The Lancet Regional Health - Western Pacific

Background Large-for-gestational-age (LGA) and macrosomic newborns are at increased risk of adverse perinatal outcomes, including death, yet the burden of neonatal mortality associated with these conditions in low- and middle-income countries (LMICs), where ongoing nutritional and epidemiological transitions suggest their prevalence will rise, remains poorly quantified. In this study, we quantify the neonatal mortality risk associated with LGA and macrosomia from 16 subnational birth cohorts in low- and middle-income countries between 2000 and 2017. Methods and findings This is an individual-participant meta-analysis to estimate neonatal mortality rates (NMRs) and relative risks among LGA infants (>90th and >97th percentile birth weight-for-gestational-age using INTERGROWTH-21st) versus appropriate-for-gestational-age (AGA, 10th-90th percentile) infants. Macrosomic ([≥]4000 g and [≥]4500 g) neonates were compared with those weighing 2500 g-3999g. Missing birth weights were imputed using recalibration and multiple imputation methods. We used random effects meta-analysis to pool relative risks. Median prevalences of LGA >90th and >97th percentile were 5.3% (interquartile range 3.6-8.2) and 2.6% (IQR 1.3-4.5), respectively; macrosomia ([≥]4000 g and [≥]4500 g) prevalences were 1.0% (IQR 0.3-3.1) and 0.06% (IQR 0.0, 0.30), respectively. Mortality was highest among preterm plus LGA infants (61.3 per 1000). LGA infants in the >90th percentile had over twofold increased mortality compared with appropriate-for-gestational-age infants (RR: 2.46; 95% CI: 1.86-3.25), while >97th percentile infants had a higher risk (RR: 3.77; 95% CI: 2.50-5.69). Term LGA >97th percentile infants also showed elevated mortality (RR: 3.14; 95% CI: 1.58-6.22). For LGA >97th percentile, the risk was higher in the early neonatal period (RR: 2.71; 95% CI: 1.92-3.82) than late (RR: 1.69; 95% CI: 1.22-2.34). There was no overall association between macrosomia ([≥]4000 g) and neonatal mortality. Population attributable fractions were 7.2% for LGA >90th percentile and 0.4% for macrosomia ([≥]4000 g). Conclusions Neonatal mortality risks were elevated among LGA infants in low- and middle-income countries, particularly at extreme values (>97th percentile) and during the early neonatal period. Macrosomia showed weaker, less robust associations. Although LGA prevalence is currently low ([~]5%) and contributes less to neonatal mortality than small newborns, ongoing nutritional and epidemiological transitions suggest increasing prevalence. This highlights the need for strengthened surveillance, monitoring, and improved delivery planning to ensure that no population is left behind.

Climate change is shifting infectious disease burdens1-6, but attributing transmission changes remains difficult where interventions and socioeconomic development interact with temperature-dependent signals7-11. Mechanistic models can isolate temperature-dependent signals from non-climatic influences5,12-16 but are often not tested against independent data. Here, we present a validation-first framework using a temperature-dependent R transmission model17 to detect and attribute temperature-mediated climate impacts on schistosomiasis transmission across Africa. First, semi-natural mesocosm experiments confirmed the model's biological constraints, with high temperatures suppressing the host-parasite system above ~33{degrees}C. Next, we established epidemiological relevance in the Lake Victoria Basin using 141,829 longitudinal infection records. Interannual temperature anomalies predicted infection risk, with anthropogenic warming accounting for 17.1% of observed infections relative to a natural-forcing-only counterfactual. Finally, across Africa, the mechanistic R predictor explained prevalence better than correlative climate metrics, even after accounting for intervention and socioeconomic covariates. Applying the validated framework to ensemble climate model simulations and a natural-forcing-only counterfactual (1984-2014) showed that anthropogenic warming increased transmission potential in cooler regions while suppressing it in hotter regions across Africa, a contrast projected to intensify under higher-emissions scenarios by mid-century. Climate impacts are not solely future threats, but present-day forces already reshaping transmission and disease burden.

