Transactions of The Royal Society of Tropical Medicine and Hygiene

Reproductive tract infections (RTI) are associated with adverse outcomes in pregnant African women. However, many diagnostic strategies are unaffordable or perform poorly. Here, we assess RTI prevalence and predictors of chlamydia/gonorrhea (CT/NG) in pregnant women reporting vaginal discharge and the performance of our previously published CT/NG risk algorithm in this population versus Rwandan National Guidelines (RNG). From 2017-2020, free sexually transmitted infections (STI) services were provided to residents in Kigali, Rwanda. Medical history and gynecologic examination were done. Laboratory assessments included HIV; syphilis; microscopy for trichomoniasis, bacterial vaginosis (BV), and candida; and PCR for CT/NG. Eighty-seven pregnant women received STI services. Prevalence was 28% for CT/NG, 15% for trichomoniasis, 24% for BV, 39% for candida, and 79% for any RTI. Predictors of CT/NG were age <=25 (adjusted prevalence odds ratio [aPOR]=4.92; 95% confidence interval [CI]: 1.52-15.90; p=0.008), inconsistent condom use (aPOR=4.86; 95%CI: 0.98-24.10; p=0.053), absence of candida (aPOR=4.23; 95%CI: 1.13-15.82; p=0.032), and endocervical inflammation/discharge (aPOR=4.91; 95%CI: 1.40-17.20; p=0.013). Our algorithm outperformed the 2019 and 2024 RNG (sensitivity: 92% versus 46% and 35% respectively). Pregnant women seeking STI services had high RTI prevalence. Our algorithm performed well. Algorithms tailored for pregnant women and including male partner risk factors should be explored.

Between 2015 and 2025, Cambodia reported a 99.9% decline in the number of cases of malaria. To aid acceleration of elimination, the National Center for Parasitology, Entomology and Malaria Control (CNM) implemented a package of interventions known as the Last Mile (LM) elimination program. The aim of this study was to determine the impact of the LM program on case numbers and evaluate the coverage of interventions. LM was rolled out between November 2020 and December 2023 in villages reporting a locally acquired case of Plasmodium falciparum or mixed infection with P. falciparum and P. vivax and included combinations of targeted drug administration (TDA), intermittent preventative treatment for forest goers (IPTf), active fever screening (AFS), the recruitment of a village or mobile malaria worker (VMW/MMW) and the top-up of insecticide-treated bed nets (ITN) depending on the vulnerability and receptivity of the village. A total of 103 full and 82 partial villages in seven provinces were included. Two rounds of TDA were administered, with a total of 10,678 individuals (67.6%) given during the first round and 9,678 (62.3%) during the second round. Coverage varied by province with none meeting the recommended threshold of 80%. IPTf was implemented each month among 35% (n=35) of full LM villages and 56% (n=42) of partial LM villages. A total of 11.7% (n=12) of full LM villages implemented AFS consistently on a weekly basis. Controlled interrupted time series showed no statistically significant difference in the number of malaria cases before and after the implementation of LM. Although we were unable to prove a statistically significant impact of LM, likely due to the small number of cases prior to LM, it is important to add to the limited evidence-based for Accelerator Strategies in countries approaching the elimination of malaria. Furthermore, findings from the feasibility and impact of individual interventions were used to change policy at the national level.

