioner (50.7%), herbal practitioner (29.0%), or homeopath (17.4%). Trust was the leading reason for provider choice (43.5%), followed by proximity (24.6%) and low cost (15.9%). Complications were reported by 21.7% of participants, and 39.1% later required formal care for the same illness. Eight qualitative themes emerged: structural and economic barriers to formal care; proximity and convenience as determinants of informal care; trust, familiarity, and social networks; cultural and religious normalisation of traditional practices; poor doctor-patient communication in formal settings; perceived safety and naturalness of alternative remedies; awareness deficits about provider qualifications; and treatment-related harm and delayed escalation to formal care. Conclusion Informal health care seeking is nearly universal in this community, driven by intersecting economic, structural, cultural, and interpersonal factors. Enhancing primary care affordability, accessibility, and the quality of provider-patient communication together with culturally sensitive health literacy programs, is essential to redirect care seeking toward qualified providers.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has continuously evolved since its emergence in the human population in 2019. As of 1st August 2025, more than 1,700 Omicron subvariants have been designated by the Pango nomenclature system. The Pango nomenclature system designates a new lineage based on genetic and epidemiological information of SARS-CoV-2 strains. However, there is a possibility that strains that have similar genetic backgrounds and the same phenotype are given different Pango lineage names. In this paper, we propose a new algorithm, called FindPart-w, which can identify groups of viral lineages that share the same relative effective reproduction numbers. We introduced a new lineage replacement model, called the constrained RelRe model, which constrains groups of lineages to have the same relative effective reproduction numbers. The FindPart-w algorithm searches the equality constraints that minimise the Akaike Information Criterion of constrained RelRe models. Using hypothetical observation count data created by simulation, we found that the FindPart-w algorithm can identify groups of lineages having the same relative effective reproduction number in a practical computational time. Applying FindPart-w to actual real-world data of time-stamped lineage counts from the United States, we found that the Pango lineage nomenclature system may have given different lineage names to SARS-CoV-2 strains even if they have the same relative effective reproduction number and similar genetic backgrounds. In conclusion, this study showed that viruses that had the same relative effective reproduction number were identifiable from temporal count data of viral sequences. These findings will contribute to the future development of lineage designation systems that consider both genetic backgrounds and transmissibilities of lineages.

Single-crystal X-ray diffraction remains one of the most direct and reliable techniques for clarifying the three-dimensional structures of small molecules; however, its wider use in developing research settings has historically been limited by access to advanced instrumentation. Here, we consider the performance of the in-house diffractometer, Turkish Light Source, for small-molecule structure determination using three rhodanine-derivative compounds. Diffraction data were collected, processed, and followed by full-matrix least-squares refinement as a user-friendly pipeline. The compounds were successfully resolved in the triclinic space group P-1 and refined to chemically reasonable models, although notable differences in data quality and refinement parameters were observed. Compounds 1 and 2 produced the most robust and internally coherent structure, whereas compound 3 displayed refinement tribulations. These might be attributed to the intrinsic structural disorder of c-5b, analogous to polymorphic perversity in higher Z' phase, likely due to the presence of dissymmetric molecules within the asymmetric unit (Z' = 2), rather than empirical limitations. Anisotropic displacement parameters were systematically computed by atom-resolved Ueq factors and anisotropy index. The combined analyses reveal that structural ambiguity of c-5b is largely governed by localized maxima in atomic displacement (up to 0.29 [A]2 in Ueq with 6.67 anisotropy) rather than by global disorder, caused by the fluorinated aryl moiety of c-5b. These findings indicate that the in-house SCXRD system, when coupled with our user-friendly downstream pipeline, can yield reliable structural data for small molecules. Brief video tutorials and detailed SOPs have been provided in the Tutorials folder, including CrysAlisPro and Olex2 tutorials, as well as are easily accessible for users.

