The Lancet Global Health

Background: People living with HIV (PLHIV) in sub-Saharan Africa exhibit high rates of pneumococcal carriage compared to HIV-uninfected adults, despite antiretroviral therapy. We established a novel controlled human infection model of experimental pneumococcal carriage in people living with HIV to understand carriage dynamics in this at-risk population. Methods: Seventy-five virally suppressed and clinically stable PLHIV and 75 HIV-uninfected controls were inoculated with escalating doses of pneumococcus serotype 6B. Carriage acquisition and density were determined by microbiological culture of nasal wash samples collected before and up to 14 days after inoculation. Adverse events were identified by active and passive surveillance. Participant-reported acceptability was established using a Likert scale. Findings: No serious adverse events occurred. Mild adverse events were similar between groups (19% [14/75] in PLHIV, 13% [10/75] in HIV-uninfected; p=0.505). More than 90% of participants reported acceptability with all study procedures. Experimental carriage occurred in 21% (16/75) of PLHIV compared with 36% (27/75) of HIV-uninfected participants (adjusted odds ratio 0.39 [95% CI 0.16-0.91]). Among PLHIV without detectable cotrimoxazole, 28% (8/29) acquired experimental carriage. Carriage clearance rates were lower in PLHIV (hazard ratio 0.44 [95% CI 0.14-1.42]). Interpretation: In carefully selected PLHIV with effective viral suppression and clinical stability experimental pneumococcal carriage acquisition did not exceed that in HIV-uninfected adults, even after accounting for antibiotic use, natural pneumococcal co-colonisation, and sociodemographic differences. These findings suggest that high carriage prevalence in PLHIV in sub-Saharan Africa may be driven more by prolonged carriage duration than increased susceptibility to acquisition. This model provides a platform to investigate mechanisms underlying carriage susceptibility and impaired clearance in PLHIV and to evaluate interventions aimed at reducing the carriage burden in sub-Saharan Africa. Funding: Wellcome Trust

Background Tuberculosis remains the leading infectious cause of death worldwide. In the WHO African region, declining incidence has coincided with antiretroviral therapy (ART) scale-up, though whether this reflects reduced progression to disease or reduced transmission is unclear. We evaluated how ART and symptom status influence within-household Mycobacterium tuberculosis complex (MTBC) transmission risk. Methods We conducted a case-contact household study in rural South Africa, enrolling index adults with bacteriologically-confirmed pulmonary tuberculosis. MTBC immunoreactivity was measured in all child household contacts (aged 2-14 years) as a proxy measure of within-household transmission. We assessed the influence of index person ART status and symptom status, and explored effect-measure modification of the association between index person HIV status and transmission risk by sex. Results Among 755 child contacts of 296 index persons, effective ART was not associated with within-household MTBC transmission risk (risk ratio [RR], 1.07; 95% CI, 0.66-1.74). Among PLHIV engaged in ART care, WHO TB four-symptom screen (WHO4SS) status was not associated with transmission risk (RR, 0.80; 95% CI, 0.43-1.47), although absence of reported cough reduced risk (RR, 0.61; 95% CI, 0.38-0.96). A pronounced interaction between sex and HIV status was observed: HIV-negative women had the highest within-household MTBC transmission risk (30.5% vs. 14.3% in women with HIV) whereas risks were similar between HIV-positive and HIV-negative men. Conclusions We found no evidence that effective ART or WHO4SS status influenced within-household MTBC transmission risk, though confidence intervals were wide. Absence of reported cough was associated with lower risk, and transmission risk was highest among child contacts of HIV-negative women. These findings suggest reported cough is a useful marker of transmission risk and that routine tuberculosis screening within ART care may reduce transmission from PLHIV; intensified efforts are nonetheless needed to achieve earlier tuberculosis detection in HIV-negative individuals.