ABSTRACT Background Dog bite injuries are a major yet largely preventable public health concern worldwide. They contribute significantly to morbidity, healthcare burden, and economic costs, particularly in emergency department .The present study aims to analyse the demographics and injury pattern of dog bite cases presenting to the emergency department of a tertiary care hospital in Chennai. Methods We conducted a cross-sectional study with dog bite injured participants attending the Causality from November 2025 to April 2026 data was collected using a structured tool including details on demographics (Age, Gender, Education) injury related characteristics , history of pure bite site of dog bite injury type, WHO bitten criteria and information to management etc. We used here non probability statistical analysis and age specific dog bite cases and independent variables were analysed using SPSS (2.0 version). Result A total of Two hundred sixteen dog bite cases were analysed in the study by period of 6 months The majority of participants were 172 (79.6%) were above 18 years and 44 (20.4) were below 18 year, 130 (60%) from rural areas and 86 (39.8%) from urban areas, 136 (63.0%) of Victims presented within a day of the bite, 61( 28.2) next day and 19 (8.8%) in after one week 66 (30.6) were bitten by own dog and 150(69.4%)were bitten by neighbour / friended dog. 124(57.4) were bitten by stray dog 92(42.6) bitten by pet dog. 117(54.2) were vaccinated dog and 99(45.8%) were not vaccinated .110(50.9) victims were injured by laceration. 26(12.0%) were injured by puncture wound.46(21.3) were injured by abrasion 10(4.6) were injured by avulsion 15(6.9%) were injured by crush injury. 156(72.2%) were had minor wound.45(20.8%) victims had moderate wound and 15(6.9%) victims had severe wound. 112(51.9%) victims were taken antibiotics.104(48%) were not taken antibiotics. 185(85.6%) victims received tetanus toxoid, 31(14.4%) were not received tetanus toxoid. CONCLUSION There is a high burden of dog bite injuries from stray dogs in India. Despite early hospital presentation in many cases gaps in first aid practices and rabies post exposure prophylaxis were evident and highlighting inadequate awareness. Key words Rabies immunoglobulin, Dog bite, WHO criteria, Anti rabies vaccine, stray Dog, wound

Background In 2017, Zambia adopted surveillance as a core intervention towards achieving malaria elimination. Among the surveillance strategies is the malaria case investigation and response 1-3-7 (MCIR 1-3-7), which has been piloted in two low-incidence districts in the Southern Province since 2021. The study aimed to assess the implementation of MCIR 1-3-7 under programmatic conditions. It examined the timeliness, and completeness of the MCIR 1-3-7 activities, including the completeness of data entry in surveillance forms, and explored the experiences and perspectives of healthcare workers involved in the pilot. Methods A mixed-methods design was employed to assess the MCIR 1-3-7. Using a descriptive cross-sectional design, quantitative data were collected from 19 healthcare facilities in the two districts to assess the timeliness and completeness of MCIR 1-3-7. Additionally, 12 qualitative interviews were conducted with 29 healthcare workers from 11 of the 19 healthcare facilities. The interviews were voice-recorded and then transcribed manually. A codebook was developed using an iterative process to explore the facilitators and barriers encountered by healthcare workers in implementing the MCIR 1-3-7 intervention. All the visited facilities were purposively selected based on logistical convenience. Results This study retrospectively assessed 510 malaria cases that were diagnosed between January 2022 and June 2023, presenting at 19 health facilities: 283 cases in Chikankata and 227 in Mazabuka districts. A total of 278 cases (54.5%) were deemed to have been imported from outside the district, province, or country, while 45.5% (232/510) of the cases were classified as transmitted locally. Overall, 29.6% of case notification forms were found to be complete. Twelve interviews with 29 healthcare workers revealed a lack of transportation modalities as the main obstacle in executing the MCIR 1-3-7 intervention. The healthcare workers also indicated that monetary incentives, and supportive supervision would help them succeed in implementing this intervention. Conclusions The MCIR 1-3-7 has the potential to accelerate elimination in areas with low-transmission of malaria in Zambia. This study highlights opportunities to improve future implementation of the MCIR 1-3-7 intervention via strengthening supportive supervision, availing job aids, and ensuring access to malaria commodities as the intervention expands.