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 Bangladesh has experienced a rapid increase in cesarean section (CS) utilization over the past two decades. While previous studies have documented socioeconomic disparities in CS use, evidence on how wealth-related inequalities differ between public and private healthcare facilities remains limited. This study assessed the magnitude and drivers of socioeconomic inequality in CS utilization among facility-based births in Bangladesh. Methods We analyzed data from 3,008 facility-based births reported in the 2022 Bangladesh Demographic and Health Survey (BDHS). Survey-weighted multivariable logistic regression was used to identify factors associated with CS utilization. Wealth-related inequality was assessed using concentration curves and the Erreygers-corrected concentration index (ECCI). Regression-based decomposition of the standard concentration index was performed to quantify the contribution of socioeconomic, demographic, and healthcare-related factors to observed inequalities overall and separately for public and private facilities. Results Overall, 71.2% of facility-based births were delivered by CS, with substantially higher prevalence in private facilities (84.2%) than in public facilities (35.9%). Women delivering in private facilities had markedly higher odds of CS than those delivering in public facilities (adjusted odds ratio [AOR]: 9.07; 95% confidence interval [CI]: 7.17-11.47). Significant pro-rich inequality was observed overall (ECCI: 0.154; 95% CI: 0.117-0.191), with inequality substantially greater in public facilities (ECCI: 0.189; 95% CI: 0.114-0.264) than in private facilities (ECCI: 0.049; 95% CI: 0.014-0.084). Decomposition analysis showed that household wealth was the dominant contributor to inequality, particularly the richest wealth quintile, accounting for 81.5% of overall inequality, 63.8% in public facilities, and 109.7% in private facilities. Conclusions Wealth-related inequalities in CS utilization remain substantial in Bangladesh despite widespread use of the procedure. Although pro-rich inequality exists across both sectors, inequality is considerably greater in public facilities and is driven by different mechanisms across facility types. Policies should simultaneously improve equitable access to medically necessary CS and reduce unnecessary procedures, particularly within the private sector.

Background Diarrhea remains a leading cause of child morbidity and mortality worldwide. Improved and ongoing estimates of the etiologies of severe diarrhea, particularly in low- and middle-income countries (LMICs), are crucial to inform the use of current vaccines and other interventions and to help prioritize the development of new vaccines. Producing rigorous longitudinal data on the global burden and etiology of pediatric diarrhea requires a geographically broad surveillance network with standardized epidemiologic, laboratory, and analytic protocols. Methods We describe the rationale and methods of the Global Pediatric Diarrhea Surveillance (GPDS) network, a World Health Organization (WHO)-coordinated public health surveillance network investigating the etiology of hospitalized diarrhea among children aged <5 years in LMICs. The GPDS network enrolls children hospitalized with diarrhea at 38 sentinel surveillance sites in 31 LMICs across all 6 WHO Regions. Randomly selected stool specimens were tested by TaqMan Array Card quantitative polymerase chain reaction for 16 enteric pathogens previously associated with pediatric diarrhea. GPDS produces estimates of pathogen-specific attributable fractions and incidence of diarrheal hospitalizations at the global, regional, and country levels. Conclusions As a WHO-coordinated global surveillance network, GPDS evaluates pathogens associated with hospitalized pediatric diarrhea. The network monitors the changing burden of pathogens over time, monitors circulating strains, and generates data to inform decision-making around public health interventions. GPDS also improves global, regional, and country diarrheal disease burden estimates, informs new enteric vaccine development, and potentially provides a platform for future enteric vaccine evaluation.

We estimated the number needed to vaccinate (NNV) with an M72/AS01E-like vaccine to prevent one tuberculosis case in U.S. high-risk groups. Targeted vaccination of Mycobacterium tuberculosis-infected persons yielded NNVs of 217 (persons with HIV) to 2,486 (U.S.-born), within the range of established adult vaccines.

