PLOS Neglected Tropical Diseases

Abstract Introduction Onchocerciasis is targeted for elimination with community-directed treatment with ivermectin (CDTI). Alternative strategies are needed in areas where transmission persists despite long-term CDTI and/or are co-endemic with loiasis. This study assessed the efficacy of 35-day treatment with 100mg doxycycline on Wolbachia density at 6 months and microfilaridermia and palpable nodules at 30 months post-treatment. Methods A treatment follow-up study was conducted in 20 high-transmission onchocerciasis communities in a co-endemic loiasis area of South-West Cameroon. Community-based directly observed treatment with 100mg doxycycline was administered to community members aged [≥]9 years. Wolbachia clearance at 6-months and treatment efficacy on microfilaridermia and palpable nodules were assessed at 30-months post treatment. Factors associated with reductions in microfilaridermia post treatment, including adherence to doxycycline treatment were assessed with mixed-effects logistic regression. Results Over 92% (2835/3080) of eligible participants took 35 days of 100mg doxycycline over 5 or 6 weeks. This regimen achieved a 62.8% microfilaridermia reduction and 99% palpable nodule reduction in the 720 participants included at follow-up. Wolbachia depletion was observed in 92% of skin samples at 6 months post treatment. The most important factor associated with microfilaridermia after 30 months was having missed at least 7 doxycycline consecutive doses (OR 3.11, 95%CI: 1.17-8.26). Incomplete treatment to a lesser extent was not associated with reduced efficacy at follow-up. Conclusion This large-scale community intervention shows that a 5-week treatment with 100mg doxycycline is feasible and has high curative efficacy against adult O. volvulus as measured by the dramatic reduction in the proportion of palpable nodules at 30-months post treatment. The high efficacy shows the tremendous potential of anti-Wolbachia drugs as part of the arsenal for onchocerciasis elimination and paves the way for the next generation of anti-Wolbachia drugs with shorter treatment courses, which will facilitate the implementation of alternative strategies to accelerate onchocerciasis elimination.

Introduction Reducing delays in leprosy case detection is essential for achieving global leprosy targets. Accurate measurement of these delays and their determinants relies largely on patient-reported data, as routine health records are often inadequate. The leprosy case detection delay (CDD) questionnaire, developed under the Post Exposure Prophylaxis for Leprosy (PEP4LEP) project, has been validated in Ethiopia, Mozambique, Tanzania, and Indonesia. However, it has not been adapted or validated for Nigeria or any major Nigerian indigenous language. This study aimed to culturally adapt and validate the CDD questionnaire for Igbo-speaking populations in Nigeria. Methodology/Principal Findings The CDD questionnaire underwent a standardized cross-cultural adaptation process. Content validity was assessed using item- and scale-level content validity indices, while construct validity was evaluated through hypothesis testing. Reproducibility was assessed using test-retest and inter-rater reliability; agreement using the Bland-Altman method and the Wilcoxon Signed-Rank test; reliability using Spearmans rank correlation coefficient and the Intraclass Correlation Coefficient (ICC); and internal consistency using Cronbachs alpha. Data were collected through face-to-face interviews with persons affected by leprosy at two time points separated by at least two weeks. Participants (n=100) had a mean age of 45.1 years (SD=18.7). Mean CDD was 77.2 months at baseline and 77.9 months at retest. The instrument demonstrated excellent content validity (I-CVI/S-CVI: 0.90-1.00), good internal consistency (Cronbachs =0.77), and excellent test-retest reliability (ICC=0.996, 95% CI: 0.994-0.997). Test and retest measurements were highly correlated ({rho}=0.985, p<0.001), with no evidence of systematic change over time (p=0.864). Seventy-two percent of participants reported identical CDD values across assessments. All items from the original English version were retained without modification. Conclusion/Significance The Igbo version of the CDD questionnaire demonstrated good validity and reliability and is suitable for assessing leprosy case detection delay among Igbo-speaking populations in Nigeria

