The Lancet Global Health

Background: Age is an important determinant of tuberculosis (TB) risk, but population-level age patterns in TB prevalence have not been systematically quantified across settings. We conducted a systematic review of surveys conducted in low- and middle-income countries to quantify trends in TB prevalence across age groups. Methods: We collated age-stratified TB prevalence data for individuals aged 15+ years, from population-based surveys reported between 1993 and 2025. We analyzed data using Bayesian meta-regression models, estimating trends in bacteriologically confirmed pulmonary TB prevalence across age groups. We extended models to understand how age trends varied with alternative outcome definitions and data subsets, and examined correlations between TB age trends and sociodemographic determinants. We also estimated age-stratified notification-to-prevalence ratios as a measure of diagnostic delays for untreated TB. Findings: We included 82 unique surveys reporting age-stratified TB prevalence, spanning 30 countries and 4.6 million participants. These data demonstrated a pattern of increasing bacteriologically confirmed TB prevalence with older age, with each 10-year increase associated with a 30% (95% credible interval: 22, 38) increase in prevalence. TB prevalence for the oldest age group (75+: 796 per 100,000 [522, 1178]) was 6.4 (4.0, 10.4) times higher than the youngest (15-19: 127 per 100,000 [79, 186]), and positive age gradients were estimated for all countries (interquartile range: 23-40% increase per 10-year increase in age). Age gradients were lower in Africa compared to other regions, and for smear-positive compared to bacteriologically confirmed TB. Countries with HIV prevalence [≥]5% had flatter age gradients above 40 years of age. Age gradients declined slowly over the study period. Notification-to-prevalence ratios demonstrated a negative age gradient, declining by 10% (7, 14) per 10-year increase in age. Interpretation: The prevalence of untreated TB disease increases substantially throughout adulthood, and lower notification-to-prevalence ratios suggest poorer case detection among older individuals.

Since its inception in 2003, the United States President's Emergency Plan for AIDS Relief (PEPFAR) has played a central role in HIV/AIDS prevention and treatment across Sub-Saharan Africa. Following the January 2025 suspension of United States foreign aid, which includes PEPFAR funding, countries across Sub-Saharan Africa demonstrated varying governmental responses to the resulting HIV funding disruptions. This study evaluates whether national characteristics were associated with a country's ability to respond to this funding crisis. Countries in Sub-Saharan Africa receiving PEPFAR funding were classified into one of three response categories: Level 1 (minimal or no governmental response), Level 2 (government response without sufficient plans or resources to fully offset funding losses), or Level 3 (high governmental response with strategies to maintain HIV/AIDS prevention and treatment services). Response categories were compared with national Human Development Index (HDI), GDP per capita, HIV prevalence, total population living with HIV, annual HIV mortality, and historical PEPFAR funding. Univariable proportional-odds ordinal logistic regression was used to identify factors associated with response level. Five countries (17.2%) were classified as Level 1, 10 (34.5%) as Level 2, and 14 (48.3%) as Level 3. Higher HDI was significantly associated with stronger governmental response (OR = 4.05; 95% CI, 1.49-11.04; Holm-adjusted p = 0.0376). GDP per capita (OR = 2.35; 95% CI, 1.00-5.51; unadjusted p = 0.0489) and HIV prevalence (OR = 3.53; 95% CI, 1.03-12.11; unadjusted p = 0.0452) demonstrated positive associations before adjustment for multiple comparisons, but neither remained significant after Holm correction (adjusted p = 0.2261 for both). Historical PEPFAR funding, total population living with HIV, and annual HIV mortality were not significantly associated with response level after adjustment. Countries with higher levels of human development demonstrated stronger governmental responses to the 2025 PEPFAR funding disruptions. Several countries with minimal documented responses were also affected by active conflict or political instability, potentially compounding their vulnerability to treatment interruptions. These findings suggest that broader national development may play an important role in governmental responses to funding disruptions and highlight the need to strengthen resilient health systems, diversify HIV financing, and prioritize support for countries at greatest risk of future funding shocks.

