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.

BackgroundGlobal under-5 mortality has declined by approximately 60% since 1990, driven largely by reductions in communicable, maternal, neonatal, and nutritional (CMNN) diseases. Yet the degree to which genetic disorders now impede further progress toward Sustainable Development Goal (SDG) 3.2 remains poorly quantified. No prior study has assessed the aggregate burden of genetically determined conditions as a unified category across the full spectrum of countries and development levels. MethodsUsing data from the Global Burden of Disease (GBD) Study 2021, we defined a composite "Total Genetic Burden" by aggregating 16 genetically determined causes of death, encompassing congenital birth defects, hemoglobinopathies, cystic fibrosis proxies, and spinal muscular atrophy proxies, across 204 countries and territories from 1990 to 2021. Age-standardized mortality rates (ASMR), proportional mortality ratios (PMR), years of life lost (YLLs), and 95% uncertainty intervals (UIs) were calculated. Temporal trends were assessed to evaluate the shifting burden over the study period. Age-specific mortality density was computed to identify periods of peak vulnerability. Deterministic frontier analysis (log-transformed quadratic quantile regression at the 5th percentile) was applied to quantify potentially avoidable mortality relative to best-observed global performance at each level of socioeconomic development. ResultsThe age-standardized mortality rate of genetic disorders in children under 5 declined from 1990 to 2021; however, the proportional mortality ratio nearly doubled (from 5.76% to 10.76%), and genetic disorders rose from the fifth to the third leading cause of under-5 death. This shift was most pronounced in high Socio-demographic Index (SDI) countries, where genetic disorders accounted for over 40% of all under-5 deaths in some nations (e.g., Libya, 46.32%). An "Epidemiological Paradox" emerged: absolute mortality correlated negatively with SDI (R = -0.79, P < 0.001), whereas proportional mortality correlated positively (R = 0.80, P < 0.001). Age-specific analysis revealed a "Neonatal Stronghold," with genetic disorders accounting for 57% of combined genetic-versus-infectious deaths in the first week of life but only 8% in children aged 1-4 years. Frontier analysis identified substantial efficiency gaps across all SDI quintiles; China and Japan sat on the effective frontier, while Afghanistan, Nigeria, and even the United States exhibited considerable potentially avoidable mortality. ConclusionsGenetic disorders have shifted from a secondary concern to a leading structural barrier to further reductions in child mortality. Achieving SDG 3.2 will require broadening global child health priorities beyond infection control to include prenatal screening, newborn screening programs, and pediatric surgical capacity building, particularly in low- and middle-income countries.

BackgroundCOVID-19 non-pharmaceutical interventions (NPIs) disrupted transmission of many infectious diseases worldwide. While disruption patterns are well-documented, systematic analysis of post-pandemic recovery trajectories across diverse pathogens remains limited. We examined disruption and recovery of 47 nationally notifiable diseases in Australia from 2015 to 2025. MethodsWe analysed NNDSS surveillance data for 47 diseases across six transmission modes, quantifying disruption using observed-to-expected (O/E) ratios against 2015-2019 baselines. We applied difference-in-differences (DiD) to estimate causal NPI effects, Kaplan-Meier survival analysis for time-to-recovery, and bootstrap 95% confidence intervals for cumulative immunity debt. ResultsDuring 2020-2021, 28 diseases decreased (median O/E 0.51), with border-sensitive and vaccine-preventable diseases most affected. DiD analysis estimated that border closures were associated with significantly greater suppression among import-dependent diseases (coefficient -0.50, 95% CI -0.90 to -0.10, p=0.016). By 2025, recovery was heterogeneous: 17 diseases exceeded baseline levels, 12 returned to expected levels, 15 remained below baseline (9 partially recovered, 6 in sustained suppression), and 3 had insufficient data for trajectory classification. Five diseases showed suppression-then-overshoot trajectories suggestive of immunity debt, though bootstrap 95% confidence intervals confirmed statistically significant cumulative excess for only one (rotavirus); for influenza, high baseline variability precluded statistical confirmation despite a large absolute overshoot. ConclusionsPost-pandemic disease recovery in Australia is heterogeneous and incomplete. Fifteen of 47 diseases have not returned to baseline levels by 2025, while 17 exhibit overshoot. These findings argue for differentiated surveillance of still-suppressed diseases and targeted catch-up vaccination in pandemic birth cohorts. Article summaryWe analysed disruption and recovery of 47 nationally notifiable diseases in Australia from 2015 to 2025, finding that 15 diseases remain below pre-pandemic levels three years after NPI relaxation. Border closures caused disproportionate suppression of import-dependent diseases, and recovery trajectories varied by disease characteristics, with immunity debt statistically confirmed for only one of five candidate diseases.