Mosquito-borne diseases continue to pose significant public health challenges worldwide, particularly in densely populated regions of South Asia and parts of North America experiencing increasing vector prevalence due to climate and environmental changes. Commercial mosquito repellents are widely used as a primary preventive measure; however, their efficacy, safety, and public health impacts vary depending on formulation, active ingredients, environmental conditions, and user practices. This study presents a comparative evaluation of commonly used mosquito repellent products in South Asia and North America, including coils, vaporizers, sprays, creams, and Natural repellents. The research aims to assess repellent efficacy against major mosquito vectors, evaluate potential health and respiratory effects associated with prolonged exposure, and analyze consumer awareness and usage patterns across different regions. Laboratory-based efficacy testing and field observations were conducted to compare protection duration, repellency rate, and environmental performance under varying climatic conditions. Safety assessments included analysis of chemical composition, indoor air quality impact, and reported adverse health symptoms among users. The findings indicate significant differences in effectiveness and safety profiles among product categories and geographical regions. Synthetic repellents generally demonstrated higher repellency duration, while herbal formulations showed improved safety and environmental compatibility. The study highlights the importance of standardized evaluation protocols, regulatory oversight, and public awareness in promoting safe and effective mosquito control strategies. These findings may support policymakers, healthcare professionals, and manufacturers in improving mosquito repellent technologies and reducing the burden of mosquito-borne diseases globally.

Effective filtration and concentration of stool specimens is an essential pre-analytical step for reducing fecal debris and improving organism recovery using microscopy-based ova and parasite (O&P) examination. This study evaluated three commercially available fecal sedimentation-based filtration/concentration systems, ParaPak SpinCon (Meridian Bioscience), Mini Parasep SF (Apacor), and the newly-available ParadeviceReingenuity), for qualitative parasite detection and workflow logistics using conventional and artificial intelligence (AI)-assisted microscopy. Forty clinical stool specimens (20 parasite-positive and 20 parasite-negative) were processed with the 3 devices, and the resultant 120 wet mount and 120 trichrome stained smear preparations were examined using conventional microscopy. Trichrome-stained slides were also scanned at 40x magnification using a Hamamatsu NanoZoomerS360 flatbed digital slide scanner and images were analyzed using the Techcyte Fusion Human Fecal Trichrome AI algorithm. Positive and indeterminate digital findings were confirmed by conventional glass slide microscopy. Slides and digital images were reviewed in a blinded manner. Concordance was assessed among the 360 initial evaluations (microscopy and AI-assisted), and discrepant parasitology results were resolved through re-review and specimen reprocessing as needed. Final qualitative agreement across slide/image evaluations using all three concentration systems was 100%. Minor discrepancies in protozoan and white/red blood cell detection/identification were noted in 5 and 7 cases, respectively, and likely reflected sampling and observer variability. While the three concentration systems produced equivalent qualitative results, the Paradevice and Mini Parasep SF offered the most streamlined workflows. These findings support the Paradevice and Mini Parasep SF as efficient, analytically equivalent systems that are compatible with traditional and AI-assisted O&P workflows.

Abstract Background Peripheral artery disease (PAD) is a major contributor to morbidity and mortality, particularly among individuals with diabetes mellitus (DM), in whom its prevalence is markedly increased. PAD is often asymptomatic and under-diagnosed, especially in low-resource settings. This study aimed to determine the prevalence of PAD and associated factors among adults with DM in Eastern Uganda. Methods We conducted a hospital-based cross-sectional study at Mbale Regional Referral Hospital from 10th/12/ 2024 to 30th/4/2025. A total of 300 adult patients with DM were consecutively enrolled. Data on sociodemographic characteristics, clinical characteristics, comorbidities, and behavioural risk factors were collected using an interviewer-administered data tool. PAD was assessed using the ankle-brachial index (ABI), defined as [&le;] 0.90. Modified Poisson regression was used to identify factors associated with PAD. As a secondary measure for PAD, we administered the Edinburgh Claudication Questionnaire (ECQ) to capture symptomatic PAD. Results The majority of the participants had a low fruit intake (68%), physical inactivity (54%), and elevated low-density lipoprotein (60%). The prevalence of PAD as measured by ABI was 42.3% (127/300; 95% CI 0.38-0.48), while the magnitude of PAD as measured by ECQ, combining participants with possible claudication and definite claudication was 37.3% 95% CI 31.9 - 42.8). Out of participants with PAD, 15.8% (20/127) were classified as having severe PAD (ABI <0.4). Socio-demographic and clinical factors were assessed for association with PAD. We found no evidence of association between the examined factors such as age (aPR 1.24 95% CI 0.73 - 2.09), sex (aPR 1.46 95% CI 0.84 - 2.55), cholesterol level (aPR 1.39 95% CI 0.86 - 2.25), glycemic control (aPR 1.35 95% CI 0.72 - 2.53), and sedentary behaviour (aPR 1.28 95% CI 0.79-2.08) and PAD. Conclusion The prevalence of PAD was high among adults with DM in Eastern Uganda. Routine health education, and ABI screening of PAD should be done for patients living with DM. The absence of significant associations despite high prevalence of PAD may reflect unmeasured factors e.g. chronic inflammation that may be unique to this population, future prospective studies with larger sample size and more detailed objective measures e.g. inflammatory markers are needed to determine locally relevant modifiable risk factors.

