The Lancet Regional Health - Western Pacific

Although the co-occurrence of diarrhea and malnutrition is well documented, research has largely focused on the acute management of diarrheal illness. Despite its importance, longitudinal evidence characterizing post-diarrheal recovery trajectories is sparse. We sought to characterize post-diarrheal nutritional recovery trajectories among children aged 6-35 months who were malnourished at enrollment using data from the Enterics for Global Health (EFGH) Shigella Surveillance study (2022-2024). EFGH enrolled children aged 6-35 months presenting with medically-attended diarrhea and followed them at 4 weeks and 3 months post-enrollment. This analysis included children with baseline wasting, stunting, or underweight (z-score < -2) and complete anthropometric follow-up. Latent class mixed-effects models were used to identify distinct post-diarrheal growth trajectories based on changes in anthropometric z-scores over time. Multinomial modified Poisson regression models examined associations between baseline factors and trajectory membership. Among 9,480 enrolled children, 16.5% (n=1,561) were wasted, 22.7% (n=2,155) stunted, and 21.0% (n=1,994) underweight at baseline. Wasting showed greater recovery potential (80.8%) compared with stunting (38.5%) and underweight (40.3%). Recovery was shaped by factors across multiple levels. Clinical severity markers ( prolonged diarrhea, dehydration, and hypoxemia) increased the risk of nutritional failure. Age also influenced outcomes: infants were more likely to worsen, whereas older toddlers more often experienced stagnation. Interventions including exclusive breastfeeding, oral rehydration therapy, appropriate antibiotics, and zinc supplementation, improved outcomes, while unimproved sanitation undermined recovery. These findings highlight the need for integrated strategies combining infection control, nutritional rehabilitation, and water, sanitation, and hygiene interventions tailored to the childrens developmental stage. Key MessagesO_LIPost-diarrheal nutritional recovery is highly heterogeneous, with wasting showing the greatest potential for improvement, while stunting and underweight often result in persistent growth stagnation. C_LIO_LIBaseline anthropometric deficits alone are insufficient to predict recovery, highlighting the need for dynamic monitoring and individualized management. C_LIO_LIInfants are particularly vulnerable to acute nutritional deterioration, while older toddlers frequently experience growth stagnation. C_LIO_LIModifiable protective factors including exclusive breastfeeding, ORS, zinc, and appropriate antibiotics, improved outcomes, whereas poor sanitation undermined recovery. C_LIO_LIIntegrated strategies, tailored to a childs developmental stage, combining clinical care, nutrition, and environmental interventions are critical to support sustained child growth and development. C_LI

Background: Child acute malnutrition remains persistently above emergency thresholds in Chad's Sahelian drylands, with a predictable, but rarely recognized, dry season peak linked to declining pasture and livestock productivity, reduced milk availability and heightened exposure to zoonotic infections. Humanitarian responses remain largely reactive and treatment-focused, with limited evidence on preventive strategies that address drivers embedded in local livelihood systems. We evaluated the effectiveness and return on investment (ROI) of an integrated livestock management intervention designed to prevent the dry-season peak of child acute malnutrition in pastoral and agro-pastoral communities in Chad. Methods: We conducted a cluster-randomised controlled trial in Kanem and Barh-El-Gazel provinces, Chad. Seventy-six villages were randomised (1:1) to intervention or control. Eligible households had at least one child aged 6-59 months and access to milking livestock during the dry season. The intervention (December 2024-June 2025) combined livestock feed supplementation to sustain milk production near households during the dry season, household-level zoonotic risk mitigation, and nutrition counselling. Primary outcomes were the prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) at the dry-season peak (May 2025), assessed in a prespecified random subsample of 52 clusters. All 76 clusters were assessed post-peak (July 2025). Analyses followed an intention-to-treat approach using mixed-effects models. A societal ROI analysis was conducted over six months with projections to 24 months. Findings: At the dry-season peak, 821 children 6-59 months from 521 households were assessed across 52 villages. GAM prevalence was 22.2% in intervention villages versus 47.4% in controls (adjusted OR 0.29 [95% CI 0.18-0.49]; p<0.001), and SAM prevalence was 4.4% versus 19.4% (adjusted OR 0.17 [0.08-0.37]; p<0.001). Intervention households had higher daily milk availability (+588 mL per household; p<0.001), and children consumed more milk (+102 mL per day; p=0.008). Odds of self-reported diarrhoeal disease and acute respiratory infection were substantially lower among children in intervention villages (aOR 0.21 [0.10-0.44] and 0.22 [0.11-0.46], respectively). Post-peak, women's dietary diversity increased (aOR 3.68 [1.90-7.13]), alongside reduced workload, lower household food insecurity and distress livestock sales, improved livestock condition, and a benefit-cost ratio of 5.40 at six months, rising to 16.40 at 24 months. Interpretation: Protecting livestock productivity and sustaining children's access to milk while reducing zoonotic exposure during the pastoral lean season effectively prevents seasonal peaks of child acute malnutrition. This integrated anticipatory action and One Health livelihood-based approach offers a scalable, dignifying, high-return lifesaving preventive model for pastoral and agro-pastoral humanitarian settings.