Introduction Improved diagnostics are needed for people at risk of tuberculosis, especially adolescents. Tongue swab (TS) molecular testing has emerged as a promising strategy for tuberculosis diagnosis. We evaluated diagnostic accuracy and acceptability of Xpert MTB/RIF Ultra (Xpert) using TS samples for tuberculosis detection among adolescents. Methods We conducted a cross-sectional diagnostic accuracy study with consecutive recruitment in Vietnam. Adolescents aged 10-19 who were recommended to undergo investigation for tuberculosis and had not received tuberculosis treatment in the past years were eligible. Participants provided TS and sputum samples and completed a structured survey regarding sampling experiences. TS was tested on Xpert, with sputum tested on Xpert and liquid culture. We utilised a composite reference standard of a positive result on sputum Xpert or sputum culture to define disease status. Sensitivity, specificity, and diagnostic yield were calculated for TS Xpert. Results From July to December 2025, we enrolled 225 adolescents from Can Tho and An Giang provinces in southern Vietnam. Fewer than half (96/225, 43%) the participants exhibited a tuberculosis -like symptom, and the majority (157/225, 70%) were close contacts of a person recently diagnosed with tuberculosis. TS were collected from all adolescents, while 116 (52%) could provide mucopurulent sputum. Tuberculosis prevalence was relatively low (12/225, 5.3%). TS Xpert sensitivity (90% CI) and specificity (90% CI) were 58.3% (35.6, 78.0) and 99.5% (97.9, 99.9), respectively. Diagnostic yield among all diagnosed was 58.3% (7/12). TS sampling was highly acceptable to adolescents; the short time and simplicity of collecting TS were considered favourably. Conclusions The sensitivity and diagnostic yield of TS Xpert was relatively low among adolescents recommended for tuberculosis investigation, which includes asymptomatic individuals who may not provide high quality sputum. Specificity was excellent, and everyone could provide a TS. TS high acceptability indicates it remains a promising sample for diagnostic algorithms.

Background Tuberculosis (TB) remains a critical public health challenge, with two-thirds of the global TB burden in ten Asian countries. Social vulnerabilities, comorbidities, health inequity, multi-dimensional poverty, malnutrition, and barriers to healthcare access continue to fuel TB epidemic. Inability to detect asymptomatic and sub-clinical TB, combined with passive approach in service delivery and overreliance on smear microscopy, leads to delayed diagnosis, a substantial burden of undetected cases, and continuing TB transmission in the communities. In such a context, the introduction and scale-up of active case-finding approaches - including community-based TB screening using highly sensitive screening tools and novel rapid diagnostics - becomes a strategic priority to interrupt transmission. The growing availability of multiple screening and diagnostic options makes evidence-based decision-making increasingly complex. Methods To estimate the potential epidemiological impact and cost implications of scaling up TB diagnostics and community-based screening in ten high-burden Asian countries, we constructed a mathematical model and evaluated multiple intervention scenarios. We then assessed and compared four service delivery models: 1) digital ultraportable chest x-ray (UPCXR) & Xpert/Truenat in community, 2) digital UPCXR in community and Xpert/Truenat at health facilities, 3) digital UPCXR in community and near point of care (nPOC) at health facilities, 4) nPOC in community & Xpert/Truenat at health facilities - for total investment required and projected health benefits for their cost-effectiveness. Results and conclusions The modelling study indicated that strengthening health facility capacity (with enhanced TB screening, expanded molecular diagnostics, reduced loss to follow-up, private sector standard of care, leading to increased treatment coverage & quality of active disease treatment and reduced post-treatment relapse, scale-up of TB preventive treatment (TPT), and provision of nutritional support to 80% of TB patients and their household contacts) can significantly reduce TB incidence and mortality; however, community-wide mass screening remains essential to achieving TB elimination targets . Targeted screening of vulnerable populations demonstrated greater cost-effectiveness than untargeted screening approaches. Achieving the End TB goals will ultimately require an effective TB vaccine with high population-level coverage. AI-enabled digital UPCXR-based screening combined with Xpert/Truenat testing at the community level demonstrated maximum epidemiological impact potential, while the most cost-efficient model is Digital UPCXR in the community combined with nPOC testing at health facilities. An investment of USD 12.7 billion over the next five years in community-level implementation of digital UPCXR and molecular diagnostics could avert an additional 9.8 million TB cases and 1.9 million deaths across ten Asian countries over a ten-year horizon.