Retention in antiretroviral therapy (ART) programmes remains a major public health challenge in HIV care, with loss to follow-up (LTFU) and death threatening treatment success. Because these outcomes are competing events, conventional survival methods may yield biased estimates of their incidence and associated risk factors. To estimate the cumulative incidence of LTFU and mortality and identify factors associated with these outcomes among adults receiving ART in Northern Ghana using a competing-risks framework. We conducted a retrospective cohort study of 329 adults living with HIV who initiated ART at Nalerigu Baptist Medical Centre, Ghana, between January 2013 and December 2019. Fine--Gray subdistribution hazard models were used to evaluate predictors of LTFU and death while accounting for competing risks. Cause-specific Cox proportional hazards models were fitted as a sensitivity analysis. The incidence rates were 2.2 per 100 person-months (95% CI: 1.9--2.6) for LTFU and 0.74 per 100 person-months (95% CI: 0.57--0.98) for death. At 36 months, the cumulative incidence was 50.2% for LTFU and 16.0% for death. Patients residing closer to the clinic had a lower cumulative incidence of LTFU than those living farther away (SHR = 0.68, 95% CI: 0.49--0.93), whereas higher baseline weight was associated with increased LTFU (SHR = 1.02 per kg, 95% CI: 1.00--1.04). Mortality was lower among patients receiving efavirenz-based regimens (SHR = 0.27, 95% CI: 0.15--0.50), females (SHR = 0.39, 95% CI: 0.18--0.85), and those with higher baseline weight (SHR = 0.93 per kg, 95% CI: 0.90--0.96). Findings were broadly consistent in cause-specific Cox models. LTFU was substantially more frequent than mortality among adults receiving ART in Northern Ghana. Travel distance to the treatment facility was an important barrier to retention, while ART regimen, sex, and baseline weight were associated with mortality. Expanding access to ART services through decentralized and community-based models may improve retention and support efforts to achieve HIV control targets.

Long-acting injectable human immunodeficiency virus (HIV) medicines expand treatment and prevention choices, but willingness to use them does not establish readiness to begin. We examined readiness to start these options, associated factors and conditions for acceptance among people living with HIV and pre-exposure prophylaxis (PrEP)-service clients in Uganda. This cross-sectional study analysed 225 participants at Mildmay Hospital and Kajjansi Health Centre IV in central Uganda. Readiness meant preferring initiation immediately or within three months. Modified Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), including age-by-service-group interaction. Separate models examined informational, perceptual and financial factors, adjusting for service group, age and sex. Logistic marginal standardisation checked demographic and expanded age comparisons. Overall, 108 participants (48.0%) were ready to start injectable HIV treatment or prevention, 111 (49.3%) wanted more information about these options, and six (2.7%) preferred initiation in six to twelve months. Readiness was 80.8% among people living with HIV aged 15-24 years and 34.4% among those aged 25 years or older (aPR 2.35, 95% CI 1.63-3.38). Corresponding proportions among PrEP-service clients were 39.2% and 41.4% (aPR 0.95, 95% CI 0.60-1.50; interaction p=0.002). In separate adjusted models, clinic-staff information (aPR 1.94, 95% CI 1.42-2.66), belief in greater effectiveness (2.00, 1.43-2.80) and a one-point increase in benefit score (3.27, 2.36-4.55) were associated with higher readiness. A one-point increase in concern score (0.70, 0.60-0.80) and financial difficulty sometimes or more often (0.68, 0.48-0.96) were associated with lower readiness. Fewer side effects was the leading condition for accepting injectable HIV treatment or prevention across service and readiness groups. Nearly half of participants were ready to start, while a similar proportion wanted further information about injectable options. Programmes should assess intended initiation timing alongside willingness and address safety, appointment flexibility, privacy and affordability through counselling and service planning.

Background Community-led interventions for female sex workers (FSW) can improve HIV prevention and treatment outcomes by lowering self-stigma and strengthening social cohesion to improve service uptake. In Zimbabwe, the AMETHIST intervention trial integrated peer-led microplanning with self-help groups for FSW and demonstrated improved HIV treatment outcomes. We investigated the role of social cohesion and self-stigma in explaining these findings. Method We conducted a mixed-method analysis of data collected during AMETHIST. We re-analysed qualitative data from interviews and group discussions to identify narratives linking self-stigma, engagement with microplanners and/or self-help groups and HIV service use. We analysed quantitative data from endline respondent-driven sampling surveys for differences in self-reported measures of social cohesion and self-stigma between trial arms, and between those who did and did not participate in intervention activities or access services. Results In both arms, FSW self-reported engaging with peer supporters, participating in self-help groups and accessing HIV services. Qualitative narratives suggested peer support and group participation could reduce self-stigma and support service uptake. Lower levels of self-stigma were seen in the intervention arm (58.6% vs 63.2%; aOR 0.77; 95% CI 0.61-0.86). Social cohesion exceeded 50% across the whole sample, but was not associated with study arm, nor with engagement in intervention-related activities. Discussion Although qualitative data suggested some FSW felt their uptake of services was influenced by intervention components, quantitative analyses did not suggest either variable was on the causal pathway to the outcomes of the intervention. A limitation may have been the measurement of these complex constructs and the high levels of social cohesion across both study arms.