Background: Cambodia is a high-TB burden country where over a third of TB cases have gone undetected. The Community Mobilisation Initiatives to End TB (COMMIT) programme, implemented across four provinces and 27 operational districts (ODs) in Cambodia from October 2019 to September 2024, aimed to improve TB case finding, diagnosis, treatment, and prevention through community-driven approaches. This study evaluated the implementation, programme outcomes, and sustainability of COMMIT to inform future TB initiatives. Methods: This mixed-methods explanatory sequential study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Quantitative data were collected from the programme database and the national TB Management Information System (TB-MIS). In-depth interviews, guided by the Theoretical Domains Framework (TDF), explored contextual factors influencing programme implementation and complement quantitative findings. Quantitative data were analysed descriptively to estimate screening coverage, diagnostic yield, and construct care cascades. Qualitative data were transcribed and translated into English, coded, consolidated into a matrix structured using RE-AIM and TDF components, and analysed thematically. Results: COMMIT screened 695,970 people for TB. Key populations were reached, though sex and age disparities in screening participation reflected underlying social and structural barriers. Approximately 98% of those screened underwent diagnostic testing. Treatment initiation (>99%) and completion (>97%) rates were high. COMMIT operationalised contact investigation and evaluation for TB preventive treatment (TPT), screening over 90% of notified contacts. More than 20,000 people were TPT-eligible, of whom 68.7% enrolled in and 86.2% completed TPT. These programme outcomes were supported by strong community engagement, expansion of rapid molecular diagnostics, and programme adaptability during COVID-19. COMMIT was scaled from 10 to 27 ODs, during which it strengthened community capacity by training healthcare workers and expanding peer support groups. Stakeholders emphasised the need to reinforce local ownership and public-private sector collaboration, strengthen integrated services, and de-implement low-value practices such as symptom-based screening. Conclusions: COMMIT improved TB case detection, treatment support, and prevention in Cambodia through community-led strategies and sustained capacity building. Maintaining the programme impact will require continued investment in community systems, de-implementation of low-value practices, and the adoption of efficient, person-centred approaches that address evolving community needs.

BackgroundTuberculosis (TB) incidence in the United States has remained elevated above pre-pandemic levels since 2021, with over 85% of cases resulting from reactivation of Mycobacterium tuberculosis (Mtb) infection. New vaccines that would prevent TB in adults are under development, but the potential health impact of a program prioritizing non-U.S.-born persons and persons with medical comorbidities, including persons living with HIV (PLWH), has not been evaluated. MethodsWe developed a deterministic compartmental transmission model that simulates Mtb infection, transmission, and progression to TB in the U.S., both in the general population and in key high-risk groups. We calibrated the model to 2024 U.S. TB surveillance data and estimated annual cases prevented, percent reduction in annual TB cases, and number needed to vaccinate (NNV, a measure of vaccine program efficiency) at equilibrium conditions for targeted vaccination strategies under optimistic and plausible scenarios, varying assumptions of vaccine efficacy, duration of protection, and achieved vaccination coverage in high-risk groups. FindingsUnder an optimistic scenario, vaccinating PLWH, non-U.S.-born persons, and persons with medical comorbidities (all high-risk groups) prevented 5,385 cases per year (51{middle dot}8% reduction, NNV = 366). Under a more conservative plausible scenario, the same strategy prevented 1,348 cases per year (13{middle dot}0% reduction, NNV = 510). The efficiency and impact of targeting strategies we considered were preserved across all sensitivity and uncertainty analyses. InterpretationTargeted vaccination of persons with Mtb infection in population subgroups recognized to be at high-risk for TB can reduce incidence substantially. Strategies that include non- U.S.-born persons and PLWH are most efficient and impactful. FundingAmerican Lung Association, U.S. National Institutes of Health, and the Ferguson Fellowship.