Introduction: Induction of labour is a widely used obstetric intervention, yet its use varies markedly, with underuse in some settings and increasing elective use in others. However, the global prevalence and trends worldwide is unknown. We aimed to synthesise national and subnational data to estimate the prevalence of labour induction internationally and assess trends over time. Methods: We sought data from 194 countries through a structured search of national databases and relevant websites. For countries lacking adequate national data, we conducted a systematic review of published studies. Eligible data were pooled to estimate the prevalence of labour induction for 2019, and to examine temporal trends from 2010 to 2022. We used mixed-effects negative binomial regression models with missing data handled using multiple imputation by chained equations. Results: Data were obtained for 62 countries, including national-level data from 19 countries and 176 studies from 43 countries. Overall, 40 countries contributed to the 2019 estimate and 43 to the trend analysis. Most countries with data were high-income (N=37, 86.0%) and in Europe (N=29, 67.4%); there were no eligible data for sub-Saharan Africa. The estimated rate of labour induction for 2019 was 23.7% (95% confidence interval (CI): 19.3% to 29.2%). Induction had an estimated annual increase of 4% between 2010 and 2022 (incidence rate ratio 1.04, 95% CI 1.02 to 1.06). Conclusion: This study provides the first international estimates of labour induction, revealing high and rising rates globally. These trends likely reflect expanded clinical indications and improved access, but also signal potential overuse in resource-rich contexts. Our findings highlight a critical data gap in LMICs, particularly in Sub-Saharan Africa. Strengthening national perinatal data systems, especially in these settings, is essential for monitoring and guiding appropriate use. Identifying the optimal induction rate should be a priority for future research and clinical practice.

Identifying the origin of an emerging epidemic wave within days of onset could enable targeted response before national spread, yet current methods rely on genomic sequencing that lags clinical detection by 2-4 weeks. We analysed daily COVID-19 cases from Japan's 47 prefectures across eight waves (2020-2023), aggregated into 11 regional blocks. Wave onset was defined by the first difference of the K-value (K'). Six surveillance indicators were evaluated with and without cumulative historical weighting ({lambda} = 0.75) and benchmarked against a large language model (Claude Haiku), scored by F1 against genomically confirmed origins. At 14 days after onset, cumulative weighting of peak and cumulative incidence (B1+prior, B3+prior) reached mean F1 = 0.622, exceeding the model (0.524); the gap was largest in Wave 7 (1.000 vs 0.333). Simple cumulative weighting of routine surveillance data identified wave origins more accurately than a language model, without proprietary tools or sequencing.

Background Foodborne diseases cause substantial global morbidity and mortality, yet remain largely unattended. To support countries to address this public health concern, the World Health Assembly Resolution 73.5 called for strengthening global food safety efforts and led to the development of the WHO Global Strategy for Food Safety 2022-2030, adopted at the 75th WHA (2022). To this end, the World Health Organization (WHO) reconvened the Foodborne Disease Burden Epidemiology Reference Group (FERG) to advise and support the work to generate updated global, regional, and national estimates of the foodborne disease burden for the reference period 2000-2021. Methods We developed an incidence-based framework expanding coverage to 42 foodborne hazards. Standardized systematic reviews, Global Health Estimates and Global Burden of Disease envelopes, and United Nations population data informed the evidence base. Missing epidemiological data were imputed using Bayesian hierarchical meta-regression models. Disease models mapped acute and chronic health outcomes, applying updated disability weights, life tables, and probabilistic Monte Carlo calculations to estimate incidence, mortality, Years Lived with Disability, Years of Life Lost and Disability-Adjusted Life Years for all 194 WHO Member States. Transparency and analysis reproducibility were ensured through availed open-source R packages and standardized workflows. Results The computational framework provides annual, country-level estimates with improved internal consistency and an expanded hazard scope compared with the WHO 2015 edition. Advances include refined modelling, enhanced uncertainty propagation, and broader inclusion of microbial, parasitic, and chemical hazards. Persistent data gaps---especially in high-burden regions---were filled through extensive imputation. Conclusions The computational framework for the WHO 2026 edition delivers the most comprehensive and transparent assessment of the global burden of foodborne diseases to date. Despite remaining limitations, it enables routine monitoring, supports evaluation of global food safety efforts, and highlights priorities for strengthening national data systems.