Abstract Introduction Onchocerciasis is targeted for elimination with community-directed treatment with ivermectin (CDTI). Alternative strategies are needed in areas where transmission persists despite long-term CDTI and/or are co-endemic with loiasis. This study assessed the efficacy of 35-day treatment with 100mg doxycycline on Wolbachia density at 6 months and microfilaridermia and palpable nodules at 30 months post-treatment. Methods A treatment follow-up study was conducted in 20 high-transmission onchocerciasis communities in a co-endemic loiasis area of South-West Cameroon. Community-based directly observed treatment with 100mg doxycycline was administered to community members aged [&ge;]9 years. Wolbachia clearance at 6-months and treatment efficacy on microfilaridermia and palpable nodules were assessed at 30-months post treatment. Factors associated with reductions in microfilaridermia post treatment, including adherence to doxycycline treatment were assessed with mixed-effects logistic regression. Results Over 92% (2835/3080) of eligible participants took 35 days of 100mg doxycycline over 5 or 6 weeks. This regimen achieved a 62.8% microfilaridermia reduction and 99% palpable nodule reduction in the 720 participants included at follow-up. Wolbachia depletion was observed in 92% of skin samples at 6 months post treatment. The most important factor associated with microfilaridermia after 30 months was having missed at least 7 doxycycline consecutive doses (OR 3.11, 95%CI: 1.17-8.26). Incomplete treatment to a lesser extent was not associated with reduced efficacy at follow-up. Conclusion This large-scale community intervention shows that a 5-week treatment with 100mg doxycycline is feasible and has high curative efficacy against adult O. volvulus as measured by the dramatic reduction in the proportion of palpable nodules at 30-months post treatment. The high efficacy shows the tremendous potential of anti-Wolbachia drugs as part of the arsenal for onchocerciasis elimination and paves the way for the next generation of anti-Wolbachia drugs with shorter treatment courses, which will facilitate the implementation of alternative strategies to accelerate onchocerciasis elimination.

Introduction Reducing delays in leprosy case detection is essential for achieving global leprosy targets. Accurate measurement of these delays and their determinants relies largely on patient-reported data, as routine health records are often inadequate. The leprosy case detection delay (CDD) questionnaire, developed under the Post Exposure Prophylaxis for Leprosy (PEP4LEP) project, has been validated in Ethiopia, Mozambique, Tanzania, and Indonesia. However, it has not been adapted or validated for Nigeria or any major Nigerian indigenous language. This study aimed to culturally adapt and validate the CDD questionnaire for Igbo-speaking populations in Nigeria. Methodology/Principal Findings The CDD questionnaire underwent a standardized cross-cultural adaptation process. Content validity was assessed using item- and scale-level content validity indices, while construct validity was evaluated through hypothesis testing. Reproducibility was assessed using test-retest and inter-rater reliability; agreement using the Bland-Altman method and the Wilcoxon Signed-Rank test; reliability using Spearmans rank correlation coefficient and the Intraclass Correlation Coefficient (ICC); and internal consistency using Cronbachs alpha. Data were collected through face-to-face interviews with persons affected by leprosy at two time points separated by at least two weeks. Participants (n=100) had a mean age of 45.1 years (SD=18.7). Mean CDD was 77.2 months at baseline and 77.9 months at retest. The instrument demonstrated excellent content validity (I-CVI/S-CVI: 0.90-1.00), good internal consistency (Cronbachs =0.77), and excellent test-retest reliability (ICC=0.996, 95% CI: 0.994-0.997). Test and retest measurements were highly correlated ({rho}=0.985, p<0.001), with no evidence of systematic change over time (p=0.864). Seventy-two percent of participants reported identical CDD values across assessments. All items from the original English version were retained without modification. Conclusion/Significance The Igbo version of the CDD questionnaire demonstrated good validity and reliability and is suitable for assessing leprosy case detection delay among Igbo-speaking populations in Nigeria

