The Lancet Regional Health - Western Pacific

Diarrhea remains a leading cause of child morbidity and mortality. Improved and ongoing estimates of the etiology of hospitalized pediatric diarrhea in low- and middle-income countries (LMICs) are needed to help prioritize and evaluate the use of existing and upcoming vaccines and interventions. The Global Pediatric Diarrhea Surveillance (GPDS) network is 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. Randomly selected stool specimens were tested by TaqMan Array Card quantitative reverse-transcription polymerase chain reaction (qPCR) for 16 pathogens associated with diarrhea. We estimated pathogen-specific attributable fractions (AFs) and incidence of diarrheal hospitalizations at the global, regional, and country levels during 3 time periods: 2017-2018, 2019-2020, and 2021-2022, with a focus on the most recent results. During 2017-2022, the GPDS network enrolled 70,750 children aged <5 years hospitalized with diarrhea, of which 16,458 (23.3%) were randomly selected for qPCR testing. The most prevalent pathogen detected, regardless of quantity or modeled etiologic attribution, was rotavirus (weighted prevalence 30.4%), followed by adenovirus 40/41 (19.1%), norovirus (17.9%), Shigella (14.1%), and Campylobacter jejuni/coli (8.6%). Overall, in 2017-2022, rotavirus was the leading etiology globally (AF 32.5%; 95% Confidence Interval (CI): 27.4, 37.6), followed by Shigella (9.8%; 8.4, 11.3), adenovirus 40/41 (8.6%; 6.3, 10.8) and norovirus (6.7%; 5.6, 7.7). Over time, rotavirus consistently declined from an AF of 36.7% (95% CI: 28.7, 46.7) in 2017-2018 to 26.7% (20.7, 34.1) in 2021-2022. Norovirus AF increased slightly from 6.2% (4.7, 7.7) in 2017-2018 to 7.3% (5.0, 9.2) in 2021-2022. Global Shigella burden remained stable, and adenovirus 40/41 demonstrated significant volatility, peaking globally in 2019-2020 (11.9%; 5.9, 17.5). In 2021-2022, rotavirus was the leading cause of hospitalized diarrhea in 6 of 9 geographic groupings, norovirus predominated in Central and South America, and Shigella was the leading etiology in South Asia. In the subset of countries that had introduced rotavirus vaccine, the leading etiologies in 2021-2022 were rotavirus (18.4%; 15.8, 21.5) and Shigella (16.4%; 11.8, 21.1). In 2021-2022, rotavirus had the highest attributable incidence of hospitalized diarrhea in children (2.3 per 1,000 child-years; 1.8, 3.0), followed by Shigella (0.9; 0.7, 1.1), norovirus (0.6; 0.4, 0.8) and adenovirus 40/41 (0.6; 0.4, 0.8). Despite the widespread use of rotavirus vaccines, rotavirus remained the leading cause of severe diarrhea among children aged <5 years in LMICs globally. However, the proportion of pediatric diarrhea attributable to rotavirus consistently declined from 2017-2018 to 2021-2022, and there were notable differences in the distribution of diarrheal etiologies between regions and across time periods. Shigella, norovirus, and enteric adenoviruses were also associated with a substantial burden of disease. Improving the efficacy and coverage of rotavirus vaccination and prioritizing interventions against other enteric pathogens could further reduce diarrhea morbidity and mortality.