The 2026 Bundibugyo Ebola outbreak in eastern Democratic Republic of the Congo (DRC) has already generated international spread to Uganda, raising concerns about further regional and international dissemination. Using International Air Transport Association origin-destination passenger flows, we assessed relative exposure to Ebola virus disease importation into Europe under six outbreak expansion scenarios reflecting plausible pathways of geographical spread, including cross-border transmission and amplification in highly connected regional capitals. Relative exposure patterns remained largely unchanged under localized transmission in eastern DRC and border-spillover scenarios. Expansion into South Sudan generated a first structural increase in importation pressure to Europe through the connectivity associated with Juba, while hypothetical amplification in Kampala, Kigali, and Kinshasa substantially increased importation pressure and reshaped exposure patterns across Europe. Across all scenarios, France, Italy, and the United Kingdom remained among the most exposed countries. Mobility-informed scenario analyses support preparedness as the geography of the outbreak evolves.

Background Outpatient groin hernia repair is widely recommended globally due to clinical and socioeconomic efficiency, yet it remains underutilized in developing healthcare systems like Tunisia. This study aimed to evaluate the feasibility of a newly implemented day-surgery clinical pathway for groin hernias and identify specific predictors associated with outpatient discharge failure. Methods A prospective, observational cohort study was conducted at a Tunisian tertiary hospital between September 2023 and April 2024. A total of 85 consecutive patients scheduled for elective groin hernia repair under an optimized clinical pathway were enrolled. Inclusion criteria spanned ASA classes I-III, age [&ge;]16 years, proximity to the hospital [&le;]50 km), and presence of a literate adult caregiver. Outpatient failure (unanticipated admission) was defined as the inability to achieve discharge within 24 hours post-surgery. Statistical associations were determined using Chi-squared, Fisher's exact, and independent t-tests. Results The cohort primarily comprised males (n = 82, 96.5%) with a mean age of 56 years (range: 19-86). Successful ambulatory discharge was achieved in 80 patients (94.1%), yielding a failure rate of 5.9% (n = 5). Unanticipated admissions were triggered by uncontrolled pain (n = 1), acute anxiety (n = 2), decompensation of comorbidities (n = 1), and a Post-Anesthetic Discharge Scoring System (PADSS) score < 10 (n = 1). Overall 30-day morbidity was low (2.4%), presenting as minor wound or scrotal hematomas managed conservatively; no surgical site infections, acute urinary retention, or mortality occurred. Univariate analysis revealed that a hernial sac size measured at its maximum diameter between 1.5 and 3 cm was significantly associated with ambulatory failure (p = 0.047). General anesthesia showed a trend toward increased failure compared to regional anesthesia (p = 0.08). Conclusion Day-surgery groin hernia repair is highly safe and feasible in resource-constrained environments, even for elderly or stable ASA III patients, provided rigorous social criteria are satisfied. A small hernial sac size (1.5-3 cm) constitutes a major anatomical predictor of failure, likely due to distinct dissection dynamics and localized post-operative pain profiles.