Comprehensive and responsive interventions are increasingly prioritized to address the diverse and evolving health challenges faced by mothers and children during the first 1,000 days of life. However, evidence remains limited on how such interventions can be operationalized in low-resource settings without overstretching frontline health workers. We developed a comprehensive yet flexible community-based intervention, the Healthy Future program, which integrates a stage-based maternal and child health curriculum with mHealth-enabled infrastructure to deliver targeted, stage-based support through home visits in low-resource settings. We evaluated its impact through a cluster-randomized controlled trial across 119 rural townships in China. The program demonstrated improvements across multiple health, behavioral, and intermediate outcomes, including young child feeding practices, caregiving knowledge, maternal mental health, and perceived social support. Overall, this study illustrates a move beyond stand-alone interventions toward a scalable, multidimensional delivery model capable of providing comprehensive, flexible, and timely support to mothers and children in low-resource communities while remaining feasible for large-scale implementation.

Mainland China experienced multiple waves of COVID19 pandemic during 2020 2022, driven by emerging variants and changes in public health and social measures (PHSMs). We developed a hypergraph-based Susceptible Vaccinated Exposed Infectious Recovered Susceptible (SVEIRS) model to reconstruct epidemic dynamics across 31 provinces, capturing transmission heterogeneity associated with clustered contacts. We assessed key characteristics of transmission at national and provincial levels during four outbreak periods: initial, localized predelta, Delta, and widespread Omicron, which accounted for 96.7% of all infections. We found significant diversity in transmission contributions across cluster sizes, with a small fraction of larger clusters responsible for a disproportionate share of infections. Counterfactual analyses showed that reducing clustersize heterogeneity, while holding overall exposure constant, could have lowered national infections by 11.70 to 30.79%, with the largest effects during Omicron period. Ascertainment rates increased over time but remained spatially heterogeneous with a range: (14.40, 71.93)%. Population susceptibility declined following mass vaccination (to 42.49% in Aug 2021, nationally) and rebounded (to 89.89% in Nov 2022) due to waning immunity with variations across the provinces. Effective reproduction numbers displayed marked temporal and spatial variability, with higher estimates during Omicron. Overall, these results highlight critical role of group contact heterogeneity in shaping epidemic dynamics.

Background: Rectal cancer (RC) is traditionally grouped within colorectal cancer (CRC), despite growing evidence of distinct epidemiologic features. However, global comparative assessments of lifetime risks of RC relative to CRC remain limited. We aimed to estimate lifetime risks of developing and dying from RC and CRC worldwide and to examine geographic, socioeconomic, and temporal variations in the proportional contribution of RC within CRC. Methods: Age-specific incidence and mortality estimates for RC and CRC across 185 countries were obtained from GLOBOCAN 2022, together with population and all-cause mortality data from the United Nations. Lifetime risks of incidence (LRI) and mortality (LRM) were calculated using the adjusted-for-multiple-primaries (AMP) method by sex, country, region, and Human Development Index (HDI). The RC-to-CRC lifetime risk ratio quantified the proportional contribution of RC. Temporal trends were assessed in 42 countries using Cancer Incidence in Five Continents Plus (CI5plus) data and average annual percent change (AAPC). Results: In 2022, the global lifetime risk of developing RC was 1.61% and dying from RC was 0.95%, accounting for approximately 35% of the corresponding CRC lifetime burden (4.61% and 2.68%). Absolute lifetime risks of both RC and CRC increased with HDI. In contrast, the proportional contribution of RC varied markedly, peaking at 41%-43% in Central and South-Eastern Asia but falling below 20% in the Caribbean and Central America, and showed a negative association with HDI. The LRI/LRM ratio increased with socioeconomic development. Temporal analyses showed increasing LRI trends in 17 of 42 countries for CRC versus 9 for RC, while declines occurred in 14 countries for RC and 11 for CRC. Conclusions: RC constitutes a substantial yet epidemiologically distinct component of the global CRC burden. Its proportional contribution varies across regions and does not parallel absolute risk patterns, supporting the need for subsite-specific surveillance and prevention strategies.

