Transactions of The Royal Society of Tropical Medicine and Hygiene

Background Affecting 40% of infants and young children worldwide, anaemia in sub-Saharan Africa hampers cognitive and physical development, often in ways that cannot be reversed. Iron-based micronutrient powders (MNPs) are recommended to combat anaemia, but concerns remain about their safety and effectiveness in malaria-endemic areas. We evaluated the impact of iron-based MNPs on growth measurements and malaria-related anaemia among preschool children in Ghana. Methods We conducted a secondary analysis of a cluster-randomized, double-blind, placebo-controlled trial in the Bono Region, Ghana. Children aged 6-35 months (n=1,958) received daily MNP containing 12{middle dot}5mg elemental iron or placebo for five months. Anthropometric indices, haemoglobin, and malaria parasitaemia were assessed at baseline and endline. Adjusted analysis of covariance (ANCOVA) models estimated effects on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) z scores. Binomial regression with identity link estimated risk differences for malaria-induced anaemia. Cluster-robust standard errors were applied at the compound level, and intracluster correlation coefficients (ICCs) were estimated. Results 1,815 (92{middle dot}7%) children completed the endline survey, but 1,806 were included in the final analysis. Baseline characteristics were balanced between groups. Iron-containing MNP had no significant effect on endline HAZ ({beta}=0{middle dot}026, p=0{middle dot}609), WAZ ({beta}=-0{middle dot}015, p=0{middle dot}719), or WHZ ({beta}=-0{middle dot}035, p=0{middle dot}463). However, the intervention reduced the risk of malaria-induced anaemia (risk difference 0{middle dot}050, 95% CI 0{middle dot}004-0{middle dot}096; p=0{middle dot}032). Female sex was associated with higher HAZ ({beta}=0{middle dot}149, p=0{middle dot}005). Conclusion Iron-containing MNP did not improve short-term growth but was associated with a modest reduction in malaria-induced anaemia. These findings support the safe use of iron fortification in malaria-endemic settings while underscoring the need for integrated strategies to address persistent growth faltering and gender specificity.

Introduction: Solitary plasmacytomas (SP) are rare neoplasm of localised proliferation of clonal plasma cells. It can be classified based on site of involvement and bone marrow involvement. It is an indolent disease in the majority of patients. Primary modality of treatment is radiotherapy and surgical excision. Materials and methods: This was a retrospective audit of SP who were treated and followed up at a tertiary care center in eastern India from January 2012 to December 2025. Patients who has solitary plasma cytoma with more than 10% plasma cells, POEMS syndrome, have been excluded from analysis. Results: We identified 46 patients of SP. The median age of the studied population was 53 years (23-75 years). Males were more commonly affected than females (M:F=2.2:1). Most common chief complaints were bony pain (67.4%). SBP was seen in 39 (84.8%) cases whereas SEP was seen in 7 (15.2%) cases. Vertebra was the most common site of involvement (61.4%). Median M band concentration 0.24 g/dL (0.1 to 1.95 gm/dL). IgG was the most common isotype accounting for 60.6% cases. Six cases (13%) had minimal bone marrow involvement. The majority of the patients received local radiotherapy (89.1%). With a median follow up of 5.4 years (95% CI: 1.8 - 9.0), median OS was not reached, median PFS was 9.22 years (95% CI: 5.8-12.6), median time to next treatment (TTNT) was 9.86 years (95% CI: 6.8 - 12.9). Conclusion: Solitary plasmacytoma commonly affects young males. Bones are more commonly affected than extramedullary sites. SP has a lower rate of progression and excellent prognosis when treated with local radiotherapy.

Background During Nigeria's largest recorded diphtheria outbreak, hospital capacity in Kano State was rapidly overwhelmed. Medecins Sans Frontieres introduced home-based care (HBC) for patients with mild disease to prioritise facility-based care for severe cases. We assessed whether HBC was non-inferior to facility-based treatment in terms of mortality, sequelae, and household transmission. Methods We conducted a retrospective matched cohort study. Mild diphtheria cases treated between January 2023 and May 2024 were matched 1:1 by treatment modality (HBC or diphtheria treatment centre [DTC]) on sex, age group, vaccination status, and residence. Conditional logistic regression estimated the association between treatment modality and mortality, with robustness assessed through propensity score weighting, sensitivity analyses, and E-value computation. Findings Of 990 sampled patients, 678 (367 HBC, 311 DTC) were enrolled (68.5%). After adjustment, treatment modality was not independently associated with mortality (HBC vs. DTC: aOR 0.40, 95% CI 0.13-1.30), with similar estimates across sensitivity analyses (E-value 4.40). Clinical complications were the strongest predictor of death (aOR 23.1, 95% CI 1.73-307). Vaccination was protective (aOR 0.28, 95% CI 0.08-0.94) and treatment delay of four or more days increased mortality (aOR 4.15, 95% CI 1.23-14.0). HBC was not associated with increased household transmission or long-term sequelae. Interpretation Vaccination and early treatment, rather than care setting, were the main determinants of survival. When supported by clinical triage and structured follow-up, decentralised care can be used to manage mild cases during diphtheria epidemics in settings with constrained hospital capacity.