Objectives To quantify the frequency of baseline control-group use in published long COVID prevalence studies and assess their key methodological features. Design Cross-sectional meta-epidemiological evaluation of published post-acute COVID-19 prevalence studies, supplemented by a corresponding-author survey. Setting Published studies identified through a systematic review by Hou et al. (2025) and supplementary data obtained through direct email contact with corresponding authors. Participants A total of 440 published long COVID prevalence studies. Main Outcome measures Presence and type of comparator group, reliance on solely self-reported outcomes, acknowledgment of lack of a control group among uncontrolled studies, and availability of additional comparator data through author survey. Results Among 440 studies, 372 (84.5%) reported no control group on their publication. Healthy or uninfected comparators were reported in 55 studies (12.5%) and other comparator types in 14 (3.2%); 1 study included both categories. Solely self-reported outcomes were used in 279 studies (63.4%). Among 372 uncontrolled studies, 244 (65.6%) did not explicitly acknowledge the absence of a baseline comparator as a limitation anywhere in text. Corresponding authors of 140 studies (31.8%) responded to the survey; among them, 126 (90.0%) reported no additional comparative data, while 14 (10.0%) mentioned some available comparative datasets (19 additional datasets). Almost all of that information (10/14, 17/19) had been already published in other articles not captured by the Hou et al. systematic review. Conclusions Most published long COVID prevalence studies lacked comparator groups and relied exclusively on self-reported outcomes without acknowledging this limitation. Direct author contact identified little additional comparator information. Much of the long COVID prevalence literature may therefore be poorly suited to estimating burden attributable specifically to SARS-CoV-2, underscoring the need for appropriately matched comparators and more objective outcome assessment. Registration The protocol was prospectively registered on the Open Science Framework (https://osf.io/f4hra).

Background: The Universal Periodic Review (UPR) is a peer-review mechanism established to hold UN Member States accountable for human rights including the right to health, yet evidence on its impact on health outcomes is limited. We evaluated whether UPR engagement is associated with accelerated improvements in maternal health trajectories. Methods and Findings: We conducted a longitudinal ecological analysis of 89 countries with a baseline maternal mortality ratio (MMR) of 70 or greater per 100,000 live births in 2005. Outcomes were trajectories of annual MMR, skilled birth attendance (SBA), and contraceptive prevalence rate (CPR), from 2005 to 2023. The exposure was the volume of health-related UPR recommendations received across three cycles, thematically classified using a validated rule-based algorithm. Mixed-effects models adjusted for time-varying GDP per capita and historical fragility. The 89 countries received 41,733 UPR recommendations across three cycles, of which 405 (1%) were related to maternal health. Maternal health recommendations were preferentially directed at countries with higher baseline MMR and lower SBA. After adjustment, each additional maternal health recommendation was associated with a 0.24% [95% confidence interval (CI): 0.08, 0.40] faster annual reduction in MMR, a 0.52% [0.12, 0.91] faster annual gain in the odds of SBA, and a 0.21% [0.09, 0.34] faster annual gain in the odds of CPR. Broader recommendations on women's health and health systems and services were also associated with faster annual improvements in trajectories across all three outcomes; recommendations on abortion, family planning, sexual health and wellbeing, and sexual education tended to be directed towards lower-burden countries and were not associated with differences in any trajectories. It is important to note that the ecological design precludes causal inference. Conclusions: Receiving UPR recommendations on the themes of maternal health, womens health, and health systems and services are associated with accelerated improvements in maternal health trajectories among high-burden countries. These findings suggest that international human rights accountability mechanisms may have a role in supporting national progress on maternal health.