Drowning remains a major global public health challenge, yet how built environment characteristics shape population-level drowning risk remains poorly understood. This study linked satellite-derived built environment data to subnational drowning mortality estimates across 203 regions in 12 countries from 2006-2021. It found that built environment associations with drowning mortality are complex, non-linear, and shaped by development context. Urban extent was strongly protective, while built area near water showed protection overall but increased risk when combined with high population crowding. Almost all drowning mortality variance occurred between regions rather than within regions over time, indicating risk is predominantly determined by place-based characteristics. Income-stratified analyses revealed profound heterogeneity: crowding was protective in low-to middle-income settings but near-null in high-income regions, while waterfront development captured very different realities across contexts. These findings highlight the importance of tailoring drowning prevention strategies to local built environment configurations and development contexts.

BackgroundDrowning remains a major global public health challenge. This study examined whether the timing and trajectories of urbanisation--beyond the current built environment--are associated with subnational drowning mortality. MethodsWe linked satellite-derived measures of built-environment change (GHSL), population crowding (WorldPop), surface water exposure (JRC Global Surface Water), and infrastructure proxies (VIIRS/DMSP nighttime lights) to GBD 2021 drowning mortality estimates across 203 ADM1 regions in 12 countries (2006-2021; 3,248 region-year observations). Temporal predictors captured recent expansion, development "newness" ([&le;]10-year built share), acceleration/volatility, and a crowdingxgrowth interaction. We screened predictors using LASSO (10-fold cross-validation) and fitted mixed-effects models with region random intercepts. Distributed-lag models tested temporal precedence and development age, and income-stratified models assessed heterogeneity. ResultsAdding temporal predictors improved fit beyond contemporaneous built-environment measures ({Delta}AIC=177; {Delta}BIC=147). In adjusted models, crowdingxgrowth was strongly positively associated with drowning mortality, and a higher share of recent development was associated with higher mortality. Lag models showed a development age gradient: older built environment was most protective. Associations differed by income group, with several key coefficients reversing sign across strata. DiscussionDrowning mortality appears shaped by development histories as well as present-day conditions, with risk concentrated in rapidly changing, dense settings and the newest built environments. Cross-context heterogeneity suggests mechanisms and prevention priorities are unlikely to be uniform. ConclusionsDevelopment timing and trajectories help explain subnational drowning mortality beyond current built form alone. Prevention and planning should prioritise transition-period safety strategies in newly developing and rapidly densifying areas.

Cameroon introduced Human papilloma virus vaccine (HPVV) into the routine immunization schedule in October 2020. By the end of 2022, coverage remained low. To increase coverage, Cameroon switched to a country-wide, gender-neutral vaccination (GNV) approach in 2023, coupled with a revamped delivery strategy consisting of Community Dialogues (CDs) and Periodic Intensification of Routine Immunization (PIRIs) activities in selected health districts (HDs). We assessed the impact of these programmatic changes, notably the GNV approach, on HPVV coverage. This retrospective, cross-sectional study measured the effect of GNV and CDs + PIRIs on HPVV coverage among 9-year-old girls in Cameroon (2022-2023). Data on HPVV coverage from all 203 HDs were extracted from DHIS2, and coverage was calculated at the HD level, based on the estimated population eligible of 9-year-old girls. Descriptive statistics and multiple regression models were employed to assess the impact of GNV on vaccination coverage while adjusting for CDs + PIRIs and urban/rural status. In 2023, of the 203 HDs, 115 (56.7%) conducted GNV only, 74 (36.5%) implemented GNV & CDs + PIRIs, and 75.9% (154) were classified as rural. Among age-eligible girls, there was an overall increase in HPV vaccination coverage, with coverage rising 39.2 percentage points from 2022 to 2023. Following multiple linear regression, there was a significant increase in HPVV coverage in HDs with GNV & CDs + PIRIs compared to those with no GNV and no CDs + PIRIs ({beta}:55.5%, 95%CI: 38.7, 72.3, p=0.000). Furthermore, there was a significant increase in HPVV coverage in HDs with GNV only compared to those with no GNV or no CDs + PIRIs ({beta}:28.7%, 95%CI: 12.5, 45.0 p=0.001). Overall, the GNV approach increased HPVV coverage for girls significantly, particularly when implemented alongside CDs + PIRIs.