Background. Women living in leishmaniasis-endemic zones are regularly exposed to the sandfly vector in their environments. While case series and laboratory evidence consistently suggest transplacental transmission of Leishmania parasites with deleterious maternal-fetal effects, this issue has received insufficient attention, particularly in areas where the predominant Leishmania species is mainly associated with cutaneous disease (CL). Methodology/Principal Findings. We conducted an exploratory cross-sectional study in a highly endemic zone of Tabasco, Mexico, enrolling 53 women with singleton term deliveries between April 2018 and April 2020. Placental PCR was positive in 18 (34%) participants. Buccal swabs were positive in 11 (21.2%) of 52 newborns. Immunofluorescence confirmed intracellular amastigotes within macrophages near the vascular endothelium of PCR-positive placentas, with no surrounding inflammatory infiltration. Sequencing revealed homology to Leishmania mexicana or L. amazonensis. Birthweight percentile was modestly lower in the PCR-positive group (predicted mean 53.8% vs. 56.5%, p = 0.76), while small for gestational age showed a non-significant trend toward higher prevalence among PCR-positive cases (prevalence ratio = 2.06, 95% CI: 0.32-13.39, p = 0.45). Conclusions/Significance. Subclinical, dynamic transmission of Leishmania parasites typically associated with cutaneous disease was detected in this endemic zone. The presence of L. mexicana in human placentas was confirmed by immunofluorescence and sequencing, without an associated inflammatory response. These findings highlight the potential of CL-associated Leishmania species to reach the placenta and buccal mucosa of newborns, warranting further epidemiological investigation into the consequences of vertical transmission in regions with endemic CL.

Identifying and characterizing zoonotic pathogens in wildlife is essential for understanding disease risk to humans. In Sub-Saharan Africa, many people live with bats in their houses and are exposed to their pathogens, yet little is known about the bacterial pathogens in Afrotropical bat species. Globally, Bartonella spp. (bartonellae) and hemotropic Mycoplasma spp. (hemoplasmas) are common bacterial pathogens in bats, and some lineages are known to spill over and cause infections in humans. To evaluate this disease risk, we screened three common synanthropic bat species in Kenya, and their ectoparasites, for hemoplasmas and bartonellae and assessed their relatedness to known human pathogens. Of 767 bats across 21 sites, 17.9% of bats were Bartonella spp. positive and 19.3% were hemoplasma positive. Bat ectoparasites had similar Bartonella prevalence (13.5-25.0%) and, for most bat species, ectoparasite loads were not associated with increased likelihood of Bartonella infection. We found that Bartonella lineages displayed phylogenetic overlap between different bat species and ectoparasites, suggesting pathogen sharing between species, while hemoplasma lineages corresponded strictly to host taxonomy. Finally, we found that 16S rRNA sequences from one heart-nosed bat (Cardioderma cor) were 97.85% similar to a human-associated hemoplasma found previously in Schreibers bats (Miniopterus schreibersii) in Spain. We show that synanthropic bats host bacteria of potential public health concern, highlighting the need to investigate the emerging impacts of these pathogens on human health in Kenya and elsewhere in Sub-Saharan Africa.

Abstract Objective: This study aimed to assess the magnitude of undernutrition and associated factors among pregnant women attending public health facilities in the Goba district, Bale zone, Oromia Region, Ethiopia, 2022. Design: Institution-based, cross-sectional study design was used. Setting: The study was conducted in selected public health facilities from May to June 2022. Participants: The study population consisted of pregnant women who lived for at least 6 months in the study area and who attended antenatal care follow-up at selected public health facilities during the study period. Pregnant women who lived for less than six months in the study area and those who were critically ill were excluded from the study. Results: 487 respondents participated in this study with a 100% response rate. More than half (50.7%) of pregnant mothers were undernourished. The significant factors associated with maternal undernutrition during pregnancy in this study were mothers with no formal education (AOR = 5.050; 95% CI: 1.470- 17.346), a history of illness during pregnancy (AOR = 2.089; 95% CI: 1.246-3.504), and eating frequency of meals less than or equal to three times per day (AOR = 3.292; 95% CI: 1.040- 10.42). Poor nutritional knowledge (AOR = 5.588; 95% CI: 2.921-10.689), poor household (HH) wealth status (AOR = 4.774; 95% CI: 2.216- 10.285), and mothers who had >= 4 pregnancies were included (AOR = 0.852; 95% CI: 342-0.989). Conclusion: The magnitude of Undernutrition among pregnant women was 50.7%. Significant associations with Undernutrition were found in mothers with no formal education, poor dietary knowledge, a meal frequency of three or fewer times per day, a history of illness during pregnancy, lower and medium household wealth status, and those who had experienced four or more pregnancies while attending antenatal care (ANC) services at public health facilities.