Routine infant vaccination has helped reduce cases and deaths from diphtheria, tetanus, and pertussis globally. However, these diseases continue to pose serious health risks as protective immunity wanes over time. Three booster doses of diphtheria-tetanus-pertussis-containing vaccine (DTPCV) administered from 12-months to 15-years of age increase duration of protection beyond childhood. Growing demands on government health spending underscore the importance of understanding the health and economic impact of vaccines prior to introduction. Using an integrated multi-disease epidemiological-economic model, we estimated the health impact (cases averted, deaths averted, and changes to population immunity) and budget impact of introducing DTPCV booster doses in Uganda. Compared to no DTPCV boosters, introducing all three booster doses is projected to result in 2.2 times the proportion of the population protected against symptomatic diphtheria and 2.8 times against tetanus infection among Ugandans under 15 years of age by 2039. Compared to introduction of the early childhood booster (EC) at 18 months of age, introducing all three DTPCV boosters simultaneously is projected to avert 3.2 times the number of tetanus cases over fifteen years at 2.4 times the incremental cost. The projected government vaccination cost per planned dose was USD 0.58 for simultaneous introduction of all three boosters compared with USD 0.68 for the EC booster alone. The average annual incremental cost of all three DTPCV booster doses is USD 2.79 million. Under modelled assumptions, simultaneous introduction of all three DTPCV booster doses in Uganda provides the greatest health gains, with a lower government vaccination cost per planned dose than introduction of the EC booster alone, but may still pose affordability challenges for Ugandas government.

Violence against women is a key contributor to mental health gender disparities, with greater gender gaps observed in low-and middle-income countries. This study examines state-level associations between gender-based violence against women and mental health burden in India over time. We linked 1) annual state-level age-standardised disability-adjusted life year rates (ASDR) from the Global Burden of Disease study for overall mental health disorders, depressive disorders, anxiety disorders, bipolar disorder, schizophrenia and self-harm, with 2) annual state-level gender-based violence rates from the Open Government Data Platform, India. We used descriptive ecological analyses and multilevel modelling to estimate the state-level association between gender-based violence and sex-stratified mental health outcomes over time (2001 - 2021). Results showed higher state-level gender-based violence (GBV) rates were associated with higher state-level ASDR of schizophrenia ({beta}women = 0.39 [95%CI 0.25 - 0.52]; {beta}men = 0.42 [0.29 - 0.55]) and bipolar disorder ({beta}women = 0.02 [0.01- 0.03]; {beta}men = 0.04 [0.03 - 0.05]), after adjustment for state-level social development, but not with other outcomes. Higher GBV rates were associated with a lower gender disparity in depressive disorders. Longitudinal findings revealed that the state-level association between GBV rates and ASDR of overall mental health disorders strengthened over time ({beta}women = 5.08 [3.96 - 6.20]; {beta}men = 3.38 [2.60 - 4.15]), whereas the association weakened for self-harm and schizophrenia. Lagged findings suggested that with an increase in GBV rate, ASDR of overall mental health disorders increased for men over two years and for both sexes over five years. Our findings highlight the importance of considering state-level trends in GBV and related policies, and considering impacts of GBV on both men and women's mental health.

Introduction: Raised blood pressure is an important cardiovascular risk factor in Cambodia; however, national averages may obscure substantial local geographic heterogeneity. We assessed the spatial distribution of raised blood pressure and its demographic, metabolic, behavioural, built-environment, and environmental correlates using the 2023 Cambodia STEPwise approach to noncommunicable disease (NCD) risk factor surveillance (STEPS) survey. Methods: We analysed 289 georeferenced primary sampling units (PSUs) from the 2023 Cambodia STEPS Survey. PSU-level case counts and numbers of adults with valid blood pressure data were modelled using a frequentist binomial generalised additive model with a two-dimensional Gaussian-process smooth. An explanatory model included selected PSU-level and contextual covariates; a separate mapping model used spatially continuous predictors to generate predictions on a 5-km grid. Design-based national and residence-specific prevalence estimates were calculated separately using the survey design and Step-2 weights. Results: Among 4,225 adults with valid blood pressure data, unweighted prevalence of raised blood pressure was 28.6%, compared with 18.8% after Step-2 weighting; weighted prevalence was 17.5% in rural areas and 21.7% in urban/suburban areas. Mean observed unweighted PSU-level prevalence was 29.0%. In the adjusted spatial explanatory model, the proportion aged 60-69 years ({beta}=1.969, SE=0.327; p<0.001) and overweight/obesity prevalence ({beta}=0.996, SE=0.265; p<0.001) were positive ecological correlates. The spatial model had lower Akaike information criterion and residual deviance than its non-spatial counterpart, although Bayesian information criterion was higher. Prediction uncertainty was greater in some sparsely sampled areas. Conclusions: Raised blood pressure showed significant geographic heterogeneity across Cambodia. Older age composition and overweight/obesity prevalence were positive PSU-level correlates, not individual-level causal effects. Predicted prevalence should be interpreted alongside uncertainty and should complement, rather than replace, design-based STEPS prevalence estimates for geographically informed NCD planning.