Globally, respiratory tract infections (RTI) are the main cause of morbidity, and in Low-middle-income countries (LMICs) RTI including pneumonia are a leading cause of morbidity and mortality in children <5 years. Diarrheal illness increases RTI risk in young children through micronutrient depletion, and immune stress, yet data on post-diarrhea RTI burden in LMICs are limited. We determined the prevalence and risk factors of RTI within three months following medically-attended diarrhea (MAD) in children aged 6-35 months enrolled in seven EFGH country sites in Asia, Africa and South America. The EFGH study prospectively enrolled children aged 6-35 months with MAD in selected health facilities during a 24-month period from 2022 to 2024 and followed them for three months. RTI was defined as cough or difficulty breathing and the presence of one of the following symptoms at any scheduled or unscheduled visit during follow-up: stridor; fast-breathing; oxygen saturation <90%; or chest indrawing. The period prevalence and 95% confidence intervals of RTI were calculated, and correlates of RTI were assessed using modified-Poisson regression. From June 2022 to August 2024, 9,476 children aged 6-35 months presenting with MAD in the EFGH study sites were screened: 9,116 (96.2%) included in the current study. Nearly half were female (46.7%), and median age was 15 months. Overall, 48.5% received all age-appropriate vaccines, and 87.6% received the pneumococcal vaccine, with significant variation across countries. Nearly one-quarter of children were stunted, 17.2% wasted, and 21.9% underweight. RTI occurred in 3.8% of children during the three-month follow-up, mostly within the first month. Higher prevalence of RTI occurred among children aged 12-23 months (8.7%), those undernourished (16.1%), unvaccinated (4.0%) or living in poor sanitation settings (4.1%). While children who received all age-appropriate or pneumococcal vaccinations had a lower crude prevalence of RTI, these associations were not statistically significant after adjusting for age, sex and study site. RTI was infrequently observed in the three months following MAD presentation, with significant variability by site and with the highest prevalence in Malawi. RTI risk was highest in 12-23-month-olds and among children with undernutrition, and those living in poor sanitation conditions.

Typhoid fever remains a significant public health challenge in low- and middle-income countries. In 2018, The World Health Organization recommended a single dose typhoid conjugate vaccine (TCV) for routine immunization in endemic settings; however, evidence guiding booster doses remains limited. Homologous TCV booster doses have demonstrated immune boosting. This study assessed the immunogenicity and safety of a heterologous booster using a Vi capsular polysaccharide-CRM197 TCV (Vi-CRM) administered 5-6 years after primary vaccination with a Vi capsular polysaccharide tetanus toxoid TCV (Vi-TT) in children. Children previously enrolled in a Phase 2 trial were recruited. Participants who had received TCV at 9-11 or 15-23 months were given a Vi-CRM booster at 6-7 years of age (Booster-TCV group), and controls received their first TCV dose at the same age (1st-TCV group). Serum anti-Vi IgG concentrations were measured at baseline and 28 days post-vaccination. Solicited and unsolicited adverse events (AEs) and serious adverse events (SAEs) were recorded. Among 147 children enrolled, 87 received a second and 60 received a first TCV dose. Baseline anti-Vi IgG geometric mean titers (GMT) were higher in the Booster-TCV group (21.5 EU/mL; 95% CI: 17.2-26.8) than in the 1st-TCV group (5.5 EU/mL; 95% CI: 4.5-6.7). At day 28, GMTs rose markedly in both groups: 5140.0 EU/mL (95% CI: 4302.0-6141.3) in the Booster-TCV group and 2084.8 EU/mL (95% CI: 1724.4-2520.5) in the 1st-TCV group. Local reactions and systemic AEs were mild. No SAEs were observed. Vi-TT-induced immunity persisted for at least 5-6 years, and a heterologous booster triggered a strong immune response with universal seroconversion. These findings support heterologous prime-boost strategies to maintain protection in school-age children and inform optimization of TCV schedules in endemic regions.