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.

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

Waldenstrom macroglobulinemia (WM) is a rare indolent neoplasm characterized by presence of more than 10% lymphoid cells in BM that exhibit plasmacytoid or plasma cell differentiation that secretes an IgM monoclonal protein. This is a retrospective analysis of 89 patients of WM that describes the clinical and laboratory characteristics, treatment patterns and outcome of patients of WM. The median age of the entire cophort was 66 years with male predominance (67.4%). Most common presentations were symptoms pertaining to anemia (77.5%) and constitutional symptoms (33.7%). Median bone marrow lymphoplasmacytic cells were 41%. Positivity for MYD88 and CXCR4 mutations were seen in 81.8% and 2.4% cases. BR was the most common regimen used (52.8%). Overall response rates were seen at 87.8%. Median overall survival, progression free survival and time to next treatment is 8.49 years, 2.15 years and 3.88 years. BR regimen was associated with highest event free survival.

Background/aims The World Health Organization (WHO) aims to eliminate schistosomiasis as a public health problem (EPHP) across 78 endemic countries by 2030. However, for low-prevalence settings that reach EPHP, guidance on managing transmission to maintain EPHP or move towards Interruption of Transmission (IoT) is limited, partly due to insufficient evidence on drivers of resurgence. In Uganda, some communities inland from Lake Victoria have achieved EPHP for Schistosoma mansoni but not progressed to IoT. This study explored whether routine, short-range travel to the highly endemic lake could sustain transmission in these settings. Methods We conducted a cross-sectional study in five Ugandan villages ~5 km from Lake Victoria. Parasitological data were collected using Kato-Katz and Point-of-Care Circulating Cathodic Antigen tests, alongside questionnaires on lake travel from 585 individuals aged 1-91 years. A structural causal model estimated the total and direct effects of travel frequency, activity type, water contact duration, and drug treatment history on infection. Bayesian regression models and counterfactual simulations predicted infection under hypothetical interventions. Results Reaching IoT in low-risk villages may be undermined by habitual, short-range travel to high-risk sites, driven by the nature and duration of lake contact. Daily lake travel caused a 1.7-fold increase in odds of infection, while occupational activities caused a 3.4-fold increase compared with no lake activity. Counterfactual analysis showed that removing lake contact duration most reduced infection risk among moderate-frequency travellers, while daily travellers showed smaller changes, and some transmission persisted among individuals with little or no lake contact. Simulations demonstrated that modifying lake contact behaviours could reduce individual infection risk but had limited population-level impact. Conclusion These findings indicate that targeting only high-risk villages or individual behaviours is unlikely to achieve sustained, wide-spread IoT, underscoring the need for integrated control strategies that account for mobility, behaviour, and local transmission ecology.

BackgroundSchistosomiasis remains a major public health challenge in sub-Saharan Africa. Recent World Health Organization (WHO) guidance calls for community-wide treatment and fine-scale data to optimise preventive chemotherapy (PC) strategies, yet the practical implications for resource allocation by health ministries are unclear. MethodsWe analysed epidemiological and cost data from Ethiopia and Zimbabwe to compare survey designs and five implementation scenarios. Scenarios varied by data source, administrative unit of implementation, WHO guidance on PC strategies. Outcomes were target population, praziquantel needs, and delivery costs. ResultsGeostatistical surveys reduced sample size by up to 90% and survey costs by [&ge;]72% compared with a design-based approach, while increasing spatial coverage. Applying updated WHO guidance expanded eligibility to pre-school-aged children and adults, and in one scenario increased treatment needs by 72% in Ethiopia and 262% in Zimbabwe. Correspondingly, praziquantel requirements and delivery costs were driven primarily by expanded age eligibility rather than geographic coverage. ConclusionsGeostatistical surveys provide substantial efficiency gains for impact assessments, enabling cost-efficient, granular targeting. However, implementing 2022 WHO guidance was the dominant driver of increases in programme scope and resource needs, underscoring the importance of accurate fine-scale data to guide efficient planning and budgeting toward elimination goals. Author summarySchistosomiasis control programmes are required to use finer-scale data and updated World Health Organization (WHO) guidance to decide where and how often to deliver praziquantel. We analysed national schistosomiasis data and programme costs from Ethiopia and Zimbabwe to compare different approaches to impact assessment surveys and to estimate how treatment needs change under alternative decision rules.We found that model-based geostatistical surveys can reduce the number of people that need to be sampled and the cost of surveys while providing more detailed information for planning at sub-district level. However, when we applied the 2022 WHO schistosomiasis guidance, expanded eligibility (including adults and pre-school-age children and a lower threshold for community-wide treatment) substantially increased the number of people needing treatment. In our scenarios, expanded eligibility drove much larger increases in praziquantel requirements and delivery costs than changes in geographic coverage. Our findings help health ministries to anticipate the operational and budget implications of updated guidance and highlight why accurate fine-scale data are essential for equitable and realistic planning toward elimination.