Background. Nigeria's reported Lassa fever case fatality ratio (CFR) rose from 18.9% at week 23 of 2025 to 25.0% in 2026, prompting concerns over failing clinical care. Because surveillance artefacts can also alter CFRs, candidate mechanisms that published data can resolve were identified and evaluated. Methods. This ecological study extracted weekly state-level counts from 474 Nigeria Centre for Disease Control and Prevention situation reports (2017-2026). Per a pre-specified plan, years were compared at phase-matched points, year-on-year CFR changes were decomposed into within-state and between-state components, and tipping-point ascertainment shifts calculated. Weekly incident and cumulative published totals were compared post hoc. Findings. Of 11 candidate mechanisms, 2 could be evaluated fully and 5 in part. On weekly incident counts, 2026 did not differ from 2025 at the phase-matched midpoint (+0.3 percentage points, 95% CI -5.0 to 7.6); within-state (-1.1, 95% CI -4.7 to 3.0) and between-state (+0.5, -2.0 to 2.9) components spanned zero. Conversely, the published cumulative CFR was 5.4 to 6.2 percentage points higher because 70 deaths were added retrospectively by week 36 outside weekly reports. Reconciling cumulative figures would require 279 missed survivors (6% of suspected cases not confirmed). Interpretation. The 2026 CFR rise came from deaths added to cumulative totals outside the weekly counts, and published data cannot attribute it to care. Endemic zoonotic CFRs cannot serve as clinical outcome measures unless testing volumes, deaths added late, and post-mortem sampling are published alongside case counts. Funding. US NSF-NIH-NIFA EEID; UK BBSRC; Birgitta Sintring Fellowship (Uppsala University).

Background: TB vaccine development is hampered by the natural history of M. tuberculosis: most infected people rarely progress to disease, so trials must be very large and long to accrue sufficient disease endpoints. Current trials enrol IGRA-positive participants (IGRA: Interferon-Gamma Release Assays), but IGRAs remain positive for many years and cannot distinguish recent from remote infection. Tests for recent infection are now in development, and we argue they could make trials substantially more efficient. Here, we investigate how screening participants prior to enrolment with a test for recent M.tb infection could impact the total number of enrollees required for an adequately-powered TB vaccine trial. Methods: Using a statistical model of vaccine trial recruitment, we estimated the number needed to contact, test, and enrol to achieve an 'effective' trial (defined as 50 disease endpoints), under IGRA-gated enrolment (life-long duration of positivity) vs. enrolment with a test for recent infection. We considered five recruitment strategies: non-test-based enrolment for ages 15-49, ages 12-34, and household contacts of recent cases; and test-based enrolment using IGRA, and a test for recent infection with two-year duration of positivity. The model explored trial recruitment in South Africa, Kenya, and India. Results: Compared with an extended-positivity test, a test for recent infection reduced the median number needed to enrol by 4.2- to 6-fold under favourable conditions. It also outperformed non-test-based strategies, including enrolling household contacts. This comes at the cost of substantially more testing, but crude estimates suggest recency-based enrolment would still be cheaper overall provided the new test does not cost more than roughly 5-10 times an IGRA. Conclusions: Diagnostics for recent M.tb infection have the potential to improve vaccine trial efficiency, but more research is now needed to understand test characteristics and to evaluate their use in this setting. Our Viewpoint sets out the test attributes that would need to be established, such as time to positivity, duration of positivity, sensitivity, and specificity, before such tests could be used in vaccine trials.