Background Ambient air pollution is a leading global health risk and disproportionately affects populations of Low- and Middle-Income Countries (LMICs). In 2021, WHO revised its Air Quality Guidelines (AQG), lowering recommended annual limits for Particulate Matter 2.5 (PM2.5) and Nitrogen Dioxide (NO2). We estimated the potential health and economic impacts of achieving WHO Interim Target 3 (IT3) and AQG concentrations across LMICs. Methods We conducted a health impact assessment across 136 LMICs to quantify one-year changes in all-cause and cause-specific mortality (chronic obstructive pulmonary disease [COPD], ischaemic heart disease [IHD], and stroke) and disease incidence (COPD, dementia, IHD, and stroke) under WHO IT3 and AQG counterfactual scenarios for PM2.5 and NO2. Concentration-response functions were applied at 1km x 1km resolution. Economic welfare impacts of mortality risk reductions were estimated using country-adjusted values of a statistical life (VSL, Int$ PPP-adjusted 2021). Direct medical and productivity-related costs associated with incident cases were estimated using a cost-of-illness (COI) framework. Uncertainty intervals (UI) reflect uncertainty in concentration-response functions. Results Attainment of WHO IT3 and AQG concentrations for PM2.5 was associated with an estimated 16.04% reduction (6.58million, UI: 6.10-7.07million) and 22.97% reduction (9.43million, UI: 8.75-10.11million) in annual deaths, respectively. Corresponding VSL-based estimates of deaths averted were Int$5.5 trillion (7.0% of aggregate LMIC GDP) and Int$8.4 trillion (10.6% of GDP), respectively. For NO2, IT3 and AQG scenarios were associated with estimated reductions of approximately 1.06% (approximately 435,000 deaths, UI: 388,000-483,000) and 2.79% (435,000 deaths; UI: 388,000-483,000), yielding gains of Int$0.6 trillion (0.7% of GDP) and Int$1.5 trillion (1.9% of GDP). Disease-specific mortality reductions were most prominent for IHD and stroke in Asia and Africa. Under the PM2.5 AQG scenario, an estimated 2.82million (1.67-2.97) COPD, 1.10million (0.83-1.37) dementia, 7.3million (6.41-8.19) IHD, and 2.3million (2.19-2.41) stroke cases could be delayed or averted in one year. Associated reductions in direct medical and productivity-related costs were greatest for IHD, COPD, and stroke. NO2-related morbidity reductions were smaller across all outcomes. All estimates represent one-year changes in risk relative to counterfactual exposure and may reflect delayed rather than permanently avoided events. Discussion Achieving both WHO IT3 and AQG values in LMICs could yield substantial reductions in premature mortality and disease incidence, particularly for cardiovascular and respiratory conditions, alongside large, monetised welfare gains from reduced mortality risk. These findings underscore the considerable societal value of air quality improvements and support accelerated action toward meeting WHO guideline levels in regions bearing the highest pollution burden.

Objectives: Group B Streptococcus (GBS) is a leading cause of neonatal mortality worldwide. However, the global burden of early-onset GBS disease (EOD-GBS) has not been fully elucidated. We aimed to describe the geographical distribution and epidemiological characteristics of the EOD-GBS burden, and analyze its association with socio-economic development and universal health coverage. Methods: We used data from the Global Burden of Disease Study 2021 and the Universal Health Coverage Service Coverage Index (UHC-SCI) to calculate estimated annual percentage changes (EAPCs) of EOD-GBS mortality. Sex differences were analyzed using the conservative overlap assessment. The geographical distribution of EOD-GBS clinical presentations and mortality was mapped. Health inequality analysis was conducted to evaluate the relationship between the sociodemographic index (SDI), UHC-SCI, and EOD-GBS burden. Results: Global EOD-GBS mortality decreased by nearly 50% from 1990 (693.41 per 100,000) to 2021 (348.80 per 100,000). However, the decline was not uniform: the most significant decrease occurred in high-middle SDI regions (EAPC: -7.17%), and the slowest in low SDI regions (EAPC: -2.23%). Male neonates accounted for the most EOD-GBS deaths, particularly in high SDI regions. Lower respiratory infections were common in Asia and Oceania; meningitis was more prominent in Europe. Inequality analysis revealed a phenomenon of "absolute convergence but relative differentiation": as social development and universal health coverage improves, the absolute mortality gap between countries narrowed, but relative burden concentrated increasingly among the poorest populations. Conclusions: The global burden of EOD-GBS has decreased substantially, but there are marked differences among countries. Continued socioeconomic development and expanded universal health coverage are critical to further reduce neonatal mortality.