Introduction: Malaria, primarily transmitted by Anopheles mosquitoes, remains a major public health concern in Maiduguri, Borno State, Nigeria. While conventional control methods (e.g., ITNs) face challenges due to insecticide resistance and accessibility constraints, many communities rely on locally sourced natural products. This study aimed to assess the prevalence, usage patterns, and associated factors of these natural alternatives. Methods: A cross-sectional survey was conducted across three purposefully selected communities in Maiduguri (Mairi, Furi, Lagos Street). A total of 450 household heads were interviewed using a structured questionnaire, collecting data on socio-demographics, specific natural products used, method of application, frequency, and perceived efficacy. Data were analyzed using descriptive statistics and binary logistic regression. Results: Overall usage prevalence of natural products was high at 68.4%. The most common products identified were Neem (Azadirachta indica) extract (45.9%) and burnt Lemon Grass (Cymbopogon citratus) (31.2%). Usage pattern was predominantly indoor fumigation (burning), and over 70% of users prepared the products crudely at home. Logistic regression revealed that rural residence (Odds Ratio (OR): 2.1; p<0.01) and low education level (OR: 1.8; p<0.05) were significant independent predictors of higher natural product reliance. Conclusion: Natural products constitute a widely adopted, community-driven vector control method in Borno State. The high prevalence and association with vulnerable populations suggest an urgent need to standardize the preparation and application of these products for potential integration into regional malaria control programs. Keywords: Anopheles, Adulticides, Borno State, Malaria, Natural Repellents, Vector Control, Usage Pattern.

Abstract Background Malaria remains a major public health challenge in Ghana, despite recent reductions in cases due to various interventions. The endemicity of the disease varies across regions, influenced by diverse seasonal and temporal factors that support mosquito proliferation and malaria cases. This study used a Generalised Additive Models to explore the impact of weather conditions on malaria cases in Ghana. Methods Generalised Additive Models were used to examine the nonlinear effects of weather conditions on malaria cases. Monthly aggregated malaria cases from the District Health Information Management System II and average monthly rainfall and temperature data from the Ghana Meteorological Agency were analysed, covering 2012 to 2023. Regional Generalised Additive Models incorporating weather variables were developed, fitted, and validated against observed data using model diagnostics to identify the most suitable model for each region. Results The analysis revealed complex temporal patterns in malaria cases across Ghana, influenced by seasonal and long-term trends. Regions constituting the Coastal and Transitional Forest zones exhibited bimodal peak malaria seasons, while the Guinea Savannah showed a unimodal peak. Significant interactions between rainfall and temperature were identified, particularly in the Eastern region, where higher rainfall combined with temperatures around 27-28 {degrees}C were associated with higher malaria cases, reflecting the complex and region-specific nature of meteorological influences. Conclusions The findings point to the dynamic and heterogeneous nature of malaria caseloads in Ghana, emphasising the need for region-specific control strategies tailored to local climatic conditions. A key recommendation is the systematic integration of meteorological data into the National Malaria Data Repository to enable continuous monitoring of climatic influences and support timely, evidence-based intervention decisions. Future research should incorporate socio-economic factors, intervention coverage data, vector surveillance, and demographic characteristics into mathematical modelling frameworks for a more comprehensive understanding of malaria cases in Ghana.