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.

Based on the 2023 Global Burden of Disease (GBD) database, this study analyzed the global burden of preterm birth from 1990 to 2023 and predicted its development trend by 2050, while exploring the disparities in disease burden across regions with different Socio-demographic Index (SDI) levels, income groups and countries. A retrospective trend analysis was conducted to collect data on preterm birth incidence, prevalence, death and disability-adjusted life years (DALYs) in 204 countries and regions worldwide from 1990 to 2023 from the GBD 2023 database. ARIMA model (p=2,d=1,q=1) and grey prediction model (GM(1,1)) were combined to predict the preterm birth burden from 2023 to 2050. In 2023, preterm birth was the primary cause of the global neonatal disease burden, with its four core indicators significantly higher than other neonatal diseases. From 1990 to 2023, the global incidence, death and DALYs of preterm birth decreased to 0.91, 0.44 and 0.52 times of the 1990 levels respectively, while the prevalence increased to 1.54 times of the baseline. Projection results showed that by 2050, the incidence, death and DALYs of preterm birth would drop to 0.79, 0.08 and 0.32 times of the 2023 levels, and the prevalence would rise to 1.23 times of 2023. Low SDI regions, lower-middle income countries, as well as India and Nigeria, bore the heaviest disease burden. Over the past three decades, the global acute health burden of preterm birth such as death has decreased notably, but the continuous rise in prevalence and severe regional and age disparities remain prominent public health challenges. The 0-6 days and 6-11 months age groups are the key time windows for preterm birth intervention. It is urgent to implement targeted prevention and control measures for low SDI regions and lower-middle income countries to reduce the global burden of preterm birth.

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.

Childhood malnutrition remains a major public health challenge in Ethiopia, where stunting and wasting co-exist but may arise from distinct spatial and etiological processes. Analyses focusing on a single outcome may overlook the interdependence of these conditions and their geographic heterogeneity. This study aimed to disentangle the determinants of stunting and wasting among children under five years of age using a Bayesian bivariate spatial modelling framework. Data from 5,405 children included in the 2019 Ethiopia Mini Demographic and Health Survey were analyzed. Stunting and wasting were modelled as correlated binary outcomes using Bayesian bivariate hierarchical geostatistical models implemented through SPDE-INLA, accounting for child, maternal, household, and environmental covariates, non-linear age effects, and spatial dependence. Model performance was assessed using the deviance information criterion, Watanabe-Akaike information criterion, and marginal log-likelihood. The bivariate model identified shared socio-economic and biological determinants. Multiple births, male sex, low maternal education, a higher number of under-five children, and household poverty were associated with increased risks of both outcomes. Female-headed households were associated with lower odds of stunting but higher odds of wasting. Spatial analysis revealed elevated residual stunting risk in the northern and central highlands, whereas wasting hotspots were concentrated in northeastern pastoralist regions. Residual spatial correlation was weak ({rho} = -0.12), indicating largely independent geographic patterns. These findings suggest that effective child nutrition policies in Ethiopia require outcome-specific and regionally tailored interventions addressing both chronic and acute forms of malnutrition.

Streptococcus pneumoniae is a leading cause of childhood meningitis, sepsis and pneumonia despite widespread implementation of pneumococcal conjugate vaccines (PCVs). Serotype 2, once a major invasive serotype that nearly disappeared in the mid-20th century, is not included in current vaccine formulations. Recent reports from multiple countries suggest potential re-emergence of serotype 2. Here, we present 30 years of hospital-based surveillance from Bangladesh (1993-2022), where serotype 2 accounted for 7.8% of invasive pneumococcal disease cases. Infections occurred predominantly in very young infants (median age, 3 months) and were largely associated with meningitis (91.3%), with nearly 90% of isolates recovered from cerebrospinal fluid. Comparative analysis of otitis media and nasopharyngeal carriage isolates demonstrated high invasive propensity relative to other serotypes. Whole genome sequencing of 170 serotype 2 isolates from 21 countries revealed that all modern isolates belong to the globally disseminated lineage GPSC96, which is distinct from the prototypical laboratory strain D39 (GPSC622). Phylodynamic reconstruction dated the emergence of GPSC96 to the late 19th century, with continued global circulation and largely preserved antibiotic susceptibility. These findings highlight serotype 2 as a potential invasive pneumococcal threat in countries such as Bangladesh and supports consideration of its inclusion in the next-generation conjugate vaccines.