Background: As tuberculosis (TB) incidence declines, transmission increasingly concentrates into vulnerable populations. There is an urgent need for affordable surveillance strategies to monitor trends, identify high-risk groups and target interventions. Mycobacterium tuberculosis (Mtb) immunoreactivity surveys indirectly detect transmission and therefore undiagnosed infectious disease. Methods: We conducted a cross-sectional community-based interferon-gamma release assay (IGRA) survey in children aged 1-4 years in Blantyre, Malawi. Community-representative participants were recruited using novel convenience sampling in health facilities alongside random household sampling, and tested for Mtb immunoreactivity using QFT-Plus IGRA. We constructed hierarchical Bayesian logistic regression models for IGRA positivity, with neighbourhood-level random effects. Findings: Of 1,545 participants, 102 (6.6%) had a positive IGRA: an annual risk of Mtb infection (ARTI) of 2.7% (95% CrI 2.2-3.2%). Immunoreactivity was higher in the poorest third of households (8.7% vs 4.9%; adjusted odds ratio: 1.88, 95% CrI 1.08-3.01) compared to the richest, but was not associated with HIV exposure, malnutrition or reported household TB exposure. There was substantial between-neighbourhood heterogeneity (ARTI range 1.1-4.1%). There was no association between neighbourhood-level TB case notifications and ARTI. Interpretation: An innovative convenience sampling approach identified a high burden and substantial spatial variation of recent TB transmission, which did not correspond to case notification rates. This strategy could support identification of high-risk populations, monitoring of trends and targeted public health interventions.

Background Malawis healthcare system faces strain due to an insufficient number of healthcare workers (HCWs). The number of HCWs currently employed falls below the Malawian governments own facility-based staffing standards, which are known as the establishment target. While vacancy rates from this target have been estimated, the health consequences of this workforce gap on the population have not. Methods This study quantifies the health-cost of unfilled establishment HCW positions using the Thanzi La Onse (TLO) model, an "all diseases - whole healthcare system" individual-based model, which self-consistently accounts for the dynamics between health system constraints and population health. We constructed two staffing scenarios: one (Current) in which the currently employed staff are represented, and another (Target) where all positions planned under the establishment target are filled. Using the TLO model, we then estimate the health impact of filling all establishment positions as the difference in the Disability-Adjusted Life Years (DALYs) incurred between the two scenarios. Results Our results indicate that fulfilling Target positions could reduce the health losses by 13.6% (43.1 million DALYs averted, 95% CI: 40.8-48.6) over the projection period. The largest proportional reductions are for DALYs caused by HIV/AIDS (41%), tuberculosis (26%), and malaria (24%) compared to the Current provision. Conclusions The analysis shows the potential health benefits associated with increasing the fulfilment of establishment positions in Malawi and offers key quantifications for policymakers as they strive to achieve Universal Health Coverage.

Background: Despite rising enthusiasm for active case-finding for TB, there have been concerns about conducting simultaneous HIV screenings due to perceived stigma, although the evidence to support this concern is scarce. We assessed the acceptability of integrated HIV-TB community screening and characterised participants' motivations and prior testing history. Methods: The SLIM study was a non-interventional cross-sectional study conducted in Puducherry (February 2023 to January 2024). In two community health camp-style screening events (one urban and one peri-urban), adults 18 years and older were offered TB screening via portable chest X-ray with AI-assisted interpretation (qXR, Qure.ai), plus sputum testing (Truenat), alongside point-of-care HIV testing. Structured questionnaires captured sociodemographics, prior testing history, and motivations for participation. Acceptability was pre-specified as >50% uptake. Results: Of 273 eligible adults approached, 264 (96.7%) accepted integrated screening, nearly double our pre-specified threshold. Participants were predominantly low-income with limited formal employment. The dominant motivation was a desire to know one's health status (HIV: 74.8%; TB: 73.7%), followed by convenience (16 to 17%). Prior HIV and TB testing was rare (7 to 13% and 15 to 18%, respectively). Participation was uniformly high across demographic groups; however, the screened population skewed older and female (mean age 58 (standard deviation: 12.6) years; 67% female). Men under 45 comprised only 3.7% of participants, substantially below their 24.7% share in the Puducherry population per the most recent census. Conclusions: Integrated HIV-TB screening achieved near-universal uptake in a socioeconomically vulnerable population with little prior testing exposure, contradicting concerns that community HIV screening would be poorly accepted in India. Integrated community-based screening should be scaled up as a cornerstone of TB elimination in high-burden settings. Crucially, because TB incidence in India peaks in the 15 to 45 age group and disproportionately affects men, targeted strategies to bring younger men and women into community screenings are essential.