Use of zooprophylaxis as a malaria control strategy has been recommended historically, but a complex relationship exists between animal ownership and malaria infection, with mixed associations described in the literature. We sought to characterize this relationship spatially and temporally in malaria-endemic regions of Africa. We used data from 392,843 individuals from 66 Demographic and Health surveys from countries within Africa to investigate the association between household animal ownership and Plasmodium infection. We used Bayesian models with Integrated Nested Laplace Approximation to incorporate spatially varying coefficient processes, allowing the association of interest to vary over space, time, and within strata of vector species occurrence, land cover, and number of animals owned by households. Spatially varying intercept models showed that ownership of cattle, chickens/poultry, goats, horses/donkeys/mules, pigs, and sheep was broadly associated with malaria infection, with odds ratios ranging from 1.55 to 1.67. However, spatially varying slope models revealed considerable heterogeneity, with odds ratio estimates for all animal types demonstrating both protective and harmful effects varying from 0.33 to 3.33 both subnationally and across time. We found no evidence that modification by vector species, number of animals owned, and land cover fully explained the variation in estimates. Unobserved localized cultural, behavioral, or ecological factors likely modify the association between animal ownership and malaria prevalence. Further exploring the nature of this relationship over space and time will be important to understanding how context-specific One Health dynamics between humans, animals and the environment affect malaria prevention and control efforts.

Artemisinin partial resistance has not yet been reported in southern Africa. Therefore, the magnitude of the spread of artemisinin partial resistance in this region is yet to be quantified. Using a two strain metapopulation modelling framework, we explored possible spread of artemisinin partial resistance in eight connected countries with high level of human movement. We explored three scenarios in which artemisinin partial resistance may first enter circulation: low malaria transmission level country; high malaria transmission level country and all countries and compared to an artemisinin partial resistance free scenario. Partial rank correlation coefficient sensitivity analysis was performed to identify key parameters that drive artemisinin partial resistance spread. Our model simulations show that high mobility between countries can increase the spread of mutations associated with delayed clearance. Suggesting that artemisinin partial resistance will be confirmed (>5% partial resistant cases) after 14 years of circulation if it is to appear in southern Africa. We confirm that human movement, both human-to-mosquito and mosquito-to-human probabilities of transmission, were significant and highly sensitive parameters in the spread of artemisinin partial resistance. Human mobility between countries can facilitate the spread of artemisinin partial resistance. More research is needed to identify strategies to preserve the efficacy of artemisinin-based combination therapies in the presence of partial artemisinin resistance, which may eventually lead to treatment failure and necessitate regimen replacement.

Background: Reliable inference of Plasmodium vivax recurrence states - relapse, recrudescence and reinfection (the ``3Rs'') - improves estimates of antimalarial efficacy. The R package Pv3Rs features a Bayesian model designed for P. vivax molecular correction, i.e., using parasite genetic data to infer recurrence states. The model is an extension of a prototype built to analyse microsatellite data from the Vivax History (VHX) and Best Primaquine Dose (BPD) trials. Methods: We re-analysed data from 212 VHX and BPD trial participants (493 recurrences) using Pv3Rs, comparing results with those from the prototype and with genetic relatedness estimated using Dcifer, a tool for estimating relatedness based on identity-by-descent. Posterior recurrence state probabilities were computed using both uniform and time-to-event priors: artificial but equal prior probabilities facilitate posterior interpretation, while time-to-event priors leverage all available information and enable re-computation of failure rates. Relatedness estimates were used to identify and correct instances of model misspecification. Results: The Pv3Rs model generated posterior probabilities for all recurrences and was able to jointly model data on all episodes per participant for 89% of participants, compared with 73% using the prototype. Recurrence state probabilities were broadly consistent across methods, though the Pv3Rs model elevated reinfection probabilities slightly. Relatedness estimates exposed various outliers consistent with half-sibling parasites and/or genotyping errors. Outlier correction impacted some per-participant failure probabilities, but reinfection-adjusted radical-cure failure rates of high-dose primaquine remained near 3%, in line with previous findings. Conclusion: Re-analysis of VHX and BPD P. vivax genetic data restates earlier reinfection-adjusted efficacy estimates. It demonstrates the increased computational capability and misspecification sensitivity of Pv3Rs, highlighting a need for careful analyses. Using relatedness-based diagnostics alongside model-based inference, we were able to harness the advantages of model-based inference and provide a framework for future P. vivax molecular correction.