There is an ongoing Oropouche Fever (OF) outbreak in Brazil since 2024. There are dengue and chikungunya prediction models available, but none to help discriminate dengue, chikungunya, and OF. Objective: This study aims to develop and validate clinical prediction models for dengue, chikungunya, OF. Methods: This study uses surveillance data from Espirito Santo state / Brazil, from 2023-2025. Epidemiological investigations and biological samples were used to conclude cases as either (a) clinical-epidemiologically confirmed, (b) laboratory confirmed, or (c) discarded. The predictors were all data related to signs, symptoms, and comorbidities available in the notification forms. The analysis was performed using random forest regression models, one for each outcome, in development and validation datasets. Results: A total of 465,280 observations were analyzed, 261,691 dengue cases (56.6%), 18,676 chikungunya cases (4.0%), 12,174 OF cases (2.6%), and 179,115 discarded cases (38.6%). All three models had good discrimination and moderate to good calibration after scaling prediction. The models retained from 26 to 16 predictors each. Leukopenia and vomiting were the most discriminatory predictors for dengue, arthritis, arthralgia, and rash were the most discriminatory for chikungunya, and epidemiological features were the most relevant for OF. The dengue, chikungunya, and OF models had ROC AUC of 0.726, 0.851, and 0.896 in the validation set, respectively. Conclusion: This research identified predictors most discriminative between dengue, chikungunya, and OF. We developed and validated predictive models, one for each condition, with moderate to very good performance available at https://pedrobrasil.shinyapps.io/INDWELL/. One may use them in diagnostic work-up and arbovirus surveillance.

Abstract: Background: Vascular access is essential in treating patients undergoing prolonged endovenous therapy such as chemotherapy, antibiotics, and parenteral nutrition. Since the 1990s, when PICCs (peripherally inserted central catheters) appeared, vascular access options have expanded significantly, revolutionizing the treatment landscape for all types of patients. Objective: To analyze and describe the profile of the use of PICCs in a Brazilian quaternary hospital over 10 years with data collected by the infusion therapy team. Evaluating the number of PICCs implanted over the years, patients epidemiology and clinical characteristics, insertion details, associated complications, and the reason for removal. Methods: A retrospective cohort study that employs a quantitative, non-experimental approach to classify and statistically analyze past events associated with 21,652 PICCs implanted from January 2012 to December 2021 in a quaternary hospital at Sao Paulo - Brazil. All the catheters were implanted, and the data was collected by a team of nurses specializing in infusion therapy. We analyzed the number of catheters implanted over the years, insertion characteristics, patients epidemiology and clinical data, possible associated complications, and the reason for removal. Statistical analyses were conducted using R software (version 4.4.1) and SPSS (version 29) for Windows (IBM Corp, Armonk, NY). Results: During the specified period, 21,652 catheters were analyzed. The patients gender distribution was nearly balanced (48.2% versus 51.8%), and the average age was 66 years. Cardiovascular and metabolic issues were the most common comorbidities, and between 2020 and 2021, 29.3% of the sample tested positive for COVID-19. The most common location of hospitalization and implantation was the medical-surgical clinic (31.6% - 41.4%), and the most used type of catheter was the Power Picc (83.9%). The estimated complication incidence density is 2.94 complications per 1,000 catheter-days. Almost all the PICCs (98,2%) were adequately located at the cavo-atrial junction after the first attempt, 82.2% of catheters were removed after therapy, and the median duration of catheter use was 12 days. Conclusion: PICCs are widely employed for drug infusion, with their use growing progressively due to specialized teams greater availability and training. The high efficiency of these devices with a relatively low risk of complications already observed in previous studies was reinforced by the findings of this study of more than 20,000 catheters.