Introduction: Malaria during pregnancy is a major risk factor for low birth weight (LBW) in newborns, which in turn negatively affects the growth and development of the child. The World Health Organization (WHO) recommended interventions for pregnant women living in malaria endemic countries that include the use of intermittent preventive treatment in pregnancy (IPTp). However, WHO asserts that the coverage of pregnant women taking the recommended doses of IPTp are still very low. The primary goal of this study was to estimate the effects of increasing the coverage of doses of IPTp and to assess the effect of pregnancy timing in relation to seasonal transmission on malaria infections during pregnancy and neonates with LBW. We explored these effects in moderate and high transmission settings. Methods and Findings: A compartmental mathematical model depicting malaria during pregnancy with IPTp doses was formulated to analyze the effects of IPTp, insecticide treated net (ITN) use and seasonal variations in moderate and high malaria transmission settings. Our simulation findings suggest that increasing both ITN use and IPTp dose coverages to high levels, prevents 90% and 84% clinical cases for pregnancies starting in August in moderate and high transmission, respectively. Our model predicts that increasing the coverage of the first dose of IPTp to 90%, while lowering subsequent doses, averts 44% and 37% LBW cases for the August cohort in moderate and high transmission settings, respectively. Unprotected pregnancies overlapping the January peak in rainfall and malaria incidence during the third trimester experience the highest LBW burden. Conclusions: The highest IPTp coverage prevents the highest number of LBWs providing evidence of the benefits of scaling up IPTp. Overall, our results demonstrate that increasing ITN use has a substantial impact in reducing clinical malaria cases during pregnancy and improves birth outcomes. This highlights its importance as a key intervention, and the health benefits it would provide for malaria control goals for pregnant women. Pregnancies that overlap with the epidemic peaks in later trimesters lead to a rise in LBWs, indicating the necessity of protecting pregnant women at risk of malaria infection till delivery.

IntroductionWith rising tick-borne disease (TBD) cases and the geographical expansion of tick populations, the need for effective surveillance and public education regarding local risk is crucial. This study assessed the effectiveness of tick-check stations as a tool for tick surveillance, and their impact on community knowledge, attitude, and practices (KAP) related to ticks and TBD. MethodsTo assess the effectiveness of tick-check stations for surveillance, we evaluated station engagement and compared tick density estimates, species composition, and life-stage distributions with those obtained through concurrent active surveillance. In addition, we compared submission numbers and tick species and life stages to those collected through a mail-in submission system conducted by the Colorado Department of Public Health and Environment (CDPHE). To quantify feasibility, we estimated effort per tick and compared effort across simulated sampling scenarios. Finally, in-person surveys were conducted at trailheads to assess baseline tick KAP and to evaluate differences between sites with and without tick-check stations ResultsEngagement with tick-check stations was sustained throughout the study. Temporal tick densities estimated from tick-check station submissions were correlated with density estimates from active surveillance (R = 0.534), and species composition and life-stage distributions did not significantly differ between methods. Tick-check stations required less effort per tick than active surveillance when sampling sites were nearby or tick densities were low, whereas sites that were farther away or had higher tick densities required less effort per tick under a hybrid surveillance approach. When asked to list tick-borne pathogens in Colorado, 47% of survey participants who had read tick-check station signage identified Rocky Mountain spotted fever compared with 20% of participants in the control group (p = 0.007; odds ratio). Notably, a low proportion of survey participants (24%) reported performing tick-checks to prevent tick bites. ConclusionTick-check stations can provide tick density estimates comparable to active surveillance while requiring less effort in many scenarios, particularly in low-density settings. Our findings also highlight opportunities for targeted outreach to address gaps in TBD knowledge. As both a surveillance and educational tool, tick-check stations offer a sustainable approach for expanding tick monitoring in resource-limited settings.