Purpose: This study assesses the association between colorectal cancer (CRC) screening and a validated, housing-based measure of individual-level socioeconomic status (SES, called HOUSES hereafter) within rural communities and determines whether HOUSES-integrated geospatial analysis can be used to tailor interventions. Methods: We used CRC screening data from a subset of Mayo Clinic Midwest patients living in cities without ready access to routine care in the Mayo Clinic Health System in 2019 to represent rural communities. At the individual level, we assessed the association between CRC screening rates and the HOUSES index, adjusting for age, sex, race/ethnicity, comorbidity, distance from home address to clinic, and area deprivation index, using a multilevel mixed-effects logistic regression model. Additionally, we conducted geospatial analysis to examine the correlation between hotspots of 1) lower CRC screening rates and 2) lower SES of the subject population (HOUSES quartile 1). Findings: Among 34,489 individuals (median age 64.0 years, 52.4% female), those with the lowest SES (HOUSES Q1) had 37% lower odds of being CRC screening adherent than those with the highest SES (HOUSES Q4) (adj. OR [95% CI]: 0.63 [0.58-0.69]). In the 14 identified HOUSES Q1 hotspots, there was a significant correlation in counts of HOUSES Q1 and low CRC screening (correlation coefficient=0.81). Conclusion: Lower SES was significantly associated with lower CRC screening among rural populations. HOUSES-enabled geospatial analysis identified geographic hotspots with lower CRC screening rates for targeted interventions to address disparities in CRC screening in rural communities. HOUSES may be a useful digital tool for cancer preventive care and research.

Exposure to fine particulate matter (PM2.5) increases paediatric respiratory morbidity, but its impact on the intensity and economic burden of care in early childhood remains unclear. Here we link nationwide health records for 3,210,381 South Korean children (99,261,945 child-month observations, 2015-2019) and exploit quasi-random variation in PM2.5 induced by thermal inversions to estimate its causal effects on respiratory care and expenditure. A 1-standard-deviation increase in monthly PM2.5 (7.23 micrograms per cubic metre) raises respiratory visits broadly, peaking at age 1 (0.29 additional visits per child-month) and remaining significant through age 6. In contrast, expenditures rise disproportionately among children under 3, increasing by 46.7%, 43.0%, and 35.4% at ages 0, 1, and 2 and becoming indistinguishable from zero beyond age 4. This shift towards higher-intensity emergency care translates into a 32.2% increase in annual respiratory spending among children under 5. Air pollution thus imposes a dual burden, amplifying both the frequency and severity of illness among the youngest infants.

Objectives: To characterize prevalence and secular trends in stunting, thinness, overweight, obesity, and the double burden of malnutrition (DBM) in urban Vietnamese children. Methods: We analyzed 249,745 annual health check visits from 97,111 children aged 18 months to 18 years attending a private school system in Hanoi, Ho Chi Minh City, and Haiphong from 2018 to 2025. Temporal trends in stunting, thinness, and obesity were modelled using generalized estimating equation (GEE) logistic regression. Results: A total of 51,034 males and 46,077 females were included. Stunting prevalence was low but rose significantly in both sexes (males: 0.7% to 1.3%, p=0.006, females: 0.7% to 1.7%, p<0.001), concentrated in children under 10 years (GEE OR/year=1.076 and 1.089, both p<0.05), females exceeded males by 2025. Obesity declined overall in males (21.4% to 17.0%) and females (6.2% to 5.0%, both p<0.001), but rose significantly among males aged 15-18 years (OR=1.055, p=0.021). Overweight increased in males (19.7% to 20.5%, p=0.010) but declined in females (18.0% to 14.8%, p<0.001). Individual-level DBM (concurrent stunting with overweight/obesity) was uncommon (<0.2%). City-level heterogeneity was marked, with Haiphong showing the highest male obesity (22.7% in 2025) and individual-level DBM. Conclusion: Vietnamese urban schoolchildren experienced simultaneous, divergent nutritional burdens from 2018-2025: rising stunting and thinness under age 10, declining early childhood obesity, and rising adolescent male obesity. Individual-level DBM was rare, but a population-level double burden was evident across age groups. City, age, and sex specific nutrition and school health policies are needed to address this complex malnutrition transition.