Background Nigeria has experienced its largest recorded diphtheria outbreak since late 2022, centred on Kano State, where facility-based surveillance documented over 25,000 confirmed cases. The true community burden remains unknown. We conducted a population-based household survey to estimate community attack rates, mortality, vaccination coverage, and determinants of infection and death. Methods We performed a retrospective household survey (September-October 2024) using spatially randomised cluster sampling (65 clusters, ~15 households each; recall period January 2023 to interview). Survey-weighted analyses, multivariable logistic regression, and sensitivity analyses were used. Findings We enrolled 7,998 individuals from 1,068 households. The community attack rate was 1.1% (95% CI 0.7-1.4), 4.2 times (2.7-5.3) higher than facility-based estimates. The case fatality ratio was 8.8% (1.9-15.6) overall and 21.3% among children under five; two thirds of deaths occurred at home. Delayed care-seeking of four or more days was associated with markedly higher mortality (risk ratio 32.6, 95% CI 2.4-450.0). Vaccination was strongly protective against death (vaccine effectiveness 57%, 95% CI 34- 72%; E-value 4.07). Among campaign-eligible children, routine EPI coverage was 56.6%; the reactive campaign reached few previously unvaccinated children (99.7% overlap with prior recipients), leaving 11.6% of eligible children unvaccinated. Interpretation Community diphtheria burden substantially exceeded facility surveillance estimates, with most deaths occurring outside the health system. Delayed care-seeking and low vaccination coverage were the main drivers of mortality, highlighting the need for improved community surveillance, decentralised care, and better-targeted vaccination.

Introduction Cesarean delivery accounts for nearly one-third of U.S. births and is associated with substantial maternal morbidity and health care costs. Persistent racial disparities have been documented, yet the structural factors contributing to these differences remain incompletely understood. The extent to which insurance coverage shapes racial disparities in cesarean delivery remains unclear. Objective To evaluate the independent and interactive associations of race/ethnicity and insurance coverage with cesarean delivery in the United States. Methods Population-based retrospective cohort study using singleton live births recorded in the United States Vital Statistics Natality files from 2014 to 2024. Multivariable logistic regression was used to estimate the independent effects of race/ethnicity and insurance status on cesarean delivery, including interaction terms to test effect modification, using national birth certificate data. Models were adjusted for maternal demographics, clinical factors, and temporal covariates. Adjusted odds ratios, predicted probabilities, and absolute risk differences were derived from post-estimation marginal effects. The main outcome measure was cesarean delivery (yes vs no). Results Among 41,543,568 deliveries from 2014 to 2024, 13,312,221 (32.0%) were cesarean deliveries. After adjustment, both race and ethnicity and insurance status were independently associated with cesarean delivery. Compared with non-Hispanic White women, non-Hispanic Black women had higher odds of cesarean delivery (odds ratio [OR], 1.22; 95% CI, 1.22-1.23). Relative to uninsured women, those with private insurance had 59% higher odds of cesarean delivery (OR, 1.59; 95% CI, 1.58-1.60). Significant interaction effects were observed, indicating that insurance coverage modified racial and ethnic differences in cesarean delivery. Non-Hispanic Black women had the highest predicted probabilities across all insurance categories, with the largest absolute disparities observed among uninsured women. Conclusion Racial and ethnic differences in cesarean delivery persist in the United States and are modified by insurance coverage, suggesting that coverage-related differences may contribute to inequities in obstetric care.