Background India accounts for nearly one-fourth of the global tuberculosis (TB) burden. The country's progress towards elimination of TB is hindered by considerable heterogeneity in behavioural, social, and health system determinants, which influence transmission dynamics and care access. Evidence from the recent national TB prevalence survey showed that almost half of individuals with active disease were asymptomatic, underscoring the limitations of symptom -based case finding. Achieving the End TB targets will therefore require strategies that simultaneously address the substantial pool of individuals with undiagnosed, asymptomatic disease and those symptomatic individuals who do not seek care. Methods We developed a transmission model of TB that explicitly incorporates individuals with asymptomatic disease, and those who do not seek care. Model calibration was performed within a Bayesian framework using epidemiological and programmatic data for India. The calibrated model was then used to project the potential impact of intervention on TB incidence and mortality. Results Under the baseline scenario, the estimated TB incidence and mortality rates for 2024 were 180 (163-203) and 24 (18-31) per 100,000 population, respectively. Across all intervention scenarios targeting improved diagnosis, active case finding, nutrition support and their combination the reduction in incidence rate by 2030 ranged from 13% to 60% compared with 2025, while the corresponding decline in mortality rate ranged from 16% to 66%. Conclusion While individual interventions yield measurable reductions in TB incidence and mortality, but greater impact is achieved when implemented in combination reflecting the need for a comprehensive, multi-component response towards TB elimination.

Background: Vaccination coverage estimates and case-based surveillance have limitations in evaluating immunization programs. Serosurveillance offers a complementary approach by directly measuring population immunity. We assessed whether serologic analyses across multiple antigens (i.e., measles, diphtheria, tetanus) could provide additional insights into vaccination program performance. Methods: We conducted a matched case-control study among children aged 2- to 10-years-old (n=1286) in Zambia using specimens from the 2016 ZAMPHIA survey. Using previously generated data on measles serostatus, measles seronegative children (i.e., cases) were matched to measles seropositive children (i.e., controls) on sex, age, HIV infection status, and province. Samples were tested for tetanus and diphtheria antitoxin IgG antibodies using commercial enzyme immunoassays. We estimated the odds of tetanus and diphtheria seropositivity by measles serostatus using conditional logistic regression and examined age-specific antibody dynamics. Results: Measles seronegative children had 1.7-fold increased odds (95% credible interval [CrI]: 1.3-2.1) of being tetanus seronegative compared to measles seropositive children. Diphtheria serostatus had no significant association with measles serostatus (odds ratio: 1.3; 95% CrI: 0.9-1.7). Tetanus seroprevalence declined monotonically with age. However, diphtheria seroprevalence initially declined through 5 years of age, then increased again beginning at 6 years of age despite the lack of vaccine booster doses given after the primary series in infancy, potentially from asymptomatic or subclinical infections. Conclusions: Serologic analyses revealed measles serostatus was positively associated with tetanus serostatus (where seropositivity arises only via vaccination and not infection), suggesting children who are measles seronegative are more likely to have missed DTP vaccination. We additionally found that measles serostatus was not associated with diphtheria serostatus, suggesting that antibody responses to diphtheria continue to boost beyond infancy when DTP vaccination is given. Our findings support consideration of DTP booster doses in Zambia to address waning tetanus immunity and further investigation of potential diphtheria carriage and transmission.