ObjectiveTo investigate the burden of environmental enteric dysfunction (EED) and its association with water, sanitation, and hygiene (WASH) and linear growth amongst infants in rural Central Java, Indonesia. Study designA longitudinal study of 119 infants aged between 5-19 months was conducted in five villages of Wonosobo District, Central Java, Indonesia. Anthropometric measurements of infants and their mothers were performed at baseline and 5-month follow-up alongside a quantitative questionnaire on household, socio-economic, WASH and caregiving variables and stool sample collection for the investigation of alpha-1-antitrypsin (AAT), neopterin (NEO), and myeloperoxidase (MPO) levels. Linear mixed-effects regression models estimated the associations between WASH and height-for-age z-score (HAZ) on log-transformed EED biomarkers. ResultsBiomarkers increased from baseline to follow-up despite a declining trend with age and 68.7%, 79.0%, and 71.4% of infants experienced elevated AAT, NEO, and MPO respectively follow-up. Infants had higher AAT if they averaged > 30 minutes playing on soiled surfaces per day ({beta} = 0.11, p<0.05). NEO was elevated in infants with diarrhoea ({beta} = 1.04, p<0.05), municipal water source ( = {beta} 0.71, p<0.05), and in infants who mouthed soiled fomites weekly ({beta} = 0.55, p<0.05). Infants in houses with municipal water source had higher MPO ({beta} = 0.56, p<0.05) and higher MPO if mouthing soil weekly ({beta} = 0.41, p<0.05). Compared to infants at risk of stunting, stunted infants at baseline had lower AAT at follow-up ({beta} = -0.39, p<0.05) while infants with HAZ > -1 had lower AAT at baseline ( = -0.43, p<0.05). HAZ at baseline was positively associated with NEO at follow-up ({beta} = 0.36, p<0.05). MPO was higher in infants with HAZ > -1 at follow-up ({beta} = 0.59, p<0.05) and stunted infants ({beta} = -0.54, p<0.05) compared to infants at risk of stunting. ConclusionElevated EED biomarker levels were frequent and associated weakly with WASH and HAZ with bi-directionality, highlighting the need for quality birth cohort studies to improve understanding of EED and develop interventions.

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.