Background Despite substantial improvements in maternal and child health over the past two decades, preventable maternal and neonatal morbidity and mortality remain major public health concerns in rural Bangladesh. Community-based interventions involving Community Volunteers (CVs), Community Groups (CGs), and Community Support Groups (CSGs) have been introduced to strengthen maternal and child health (MCH) services through health promotion, community engagement, and improved linkage with primary healthcare facilities. This study explored the roles, challenges, and opportunities of these community-based platforms in improving maternal and child health services. Methods A qualitative study was conducted in Kalaroa Upazila of Satkhira District, Bangladesh, between July and October 2020. Data were collected through focus group discussions and in-depth interviews with mothers, Community Volunteers, Community Group members, and Community Support Group members. Participants were purposively selected to capture diverse experiences from intervention and comparison areas. Interviews were conducted using semi-structured guides, audio-recorded with informed consent, transcribed verbatim, translated into English, and analyzed thematically using an inductive approach. Results Participants from intervention areas demonstrated greater knowledge of birth preparedness, antenatal care, pregnancy danger signs, institutional delivery, postnatal care, and newborn care than those from comparison areas. Community Volunteers, CGs, and CSGs played important roles in identifying pregnant women, conducting household counselling, promoting skilled maternal healthcare, facilitating referrals, and strengthening community participation. Participants perceived that these activities increased maternal awareness, improved health-seeking behaviour, and enhanced utilization of maternal and newborn health services. However, persistent barriers, including socio-cultural beliefs, financial constraints, transportation difficulties, shortages of skilled healthcare providers, and inadequate logistical support for community volunteers, continued to limit equitable access to quality services. Participants recommended strengthening community awareness programmes, improving community clinic readiness, enhancing referral systems, and providing regular training and supportive supervision for community-based health workers. Conclusions Community-based maternal health interventions involving Community Volunteers, Community Groups, and Community Support Groups contribute to improved maternal knowledge, health-seeking behaviour, and utilization of essential maternal and newborn health services in rural Bangladesh. Sustaining these gains will require stronger primary healthcare services, continued community engagement, and targeted strategies to address persistent health system and socio-cultural barriers. These findings provide important evidence for strengthening community-based maternal and child health programmes in Bangladesh and similar resource-constrained settings.

BACKGROUND: Indigenous tribes face a disproportionately high tuberculosis (TB) burden due to deep-rooted socioeconomic disadvantage, highlighting the need for strengthened, culturally sensitive control strategies. METHODS: We conducted a 21-year retrospective study (2005-2025) among tribal and neighboring non-tribal populations attending a tribal-serving hospital in Karnataka. Pre-Nikshay data were transcribed from paper registers, and post-Nikshay data were obtained from the digital system. We assessed negative binomial interrupted time-series regression model, data completeness, TB risk factors, and used multivariable logistic regression to identify determinants of poor treatment outcomes and household contact screening yield. RESULTS: We analyzed 1,512 TB cases (tribal = 1,021; non-tribal = 491). TB detection increased significantly over time, with a steeper rise among tribal populations (p<0.001). Nikshay implementation significantly improved data completeness (Wilcoxon W = 9900, p<0.001). Among tribal patients, males had higher odds of poor treatment outcome (aOR 2.81, 95% CI 1.70- 4.85; p<0.001). Diabetes (aOR 2.10, 95% CI 1.05- 4.03; p=0.029) was independently associated with poor treatment outcome. Among 503 index cases, 1,535 household contacts were identified and 1,161 (75.6%) screened; coverage was lower among tribal contacts (69.8% vs 87.2%; p<0.001). CONCLUSIONS: Nikshay strengthened TB surveillance and improved assessment of TB burden and risk factors in tribal communities.

Introduction Cancer incidence is rising rapidly in low- and middle-income countries (LMICs), where diagnostic pathology capacity is constrained. AI applied to routine histopathology could strengthen diagnostic capacity and offer leapfrogging potential by embedding AI into diagnostic systems as they are built up. However, without empirically identifying implementation determinants in LMIC cancer-diagnostic settings, AI solutions risk being poorly aligned with local constraints, limiting impact or exacerbating existing disparities. Methods We conducted an exploratory mixed-methods pilot study across three phases: 1) a structured survey characterising the diagnostic and technical landscape and AI priorities; 2) focus group discussions (FGDs) to inductively identify implementation determinants and 3) a second survey quantifying FGD-derived themes. Twelve physicians were purposively recruited (10 from LMIC, 2 from high-income countries for reference) and findings integrated through narrative triangulation. Results There was substantial heterogeneity in diagnostic and AI infrastructure that did not track consistently with country income classification. H&E staining was universally available, immunohistochemistry capacity was rudimentary at 7 of 10 sites and molecular testing absent or minimal at 6 of 10 sites. Whole-slide-imaging scanners were available at 8 of 10 sites, while graphical processing units, required for efficient AI inference, were available at only 4 of 10 sites. The participants would prioritise use of AI for cancer screening, cancer diagnosis, and biomarker prediction from H&E slides. Six implementation determinants were identified: AI literacy, governance frameworks, funding, evidence generation, clinical deployment, and collaboration. Financial constraints emerged as the dominant barrier across all determinants, and collaboration as an important enabling mechanism. Conclusion AI implementation readiness in LMIC cancer-diagnostic settings is highly heterogeneous and cannot be inferred from income classification, underscoring the need for institution-level assessment. Realising the leapfrogging potential of AI in this context requires coordinated progress across all determinants, with sustainable financing, and collaboration enabling the remaining determinants.