Background: Maternal micronutrient deficiencies (MNDs) and inflammation contribute to adverse birth outcomes While the individual effects of MNDs have been studied, the consequence of co-occurring MNDs remains unclear. Objectives: To examine the associations between maternal micronutrient deficiencies and inflammation with adverse birth outcomes (ABOs). Methods: Data from 5,408 pregnant women across 11 datasets from 10 countries were analyzed. Descriptive analyses explored the distribution of MNDs (iron, vitamin A, zinc, serum folate, vitamin D, and vitamin B12) and inflammation (c-reactive protein >5 mg/L or -(1)-acid glycoprotein > 1g/L) by maternal characteristics (age, height, education, socioeconomic status [SES]) using chi-square tests. Associations of 1) single MNDs and inflammation and 2) co-occurring MNDs (2 deficiencies at a time) with low birth weight (LBW, < 2500 g), preterm birth (PTB, < 37 wks), and small-for-gestational age (SGA, < 10th percentile for gestational age), were examined using modified Poisson regression to estimate relative risk (RR), adjusting for age, SES, and dataset. Results: Young maternal age and short height were associated with up to 9.7% and 25% higher prevalence of MNDs and inflammation, respectively. Lower education and SES level were associated with higher prevalence of Vitamin B12 deficiency. Women with folate deficiency had an increased risk of LBW (RR [95% CI]: 1.22 [1.06, 1.39]). Co-occurring MNDs for folate and vitamin B12 were also associated with increased LBW risk (1.38 [1,1.9]) as was folate deficiency without iron (1.28 [1.09, 1.51]) or vitamin B12 deficiency (1.67 [1.09, 2.56]) compared with mothers without either deficiency. Iron deficiency without vitamin B12 deficiency was associated with a reduced LBW risk (0.4 [0.2, 0.79]). Conclusion: Maternal MNDs, especially folate and vitamin B12, are linked to adverse birth outcomes. Complex nutrient interactions highlight the need to explore these relationships to improve maternal and neonatal health interventions.

Background: Mortality rates have declined across most high-income countries for decades, but recent evidence suggests a slowdown in improvements or a shift to increasing mortality, particularly among working-age populations. The international distribution and drivers of these trends remain incompletely understood. Methods: Mortality trends during 2012-2019 were analysed using all-cause and cause-specific data from 30 countries. Trends were estimated via linear regression. K-means clustering with Dynamic Time Warping identified countries and ICD-10 chapters with similar temporal trajectories. Results: Trends varied substantially by nation. While Japan, Switzerland, and the Republic of Korea maintained consistent declines in all-cause mortality rates, increases were concentrated in the United States, Canada, and the United Kingdom, most prominently in persons aged 30-59 years. However, cause-specific analysis showed that rising mortality was not confined to these countries: most countries exhibited increases in at least one ICD-10 chapter, with several European countries showing increases across multiple chapters. Across countries, a small set of causes recurred among increasing trends, including external causes (self-harm, drug poisoning) at younger ages and chronic conditions (cardiovascular and liver diseases, specific cancers) in mid-life. Notably, ill-defined causes of death consistently appeared among the increasing causes across countries and age groups. Conclusions: Mortality increases in the 2010s were geographically more widespread than previously recognized. The recurrent rise in mortality from ill-defined causes suggests that an important component of mortality change remains poorly characterized. These findings indicate that stalled health progress is a systemic challenge across many high-income societies.

This study examines the effects of rural out-migration and remittance inflows on food consumption outcomes among rural households in the Tigray region of Ethiopia. Utilizing household survey data collected from 521 rural households across three distinct Weredas (districts) (Tahtay Maichew, Kola Tembien, and Kilte-awlaelo). A Binary Probit model was employed to identify factors influencing migration decisions, while an Endogenous Switching Regression (ESR) model was used to estimate the impact of migration on food consumption outcomes while controlling for selection bias and unobserved heterogeneity. Food security was measured using the Food Consumption Score (FCS) and dietary diversity indicators. The empirical results reveal that severe food insecurity is widespread, with over 60% of all surveyed households falling into the "Poor" food consumption category. Descriptive baseline comparisons show that migration and remittance transfers marginally shift the raw average FCS upward from 23.86 to 25.48. However, this impact is profoundly nuanced: remittances serve as an immediate consumption-smoothing safety net but run parallel to a "labor-lost" constraint that reduces own-production capacities, forcing households to rely increasingly on market purchases for staple foods. The findings reveal that migration creates short-term labor shortages in agricultural production; however, remittance inflows substantially improve household food consumption frequencies, particularly for pulses, vegetables, and other nutrient-rich foods. After accounting for self-selection bias and unobserved traits, the rigorous ESR estimates indicate that migration increases the Food Consumption Score of participating households by an average Treatment Effect on the Treated (ATT) of 10.75 points, shifting them into more secure dietary tiers. Moreover, remittances help households mitigate the adverse effects of drought and other shocks by relaxing liquidity constraints and supporting both food purchases and agricultural investments. The study recommends establishing target food security safety nets for non-remittance households, promoting scale-appropriate labor-saving agricultural technologies, expanding traditional communal labor-sharing innovations, and boosting irrigation and agricultural input support programs to enhance rural food security and livelihood resilience.