Carbapenem-resistant Escherichia coli (CR-E. coli) is an emerging One Health threat, but recent shifts in predominant lineages and genomic links between clinical and food reservoirs in Hong Kong remain poorly defined. We analyzed 271 CR-E. coli isolates from four hospitals (2022-2026) and 585 isolates recovered from 4,917 retail food samples (2022-2025). Isolates underwent antimicrobial susceptibility testing, whole-genome sequencing, multilocus sequence typing, resistance-gene and plasmid profiling, core-genome SNP phylogenetics, and comparative genomics. Food isolates were mainly from raw pork (268/585, 45.8%) and raw chicken (231/585, 39.5%). blaNDM-5 was detected in 527/585 (90.1%) food and 241/271 (88.9%) clinical isolates. ST69 was the most frequent defined sequence type in both collections, representing 44/585 (7.5%) food and 36/271 (13.3%) clinical isolates, in contrast to the heterogeneous lineages and carbapenemases previously reported in Hong Kong. Applying a predefined [&le;]50-pairwise-SNP threshold for close genomic relatedness, core-genome phylogeny of 80 ST69 isolates identified two major mixed-source clusters collectively comprising 28 clinical and 27 food isolates. Clustered isolates showed similar antimicrobial resistance profiles, carried blaNDM-5 and blaTEM-1, and were associated with IncI1 MLST | ST136 plasmids. Comparative analyses showed >99.85% average nucleotide identity and broad conservation of the blaNDM-5-associated plasmid backbone across sources. These findings indicate the emergence of blaNDM-5-carrying ST69 as a prominent CR-E. coli lineage in Hong Kong and demonstrate close genomic relatedness between selected clinical and retail food isolates. Although transmission direction have not been inferred yet, the findings support integrated One Health surveillance and source-tracing across clinical, food, animal, and environmental sectors.

Background Concurrent wasting and stunting (WaSt) is a severe form of child undernutrition, linked to higher mortality and long-term negative health outcomes. Malnutrition is a significant challenge in Yemen, where the country is experiencing a long-standing conflict, food insecurity, and socioeconomic deprivation. But there is still limited evidence on the burden and determinants of WaSt in Yemen on a national level. This study aimed to estimate the prevalence and identify factors associated with WaSt among children under 5 years in Yemen. Methods We conducted a cross-sectional analysis using nationally representative data from the 2022-2023 Yemen Multiple Indicator Cluster Survey (MICS). A significantly large dataset of 17,734 children aged 0-59 months from all the 22 governorates of Yemen was analyzed. Concurrent wasting and stunting (WaSt) was defined as the coexistence of a weight-for-height z-score (WHZ) below -2 standard deviations and a height-for-age z-score (HAZ) below -2 standard deviations from the WHO Child Growth Standards in the same child. Survey-weighted logistic regression was performed to analyze the factors associated with WaSt among the under 5 children in Yemen. Results The national prevalence of WaSt was 8.4% (95% CI: 7.6-9.2). The highest prevalence of WaSt was found in children aged 12-23 months (12.0%) and in the Western Coastal region (11.6%). After adjustment, male sex (AOR 1.52, 95% CI: 1.30-1.80), residence in the Western Coastal (AOR 2.00, 95% CI: 1.60-2.40), Eastern (AOR 2.00, 95% CI: 1.50-2.70), and Southern regions (AOR 1.60, 95% CI: 1.20-2.10), poorest household wealth (AOR 1.96, 95% CI: 1.30-2.90), moderate (AOR 1.51, 95% CI: 1.13-1.94) and severe food insecurity (AOR 1.94, 95% CI: 1.40-2.60), and recent diarrhoea (AOR 1.22, 95% CI: 1.02-1.44) were associated with higher odds of WaSt. Having a handwashing facility and improved sanitation were protective. Conclusion At least 1 in every 12 under-five children in Yemen was affected by WaSt, and there were significant socioeconomic, geographic, food-security and WASH-related factors influencing this devastating outcome. Instead of simple, one-dimensional approaches, multi-sectoral interventions are needed to address this adversity. And those efforts must be integrated into the system, interconnected with each other and specifically targeted to vulnerable children and households.