Background Appendicitis is a readily treatable surgical emergency, yet it remains a cause of preventable death among children in resource-limited settings. While recent studies have documented the global burden of pediatric appendicitis, none have systematically examined its geographic clustering or spatial spillover effects. Understanding whether high-mortality countries cluster geographically, and whether neighboring countries influence each other's outcomes, is essential for designing regional surgical capacity strategies. Methods We conducted a spatial analysis of pediatric appendicitis case fatality rates in children aged 0-14 years across 169 countries from 2000 to 2019. Data were obtained from the Global Burden of Disease Study 2023 and World Bank databases. We calculated global Moran's I to assess spatial autocorrelation, used Getis-Ord Gi* to identify local hotspots, and fitted spatial lag and spatial error regression models to quantify spatial spillovers while adjusting for GDP per capita, physician density, and basic sanitation access. Results Global Moran's I was 0.621 in 2000 (p < 0.001), 0.621 in 2010 (p < 0.001), and 0.592 in 2019 (p < 0.001), indicating strong and persistent spatial clustering. Hotspots at 99% confidence were consistently concentrated in sub-Saharan Africa and parts of South Asia, with little change in geographic distribution over two decades. The spatial error model provided the best fit (AIC = 212.6), with a spatial error coefficient ({lambda}) of 0.663 (p < 0.001), suggesting that approximately 66% of residual variation was explained by unobserved regional factors. In the final model, higher GDP per capita ({beta} = -0.497, p < 0.001) and higher physician density ({beta} = -0.568, p < 0.001) were independently associated with lower case fatality, while basic sanitation access showed no significant association (p = 0.284). Conclusions Pediatric appendicitis case fatality exhibits strong and persistent geographic clustering. The substantial spatial spillover effect suggests that regional coordination of surgical capacity building may be more effective than country-by-country investments. Priority should be given to hotspot countries in sub-Saharan Africa and South Asia, with emphasis on surgical workforce expansion rather than broad economic development alone.

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.

Objectives Tuberculosis (TB) in the United States disproportionately affects non-U.S.-born individuals. While testing this population for TB infection is recommended, little is known about individuals' willingness to take treatment for latent TB infection (LTBI). To address this gap, we conducted a pilot preference survey among individuals from countries with high TB incidence. Design Cross-sectional survey supported by language concordant community health workers. Setting Federally qualified health center, serving a primarily Asian immigrant community, in San Francisco. Participants Adults eligible for risk-based LTBI testing based on place of birth seeking primary care. Outcome measures Perspectives on TB disease, risk of reinfection, and willingness to accept treatment if diagnosed with LTBI conditional on different factors, such as side effects, costs, and other treatment burden. Results Among 60 participants, the median age was 48 years (interquartile range 35-63 years), 52% were women, and 100% spoke Chinese. Infecting others (n=35, 58%), risk of death (n=30, 50%), and potential isolation (n=25, 42%) were the most worrisome consequences of TB disease. Reinfection risk, risk of liver damage, cost, TB progression risk, clinic visits, and blood draws were most often considered moderately or very important when deciding whether to take LTBI treatment (n=53 to 57, 88-95%). While most participants (n=56, 93%) were willing to take treatment if diagnosed with LTBI even at a 10-year TB progression risk below 1% and willing to accept a risk of liver damage (n=41, 68%), less than half would accept LTBI treatment if there were any associated cost (n=28, 47%). Finally, many participants had concerns about their reinfection risk after completing LTBI treatment (n=34, 57%). Conclusions Amongst surveyed participants, TB disease and its consequences such as hospitalization, death and infecting others were worrisome, and participants had a high level of willingness to take treatment if diagnosed with LTBI. Future assessments of how people weigh tradeoffs regarding LTBI diagnosis and treatment could inform interventions to increase LTBI treatment acceptance and completion.