Background Recent mouse model data demonstrate that chronic colonization with toxigenic Clostridioides difficile promotes colonic tumorigenesis via intraluminal toxin B (TcdB), its main virulence factor. In a prior multisite hospital cohort, we found that history of positive tcdB stool testing was associated with increased CRC risk in a dose-dependent manner, though limited by small sample size. We aimed to validate this association in a larger cohort with extended follow-up and greater geographic distribution using the Veterans Health Administration (VHA) Corporate Data Warehouse (CDW). Methods We conducted a retrospective cohort study among adults receiving care through the VA from 2000-2025 who underwent C. difficile testing. Data collected from the VHA CDW and National Death Index (NDI) included demographics, comorbidities, medications, CRC risk factors, and cancer incidence and death. The first C. difficile test date defined cohort entry; individuals with prior CRC were excluded. Ever C. difficile positivity was defined by a positive PCR or EIA results. The number of positive tests (episodes) was also determined to define recurrent positivity. Follow-up time ended at the first occurrence of CRC incidence or mortality, death from other causes, or censor date. Follow-up time was split for individuals who converted from negative to positive, with follow-up time updated accordingly. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) for C. difficile exposure and CRC incidence and mortality after adjustment for confounders. Tests for linear trend and tests for interaction were conducted to assess effect modification by sex and IBD status, while time-lag intervals were evaluated for 1, 3, 5, and 10 years before the outcome. Results Among 806,844 veterans with C. difficile testing, those with positive tests were more likely to be older, male, to have diabetes, to use aspirin, and to have a lower BMI than those with negative tests. Race and IBD prevalence were similar between the groups. There was no overall association between ever C. difficile positivity and CRC incidence (HR = 0.99, 95% CI 0.93-1.05). However, recurrent C. difficile positivity was associated with increased risk in a dose-response manner [2-3 episodes HR = 1.30 (95% CI 1.16-1.47), and >3 episodes HR = 1.58 (95% CI 1.17-2.14) compared to negative tests; ptrend< 0.001]. Further, ever C. difficile positivity was associated with increased CRC mortality risk (HR = 1.21, 95% CI 1.13-1.30; p < 0.001). Recurrent C. difficile positivity was associated with increased mortality risk but was particularly strong for those with >3 episodes among individuals with IBD (HR=3.84, 95% CI 1.98-7.45). In sensitivity analyses, the increased risk of CRC incidence and mortality attenuated beyond 10 years. Conclusion Prior positive C. difficile testing was associated with increased CRC incidence and mortality in a dose-dependent manner, particularly among patients with IBD. These findings extend animal model evidence, epidemiologically establishing C. difficile presence as an independent risk factor for subsequent colorectal tumorigenesis and supporting investigation into recurrent CDI, especially among patients with IBD, as a potential modifiable CRC risk factor.

Objective To determine if it is possible to assess individual patient risk of the development of colorectal cancer (CRC) in people in high-risk groups due to their family history. Design/Method Retrospective observational study of prospectively collected data from consecutive patients referred for a colonoscopy. 2,478 consecutive patients were referred to a single colorectal surgical practice in Sydney, Australia between 1977 and 2018 for a colonoscopy because of a family history of CRC. Of these, 1,963 have been followed for more than 10 years and are the subject of this paper. Histopathological findings categorised as normal (N), non-advanced adenoma (NAA) or advanced neoplasia (AN) with AN proven to be the precursor to CRC. Intervention Colonoscopic screening on the basis of contemporary practice to 2006 and subsequently according to Australian National Health and Medical Research Council guidelines. Results Participants with normal or low-risk findings in the first decade remain at lower risk of CRC for 30 years from the commencement of screening. Conclusion It is possible to stratify individual patients in a high relative risk cohort into those with high or low personal risk of CRC based on colonoscopic findings in the first 10 years of surveillance. Those with no AN in the first ten years have a lower 30-year risk of developing AN than the general community. This offers the possibility of structuring surveillance programs around individual risk rather than group risk, lessening the need for multiple surveillance colonoscopies in the majority of such patients and improving the cost effectiveness of CRC screening at the population level.