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

Aim: This study aimed to estimate the prevalence and distribution of minimum dietary diversity for women (MDD-W) and underweight/thinness and examine sociodemographic and dietary factors associated with underweight/thinness among Cambodian women aged 15-49 years. Methods: We conducted a cross-sectional analysis of 9,181 women aged 15-49 years (9,262.5 weighted) from the 2021-22 Cambodia Demographic and Health Survey. Survey-weighted descriptive statistics and provincial mapping were used to describe MDD-W, food-group consumption and underweight/thinness. Rao-Scott chi-square tests assessed group differences, and survey-weighted logistic regression estimated factors associated with underweight/thinness. MDD-W and household wealth were retained a priori in the adjusted model, while other covariates with an overall crude Wald P value <0.20 were included. Results: The analysis included 9,181 women (9,262.5 weighted). Overall, 57.2% achieved MDD-W, and 6.7% had underweight/thinness; 22.8% were overweight, and 5.7% had obesity. Underweight/thinness was highest among women aged 20-24 years (17.7%). Achieving MDD-W was not associated with underweight/thinness in crude analysis (OR 0.93, 95% CI 0.74 to 1.17; P=0.545). In the adjusted analysis, the association remained imprecise (aOR 0.86, 95% CI 0.67 to 1.09; P=0.219). Provincial estimates showed geographic variation in both MDD-W and underweight/thinness. Conclusion: More than half of Cambodian women achieved MDD-W, while underweight/thinness coexisted with overweight and obesity. MDD-W was not clearly associated with underweight/thinness. These findings support monitoring dietary diversity, anthropometric status, and socioeconomic inequalities together in women's nutrition.

Micronutrient deficiencies are prevalent in Madagascar, where diets rely heavily on starchy staples and access to animal-source foods is limited. Small dried fish (SDF) are widely available, yet their nutritional value and health risks remain poorly documented. We combined market surveys, taxonomic identification, and micronutrient and heavy metal analyses of nine SDF types collected along National Road 7. The samples encompassed 33 fish families, were dominated by small pelagic species (Clupeidae and Engraulidae), and were appreciated by consumers. A daily portion (5 g for infants; 10 g for young children and women of childbearing age) contributed substantially to Recommended Nutrient Intakes (RNIs). Across samples and groups, SDF were rich (>30% of RNI) in selenium and, for infants and young children, in calcium. All samples were a source of (>15% of RNI), or rich in, phosphorus, whereas iron contributions were more variable but often substantial. Several samples exceeded 100% of RNIs for selenium, calcium, iron, or manganese in infants and young children, and some were also sources of magnesium and, less frequently, zinc. Vitamin A was absent from sun-dried samples but detected in a smoked freshwater type. Heavy metal concentrations varied markedly, and portions of several types led to estimated exposures to inorganic arsenic or cadmium exceeding reference values, whereas freshwater species and some pelagic types showed a more favorable nutrition-risk balance. Overall, SDF are affordable, nutrient-dense foods with strong potential to alleviate micronutrient deficiencies in Madagascar, while highlighting the need for type-specific guidance to balance nutritional benefits and contamination risks.

Wildfire smoke exposure is increasing across the U.S., but the long-term neurological effects of smoke-specific fine particulate matter (PM2.5) and its carbonaceous components remain uncertain. Using Medicare data from 2002 through 2019, we examined incident Alzheimer's disease (AD) and Alzheimer's disease and related dementias (ADRD) among 39,678,630 fee-for-service Medicare beneficiaries followed from 2005 through 2019. We identified 3,501,414 incident AD cases over 258.5 million person-years and 8,377,416 incident ADRD cases over 248.6 million person-years. We linked the cohort with annual, high-resolution estimates of smoke and non-smoke PM2.5 mass and carbonaceous components (elemental and organic carbon) and fitted stratified Cox proportional hazards models. Per 1 g/m3 increase, smoke PM2.5 was associated with incident AD (hazard ratio [HR], 1.015, 95% confidence interval [CI], 1.005-1.026) and ADRD (1.029 [1.024-1.035]). Smoke carbonaceous fraction was also associated with AD (1.063 [1.042-1.085]) and ADRD (1.090 [1.077-1.103]). Within the ADRD endpoint, smoke-related associations exceeded their corresponding non-smoke associations on a per-unit-mass basis. Per interquartile range, associations were smaller for smoke PM2.5 (AD, 1.005 [1.002-1.008]; ADRD, 1.009 [1.008-1.011]) than for non-smoke PM2.5 (AD, 1.086 [1.079-1.094]; ADRD, 1.048 [1.043-1.053]). Associations varied across geographic, racial, socioeconomic, and clinical subgroups. Long-term wildfire smoke exposure, particularly its carbonaceous fraction, was associated with higher incidence of AD and ADRD among older U.S. adults. The associations correspond to 2,284 and 11,142 incident cases per year of AD and ADRD attributable to smoke PM2.5 among older Medicare beneficiaries, with the carbonaceous fraction accounting for most of this burden. These findings support the use of source-resolved and composition-specific smoke metrics in dementia research and wildfire-smoke health-impact assessments.