BackgroundNewborns requiring inpatient care, particularly small and sick newborns (SSNBs), face high risk of mortality. Newborns referred from other facilities may experience worse outcomes than those born and managed within the same hospital (inborn newborns). Understanding factors contributing to this disparity in outcomes could support efforts to scale-up care and accelerate progress towards achieving Sustainable Development Goals target 3.2. MethodsData on 130,773 newborns admitted to 13 hospitals implementing with NEST360 in Kenya were obtained from the Neonatal Inpatient Dataset, between January 2019-October 2024. We described characteristics and primary diagnoses. Logistic regression was used to evaluate factors associated with mortality. ResultsAmong admissions, 114,084 (87.2%) were inborn and 16,689 (12.8%) referred. Referred newborns were more likely to be extremely preterm (6.1% vs 3.1%), have extremely low birthweight (<1,000g) (4.6% vs 2.6%) and present with respiratory distress (26.2% vs 15.0%) and hypoxia (23.2% vs 15.3%) compared to those inborn. Only 59.6% of referred newborns were admitted on first day of life compared to 80.2% inborn newborns. Unadjusted mortality among referred newborns was 29.0% compared to 11.3% in those inborn. Risk factors associated with mortality among referred newborns included being extremely low birthweight (odds ratio [OR] 13.57, 95% CI 11.19-16.44), respiratory distress (OR 4.07, 95% CI 3.77-4.39), and congenital anomalies (OR 1.66, 95% CI 1.41-1.95). Prematurity and intrapartum-related complications were also associated with increased odds of death. In multivariable analysis, being referred remained strongly associated with mortality (adjusted OR [aOR] 2.54, 95% CI 2.39-2.71). ConclusionReferred newborns had nearly three times higher odds of mortality compared to those inborn. This may highlight referral selection bias amongst this group and could also be related to inadequate pre-referral stabilisation, unsafe neonatal transportation and admission delays. If successfully implemented, a strong hub-and-spoke approach may improve care at lower levels of care and decongest receiving facilities. Overall, improving quality of care across the continuum of referral process is a cornerstone in strategies to reduce neonatal mortality towards attainment of national and global newborn survival targets. KEY FINDINGSO_ST_ABS1. WHAT WAS KNOWN?C_ST_ABSO_LINeonatal mortality remains high in sub-Saharan Africa and newborns referred from other health facilities may experience poorer outcomes than those born and managed within the same hospital. C_LIO_LIThere is limited evidence on morbidity and mortality outcomes among inborn and referred newborns. This is important to inform specialised newborn care and targeted improvements in referral. C_LI 2. WHAT WAS DONE THAT IS NEW?O_LIThis study analysed routinely collected clinical data on 130,773 newborns admitted to 13 hospitals implementing with NEST360 in Kenya between 2019 and 2024. C_LIO_LIDiagnoses outcomes and neonatal characteristics were described and compared between inborn and referred newborns. Factors associated with neonatal mortality were also examined using logistic regression analysis. C_LI 3. WHAT WAS FOUND?O_LIReferred newborns had higher unadjusted mortality rate than inborn newborns (29.0% vs 11.3%; p<0.001), with 3 times higher odds of death in univariable logistic regression analysis (OR 3.20, 95% CI 3.08-3.33). C_LIO_LIReferred newborns were more clinically vulnerable at admission and had higher proportions of extreme prematurity (6.1% vs 3.1%), very preterm birth (14.0% vs 8.6%), and extremely low birthweight (4.6% vs 2.6%). Among both groups, key risk factors associated with mortality included birthweight, gestational age, respiratory distress, hypothermia, and clinical diagnoses. C_LIO_LIAmong referred newborns some of the risk factors associated with mortality included being extremely low birthweight (OR 13.57, 95% CI 11.19-16.44), respiratory distress (OR 4.07, 95% CI 3.77-4.39), congenital anomalies (OR 1.66, 95% CI 1.41-1.95), and intrapartum-related complications (OR 1.35, 95% CI 1.20-1.52). C_LI 4. WHAT NEXT?O_LIStrengthen neonatal referral systems through clearer referral criteria, improved pre-referral stabilisation, better neonatal transport, and prompt triage on arrival at receiving hospitals. Routine clinical data should be used to monitor referral processes and outcomes and to guide continuous quality improvement. C_LIO_LIFurther research is needed to capture referral to admission time, transport characteristics, and quality of pre-referral stabilisation. Linking neonatal admission data with maternal records and assessing outcomes beyond hospital discharge would also improve understanding of referral pathways and long-term outcomes. C_LI

In 2024, mpox cases surged in the Democratic Republic of the Congo (DRC) with cross-border spread to Burundi. We developed a transmission-dynamic model calibrated against surveillance data to understand drivers in enzootic (Clade Ia) and non-enzootic (Clade Ib) areas, and the potential impact of vaccination. In non-enzootic areas we estimated that 58-84% of transmission occurred within sexual networks. MVA-BN vaccination of sex workers could have averted 91% (95% CrI 81%-98%) of infections in Sud Kivu (DRC) but only 35% (95% CrI 26%-47%) in Bujumbura (Burundi), due to later outbreak detection. In historically enzootic Equateur (DRC), ongoing zoonotic spillover best explained sustained incidence. There, pledged Lc18m8 vaccines could have averted 42% (95% CrI 40%-46%) of infections; prioritising children improved impact. Across all settings, doubling vaccine coverage by using a single dose of MVA-BN outperformed two-dose strategies. Timely detection and tailored vaccination strategies are critical to reducing mpox burden.