BackgroundLymphatic filariasis remains a public health concern in many endemic regions, where chronic disease persists despite substantial reductions in transmission. In Ghana, more than two decades of mass drug administration have significantly reduced disease prevalence and transmission; however, chronic manifestations and gaps in community understanding continue to be reported in parts of the north. This study assessed infection status, chronic morbidity burden, and community knowledge in a rural setting in northern Ghana approaching elimination. Methodology/Principal FindingsA community-based cross-sectional study was conducted in Birifor, northern Ghana, from October 2024 to January 2025. A total of 261 residents aged ten years and above were selected using random sampling. Data collection included structured questionnaires, clinical examination for chronic disease, and night blood microscopy for the detection of infection. No microfilariae were detected (0/261; 0%). However, chronic lymphoedema was identified in five individuals (1.9%), all aged over 40 years. Awareness of the disease was high (95.8%), yet only 39.5% of participants demonstrated good community knowledge and perceptions and self-reported preventive practices. Misconceptions regarding transmission, particularly beliefs that the disease is hereditary or caused by spiritual factors, were common. Participation in mass drug administration was high (93.1%). Despite this, chronic disease imposed a notable socioeconomic burden: all affected individuals reported loss of income, and 60% reported additional household income loss due to caregiving. Conclusions/SignificanceThese findings suggest that transmission in the study area is likely very low, although residual infection cannot be excluded; however, chronic disease and gaps in community knowledge persist. Strengthening morbidity management, improving community education, and providing support for affected households are essential. Sustained surveillance and integrated approaches will be critical to prevent resurgence and support long-term elimination efforts. Author SummaryLymphatic filariasis, also known as elephantiasis, is a mosquito-borne disease that can cause long-term swelling of the legs, arms, or genitals. Global efforts have greatly reduced its occurrence, especially through repeated mass drug administration to afflicted communities. However, many people continue to live with chronic swelling caused by past infections, which can affect their ability to work and participate fully in daily life. In this study, we examined the current situation of lymphatic filariasis in a rural community in northern Ghana that has received many years of treatment. We tested people for active infection, assessed signs of chronic disease, and explored what community members know and believe about the disease. We found no evidence of active infection, suggesting that transmission is now very low. However, some individuals were still living with chronic swelling and reported loss of income, while households also experienced financial strain due to caregiving. Although most people had heard of the disease, many did not fully understand how it is transmitted. Our findings show that reducing transmission alone is not enough. Continued education, community support, and access to care are needed to address the long-term impact of the disease and support ongoing elimination efforts.