Background In northern Thailand, scrub typhus primarily affects rural and hill tribe communities, yet awareness is low. In 2020 we trained community health volunteers (CHVs) to raise awareness in their communities using a train-the-trainer approach. CHV knowledge rose dramatically. However, we did not assess the effectiveness in community members and our strategy relied heavily on CHVs, who have limited availability. Methods In a second phase, object of this manuscript and conducted in 2022-2023, after training CHVs we measured the effectiveness in community members and compared in-person sessions carried out by CHVs with sessions using video or audio recordings only. All materials included key information about scrub typhus transmission, symptomatology, prevention, and management and had been developed following feedback from participants from the first round of activities in 2020. Effectiveness was evaluated using a questionnaire assessing scrub typhus knowledge. CHVs were also asked to rate the feasibility of suggested preventative measures. Results A total of 74 community members participated in six sessions. Knowledge of scrub typhus significantly improved post-training (median score increased from 2 to 6 out of 9, p<0.001) and audio and video recordings were as effective as in-person trainings. CHVs noted that some of the preventative measures recommended are difficult to put in practice such as wearing gloves, washing daily after work, avoiding kneeling and resting on the ground, and washing clothes daily. Conclusions Our findings support the use of locally adapted multimedia training for scrub typhus prevention, showing that scalable formats can be as effective as in-person ones. Further collaborative work with people at risk should refine preventative messages to improve feasibility and acceptance.

Background Vector control is essential to malaria control and elimination. National Malaria Programmes (NMPs) must make complicated decisions about vector control in the face of evolving epidemiology, biological threats like insecticide resistance, a growing vector control toolbox, and an increasingly constrained funding landscape. The WHO recently published a manual on subnational tailoring of malaria strategies, but limited efforts have been made to understand how NMPs prioritize data and factors that impact decision-making in practice. This study explores vector control decision-making processes, enablers, and barriers across 12 African malaria programmes. Methods We conducted semi-structured interviews with 13 NMP managers or designated representatives from 12 African countries. Interviews were conducted virtually via Zoom or in-person, audio-recorded, transcribed, and thematically analyzed using content analysis. Participants described the interventions in use, decision-making factors, stratification approaches, perspectives on new tools, and operational challenges. Results Insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS) are the core interventions in all countries, with limited but growing use of larval source management, mainly larviciding. Vector control tool selection is driven by WHO guidance, resistance profiles and patterns, epidemiological trends, operational feasibility, and donor funding priorities. Sub-national stratification is widely applied; however, limited analytic and modeling capacity hinder consistent application. Gaps in entomological data result in incomplete data availability to guide stratification. New vector control tools were perceived as promising options, albeit constrained by cost, limited evidence, regulatory delays, and community acceptability. Funding emerged as the dominant driver of decisions, shaping intervention choices regardless of country preference. Participants emphasized substantial gaps in vector control protection related to residual transmission, outdoor biting, insecticide resistance, and unprotected populations living in temporary structures or associated with high-risk occupations. Conclusions Vector control decision-making among NMPs is shaped by an interplay of scientific evidence, operational realities, and external funding dynamics. Strengthening entomological surveillance, enhancing SNT analytic and model output interpretation capacity, securing sustainable financing, and improving community engagement are critical to advancing tailored deployment of tools. Decision-support frameworks that reflect the complexities facing NMPs may further enhance evidence-based, context-specific vector control planning.