Objective: To describe the clinical characteristics of term neonates with neonatal bacterial meningitis (NBM) and explore the association between different pathogens and imaging complications, providing clinical evidence for early identification and individualized management. Methods: A retrospective study was conducted on 531 term neonates diagnosed with NBM admitted to the Capital Institute of Pediatrics from 2013 to 2025. Demographics, clinical manifestations, laboratory parameters, etiological results, imaging complications and treatment measures were collected. Patients were divided into favorable/adverse discharge outcome groups and pathogen-positive/negative groups. Statistical analyses were performed using appropriate tests, and Cramers V coefficient was used to analyze the association between pathogens and imaging complications. Results: (1) The most common clinical manifestations were abnormal body temperature (79.85%), altered consciousness (55.18%) and jaundice (46.52%). CSF/blood culture was positive in 133 cases (25.05%), with Escherichia coli (27.07%), group B streptococcus (17.29%) and Staphylococcus species (16.54%) as predominant pathogens. The overall incidence of imaging complications was 22.22%, mainly hydrocephalus (5.84%), subdural effusion (4.90%) and encephalomalacia (2.64%). (2) Adverse discharge outcomes occurred in 107 cases (20.15%). Compared with the favorable group, the adverse group had higher incidences of convulsions, altered consciousness, anterior fontanelle bulging, abnormal muscle tone and primitive reflexes (all P<0.001), more obvious laboratory abnormalities (higher CRP, CSF leukocytes and protein, lower CSF glucose, all P<0.05), higher culture positive rates and greater need for adjuvant therapy (all P<0.001). (3) Pathogen-positive patients had higher imaging complication rates. Gram-negative infections were associated with higher hydrocephalus and subdural effusion rates, while Gram-positive infections had higher brain abscess risk. Specifically, Escherichia coli correlated with hydrocephalus and subdural effusion; group B streptococcus with cerebral infarction and encephalomalacia; LM with intracranial hemorrhage and brain abscess; negative cultures correlated with no imaging complications (all P<0.05). Conclusion: Term NBM neonates have non-specific manifestations, mainly abnormal body temperature and altered consciousness. Predominant pathogens are Escherichia coli, group B streptococcus and Staphylococcus species, with hydrocephalus and subdural effusion as common imaging complications. Adverse outcomes are associated with severe symptoms, obvious laboratory abnormalities and higher pathogen positivity. Specific pathogens correlate with distinct imaging complications.

Background. Targeted Universal Tuberculosis Testing (TUTT) may increase tuberculosis (TB) case detection by including people who are not actively seeking TB care but are at high risk of the disease. Non-invasive tongue swab (TS) testing may facilitate TUTT. We evaluated two TS testing protocols in people with HIV (PWH) tested irrespective of TB symptoms. Methods. Study staff collected Copan FLOQSwab and Medline foam swab specimens, alongside urine and sputa, from PWH, most of whom were presenting for antiretroviral therapy initiation at primary healthcare clinics in KwaZulu-Natal, South Africa. FLOQSwabs were tested by sequence-specific magnetic capture (SSMaC) with qPCR (FLOQSwab-SSMaC). Foam swabs were tested by centrifuge-sedimentation and high-volume qPCR (foam-sedimentation). Urine lipoarabinomannan was detected using LF-LAM. The extended microbiological reference standard (eMRS) comprised any positive result on Xpert Ultra and/or liquid culture of sputum. Results. We enrolled 251 participants (median age 34 years, 56% female, 67% with self-reported TB symptoms). Participants had a median CD4 count of 347 cells/ul, and 16% (40/251) had prior TB. FLOQSwab-SSMaC was 43% sensitive (13/30) and 100% specific (131/131) relative to eMRS. Foam-sedimentation was 47% (9/29) sensitive and 100% (176/176) specific. Sensitivity increased to 52% (FLOQSwab-SSMaC) and 50% (foam-sedimentation) when sputum Xpert Ultra Trace positive results were excluded from eMRS. TS was more sensitive than urine LAM, and both sample types were more sensitive when CD4 counts were below 200. Discussion. TS testing detected about half of PWH with TB and outperformed urine LAM within this population, including among PWH with low CD4 counts.