Summary Background Persistent transmission from relapsing Plasmodium vivax infections threatens malaria elimination programs in the Asia-Pacific and Americas. Tools to identify people at risk of relapse are urgently required. We aimed to validate a panel of eight P. vivax serological biomarkers for predicting future relapses. Methods In this observational study, soldiers returning from malaria-endemic Papua to non-endemic East Java, Indonesia, were screened at enrolment using antibody measurement (Luminex) and trained random forest classification algorithms, then followed for 6 months. Active case detection was performed fortnightly by microscopy. Algorithms classified soldiers as recently infected (last nine months) and thus at risk of relapse, based on anti-vivax antibody measurements at enrolment. Findings Between December 2018 and July 2022, 592 soldiers were enrolled, with 553 completing follow-up; 119 experienced a P. vivax relapse. Of these, 102 were correctly classified as at risk of relapse at enrolment, corresponding to 86% sensitivity and 86% specificity, with an AUC of 0.92. Interpretation P. vivax serological biomarkers can identify people at risk of relapse with high sensitivity and specificity and could be used as a novel public health intervention, P. vivax serological testing and treatment (PvSeroTAT), to reduce relapse-driven transmission.

An ongoing outbreak of Bundibugyo virus disease (BVD) in the Democratic Republic of the Congo was deemed a public health emergency of international concern in May 2026. To prevent cross-border importation, many countries, including the United States, Canada, India, Thailand, and Kenya have already proposed containment strategies, and others are likely to follow suit. How well (or poorly) are screening and quarantine containment measures are likely to work? We leverage established epidemiological theory and develop a mathematical model of traveler screening and post-arrival quarantine for BVD to answer this question. We find that traveler screening via symptom screening or molecular testing will miss the majority of infected travelers, and should be complemented by post-arrival quarantine and monitoring of sufficient duration to detect those with long incubation periods. Our findings underscore the limitations of border screening and the importance of complementary measures like post-arrival quarantine to prevent local importation of BVD.

Objective: The study aimed to describe the challenges, best practices, and lessons learned during meningitis vaccination campaigns conducted in the context of COVID-19 in Cameroon in 2020. Results: During the prevention campaigns, 3,460 individuals were selected. All were tested before the campaign (100%). Eight cases were positive, representing a positivity rate of 0.23% (8/3,460). The campaign was carried out using a fixed strategy in health facilities and prisons and a fixed-temporary strategy in communities. Most health areas received sufficient quantities of COVID-19 equipment for some items and insufficient quantities for others. No screening was done during or after the campaign. The main difficulties encountered were compliance with social distancing and the continuous wearing of gowns. The challenges faced were the screening of actors and the use of personal protective equipment. Lessons learned: aspects related to COVID-19 impacted the speed of the campaign. Vaccination coverage ranged from 91% to 140% in prisons on the one hand, and from 35% to 112% in the health areas surrounding prisons on the other. The campaign in the context of COVID-19 was effective. Compliance with barrier measures was not optimal due to difficulties encountered with aspects such as social distancing, continuous wearing of gowns, screening of participants during and after the campaign, and insufficient personal protective equipment.