BackgroundAcute respiratory infection (ARI) remains a leading cause of morbidity and mortality among children under five in Nigeria. Although polluting cooking fuels are widely considered a key risk factor, their effects may be shaped by broader socioeconomic and geographic conditions. This study examined both individual and structural determinants of ARI and assessed how these factors intersect to pattern risk. MethodsWe analysed data from 28,728 children under five in the 2024 Nigeria Demographic and Health Survey. Three ARI definitions were applied. Survey-weighted quasibinomial logistic regression estimated associations between ARI and cooking fuel type, child age and sex, household wealth quintile, residence type, geopolitical zone, and parental education. To examine intersectional patterning, we conducted a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), constructing strata defined by combinations of cooking fuel, wealth, residence, and geopolitical zone. The intraclass correlation coefficient (ICC) quantified between-strata variance. ResultsStrict ARI prevalence was 1.9%, and 8.3% of children had broader respiratory symptoms. In unadjusted analyses, polluting fuel use was associated with higher odds of respiratory symptoms (OR 1.85, 95% CI 1.43-2.39). After adjustment, this association was substantially attenuated, indicating confounding by structural factors. Child age was the most consistent predictor: children aged 24-59 months had about half the odds of strict ARI compared with infants (aOR 0.53, 95% CI 0.41-0.68). Geopolitical zone showed the strongest overall association. MAIHDA revealed that 9% of total ARI variance lay between intersectional strata (ICC = 0.09), and this variance was not explained by child age or sex. The population-attributable fraction for polluting fuel declined from 41.4% to 12.4% after adjustment. ConclusionsARI risk among Nigerian children is shaped more by structural and geographic inequalities than by household fuel use alone. Equity-focused, subnational policies addressing intersecting socioeconomic and regional disadvantage are needed to reduce the ARI burden.

The spread of successive novel COVID-19 variants presented a challenge for outbreak surveillance, epidemiology, and emergency responses. Monitoring the emergence and spread of SARS-CoV-2 variants is essential to allocate limited public health resources and optimize control efforts. Global collaboration among the scientific community enabled large-scale viral surveillance and sequencing efforts. However, translating these vast datasets into actionable public health inferences requires rapid statistical methodologies, scalable workflows, and robust frameworks. In this study, we focused on the Delta epidemic wave in Georgia by applying a hybrid maximum likelihood (ML) and Bayesian phylodynamic approach. We characterized the Delta variant introduction to Georgia and its subsequent local spread. Our analysis of 9,783 Delta sequences collected between August 1, 2020 and January 25, 2022 detected at least 344 introductions into Georgia, resulting in 34 highly-supported local clusters. On average, clusters circulated for one month before the earliest detected sequence, highlighting critical delays in detection. While most clusters remained small, a few introduction events led to large, sustained outbreaks. We jointly inferred the statewide transmission network, estimated from all locally circulating clusters with a modified Bayesian discrete trait phylogeographic reconstruction of statewide health districts. We showed that South Central, Georgia was a major source of transmission, despite having smaller numbers of infected people, compared to major metropolitan areas. Our study addresses the urgent need for methodologies and data-driven recommendations for public health practice, particularly given large, dynamic, and integrated datasets. By identifying key geographic sources and sinks of transmission, our findings can guide resource allocation and prepare for future epidemics among high-risk populations. Additionally, by characterizing introduction events, local circulation, and detection lags, we highlight critical gaps in surveillance. These gaps can inform outbreak investigation and response, such as targeted contact tracing and testing.