IntroductionFamily Constellation Therapy (FCT) has been widely disseminated in clinical, public health, and judicial settings despite persistent concerns regarding its theoretical basis, safety, and the limited availability of rigorous randomised evidence supporting its clinical use. ObjectiveThe aim of this systematic review is to assess the effects of FCT across all clinical conditions, explicitly considering both benefits and harms; and summarise the characteristics of studies and intervention settings used in randomised controlled trials of FCT. MethodsFollowing a prospectively registered protocol (CRD420251136190), we conducted a systematic search of seven databases (PubMed, EMBASE, APA PsycInfo, CENTRAL, BVS, Web of Science, and CINAHL) and grey literature (ICTRP and ProQuest database) without language or date restrictions to identify published and unpublished randomised controlled trials of FCT. Study selection, data extraction, risk of bias (RoB 2), and certainty of evidence (GRADE) were performed in duplicate. Statistical analyses followed a prospectively registered analysis plan with prespecified criteria for data pooling and for handling analytical limitations. ResultsNo reliable evidence was found to support the use of FCT for any condition across both clinical and non-clinical samples. All trials included were judged to be at high risk of bias and all comparisons were rated as very low-certainty evidence. Concerns regarding potential adverse effects were identified, and the available data was insufficient to establish the effectiveness of the intervention, precluding any clinical recommendation. ConclusionClinicians, policymakers, and consumers should reconsider adopting FCT while reliable evidence is not available.

Urinary tract infections (UTIs) are among the most common infectious diseases worldwide, with Escherichia coli being the predominant uropathogen. The increasing prevalence of extended-spectrum beta-lactamase (ESBL)-producing strains and their association with fluoroquinolone resistance pose a significant challenge to empirical therapy, particularly in community settings. The aim of this study was to determine the epidemiology and predictive factors associated with ESBL-producing E. coli and its concomitant fluoroquinolone resistance in community-acquired clinical isolates. A retrospective cross-sectional study was conducted analyzing 244 clinical E. coli isolates. Demographic and microbiological data were collected, including age, sex, sample type, and antibiotic susceptibility. Associations between variables and ESBL production were assessed using Pearsons chi-squared test, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Of the isolates, 165 (68%) were ESBL-producing. A significant association was observed between age group and ESBL production (p < 0.001), with the highest frequency in the 20-39 age group. Most ESBL-positive isolates were obtained from women (73%), although odds ratio (OR) analysis suggested a non-significant trend toward a higher probability in men (OR = 1.29; 95% CI: 0.72-2.31). High rates of fluoroquinolone resistance were identified among the ESBL-producing isolates, with 30% resistance to levofloxacin and 35% to ciprofloxacin (p < 0.001). Urine samples showed the highest concentration of ESBL-positive isolates, with a significant association between sample type and resistance (p < 0.001). The high prevalence of ESBL-producing E. coli and its concomitant resistance to fluoroquinolones highlight a critical challenge for the empirical treatment of urinary tract infections in Mexico, underscoring the need to strengthen antimicrobial use management and local surveillance strategies.

Toxoplasma gondii is a widespread human pathogen that has multiple, clinically relevant stages in its complex life cycle, including fast-replicating tachyzoites and latent bradyzoites. Bradyzoite differentiation is triggered by stress responses that lead to changes in transcription, translation, and metabolism. Two aspects of this process are addressed in this report: first, whether proteins that play roles in bradyzoite differentiation are specific to T. gondii and other bradyzoite-forming parasites of the Sarcocystidae family, and second, whether new bradyzoite differentiation proteins can be identified in T. gondii. To answer these questions, a phylogenetic approach was used, comparing proteomes of select members of the Sarcocystidae family that form morphologically different bradyzoite cysts and members of the Eimeriidae family that do not form cysts. This approach resulted in 8 distinct clusters of T. gondii proteins that reflected different conservation patterns; for example, one cluster showed conservation among all organisms, while another showed conservation in bradyzoite cyst-forming organisms. Known T. gondii proteins involved in bradyzoite differentiation were found in all clusters, indicating that this process uses both highly conserved pathways as well as bradyzoite-specific pathways. Importantly, the cluster containing proteins that are conserved in bradyzoite-forming organisms contained several known regulators of bradyzoites, and will be a source for identifying novel T. gondii proteins that are involved in bradyzoite differentiation.