Objective Reducing household air pollution exposure during gestation and infancy may have longer-term benefits for child linear growth. We examined whether a liquefied petroleum gas (LPG) cookstove and fuel intervention delivered during gestation and infancy could improve height-for-age Z scores (HAZ) and reduce the risk of stunting at ages 2-5 years in India, Rwanda, and Guatemala. Materials and method The Household Air Pollution Intervention Network (HAPIN) was a randomized controlled trial that enrolled ~3200 pregnant women across Guatemala, India, Peru, and Rwanda. Women in the intervention group received an LPG cookstove and free fuel during pregnancy and until the infant reached 12 months of age. Following the HAPIN trial, we continued following children in Guatemala, India, and Rwanda (N=2169) and measured child height at ages 2, 3, 4, and 5 years (HAPIN 2.0). As prespecified in the study protocol, we used mixed-effects models, as well as linear and log-binomial regression, within the intention to treat (ITT) framework, to evaluate the interventions effect on HAZ and stunting. Subgroup analyses were performed to assess effect modification by child sex, maternal height, and intervention country. Results The intervention reduced gestational exposures to particulate matter (PM2.5: 80.7 vs 117.5 {micro}g/m3), carbon monoxide (CO: 1.3 vs 2.0 ppm), and black carbon (BC: 8.6 vs 12.1 {micro}g/m3) and infancy exposures (PM2.5: 36.9 vs 113.2 {micro}g/m3; CO: 0.60 vs 2.2 ppm). Post-trial PM2.5 exposure were similar between arms: 99.9 vs 98.7 {micro}g/m3. We found no statistically significant effect of the intervention on repeated measures of HAZ ({beta} = -0.06, 95% CI: -0.16, 0.03 p=0.204), annual HAZ, stunting, nor severe stunting at any age during the follow-up. There was no statistically significant effect modification by subgroups. Conclusion Despite substantial reductions in air pollution exposures during the trial, the LPG intervention did not improve growth or reduce stunting risk from ages 2 through 5 years in this multi-country cohort. These findings, consistent with prior results of the lack of effects on growth through 12 months, provide additional evidence that a clean cooking intervention alone may not be sufficient to address childhood stunting in low-resource settings. Future exposure-response analyses will supplement these ITT analyses.

We develop an age- and immunity-structured COVID-19 model with setting-specific contacts, calibrated to Ontario incidence and hospital admissions before Omicron. We simulate counterfactual vaccination strategies and contact restrictions in schools, workplaces, and other community settings, evaluating projected severe-case demand against an illustrative healthcare-capacity benchmark. Vaccination combined with workplace and community contact restrictions keeps simulated demand within capacity. In contrast, relaxing restrictions in either setting produces large surges and repeated capacity threats, even when school restrictions remain. School-only changes produce smaller effects on severe disease. These findings highlight the value of vaccination and setting-specific contact restrictions that prioritize workplace and community settings for pathogens with adult-concentrated severe outcomes.

Background: Both over- and under-antibiotic use pose major global health challenges, yet there is no consensus on how to quantify deviations from optimal prescribing or set evidence-based targets. We developed a benchmarking tool for inpatient antibiotic use and evaluated its application in 10 countries. Methods: We developed decision-tree models to estimate expected empiric antibiotic use for 11 indications, based on the WHO AWaRe book for two age groups: 28 days to 12 years and >12 years. We parameterised the models using country-specific antimicrobial resistance estimates in the 10 countries and cross-sectional Global Point Prevalence Survey (Global-PPS) case-mix data from 2021 for 10 countries and from 2015-2022 in a subset of five countries. We then compared estimated expected antibiotic use with observed empiric use (from Global-PPS) in defined daily doses for adults and days of therapy for children, across indications and AWaRe categories. Findings: In 2021, among patients aged >12 years, in all countries but one, observed empiric Access antibiotic use, as a proportion of total antibiotic use, was lower than expected and empiric Watch antibiotic use was higher than expected. Similar patterns were observed in all countries but one in patients aged 28 days to 12 years. The magnitude of discrepancies between expected and observed Access and Watch antibiotic use varied across indications and countries. The median observed-to-expected ratios of usage across countries ranged from 0.3-0.8 for Access antibiotics, and 0.7-5.3 for Watch antibiotics in patients aged >12 years in 2021. Temporal trends from repeated surveys from 2015 to 2022 showed little change in observed-to-expected ratios for Access and Watch antibiotics. Interpretation: This benchmarking tool uses Global-PPS data to quantify differences between observed antibiotic use and WHO AWaRe recommendations. Our tool can be adaptable to local guidelines, provides policy-relevant estimates of expected antibiotic use to support monitoring, procurement planning, and targeted stewardship intervention.