BackgroundTyphoid fever incidence estimates are central to policy decisions on vaccine introduction and investments in non-vaccine prevention and control but are often unavailable. We explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local Salmonella Typhi (S. Typhi) incidence. MethodsUsing a previous systematic review (January 2018-December 2024), we identified studies reporting both typhoid incidence and prevalence of community-onset bloodstream infections from sentinel sites. From authors, we requested data on blood culture isolates and analysed four metrics: (i) S. Typhi prevalence among probable pathogens, (ii) S. Typhi rank order, (iii) S. Typhi to Escherichia coli ratio, and (iv) S. Typhi to stably endemic organisms ratio. Typhoid incidence was categorized as low (<10), medium (10-100) or high (>100) per 100,000 person-years. We used univariate ordinal regression to assess the association between each metric and typhoid incidence level. The model performance was evaluated by the c-statistic, sensitivity, and specificity. FindingsAnalysis of 29 study sites (20 Africa, 9 Asia) yielded 4,625 probable pathogens. The median (IQR) typhoid incidence was 140 (28-319) per 100,000 person-years. All metrics were associated with increased typhoid incidence level: for each 1% increase in S. Typhi prevalence OR 1.07 (95%CI 1.02-1.15); rank order OR 0.25 (95%CI 0.06-0.64); log S. Typhi to E. coli ratio OR 2.91 (95%CI 1.45-7.42); log S. Typhi to stably endemic organisms ratio OR 3.69 (95%CI 1.69-11.3). A parsimonious model using S. Typhi prevalence alone achieved c-statistics of 0.87 (0.58-0.97), 0.76 (0.51-0.91), and 0.88 (0.69-0.96) for low, medium, and high incidence, respectively. InterpretationSentinel prevalence metrics from bloodstream infections, particularly S. Typhi prevalence among probable pathogens, could be useful for inferring local typhoid fever incidence where direct data are unavailable. FundingGates foundation Research in contextO_ST_ABSEvidence before this studyC_ST_ABSGlobally, annual deaths from typhoid fever were estimated at 71,954 (95% uncertainty interval 38,051 to 118,560) in 2023. Typhoid conjugate vaccines (TCV) are recommended for regions with high typhoid incidence. Implementation, however, can be challenging due to a lack of local incidence data. Generating community incidence estimates requires expensive and time-consuming large prospective or hybrid surveillance studies, or novel techniques such as serology or environmental surveillance. Our previous study proposed that metrics from sentinel healthcare facilities such as the prevalence of Salmonella Typhi (S. Typhi) among all bloodstream pathogens or its rank order relative to other pathogens could serve as proxy for community incidence. However, contemporaneous incidence and prevalence data from the same time and location were limited in our previous study. To explore typhoid incidence estimation strategies, we searched PubMed and MEDLINE on January 8, 2026 with search terms including keywords of "typhoid fever", "incidence", and "prediction" without restrictions to language or publication date. Previous studies estimated incidence based on complex country-level covariates and disease modelling that lack ease of applicability for policy decisions. Recognising the need for pragmatic tools, we explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local S. Typhi incidence. Added value of this studyOur study was based on typhoid incidence studies that had available data for isolates of bloodstream infections. Of 29 sites across Africa and Asia with 4,625 probable pathogens, we found that all four sentinel metrics were significantly associated with typhoid incidence level. We demonstrated that a parsimonious model using S. Typhi prevalence alone achieved good discriminative performance in identifying high incidence settings. Implications of all the available evidenceWhen typhoid incidence estimates are unavailable, prevalence metrics from sentinel studies of community-onset bloodstream infections could help policymakers infer typhoid incidence and optimise resource allocation in water, sanitation, and hygiene, and TCV introduction.

The resurgence of measles in the United States, driven by declining childhood vaccination coverage, poses a substantial public health and economic threat. Using county-level MMR vaccine coverage data and spatial incidence models, we quantified the economic burden of measles in 2025 and projected the impact of continued declines in vaccine uptake. In 2025, the estimated cost per measles case was $104,629 (50% High-Density Interval [HDI]: $100,729-$110,140), yielding a national burden of $244.2 million (50% HDI: $69.9-$872.5 million). The cost per case varied widely across counties and was inversely correlated with local population immunity levels (Spearman correlation = -0.75, p < 0.001). We modeled a scenario in which coverage among children aged 0-6 years declined by 1% per year, reaching a 5% absolute reduction by year 5 relative to baseline. Under this scenario, we projected a nonlinear surge in cases, hospitalizations, and annual expenditures arising from outbreak response, direct medical costs, and productivity losses. This scenario produced 17,232 (50% HDI: 9,177-26,428), 4,085 (50% HDI: 2,184-6,210) hospitalizations, 36 (50% HDI: 19-54) deaths, and $1.50 (50% HDI: $0.90-$2.85) billion in annual costs in 2030, with a cumulative cost of $7.77 billion (50% HDI: $5.56-$11.58 billion) over 5 years. These findings demonstrate that even marginal reductions in MMR vaccine uptake can result in disproportionately large health and economic burdens. Significance StatementThe United States is experiencing a resurgence of measles amid recent declines in childhood MMR vaccination. Using mathematical modeling informed by spatially resolved data on vaccination coverage, incidence, and associated economic costs, we quantified both the current and projected financial burden of measles in the United States under continued declines in coverage. For 2025, we estimated that measles imposes a cost of $244.2 million nationwide, with substantial heterogeneity in cost per case across counties driven by gaps in population immunity. Even modest annual reductions in vaccine coverage among young children generate a nonlinear increase in cases and hospitalizations, with costs totaling $7.77 billion over a five-year period.

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.