BackgroundTuberculosis (TB) remains a leading cause of infectious disease mortality worldwide, and treatment failure contributes to ongoing transmission, drug resistance, and poor clinical outcomes. Artificial intelligence and machine learning approaches have attracted growing interest for predicting tuberculosis treatment outcomes, but the literature is heterogeneous and lacks a comprehensive synthesis. MethodsWe conducted a systematic review and meta-analysis of studies that developed or validated machine learning models to predict TB treatment failure. We searched PubMed/MEDLINE and Embase from January 2000 to October 2025. Studies were eligible if they developed, validated, or implemented an artificial intelligence or machine learning model for the prediction of TB treatment failure or a closely related poor outcome in patients receiving anti-TB treatment. Risk of bias was assessed using the Prediction model Risk Of Bias Assessment Tool. Random-effects meta-analysis was performed to pool area under the curve values, with subgroup analyses and meta-regression to explore heterogeneity. ResultsThirty-four studies were included in the systematic review, of which 19 reported area under the curve values suitable for meta-analysis (total participants, 100,790). Studies were published between 2014 and 2025, with 91% published from 2019 onward. Tree-based methods were the most common algorithm family (52.9%), and multimodal models integrating three or more data types were used in 41.2% of studies. The pooled area under the curve was 0.836 (95% confidence interval 0.799-0.868), with substantial heterogeneity (I{superscript 2} = 97.9%). In subgroup analyses, studies including HIV-positive participants showed lower discrimination (pooled area under the curve 0.748) compared to those excluding them (0.924). Only eight studies (23.5%) performed external validation, and only one study (2.9%) was rated as low risk of bias overall, primarily due to methodological concerns in the analysis domain. Eggers test suggested publication bias (p = 0.024). Major evidence gaps included underrepresentation of high-burden countries, HIV-affected populations, social determinants, pediatric TB, and extrapulmonary disease. ConclusionsMachine learning models for predicting TB treatment failure show promising discrimination but are not yet ready for routine clinical implementation. Performance varies substantially across populations and settings, and methodological limitations, including inadequate validation, poor calibration assessment, and high risk of bias, limit confidence in current estimates. Future research should prioritize rigorous external validation, calibration assessment, and development in underrepresented populations, particularly HIV-affected and high-burden settings. Author SummaryTB kills over a million people annually. While curable, treatment failure remains common and drives ongoing transmission and drug resistance. Researchers increasingly use artificial intelligence and machine learning to predict which patients will fail treatment, but it is unclear if these models are ready for clinical use. We reviewed 34 studies including nearly 1.1 million participants from 22 countries. On average, models correctly distinguished patients who would fail treatment from those who would not 84% of the time, a performance generally considered good. However, this average hid enormous variation. Models developed in populations including HIV-positive people performed substantially worse, suggesting prediction is harder with HIV co-infection. Worryingly, only one study used high-quality methods; 97% had serious flaws in handling missing data, checking calibration, or testing in new populations. Only eight studies validated their models in different settings. To conclude, we found that machine learning is promising in predicting TB treatment failure, but it is not ready for clinical use. Researchers should prioritize validation in high-burden settings, include social determinants, and improve methodological rigor before these tools can help patients.

Background Regulatory inconsistency across African countries contributes to duplicative scientific assessments, prolonged approval timelines, and delayed access to essential medical products. To inform the operationalisation of the African Medicines Agency (AMA), the African Medicines Regulatory Harmonisation (AMRH) programme implemented Africa's first continental pilot study for the scientific evaluation and listing of human medicinal products. This study evaluates the pilot's procedural performance and examines how continental scientific opinions were translated into national regulatory decisions through reliance mechanisms. Methods and Findings A mixed-methods programme evaluation was conducted using regulatory datasets generated during the pilot study. Quantitative data included assessment timelines, GMP inspection outcomes and national post-listing regulatory actions. Retrospective qualitative thematic analysis was applied to governance documents and National Regulatory Authority (NRA) feedback to identify legal, institutional and procedural determinants influencing uptake. Of 64 expressions of interest, 24 products progressed to full evaluation and 12 received positive continental scientific opinions. Ten met the predefined performance target of [&le;]210 working days. Twenty-four GMP inspections identified no critical deficiencies and aligned with global regulatory benchmarks. National uptake demonstrated active reliance: full reliance (continental opinion as primary basis for national approval) for 7 products (58%); sequential reliance (continental assessment supplemented with targeted national queries) for 3 products (25%); and supplemented national review (separate national assessment undertaken) for 2 products (17%). Products with broader market strategies achieved registration in up to 23 African countries within a median of 77 working days post-listing. Variability in uptake reflected national legal authority, administrative requirements, and applicant submission strategies Conclusions The pilot study demonstrates the feasibility of a continent-wide regulatory assessment mechanism capable of producing trusted scientific outputs and enabling reliance-based national decision-making in Africa. While reliance was widely applied, heterogeneity in national procedures and administrative sequencing affected time to national registration. Findings provide empirical evidence to inform the AMA scale-up, highlighting the need for harmonised reliance pathways, streamlined administrative processes, and coordinated digital regulatory infrastructure.