Importance: Coccidioidomycosis, also known as Valley fever, is a serious fungal disease caused by inhaling Coccidioides spores aerosolized from the soil. Despite rising public health concern, the distribution and incidence of coccidioidomycosis in the US remain poorly characterized as not all states are required to report cases, and case under-ascertainment is presumed to be high, particularly outside of the endemic region. Objective: To estimate monthly, county-level coccidioidomycosis incidence across the US while accounting for widespread under-ascertainment. Design, Setting, and Participants: We integrated multisource data, including human cases diagnosed in electronic health records, serological testing of dogs, and ecological and sociodemographic predictors, in a machine learning model estimating monthly, county-level coccidioidomycosis incidence. The model was trained on surveillance data from Arizona and California from 2013 to 2023, then applied to predict incidence in states across the contiguous US over the same time period. Main Outcomes and Measures: Incidence of coccidioidomycosis at the monthly county level. Results: The model predicted coccidioidomycosis incidence from 2013 to 2023 for 3,108 counties from all states in the contiguous US. The model identified 60 counties in non-reporting states where predicted incidence was [&ge;]2 cases per 100,000 population (considered moderate to high incidence). In states with mandatory reporting outside of Arizona and California, the model predicted county-level incidence rates that were 28% higher (95% bootstrap interval, 0.1%-69.8%) than those captured in national surveillance, equating to a total of 608 potentially missed cases per year (95% bootstrap interval, 340-964). Conclusions and Relevance: In this cross-sectional study, the model quantified case under-ascertainment for coccidioidomycosis relative to Arizona and California, and highlighted the potential for alternative data sources to fill in gaps in mandatory reporting. Estimating incidence while accounting for under-ascertainment and non-reporting may help efforts to improve public and physician awareness and to detect emergence in new regions.

Background: Severe malaria remains a major cause of hospitalization in malaria-endemic sub-Saharan Africa, and anemia is among its most frequent severity criteria. Data on the impact of anemia on hospital length of stay (LOS) among adults with severe malaria remain limited in Central Africa. We assessed the impact of anemia on LOS among adults hospitalized for severe malaria in Brazzaville, Republic of Congo. Methods: We conducted a cross-sectional, descriptive, and analytic study of medical records from adult patients ([&ge;]18 years) diagnosed with severe malaria (WHO criteria) and admitted to four hospitals in Brazzaville between January 2020 and December 2024. We dichotomized LOS as short (<5 days) or prolonged ([&ge;]5 days). Multivariable logistic regression, using a backward stepwise procedure, identified factors independently associated with prolonged LOS; isolated hemoglobinuria served as the reference severity category. Results: Among 523 patients hospitalized for severe malaria, 296 met the inclusion criteria. Median age was 25.5 years (IQR 20-40); 51.7% were female, and 82.1% had a low socioeconomic status. Median hemoglobin was 10.55 g/dL, and median LOS was 4 days (IQR 3-5). In multivariable analysis, prolonged LOS was independently associated with delay to consultation (aOR 1.25/day, 95% CI 1.09-1.44), isolated anemia (aOR 7.07, 1.23-40.55), convulsions (aOR 5.86, 1.81-18.97), prostration (aOR 4.42, 1.21-16.2), and impaired consciousness (aOR 4.29, 1.17-15.7). The strongest associations involved combined severity criteria: anemia with prostration (aOR 8.58), anemia with jaundice or hemoglobinuria (aOR 16.21), and impaired consciousness with anemia (aOR 33.31). Conclusions: Anemia is a major, potentially modifiable determinant of prolonged hospitalization in adults with severe malaria, with a markedly amplified effect when combined with neurologic impairment. Early anemia screening, improved access to safe blood transfusion, and reduced delays to care could shorten hospital stays and ease the burden on health systems in this setting.