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

BackgroundControl of Aedes aegypti, the primary vector of dengue and other Aedes-borne viruses, is challenged by insecticide resistance, limited efficacy of existing tools and the large and widespread epidemics. Targeted Indoor Residual Spraying (TIRS), a modification of traditional indoor residual spraying focused on Ae. aegypti resting sites, has demonstrated promising results, yet its indirect community-wide effects remain underexplored. Methodology/Principal FindingsWe conducted an entomological cluster-randomized controlled trial in Iquitos, Peru, to evaluate the direct and indirect entomological impacts of TIRS using pirimiphos-methyl. Thirty clusters were randomized to receive either TIRS (15 clusters, 898 structures) or standard Ministry of Health vector control activities (15 clusters, 1,018 structures). Aedes aegypti indoor densities were assessed in the 45 days pre-intervention and at four time points up to 255 days post-intervention using Prokopack aspiration. Generalized linear mixed models with a negative binomial link were used to estimate incidence rate ratios (IRRs) and calculate efficacy (1-IRR) for houses that received TIRS (direct effect) and untreated houses in TIRS clusters (indirect effect). Direct efficacy reached 96% at 15 days post-spraying and remained significant (40%) at 255 days post-spraying. Indirect efficacy reached 69% at 15 days and declined to 7% by 255 days post-spraying. Despite only 57% household-level TIRS coverage, both direct and indirect impacts on Ae. aegypti were significant during early post-intervention surveys, and after 8 months in TIRS clusters. Conclusions/SignificanceTIRS provided substantial and sustained reductions in indoor Ae. aegypti density, including measurable indirect effects in untreated homes within intervention clusters. These findings demonstrate the entomological value of TIRS even at moderate coverage levels and highlight its potential for both preventive and reactive vector control programs and should be considered for implementation by Ministries of Health in dengue-endemic urban settings as well as by the U.S. military when deployed to tropical or subtropical locations.

Objective: The study aimed to describe the challenges, best practices, and lessons learned during meningitis vaccination campaigns conducted in the context of COVID-19 in Cameroon in 2020. Results: During the prevention campaigns, 3,460 individuals were selected. All were tested before the campaign (100%). Eight cases were positive, representing a positivity rate of 0.23% (8/3,460). The campaign was carried out using a fixed strategy in health facilities and prisons and a fixed-temporary strategy in communities. Most health areas received sufficient quantities of COVID-19 equipment for some items and insufficient quantities for others. No screening was done during or after the campaign. The main difficulties encountered were compliance with social distancing and the continuous wearing of gowns. The challenges faced were the screening of actors and the use of personal protective equipment. Lessons learned: aspects related to COVID-19 impacted the speed of the campaign. Vaccination coverage ranged from 91% to 140% in prisons on the one hand, and from 35% to 112% in the health areas surrounding prisons on the other. The campaign in the context of COVID-19 was effective. Compliance with barrier measures was not optimal due to difficulties encountered with aspects such as social distancing, continuous wearing of gowns, screening of participants during and after the campaign, and insufficient personal protective equipment.