Background: Several large multisite studies have been conducted to describe etiology-specific burden of diarrhea among children in low-resource settings. Here, we combined data across studies to describe geographic and temporal trends in incidence and attributable fractions (AFs) of etiology-specific moderate-to-severe diarrhea (MSD), and to evaluate etiology-specific case fatality ratios (CFRs). Methods: We harmonized case definitions and analytic methods across the Global Enteric Multicenter Study (GEMS), Malnutrition and Enteric Disease (MAL-ED), Vaccine Impact on Diarrhea in Africa (VIDA), AntiBiotics for Children with severe Diarrhea (ABCD), and Enterics for Global Health (EFGH) studies. Cases were 6-35-month-olds with acute MSD. Incidence estimates for GEMS, VIDA, and EFGH were adjusted for enrollment, healthcare seeking, and diagnostic testing. AFs were calculated as the proportion of MSD cases attributed to each etiology, and CFRs were estimated within 14 and 90 days of an MSD episode. Findings: Pre-rotavirus vaccine introduction, rotavirus had the highest incidence and was the leading etiology among 6-11-month-olds, accounting for approximately 22-28% of MSD; the proportion of diarrhea due to rotavirus declined following vaccine introduction, with average AF 10-11% in Africa and Asia. Shigella incidence was highest among 12-23-month-olds and was the dominant etiology among 12-23 and 24-35-month-olds, causing approximately one-third to one-half of MSD. Overall, 90-day mortality declined substantially over time, from 2.21% in GEMS to 0.30% in EFGH. Bacterial (2.52%) and protozoal pathogens (3.55%) had higher average CFRs than viral pathogens (1.42%). Conclusion: Harmonized analysis of five multisite studies reveals consistent evidence that rotavirus and Shigella are the dominant causes of MSD in children under three years in low-resource settings, with burden shifting toward Shigella following rotavirus vaccine introduction.

Child undernutrition remains a major public health challenge in Kenya. Suboptimal feeding practices contribute significantly to persistent underweight and stunting. This study evaluated the effect of a community-based Positive Deviance Hearth (PDH) intervention on feeding practices among children aged 6-59 months in Sub County within a County of study. The study adopted a two-group pretest-posttest randomized experimental study design conducted for six months period, among 84 caregiver-child pairs in intervention and control groups. A multi-stage sampling was employed to identify study settings and participants. Structured and pretested questionnaires, 24-hour food recall questionnaires and meal diversity questionnaires were used for data collection at pre-intervention and post-intervention periods. Data was analyzed using R software v.4.5.2. The differences between intervention and control groups at baseline and endline were assessed using difference-in-difference analysis, relevantly summarized using adjusted DID estimates, 95% confidence intervals and p-values, with p<0.05 considered significant. The PDH intervention significantly improved feeding practices among children 6-59 months. Meal frequency increased for 9-23 months (DiD = +1.4; 95% CI: 1.2-1.7; p = 0.034) and 24 months and above (DiD = +1.2; 95% CI: 1.1-1.5; p = 0.017), and dietary diversity rose (DiD = +1.3; 95% CI: 1.1-1.9; p < 0.001). Nutrient-dense food consumption improved, including legumes (DiD = +32.6%; p < 0.001) and animal-source foods (DiD = +35.4%; p < 0.001). Energy and protein intake increased across all age groups (p < 0.05), and micronutrients iron, vitamin A, vitamin C also rose significantly (p < 0.05). The PDH intervention substantially improved caregiver feeding practices, increased dietary diversity, and enhanced macro- and micronutrient intake, demonstrating its effectiveness as a scalable, community-driven strategy for sustainably improving child nutrition in high-burden settings.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

Introduction Acute malnutrition in children aged 6-23 months remains critical in Tigray, Ethiopia, where global acute malnutrition (GAM) rates have reached emergency levels. Small-quantity lipid-based nutrient supplements (SQ-LNS) show promise for prevention, but evidence from post-conflict settings is limited. Objective This study evaluated SQ-LNS effectiveness in preventing acute malnutrition and rightward shifting in the distribution of weight-for-height among young children in post-conflict Tigray, Ethiopia. Methods A non-randomized cluster trial enrolled 8,442 children aged 6-23 months across four districts. The intervention group (n=6,838) received daily 20g SQ-LNS sachets for six months plus behavior change communication; the control group (n=1,604) received standard nutrition programming. Primary outcomes were acute malnutrition prevalence (WHZ < -2 or MUAC < 12.5cm) and distribution of weight-for-height z-scores. Data were collected biweekly and analyzed using longitudinal comparisons and difference-in-differences (DiD) estimation. Results Acute malnutrition declined from 22.1% to 4.2% in the intervention group (17.9 percentage point reduction) versus 19.6% to 11.4% in controls (8.2-point reduction). Mean WHZ scores increased from -0.35 to +0.33 in the intervention group (gain of +0.68 z-scores), while controls improved from -0.79 to -0.63 (gain of +0.16). The net intervention effect (DiD) showed a 4.9 percentage point reduction in WHZ-defined GAM and a 9.7-point reduction in MUAC-defined GAM. Mean WHZ and MUAC increased significantly more in the intervention group (DiD: +0.52 z-scores and +3.88 mm, respectively). Critically, the entire WHZ distribution shifted rightward, indicating population-level nutritional improvement, not merely reduced caseloads. Conclusions Six months of daily SQ-LNS effectively prevented acute malnutrition and shifted the entire weight-for-height distribution rightward among young children in post-conflict Tigray. Benefits extended beyond treatment, lifting whole-population nutritional status and building resilience. Findings support SQ-LNS inclusion in post-conflict nutrition packages and highlight the importance of assessing distributional outcomes, not just prevalence, when evaluating nutritional interventions. Trial registration number This trial was registered as NCT06103084.