Malaria control programs are increasingly tailored at subnational scales; however, neighboring areas remain connected through human mobility, allowing parasite importation that may undermine independently timed interventions. Although the spatial targeting of control has been the focus of extensive research, the epidemiological consequences of temporal misalignment in intervention deployment across interconnected regions remain to be elucidated. We investigate how asynchronous timing of malaria interventions affects transmission dynamics using a two-patch susceptible-infected-susceptible metapopulation model. We compare synchronous and asynchronous intervention schedules and quantify their impact using measures of excess cumulative incidence attributable to asynchrony. The measure that will be used for this purpose is referred to as Asynchrony Induced Growth (AIG). Across a range of 10,000 parameter combinations, asynchronous implementation has been observed to result in a heightened incidence compared to synchronized deployment, though the impact is typically negligible in most endemic settings. Sensitivity analyses indicate that the impact is most significant when interventions are highly effective, infectious duration is brief, and transmission intensity approaches the elimination threshold. In such circumstances, asynchrony has the potential to substantially inflate case numbers, delay transmission interruption, or even prevent elimination entirely. In illustrative scenarios that reflect realistic settings, synchronizing interventions has been shown to avert large numbers of infections and shorten elimination timelines by years to decades. These findings demonstrate that, beyond spatial targeting, temporal coordination of interventions across connected areas can meaningfully enhance malaria control and elimination. Coordinated timing may be particularly valuable for cross-border or near-elimination programs and should be considered in operational planning and resource allocation.

During the 2026 Bundibugyo virus disease outbreak in the Democratic Republic of the Congo and Uganda, we projected potential airline-mediated importation risk using contemporary airline network and an externally calibrated Ebola importation hazard. Effective-distance analyses identified major international hub countries, including Belgium, France, South Africa, Kenya, and the United Arab Emirates, as higher-probability gateways within 30 days. These early projections provide a reproducible framework for real-time international situational awareness, while emphasizing that importation risk does not imply local transmission risk.

Introduction: Stroke care is time-sensitive, yet patients in low-resource settings may reach tertiary services only after passing through multiple formal and informal care options. This study examined documented care-seeking pathways and time to presentation among stroke cases recorded at the University of Medical Sciences Teaching Hospital (UNIMEDTH), Ondo State, Nigeria. Methods: A retrospective hospital record review was conducted using secondary data from the Stroke Registry, radiology department records, referral notes, and ambulance records at UNIMEDTH. The analysis included 371 stroke cases with documented time from symptom onset to UNIMEDTH presentation and reconstructable care pathways. First-contact routes were classified as hospital/biomedical, self/informal or traditional/faith-based care, and the number of documented steps defined pathway complexity before and including tertiary presentation. Frequencies and percentages described pathway patterns; median presentation times were compared using Mann-Whitney U and Kruskal-Wallis tests. Results: The median time to tertiary presentation was 24 hours (interquartile range [IQR] 9-72), and 317 patients (85.4%) presented after four hours. Only 30 patients (8.1%) presented directly to UNIMEDTH; 44 distinct care-pathway sequences were recorded. Hospital-facility first contact was documented for 81 patients (21.8%). It was associated with a median presentation time of 3 hours (IQR 2-6), compared with 48 hours (IQR 24-72) among patients whose initial contact was outside a hospital facility (U = 699.50, p < 0.001). The median time also differed across grouped first-contact categories and pathway complexity levels (both p < 0.001). Conclusion: Non-hospital or multi-step care-seeking pathways commonly preceded tertiary stroke presentations in this setting. The findings indicate that delayed tertiary arrival is partly embedded in the pathway followed after symptom onset. Interventions should combine public recognition of stroke warning signs with urgent referral linkages involving hospitals, patent medicine vendors, traditional and faith-based providers, and emergency transport systems.

Background. The 2026 FIFA World Cup will bring an estimated 1--5~million international visitors to 11~US host cities between June~11 and July~19, 2026---the largest tournament in history. Large-scale international gatherings accelerate importation of infectious diseases from diverse source populations. Advance estimation of importation risk is essential for public health preparedness and surveillance prioritization. Methods. We developed a Poisson importation framework applied to five diseases (dengue fever, influenza, malaria, measles, and pertussis) across the 11~US venue cities. Three nested travel models of increasing resolution were constructed: a baseline model using routine June~2024 arrival data; a World Cup--adjusted model incorporating projected visitor growth factors; and a schedule-driven model routing WC fans to specific cities based on match assignments. WHO incidence and BTS T-100 routing fractions were combined with Monte Carlo uncertainty propagation (5,000 Uniform draws on under-reporting and travel-while-infectious parameters) to yield median importation estimates with 95\% uncertainty intervals. Results. Dengue posed the highest importation risk at most venue cities under the schedule-driven model (median $\Lambda > 10$ expected importations from Brazil alone; 95\% uncertainty interval 5.9--33.1), robust across the full literature-supported parameter range; Atlanta was the exception, where malaria probability exceeded dengue, driven by direct travel from West and Central African nations. Influenza ranked second at most cities, coinciding with the Southern Hemisphere winter peak. Pertussis showed broad geographic spread but carries the widest relative uncertainty, as the assumed detection rate sits at the upper bound of the literature range. Background tourism accounted for the dominant share of total importation risk; the World Cup fan increment contributed approximately 8.3\% of projected arrivals for WC-qualified nations. Conclusions. This Poisson importation framework, built entirely from publicly available data, provides reproducible importation risk estimates for mass gathering events. The framework extends to additional diseases, cities, and gatherings, offering a transparent baseline complementary to proprietary modeling systems.