Women living with HIV face about a six-fold higher risk of cervical cancer, yet screening uptake remains low in many sub-Saharan African settings. We explored factors influencing repeated decisions to decline cervical cancer screening during routine HIV care among women living with HIV at a large HIV clinic in Jos, Nigeria. Between September and December 2024, we conducted an exploratory qualitative study at the AIDS Prevention Initiative in Nigeria Clinic in Jos, Nigeria. We purposively recruited 27 women living with HIV aged 21 to 65 years who had never undergone cervical cancer screening and had repeatedly declined screening offers during routine HIV care, including at the current clinic visit. Semi-structured in-depth interviews were conducted in English or Hausa, audio-recorded, transcribed verbatim, and translated into English where needed. Data were analyzed thematically using theory-informed coding based on the Health Belief Model and Social Ecological Model. Among 27 women living with HIV who had repeatedly declined screening, perceived susceptibility was often low or uncertain despite recognition of cervical cancer severity. Perceived benefits were acknowledged but were frequently outweighed by overlapping barriers, including knowledge gaps and misinformation, indirect and downstream costs, emotional barriers, logistical constraints, clinic-flow and service-delivery barriers, and anticipated stigma. Education, reminders, and supportive clinic processes acted as cues to action, and most participants expressed willingness to screen in future. Among women living with HIV at this clinic who repeatedly declined screening when it was offered, perceived benefits were often outweighed by multilevel barriers. Screening programs may integrate fear-reduction and stigma-sensitive counseling with practical service delivery improvements, including shorter waiting times, reduced indirect costs, predictable and streamlined clinic flow, and consistent provider invitations and reminders, while addressing misinformation through community-embedded, culturally tailored messaging. These strategies may improve screening uptake and support more equitable cervical cancer prevention for women living with HIV in similar HIV-care settings.

While vaccination conflicts have become apparent, physicians' attitudes toward those with differing views remain unclear. Through an online survey of 492 physicians and 5,252 members of the general public in Japan in February 2026, we investigated attitudes toward four vaccines (influenza, measles, HPV, and COVID-19). Intergroup bias was assessed as ingroup minus outgroup attitudes using a feeling thermometer. Multilevel regression examined associations with agreement group and physician status. Intergroup bias was significantly positive in both agreement and disagreement groups across all vaccine types, and was higher in the agreement group. Physicians exhibited higher intergroup bias than the general public. These findings indicate that vaccination conflict is bidirectional: physicians, often viewed as targets of hostility from vaccine-hesitant individuals, themselves exhibit greater intergroup bias toward those with opposing views. Interventions to raise physicians' awareness of their own bias, alongside communication strategies for vaccine-hesitant individuals, are needed.

Objectives: In Latin America, up-to-date information to monitor UNAIDS 95-95-95 HIV targets in key populations, such as men who have sex with men, is limited. Elsewhere, structural homophobia restricts access to ART. Conceptual frameworks suggest that intersecting forms of violence and discrimination may negatively influence HIV care outcomes through psychosocial and structural pathways, although empirical evidence remains limited. The study aimed to assess whether sexual orientation outness and recent homophobic violence are associated with not being on ART among Latin American MSM living with HIV. Methods: This cross-sectional study is a secondary analysis of data from LAMIS-2018, including 7,609 MSM aged 18+ with an HIV diagnosis [&ge;]1 year prior from 18 Latin American countries. Participants self-reported ART status, sociodemographic characteristics, homophobic violence, and sexual orientation outness. Bivariate and multivariate logistic regressions identified those factors associated with not being on ART. Results: Nine percent of MSM with HIV were not on ART, 18% reported low sexual orientation outness, and 27% experienced homophobic violence, especially in Andean and Central American countries. Not being on ART was associated with recent homophobic violence (aPR=1.25), low outness (aPR=1.22), unemployment (aPR=1.27), and residence in the Andean subregion (aPR=1.87), Mexico (aPR=1.28), or the Southern Cone (aPR=1.45) versus Brazil. Protective factors included being older (25-39: aPR=0.72; >39: aPR=0.49), living in large cities (aPR=0.72), having a stable partner (aPR=0.78), and university education (aPR=0.74). Conclusions: Recent homophobic violence and low sexual orientation outness were associated with not being on ART among MSM in Latin America. While access varies across countries, structural factors such as stigma and violence may limit engagement in care. Addressing these barriers alongside strengthening health systems may be key to improving ART uptake and advancing progress toward the 95-95-95 targets.