Introduction: Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) has become less effective at preventing malaria due to rising parasite resistance. IPTp with dihydroartemisinin-piperaquine (DP) alone or in combination with SP (DP+SP) dramatically lowers the risk of malaria in pregnancy compared to SP but is associated with lower birthweight and early life wasting. We estimated the effect of IPTp-DP, DP+SP, and SP on infant growth outcomes and assessed possible treatment mechanisms through a causal mediation analysis. Methods: We used infant follow-up data (N=761) from a trial (NCT04336189) that randomized pregnant women to receive monthly IPTp-DP, SP, or DP+SP. We compared weight-for-length (WLZ) and length-for-age (LAZ) z-scores between treatment arms. We assessed possible mediation through pregnancy, birth, and infancy factors using interventional indirect effect models. Results: Compared to IPTp-SP, IPTp-DP+SP decreased mean WLZ by 0.18 [95% confidence interval (CI) -0.03, 0.39] between 1-3 months and 0.28 (95% CI 0.07, 0.49) between 4-6 months, with the largest differences among primigravidae. Lower risk of active placental malaria in IPTp-DP+SP helped reduce differences in mean WLZ vs IPTp-SP (+0.06, 95% CI 0.02, 0.10). The IPTp-DP+SP arm had up to 0.28 lower mean LAZ between 7-13 months compared to IPTp-DP, particularly among children who were wasted between 0-6 months; low birthweight had a persistent, mediating effect on linear growth. Conclusion: Adverse birth outcomes contributed to early growth faltering among children born to mothers receiving IPTp-DP+SP vs IPTp-SP, but the prevention of placental malaria partially counteracted the negative effects of IPTp-DP+SP on ponderal growth.

Background Diverse epigenetic clocks are known to capture health risks associated with increased adiposity, but their estimates have never been combined to represent a holistic estimate of biological age acceleration (BAA). There is also a gap in research using epigenetic clocks to study adiposity in lower-middle income Asian countries. Methods and Findings Data from 1,745 participants (21.7{+/-}0.3 years old, 45% female) of the Cebu (Philippines) Longitudinal Health and Nutrition Survey were analyzed. BAA was calculated using PCHorvath 2, PCHannum, PCPhenoAge, PCGrimAge, PCDNAmTL, and DunedinPACE. After ascertaining suitability for factor analysis (Kaiser-Meyer-Olkin 0.81), factor analysis was used to create PCFactorAge. Analogously, FactorAge was created using Horvath, Hannum, PhenoAge, GrimAge, DNAmTL, and DunedinPACE. BMI, waist circumference (WC), and waist-to-height ratio (WHtR) were used to represent adiposity. Linear regression was used to test the association of each adiposity measure with each BAA measure. BMI, WC, and WHtR were positively associated with both BAA combinations: 5 kg/m2 higher BMI corresponded to 0.097 (p=0.015) standard deviation (SD) increase in FactorAge and 0.099 (p=0.004) SD increase in PCFactorAge; 10 cm increase in WC--with 0.091 (p=0.005) SD increase in FactorAge and 0.094 (p<0.001) SD increase in PCFactorAge; 0.1 increase in WHtR--with 0.164 (p=0.001) SD increase in FactorAge and 0.163 (p<0.001) SD increase in PCFactorAge. Additionally, WHtR was associated with meaningful increases in PhenoAge, PCPhenoAge, PCHorvath 2, PCHannum, PCGrimAge, and DunedinPACE. WC was positively associated with PCHorvath 2, PCHannum, PCPhenoAge, and DunedinPACE. BMI was positively associated with PCHannum, PCPhenoAge, and DunedinPACE. Conclusions Our study presents a novel approach to creating a BAA estimate using multiple epigenetic clocks and shows that adiposity measures predict this factor in a young Filipino cohort.