Background: Short birth intervals are a well-documented, modifiable risk factor for child death in low- and middle-income countries, yet nationally representative evidence from Ghana's most recent Demographic and Health Survey has not been fully examined. This study assessed the association between the preceding birth interval and under-five mortality using the 2022 Ghana Demographic and Health Survey. Methods: The analysis used the complete birth history reported by women aged 15-49 years. The cohort comprised births occurring 60-119 completed months (5-10 years) before the survey, which allowed a complete five-year observation window for under-five survival (n = 8,418; 397 deaths). Spacing models were restricted to second-or-higher-order births with a defined preceding interval (n = 6,340; 282 deaths), categorised as under 18, 18-23, 24-35 (reference), 36-47, and 48 or more months. Crude and adjusted odds ratios were estimated using survey-weighted, Taylor-linearised logistic regression, adjusting for birth order, child sex, plurality, maternal age, residence, region, maternal education, wealth quintile, and marital status. Results: Weighted under-five mortality in the cohort was 45.4 per 1,000 live births (4.54%). Among second-or-higher-order births, weighted mortality fell from 9.3% after intervals of under 18 months and 8.0% after 18-23 months to 4.2%, 3.2%, and 3.5% after 24-35, 36-47, and 48 or more months, respectively. Relative to 24-35 months, the adjusted odds of death were higher after intervals of under 18 months (adjusted odds ratio [AOR] 2.58, 95% confidence interval [CI] 1.48-4.49, p < 0.001) and 18-23 months (AOR 2.09, 95% CI 1.33-3.29, p = 0.001); longer intervals did not differ from the reference. Multiple birth (AOR 2.48, 95% CI 1.33-4.63) and having a mother who was never in union (AOR 3.25, 95% CI 1.29-8.17) were also associated with higher odds of death, and marked regional variation persisted after adjustment. Conclusion: A short preceding birth interval, particularly one of under 18 months, was independently associated with an approximately two- to two-and-a-half-fold increase in the odds of under-five death in this nationally representative sample. The findings support continued investment in postpartum family planning to help women space births at least 24 months apart, alongside closer attention to multiple births, unmarried mothers, and the regions carrying the greatest burden.

Background Urban inequities are often masked by the misleading notion of an urban advantage, despite persistent unequal access to quality healthcare services. Moreover, negative perceptions about the urban poor and slum-dwellers persist, despite their substantial role in driving and holding up the urban economy. It is thus essential to work with the media to bring visibility to these realities, raise public awareness, and inform more equitable health policies. In low- and middle-income countries (LMICs), evidence remains scarce on how health-related information from media outlets influences policy decisions. This study aimed to understand how journalists get information, engage with stakeholders in the health systems, and contribute to influencing urban health discourse in Bangladesh and Nepal. Methods We conducted a cross-country exploratory qualitative study comprising 30 key informant interviews from Bangladesh and Nepal, including 17 journalists, 10 health policymakers, and 3 public health advocates. Participants were purposively selected to ensure diversity across media types, gender, and professional roles. Interviews were conducted between September 2024 and March 2025. Data were transcribed, translated, and analyzed thematically using NVivo software. Cross-country comparative analysis was carried out to identify common themes and contextual differences. Findings Across both countries, participants relied on multiple and diverse information sources. Government data were often prioritized as a primary source of information, although they were shaped by political influences and accessibility constraints. Research evidence was valued but underutilized due to difficulties in interpreting scientific articles. Urban health issues received limited priority in health news reporting due to journalists constraints in covering multiple issues and financial constraints for in-depth coverage. Additional challenges included inadequate health and urban health-related training, limited fellowship opportunities for investigative reporting, and restricted access to data, while health policymakers and public health advocates frequently questioned the credibility and use of media-reported information. Media engagement in policymaking largely remained indirect and issue-focused or event-driven. However, consistent media coverage raised public awareness and generated public pressure and, at times, indirectly influenced health policy decisions such as immediate inspection after reporting on pesticides, installation of oxygen plants during the pandemic, dengue surveillance, and tobacco control measures and actions. Conclusion In Bangladesh and Nepal, news media play a significant but indirect role in shaping urban health policy decisions. Enhancing journalists capacity, improving access to credible information and data, and continuous engagement of stakeholders could strengthen evidence-informed urban health policymaking. Furthermore, establishing greater independence of journalists and government and community recognition of their responsible health reporting could help and motivate the media to contribute more meaningfully to public debate and policy reform processes.