Dropout from essential maternal health services across pregnancy, childbirth, and the postnatal period remains a major barrier to improving maternal and neonatal outcomes in Bangladesh. This study examined stage-specific dropout patterns along the maternal continuum of care and identified factors associated with discontinuation. We analysed nationally representative data from the Bangladesh Demographic and Health Survey 2022 for 5,162 women with a recent live birth. Dropout from antenatal care, skilled birth attendance, and postnatal care was examined using multivariable logistic regression to estimate adjusted odds ratios and 95% confidence intervals, with comparisons to BDHS 2017-18 and assessment of regional variation. Only 44% of women received four or more antenatal care visits. Of these, 33% delivered with a skilled birth attendant, and among those receiving both antenatal care and skilled delivery, only 15% received postnatal care within 48 hours. Overall, 57% dropped out before completing adequate antenatal care, with additional dropouts between antenatal care and delivery (10%) and between delivery and postnatal care (18%). Compared with 2017-18, overall dropout from the maternal continuum of care more than doubled in 2022 (5.0% to 11.7%), driven by increased antenatal care dropout, while skilled birth attendance dropout declined and postnatal care dropout increased slightly. Higher maternal education, household wealth, media exposure, and womens decision-making power were consistently associated with lower odds of dropout, whereas higher birth order increased dropout risk. Substantial regional variation was observed, with the highest overall dropout in Sylhet and the lowest in Khulna. High dropout from the maternal continuum of care in Bangladesh occurs predominantly at the antenatal care stage and is shaped by socioeconomic status, birth order, womens access to information, and regional disparities. Strengthening early antenatal engagement and womens decision-making autonomy is critical to improving continuity of maternal care and reducing preventable maternal and neonatal risks.

Objectives: To identifiy risk factors for antimicrobial resistance (AMR) in seven pathogen-antimicrobial combinations in patients with cancer and cancer survivors. Methods: Using data from patients with recent or past cancer diagnostic codes in Oxfordshire, UK, we examined associations between 22 potential risk-factors and AMR in blood culture isolates, collected between 1-April-2015 and 31-March-2025. Results: Among 5,975 bacteraemias in 4,365 adults, we analysed 3,141 (52.6%) due to Enterobacterales and 620 (10.4%) due to Enterococcus faecalis/faecium in 2,752 patients. Fourteen risk-factors for antimicrobial-resistant bacteraemia were identified, varying across pathogen-antimicrobial combinations. Compared with no previous antimicrobial susceptibility test result, prior resistance to the same antibiotic in any culture in the last year was strongly associated with AMR across all pathogen-antimicrobial combinations (all p<=0.001). Prior antibiotic exposure and younger age were also positively associated with AMR in four and five combinations, respectively. Cancer type showed modest effects; lymphoid/haematopoietic malignancies were associated with higher odds (vs colorectal cancer) of trimethoprim-sulfamethoxazole-resistant Enterobacterales (aOR=2.07 95%CI 1.40-3.06) and vancomycin-resistant Enterococcus bacteraemia (aOR=6.68, 1.21-36.91). Conclusions: Previous resistance was the greatest risk factor for bacteraemia with AMR in cancer patients and survivors, with prior antibiotic exposure and age also contributing. Lymphoid/haematopoietic malignancies increased risk of resistance to specific antimicrobials. Keywords: antimicrobial resistance, bacteraemia, cancer, risk factors