Background/Objectives: Children aged 6-24 months are highly vulnerable to malnutrition during conflict because they depend on breastfeeding, complementary feeding and functioning nutrition services. This study assessed nutritional status, socioeconomic correlates, maternal knowledge and primary health care centre (PHCC) nutrition service gaps in Gaza. Subjects/Methods: This cross-sectional study was conducted at Al-Daraj Martyrs Health Centre, one of the remaining functioning PHCCs in Gaza City during the study period, between late August and October 2025. Mother-child pairs were recruited by convenience sampling. Of 276 approached, 200 were included after non-response and exclusion of questionnaires with missing anthropometric data. Data came from structured interviews and medical records; haemoglobin results were available for 55 children. Results: Stunting affected 12.5% of children, underweight 20.1%, wasting 20.8%, and anaemia 63.6% of the haemoglobin-tested subsample. Underweight was associated with household food shortage (p=0.013) and previous malnutrition treatment (p=0.002), wasting with child age category (p=0.0024), and anaemia with paternal unemployment (p=0.020). Maternal knowledge and practice scores were positively correlated (r=0.177, p=0.012), but neither was independently associated with stunting or underweight in adjusted models. PHCC nutrition support was limited, with 71.0% of mothers reporting nurse-provided nutrition advice and 52.5% reporting growth-chart review. Conclusions: In this clinic-based sample from conflict-affected Gaza, malnutrition among children aged 6-24 months was substantial. The overall pattern suggests that nutritional risk was shaped more by structural deprivation and weakened PHCC support than by maternal knowledge alone. These findings underline the need to restore essential nutrition services and improve access to adequate food for young children.

Rectal artesunate (RAS) is a pre-referral intervention recommended for children with suspected severe malaria in remote settings where injectable treatment is not readily available. Although clinical trials have demonstrated efficacy, less is known about the behavioural and health system factors influencing effectiveness under routine conditions. A convergent parallel mixed-methods design was used to assess implementation of Zambia's RAS intervention package across three districts: Serenje, Chama, and Mwinilunga. A retrospective case-tracking investigation of all 300 children with suspected severe malaria recorded by community health workers (CHWs) assigned to study facilities examined progression and attrition across the severe malaria care cascade. In-depth interviews and focus group discussions with caregivers, CHWs, and other stakeholders explored barriers and facilitators influencing progression. Among 300 enrolled children, early attrition occurred due to negative rapid diagnostic test results. Of 239 RDT-positive children, 218 (91.2%) received RAS. Referral completion was lower; among 261 children referred and followed up at health facilities, 209 (80.1%) were confirmed to have completed referral. Of 186 children diagnosed with severe malaria at the facility, 167 (89.8%) received both injectable artesunate and follow-on artemether-lumefantrine. Patterns of disengagement varied by district, with Serenje demonstrating the most consistent progression, Chama experiencing the largest drop-off at RAS administration, and Mwinilunga showing the lowest completion of follow-on treatment. Qualitative findings revealed strong community appreciation for RAS despite stockouts, alongside social and behavioural barriers, including gendered responsibilities, transport challenges, and confusion following symptom improvement, that discouraged referral completion. RAS can be a life-saving intervention when embedded within strong health systems and community structures. Zambia's experience underscores the need for comprehensive implementation strategies that extend beyond drug distribution to include sustained CHW training, reliable commodity supply, functional referral systems, and meaningful caregiver engagement.

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

Summary Background Persistent transmission from relapsing Plasmodium vivax infections threatens malaria elimination programs in the Asia-Pacific and Americas. Tools to identify people at risk of relapse are urgently required. We aimed to validate a panel of eight P. vivax serological biomarkers for predicting future relapses. Methods In this observational study, soldiers returning from malaria-endemic Papua to non-endemic East Java, Indonesia, were screened at enrolment using antibody measurement (Luminex) and trained random forest classification algorithms, then followed for 6 months. Active case detection was performed fortnightly by microscopy. Algorithms classified soldiers as recently infected (last nine months) and thus at risk of relapse, based on anti-vivax antibody measurements at enrolment. Findings Between December 2018 and July 2022, 592 soldiers were enrolled, with 553 completing follow-up; 119 experienced a P. vivax relapse. Of these, 102 were correctly classified as at risk of relapse at enrolment, corresponding to 86% sensitivity and 86% specificity, with an AUC of 0.92. Interpretation P. vivax serological biomarkers can identify people at risk of relapse with high sensitivity and specificity and could be used as a novel public health intervention, P. vivax serological testing and treatment (PvSeroTAT), to reduce relapse-driven transmission.