Introduction. Routine childhood immunisation is frequently disrupted in conflict-affected settings, leaving many children unvaccinated (zero-dose [ZD]). Their vaccination is now a global priority, but published evidence on restoring immunisation services in these settings is limited. We evaluated a nurse-led, community-based Expanded Programme on Immunisation adapted to a conflict-affected setting in Myanmar, focusing on factors associated with full immunisation (FI) among ZD children. Methods. This mixed-methods observational cohort study enrolled children from November 2023 to December 2025; analyses of FI outcomes were restricted to children enrolled >=18 months, with primary analyses focused on ZD children. Associations between programme delivery factors including vaccination opportunity (the ratio of vaccination sessions available to visits required for FI based on age and vaccination schedule [accelerated versus routine]) and FI were assessed using mixed-effects logistic regression with a random intercept for site. Programme cost and qualitative data from document review and questionnaires were also analysed. Results. Of 13,263 children enrolled, 6563 (49%) were in the analytic cohort; 2,684 (20%) were ZD. Among ZD, 452 (17%) were FI at 12 months and 1329 (50%) at 18 months. Accelerated schedule (OR 3.00, 95% CI 1.11-8.13) and greater vaccination opportunity (OR 2.1 per 0.5 unit increase in opportunity, 95% CI 1.8-2.4) were strongly associated with FI at 12 months, with smaller effects at 18 months. The cost per fully immunised ZD child was US$147, primarily reflecting substantial vaccine costs. Qualitative findings indicate that community engagement increased demand and access, but insecurity and logistical challenges limited service continuity and vaccination opportunities. Conclusion. FI improved over time but remained suboptimal through 18 months. Vaccination opportunity and schedule influenced the timing of FI, but sustained follow-up was critical for completion. Community-based delivery enabled restoration of immunisation services where formal systems had collapsed, demonstrating what is possible and what it demands in active conflict.

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.

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. The recent approval of long-acting monoclonal antibodies (la-mAbs) and a maternal vaccine (MV) in the EU enables universal RSV prevention in infants. Modelling studies are widely used to quantify the population-level impact of alternative immunisation strategies. However, existing assessments of new RSV immunisation products focus on national or sub-national settings. Methods. We developed an age-stratified, stochastic compartmental model of RSV transmission for 28 EU/EEA countries. It combines literature-based parameters on RSV natural history and product efficacy with country-specific demographic and contact patterns. After model calibration against age- and country-specific RSV hospitalisation rates, we designed scenarios for both la-mAbs and MV at four coverage levels, with and without catch-up immunisation for infants under six months at season onset. We then evaluated each scenario against a no-immunisation baseline. Results. At 95% coverage, the cross-country median reduction in RSV hospitalisations over one season in infants under 12 months is 29.9% for la-mAbs (country median range: 27.7-33.9%) and 22.4% for MV (20.0-25.6%), scaling linearly with coverage. Out of all averted hospitalisations, 78.3% (90% CI: [67.3, 92.7]%) are concentrated in infants aged 0-2 months for la-mAbs and 72.7% (90\% CI: [61.4, 88.6]%) for MV. A catch-up campaign nearly doubles the overall reduction in RSV hospitalisations. Conclusions. Despite country-specific heterogeneities, impact of la-mAbs and MV is comparable across settings and herd-immunity effects are largely negligible. This supports harmonised European guidelines on coverage targets. Seasonal catch-up campaigns emerge as an effective lever to maximise the impact of immunisation programmes.