Background Bacteriological contamination of drinking water remains a major public health burden in sub-Saharan Africa, yet the full contamination chain from source to household has rarely been quantified at national scale. This study analyses water quality at both levels using the 2021 Cote d'Ivoire Demographic and Health Survey (DHS-CI 2021). Methods Cross-sectional secondary analysis of DHS-CI 2021 data. Households with paired bacteriological tests at the source (SH3227) and at the household (SH3225) were included (n = 2,541 for determinants; n = 2,528 for chain analysis). Contamination was defined as >0 CFU/100 ml. Determinants of source contamination were assessed by weighted logistic regression accounting for complex survey design. The contamination chain was described across four categories: safe throughout, recontaminated during transport/storage, decontaminated at home, and contaminated throughout. Results Weighted prevalence of source contamination was 63.6% [95% CI: 60.7-66.5%] and 77.0% [74.1-79.9%] at the household. Only 15.0% of households had safe water throughout the chain; 21.2% showed domestic recontamination and 60.8% consumed water contaminated at both levels. Key determinants of source contamination were use of an unimproved source (aOR = 8.15; 95% CI: 4.54-14.66), administrative region, travel time [&le;]30 minutes (aOR = 1.92; 95% CI: 1.41-2.62), and higher wealth quintiles (protective; aOR = 0.25 for richest). Model discrimination was good (AUC = 0.809). Conclusions The vast majority of Ivorian households consume bacteriologically unsafe water, with domestic recontamination representing a distinct and significant degradation pathway even among users of improved sources. Dual interventions targeting source protection and safe household water storage are urgently needed to advance progress toward SDG 6 in Cote d'Ivoire.

Background High-risk subgroups among household contacts of persons with tuberculosis (TB) might benefit from additional interventions. However, the significance of an abnormal baseline chest radiograph (CXR) suggestive of TB, despite negative sputum microbiology, is uncertain. Methods Adults ([&ge;]18 years) with recent household TB exposure were enrolled at three South African sites (April 2021-September 2022). All participants underwent symptom screening, CXR, and sputum Xpert Ultra and MGIT culture. Pulmonary TB diagnosis was microbiologically-confirmed. Participants without prevalent TB were followed for symptomatic incident TB through 12 months. Multivariable logistic regression identified factors associated with abnormal CXR suggestive of TB. Poisson regression estimated adjusted incidence rate ratios (aIRR) with 95% confidence intervals (95%CI). Results Baseline CXR were available for 795/846 (94.0%) participants without prevalent TB and were abnormal in 157/795 (19.7%); associated with older age (adjusted odds ratio, aOR=1.04, 95%CI 1.02-1.05); prior TB (aOR=6.39, 95%CI 4.18-9.78); and current smoking (aOR=1.61, 95%CI 1.00-2.62). Symptomatic incident TB developed in 8/795 (1.0%) participants, including 7/8 (87.5%) who were asymptomatic and 4/8 (50.0%) with abnormal CXR at baseline. TB incidence was higher in those with abnormal versus normal CXR (aIRR=4.11, 95%CI 1.29-13.09), but after median 12.1 (IQR 11.1-13.1) months follow-up, 153/157 (97.5%) had not progressed to incident TB. Conclusions Adult household contacts with CXR abnormalities, but without prevalent TB, had a four-fold higher incidence of TB within one year, compared to those with normal CXR. This additional risk warrants targeted preventive treatment and extended surveillance, but since most remained TB-free, therapeutic TB treatment is not justified.

BackgroundHIV-related stigma remains a primary barrier to the elimination of the HIV epidemic worldwide. No studies have examined long-term changes in the distribution of stigmatizing attitudes within populations. MethodsWe conducted a whole-population, open cohort study of adults in 8 villages in rural southwestern Uganda, with 5 biennial surveys spanning 2014-2024 (N=1,776 at baseline; 869 participated in all waves). We measured individual negative attitudes toward people with HIV ("public stigma") and perceptions of negative attitudes among others ("perceived stigma") using parallel 15-item scales. We estimated mean stigma scores, computed inequality measures at each wave, and decomposed inequality by sociodemographic characteristics. Leveraging the cohort design, we estimated intraclass correlation coefficients and rank-order stability over time. ResultsBoth public and perceived stigma declined substantially from baseline to endline and became concentrated in an increasingly smaller subgroup of the population. Theil decomposition failed to identify any stratifying variables that explained more than 3% of this variation: nearly all the inequality in HIV stigma occurred within population subgroups rather than between them. In longitudinal analyses, public stigma showed trait-like properties (intraclass correlation coefficient=0.35; 95% CI, 0.31-0.38) and meaningful rank-order stability (baseline-to-endline r=0.41). Perceived stigma showed no rank-order stability, no appreciable between-person variance, and universal convergence to low levels regardless of baseline. ConclusionsBoth public and perceived HIV stigma declined substantially in this rural Ugandan population, but remaining public stigma has become concentrated within a persistent minority. Sociodemographic profiling to target individuals who carry persistently negative attitudes toward people with HIV is unlikely to succeed.