While cholera imposes a substantial burden across the Democratic Republic of the Congo, its transmission dynamics vary by geography, socio-economic context or population habits. We investigated risk factors associated with laboratory-confirmed cholera among suspected cases in urban Goma and rural Bukama sites, across 2021-2022. Mixed-effects logistic regression models were fitted independently by site. Positivity rates were higher in Goma (70.2%, 1688/2405) than in Bukama (49.4%, 390/790). In both sites, rainy seasons increased odds of testing positive (OR=3.89, 95%CI [2.93-5.16] and 2.00 [1.39-2.86] for Goma and Bukama, respectively) while receiving [&ge;]1 Oral Cholera Vaccine dose was protective (0.53 [0.37-0.74] and 0.58 [0.37-0.91]). Some risk factors were significant only in Goma, including displacement status (1.93 [1.11-3.35]), household cholera case exposure (1.79 [1.31-2.45]), consumption of surface water (2.11 (1.46-3.03]) or from water tankers (1.75 (1.24-2.47]). This study shows that cholera risk factors vary across endemic settings, giving insights for improved, locally-adapted control measures.

Background Alcohol-associated liver disease (ALD) has emerged as a major cause of chronic liver disease and liver-related mortality in China. This study aimed to project the future burden of ALD in Chinese adults from 2020 to 2050, including prevalence of ALD, number of alcoholic steatohepatitis (ASH) cases, incident hepatocellular carcinoma (HCC) cases, liver transplantation (LT) demand, liver-related deaths, and disability-adjusted life years (DALYs). Methods We developed an agent-based state-transition microsimulation model with yearly cycles and a lifetime horizon. The model simulated 5,678,912 representative Chinese adults (mean age 36.2 years, 51.2% male). Health states included no steatosis, alcohol-associated steatotic liver, ASH, fibrosis stages F0-F4, decompensated cirrhosis, HCC, LT, and liver-related death. Model inputs were derived from the China Kadoorie Biobank, Global Burden of Disease Study 2021, China's national surveys, published meta-analyses, and transplant registry data. Projections incorporated demographic shifts, alcohol consumption trends, and calibrated transition probabilities. Uncertainty was assessed via 1,000 Monte Carlo simulations generating 95% uncertainty intervals. Results ALD prevalence was projected to increase from 4.8% (55 million individuals) in 2020 to 8.5% (94 million individuals) by 2050. ASH cases rose from approximately 18 million to 20 million. Annual incident HCC cases nearly doubled from 20,500 in 2020-2025 to 45,200 by 2046-2050. LT demand quadrupled from 2,300 to 9,800 cases. Liver-related deaths increased from 50,000 in 2020 to 85,000 in 2050, while DALYs rose from 1.5 million to 2.6 million. Conclusions In the absence of strengthened alcohol control policies, ALD will impose a substantial and growing burden on China's health system by 2050, with marked increases in HCC incidence, LT demand, and liver-related mortality.

Zero-dose children remain a marker of populations unreached by routine immunisation, but national averages can obscure substantial subnational and multidimensional inequities. We analysed the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted between 2015 and 2024, including 170,553 children aged 12-23 months from 77 countries and 1,571 first-level administrative areas. Zero-dose prevalence ranged from 0.22% to 37.21% nationally, and 33 subnational areas had prevalence of at least 50%. Using the Vaccine Economics Research for Sustainability and Equity (VERSE) framework, we found that zero-dose children were consistently concentrated among multidimensionally disadvantaged groups, although the magnitude and drivers of inequity varied across countries. Maternal education, household wealth, geographic region, residence and health insurance were context-specific contributors. Combining burden, subnational distribution and multidimensional inequity can help identify where zero-dose children are concentrated and which barriers should be prioritised to advance equitable immunisation.