Malaria molecular surveillance (MMS) is becoming increasingly common in endemic settings and has been proposed as a tool for monitoring parasite transmission to inform programmatic decision-making. However, the conditions under which parasite genetic metrics provide interpretable signals for broader use cases, such as assessing intervention impacts and detecting importation, remain under-characterized. We present EMOD with Full Parasite Genetics (FPG), a simulation framework designed to explore how parasite genetic metrics arise from transmission, intervention, importation, and sampling processes at programmatically relevant timescales. Using seasonal scenarios across a range of transmission intensities, we demonstrate three principal findings. First, genetic metrics can detect insecticide-treated net intervention impacts at seasonal and yearly timescales, but the strength, timing, and form of the relationship between genetic and epidemiological measures vary by metric and sampling timing. Second, importation can break the expected relationship between parasite genetic diversity from local transmission intensity at very low incidence, allowing low-transmission settings with substantial importation to maintain elevated diversity metrics. Third, convenience sampling practices, including sample size, collection timing, and the clinical composition of sampled populations, introduce non-random biases in genetic metric estimation in a way that obscures the true transmission signal. Together, these findings show that parasite genetic metrics can support operational surveillance, but that their interpretation depends on transmission context, importation, metric choice, and sampling design. EMOD FPG provides a framework for evaluating these dependencies in future setting-specific analyses and for guiding the interpretation of parasite genetic data across sites and over time.

Women shoulder the majority of water collection labor globally, yet how their water collection and water-related work experiences may change over time or by water source type remains insufficiently understood. We conducted a longitudinal, mixed-methods study in rural Kenya and Honduras to understand how women's experiences collecting water and performing water-related work varied between (a) two time points, (b) improved and unimproved water source types, and (c) water source location. Data were collected in 2023 and 2024 using interviews, observation, GPS-enabled watches, and scales to measure time and distance traveled, water weight and volume carried, and calories expended. 133 women participated in data collection (66 Kenya, 67 Honduras). We compared women's experience data by time point (2023 vs. 2024), source type (improved vs. unimproved), and source location (off-premises vs. on-premises) (t-test, Mann-Whitney U test). We also mapped participants' routes and activities to show which sources were visited, when, and for what activities. In Kenya, mean water collection time, distance, and caloric expenditure were significantly lower and water volume was significantly higher in 2024 when there were unexpected rains compared to 2023 when there was a persistent drought. When comparing source types during the 2023 drought, journeys to improved sources took significantly less time and energy and covered less distance than journeys to unimproved sources. These differences were not observed during the rainy conditions of 2024 when unimproved sources were closer and more accessible. In Honduras, water collection and water work burdens did not differ significantly by time point or source type. We found women with on-premises water access to still expend considerable time and caloric expenditure engaging in water work within their household compounds. Findings from Kenya suggest that water infrastructure improvements can reduce women's water collection burdens, though benefits may depend on and vary by season and source location. Findings from Honduras show that water labor does not end once water is in the household. Rather, substantial time and energy are expended carrying out water-related work even when sources are on premises, suggesting that efforts to assess water labor need to extend beyond collection alone. To meaningfully reduce burdens and ensure improved water sources are utilized during all seasons, initiatives need to consider source location, seasonal variability, and work beyond collection. Evaluations to assess infrastructure impacts on women's labor and well-being are needed and long overdue.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.