Background Microbiological confirmation of paediatric pulmonary tuberculosis is frequently unattainable, rendering chest radiography a critical yet underutilised diagnostic tool. Methods We conducted a retrospective diagnostic accuracy study of the qXR version 4.2.1 (Qure.ai), a paediatric optimized computer-aided detection (CAD) algorithm, for pulmonary tuberculosis. Diagnostic performance was assessed against microbiological (MRS) and clinical reference standards (ClRS). Bayesian latent class analysis (LCA) was applied to address the imperfection of both reference standards in children. Performance was quantified using area under the receiver operating characteristic curve (AUROC) and estimates of sensitivity and specificity. Results We included digital chest radiographs of 932 Gambian children (< 15 years) comprising 80 (9%) children with confirmed tuberculosis, 163 (17%) with unconfirmed tuberculosis, and 689 (74%) classified as unlikely tuberculosis. Against MRS, qXR demonstrated AUROC, sensitivity and specificity of 0.68 (95% CI, 0.61 to 0.75), 54% (95% CI, 43 to 64%), and 82% (95% CI, 79 to 84%), respectively. Against ClRS, the AUROC, sensitivity and specificity were 0.73 (95% CI, 0.69 to 0.77), 41% (95% CI, 34 to 49%), and 87% (95% CI, 84 to 89%), respectively. Bayesian LCA, assuming conditional independence, estimated sensitivity of 79% (95% CrI, 65 to 89%) and specificity of 82% (95% CrI, 79 to 84%). Assuming conditional dependence between qXR and expert radiologist, and between culture and Xpert, estimated sensitivity increased to 89% (95% CrI, 71 to 98%), with specificity remaining at 82% (95% CrI, 79 to 84%). Conclusions Paediatric optimized qXR algorithm provides a valuable complementary tool for diagnosis of paediatric pulmonary tuberculosis. Conventional reference standards likely underestimate the true diagnostic performance of CAD systems in children.

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.

Women's disproportionate responsibility for unpaid domestic and care work, including water collection, remains a barrier to gender equality globally and may constrain women's ability to engage in income-generating activities. We compared women's and men's time use in rural Kenya and Honduras and assessed whether women's time spent on water collection and income-generating activities differed between communities that had or had not received an improved water source from World Vision. We also examined the measurement of time-use agency among women and men. In-person surveys were conducted in July-August 2024 with 95 participants (48 women, 47 men) in six Kenyan communities and 102 participants (53 women, 49 men) in six Honduran communities. Surveys included a 24-hour time-use recall module and items on time-use agency. Analyses compared time use by gender and by community intervention status (improved vs. not yet improved water supply), and confirmatory factor analysis assessed the validity of the time-use agency measure. Women in both study sites spent substantially more time than men on unpaid domestic and care work activities, including cooking, cleaning, laundry, and caregiving. In Kenya, women also spent significantly more time collecting water. Men spent more time sleeping (Kenya), on paid work (Honduras), unpaid agricultural work (both settings), and traveling (both settings). Across both countries, there were no significant differences between intervention and comparison communities in women's time spent on water collection or income-generating activities. In Kenya, most respondents reported high influence over their time, and six items showed strong validity for measuring instrumental time-use agency. Women's time burdens remained high even in communities that had received improved water sources, including at the household level. Our results suggest that more transformative water infrastructure, combined with interventions that address gendered social norms, may be needed to meaningfully reduce women's domestic work burden and support their economic empowerment.