Introduction Measles remains a major public health threat worldwide. Following a resurgence of cases, Ho Chi Minh City (HCMC) experienced a severe outbreak in 2024-2025 that differed from the 2018-2020 epidemic. We compared the epidemiology and transmission dynamics of these two outbreaks to inform future surveillance and vaccination strategies. Methods Line-list data for measles cases reported in HCMC between 2018 and 2025 were extracted from the infectious disease surveillance system. Demographic changes were assessed using cross-sectional age distributions and longitudinal birth-cohort analyses. Transmission dynamics were characterized by estimating the effective reproduction number (Rt) using the Cori and Wallinga-Teunis methods. Age-stratified Who-Infected-Whom transmission matrices were constructed to quantify within- and between-age-group transmission before and after interventions. Results The 2018-2020 outbreak primarily affected children under five years of age (median age 3.75 years, IQR 0.9-9.1), whereas the 2024-2025 outbreak shifted toward older age groups (median age 8.4 years, IQR 1-14). Birth-cohort analyses identified two major immunity gaps: children born during the COVID-19 immunization disruption (2019-2023) and adolescents and young adults born before 2014 who were not eligible for the 2018 outbreak response immunization campaign. The 2024-2025 outbreak also showed broader spatial spread and a reversed geographic trajectory compared with the earlier epidemic. Transmission patterns changed substantially, with the 2018-2020 outbreak sustained mainly by transmission among young children, whereas the 2024-2025 outbreak was driven by older age groups, with individuals >15 years acting as an important source of infection for infants. Conclusion The epidemiology of measles in HCMC has shifted from predominantly pediatric transmission to increasing involvement of adolescents and adults, reflecting accumulated immunity gaps across multiple birth cohorts. These findings suggest that age-restricted outbreak response immunization may leave residual susceptible populations that contribute to future outbreaks. Achieving sustainable measles elimination will require vaccination strategies that address historical immunity gaps across all vulnerable age groups, in addition to maintaining high routine childhood vaccination coverage.

Purpose: Childhood immunisation witnessed reduced coverage and delays globally during the Covid19 pandemic. This study aimed to identify gaps in routine childhood immunisation in southern India and the effect of the pandemic in censused rural and tribal populations. Methods: This study was conducted between August and September 2021 in a hard-to-reach tribal block (Jawadhu Hills) and rural (Timiri) block in Tamil Nadu. The proportion of full immunisation coverage (FIC), age-appropriate coverage and vaccination delays were calculated in the pre-pandemic (prior to March 2020) and pandemic (lockdown) period. Results: Among 2746 children (aged <30 months, with immunisation cards available) surveyed in these populations, overall FIC among children between 12-23 months of age was 50.8% (95%CI: 46.6-55.0) in Jawadhu and 83.7%; (81.1-86.2) in Timiri. In Jawadhu, coverage of oral polio vaccine3 (OPV3) decreased from 78.3% (73.4-82.6) pre-pandemic to 70.0% (66.6-73.2) during the pandemic; inactivated polio vaccine2 (IPV2) from 76.9% (72.1-81.2) to 69.1% (65.5-72.4); Pentavalent3 from 78.0% (73.1-82.4) to 70.2% (66.8-73.5); and Measles containing vaccine1 (MCV1) from 74.6% (67.6-80.8) to 56.7% (53.3-60.1). In Timiri, only MCV1 coverage decreased from 92.9% (88.7-95.9) to 85.4% (83.3-87.3). Factors associated with not receiving MCV1 included due date of vaccination falling during the pandemic lock downs, higher birth order, younger and less educated parents, and residing in the tribal block. Conclusion: This study highlighted differences in routine childhood immunisation vaccine coverage and impact of the pandemic in a geographically remote tribal block in contrast to a more accessible, rural block. Resilient health systems are essential to ensure sustainability in gains in vaccination coverage, especially in remote areas, and should be part of pandemic preparedness.

BACKGROUND: Adverse consequences of neonatal hyperbilirubinemia disproportionately affect babies in low- and middle-income countries. Laboratory measurement of total serum bilirubin is limited in low-resource settings, necessitating simpler alternatives. Our study aimed to evaluate the diagnostic accuracy of visual inspection of jaundice via the World Health Organization Integrated Management of Childhood Illnesses algorithm compared to transcutaneous bilirubinometry for the identification of hyperbilirubinemia in community settings. METHODS: Hyperbilirubinemia was assessed by visual inspection for jaundice and transcutaneous bilirubinometry at 0-72 hours, 3-5 days, and 5-14 days postnatal in the PRISMA prospective cohort study in six sites in Asia and Africa. We assessed sensitivity, specificity, and positive and negative percent agreement. RESULTS: We analyzed data from 14,331 infants, including 1,852 preterm infants. 15% had hyperbilirubinemia, as defined by transcutaneous bilirubin values and the NICE nomograms, at 3-5 days postnatal. Visual inspection had a sensitivity of 16%, specificity of 96%, positive percent agreement of 56%, and negative percent agreement of 86% at 3-5 days postnatal age, pooled across all sites and gestational ages, versus transcutaneous bilirubin defined by NICE nomograms. CONCLUSION: The poor sensitivity of visual inspection underscores an urgent need for accurate, affordable screening tools to improve screening for hyperbilirubinemia.

Background Childhood respiratory mortality in China has fallen by over 90% in three decades alongside sustained national warming, yet national long-run evidence on temperature and child respiratory mortality is lacking. Methods We linked Global Burden of Disease (GBD) 2021 mortality estimates for China - lower respiratory infections (LRI), ages 0-19, and asthma, ages 0-24, 1990-2021 - with C-LSAT 0.5 deg gridded temperature data (1990-2019), aggregated nationally and to five climate zones. Four annual indicators (mean temperature, diurnal temperature range, seasonal amplitude, interannual variability) entered regressions of log mortality rates with Newey-West standard errors. A bootstrapped (500 resamples) quadratic model probed the minimum mortality temperature (MMT), with PM2.5-adjusted analyses and future-exposure, permutation, and detrended falsification tests. Results LRI deaths fell by 96.3% (330,194 in 1990 to 12,098 in 2021; 95% uncertainty interval 9,669-14,891) and asthma deaths by 94.9% (3,287 to 167), while mean temperature rose 0.364 deg C per decade and diurnal temperature range narrowed 0.092 deg C per decade. Baseline coefficients were large (mean temperature -1.696, SE 0.174; diurnal temperature range +2.408, SE 0.336; seasonal amplitude -0.162, SE 0.082; interannual variability +2.924, SE 1.514, per 1 deg C in log rate), but the future-exposure test failed and detrending nullified every coefficient: the associations are trend-level, and short-cycle causal effects are not identifiable. Nor was the national MMT identifiable - observed temperature support spans only 6.66-8.13 deg C, and the nominal turning point of 35.84 deg C is an extrapolation artifact (quadratic term p = 0.963). Within the observed range, warming and declining mortality moved in the same direction. Conclusions The 96% decline in childhood respiratory mortality cannot be attributed to warming. China sits on the low-temperature side of the optimum, and the marginal direction of future warming requires stronger designs to establish. The falsification framework offers a discipline for climate-health inference in China.

Mechanisms shaping population vulnerability to typhoon-related mortality remain poorly understood. Constructing a Bayesian spatio-temporal model, we linked 12.9 million deaths across Japan from 2010 to 2019 to population-weighted typhoon wind exposure and assessed effect modification by income, natural hazard vulnerability and healthcare access. Typhoon exposure was associated with 2,426 cumulative excess deaths [95% credible interval: 139, 4,632] among adults [&ge;]70 years, with mortality increasing within 0-1 weeks of exposure and more strongly in areas with limited healthcare access and greater hazard vulnerability. Among individuals <70 years, cumulative excess mortality was uncertain [781 deaths; -309 to 1,900], but delayed mortality increases were concentrated in lower-income and landslide-prone areas. These distinct patterns suggest that typhoon mortality reflects an interaction between acute exposure, demographic ageing and geographically uneven adaptive capacity, highlighting the need to incorporate local vulnerability into climate-resilient health systems.

Introduction. By the end of 2023, many low-income countries had not reached 50% COVID-19 vaccine coverage, while most high-income countries had exceeded 80%. It remains unclear whether receiving vaccine deliveries translated into faster population coverage. We examined cross-national inequalities in the timing of the vaccine rollout and whether deliveries through the COVID-19 Vaccines Global Access (COVAX) facility were associated with subsequent national uptake. Methods. We conducted an observational study of 218 countries and territories using country-level data up to December 2023. We used generalized additive mixed models to identify country-level correlates of coverage at an early and a later stage of the pandemic, survival analysis to compare the time to 50% coverage between COVAX Advance Market Commitment (AMC) and non-AMC countries, and an event study to estimate the association between the timing of the first COVAX delivery and subsequent monthly coverage in AMC countries. Results. AMC-supported countries reached 50% coverage substantially more slowly than non-AMC countries. The hazard of reaching the threshold was 0.17 times that of non-AMC countries at month 1 (95% CI 0.07 to 0.41) and 0.53 times at month 18 (95% CI 0.33 to 0.85). One year after rollout began, 65.9% of AMC countries (95% CI 56.7 to 76.6) had not reached 50% coverage, compared with 21.1% of non-AMC countries (95% CI 15.1 to 29.5). The timing of COVAX deliveries was not significantly associated with subsequent national uptake in any post-delivery month. In the early stage of rollout, higher maternal mortality was associated with lower coverage, while a larger urban population was associated with higher coverage. By the end of the observation period, larger household size was associated with lower coverage, while higher health expenditure and a larger urban population were associated with higher coverage. Conclusion. Receiving COVAX deliveries was not, on its own, associated with faster coverage. Coverage differences were more consistently associated with country-level structural and health-system characteristics, while we found no significant association with the timing of the first COVAX delivery. Achieving vaccine equality likely requires strengthening the capacity of health systems to convert deliveries into administered doses, and preparedness efforts should invest in last-mile delivery capacity ahead of future emergencies.

Introduction Adults globally are experiencing increases in diseases attributable to overnutrition, yet child undernutrition persists at high levels. This "double burden of malnutrition" increases the risk of nutrition-related non-communicable diseases in mother and child. Evidence-based interventions promote optimal maternal weight or child growth, but gaps remain in implementing them as integrated, sustainable, and equity-focused solutions. Methods and analysis K'ASLEM is an individually randomized, parallel-group Hybrid Type 1 effectiveness-implementation trial in Indigenous Maya communities in Guatemala with high levels of the double burden of malnutrition. We will enroll 766 pregnant women aged [&ge;]16 years at less than 28 weeks' gestation, allocated 1:1 to intervention or comparator. The intervention integrates (a) food supplementation for pregnant and postpartum mothers and their infants and (b) behavioral counseling to optimize maternal weight and promote healthy nutrition, physical activity, and infant feeding practices. The comparator is enhanced usual care. Mother-child dyads will be followed until 12 months after birth. Co-primary outcomes are maternal weight and child length-for-age z-score at 12 months. Secondary outcomes are child stunting, child development, maternal overweight or obesity, and maternal hemoglobin. We will collect quantitative and qualitative implementation data, use Implementation Mapping to identify factors shaping implementation, and conduct an economic evaluation of costs and cost-effectiveness. Ethics and dissemination Ethics approval was obtained from the Institutional Review Boards of Mass General Brigham and Maya Health Alliance and the Institute of Nutrition of Central America and Panama Research Ethics Committee. Results will be published in peer-reviewed, open-access journals.