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 Nepal has set a goal to eliminate lymphatic filariasis (LF) by 2030. As of 2024, Nepal has stopped the mass drug administration (MDA) in 56 of the 64 endemic districts and completed two rounds of MDA in six districts with persistent LF ([&ge;]2% antigen prevalence) using the three-drug regimen of Ivermectin, Diethylcarbamazine, and Albendazole (IDA), exceeding 65% coverage. We subsequently conducted an Epidemiological Monitoring Survey (EMS) to assess the impact of the MDA in reduction of LF infection prevalence below the transmission threshold and examine the factors associated with it. Methods We conducted a cross-sectional EMS nine months after MDA in 12 evaluation units (EUs) across six districts, with two sites per EU. We recruited a total of 7,343 individuals aged [&ge;]20 years, sampled using multi-stage sampling, ensuring at least 300 blood samples collected per site. We collected data on demographics and MDA participation. We performed the LF antigen testing for all participants, followed by night blood microfilariae testing in antigen-positive individuals. Statistical analyses included non-parametric tests, Chi-square and Fishers Exact tests, and multivariable logistic regression to assess outcomes after adjusting for potential confounders. Results Nine of 12 evaluation units (EUs) recorded <1% microfilaremia, meeting the WHO threshold for passing EMS, while three EUs failed with [&ge;]1% prevalence in at least one site. Antigen and MF prevalence were 4.47% and 0.34%, respectively (ratio 13:1). Both Antigen and MF prevalences were significantly associated with female sex (AOR= 0.564, 95% CI: 0.441-0.721 and AOR = 0.326, 95% CI: 0.129-0.826 respectively) and participation in the most recent MDA round (AOR = 0.477; 95% CI: 0.385-0.591 and AOR = 0.089; 95% CI: 0.017-0.464 respectively). MDA uptake was influenced by age (<40 years, AOR = 0.72; 95% CI: 0.653-0.793), sex (female, AOR = 1.438; 95% CI: 1.29-1.603), cross-border residence (AOR = 0.616; 95% CI: 0.558-0.681), and occupation (agriculture and housewife, AOR = 1.144; 95% CI: 1.008-1.298). MF prevalence was also associated with younger age (<40 years, AOR = 0.211; 95% CI: 0.071-0.626). Conclusion The survey indicates progress toward LF elimination, with nine of twelve EUs achieving WHOs <1% microfilaremia threshold after two rounds of IDA-MDA. However, transmission persists in three sites, likely linked to poor MDA participation among specific subgroups--particularly males, younger adults, and cross-border populations. Strengthening MDA coverage and compliance across all demographic and occupational groups, with special focus on border areas, is essential to achieve LF elimination in Nepal.

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

ABSTRACT Background: Malaria remains a leading public health burden in sub-Saharan Africa, disproportionately affecting children under five years. In response, Kenya introduced the RTS,S/AS01 malaria vaccine in selected regions, including Siaya County where malaria transmission is endemic. Despite this milestone, uptake has been inconsistent, with hesitancy emerging as a significant barrier. Objective: This study aimed to determine factors associated with malaria vaccine hesitancy among caregivers of children 6-59 months in Ugenya Subcounty, Siaya County. Methodology: A cross-sectional mixed methods design was employed involving 425 caregivers and 15 healthcare workers and County health officials between January to February 2025. Quantitative data were collected using structured questionnaires and analyzed in Stata version 17 through descriptive statistics, bivariate analysis at 20% significance threshold, and multivariable logistic regression at 5% level to determine key factors associated with malaria vaccine hesitancy. Qualitative data from 15 key informant interviews were transcribed verbatim and thematically analyzed using NVivo. Thematic analysis, guided by a predefined codebook, was used to identify recurring patterns and extract key themes, which were illustrated with direct quotations from participants Results: Overall, 42.9% of caregivers (n=181; 95% CI: 38.9%-47.3%) reported hesitancy. Significant predictors included caregiver age, marital status, family size, access to health facilities, and vaccine availability. Single caregivers, those from smaller households, and those facing health facility access challenges were more likely to be hesitant to malaria vaccine. Despite high levels of knowledge, misconceptions and misinformation about vaccine safety, often spread via social media persisted. Conversely, caregivers relying on healthcare workers and mainstream media showed greater acceptance of malaria vaccine. Conclusion and Recommendations: Malaria vaccine hesitancy remains significant at 42.9%, driven by demographic factors such as younger age, single status, and smaller household size. Structural barriers including limited vaccine availability and poor access to health facilities further contribute to reluctance. Although knowledge and awareness were high, misinformation, particularly from social media, persisted, while information from healthcare workers improved acceptance. Addressing these gaps through targeted community engagement, improved access, and trusted communication channels is essential to increase uptake of malaria vaccine.

Background: The WHO End TB strategy targets 80% and 90% reductions in TB incidence and mortality, respectively, between 2015 and 2030. Objective: We assess which epidemiologic factors, including existing and new interventions, are most critical to reducing future TB in South Africa. Methods: We adapted an existing mathematical model of TB and HIV in South Africa. Prior distributions were specified to represent uncertainty ranges for 27 model parameters that are highly uncertain and potentially important in driving future TB dynamics. Latin Hypercube Sampling was used to sample 1000 parameter combinations from these distributions, and the model was projected to 2040 for each. Partial rank correlation coefficients (PRCCs) were calculated to assess correlation between each parameter and average adult TB incidence and mortality rates over 2025-2040. Results: Adult TB incidence and mortality rates in South Africa are projected to decline by 46% (95% CI: 17-69%) and 54% (95% CI: 21-84%) respectively by 2030, relative to 2015. The parameters most strongly associated with future TB incidence are the increase in microbiological testing in symptomatic individuals due to near-point-of-care/tongue swab (NPOC/TS) testing (PRCC=-0.67), reductions in social contact rates post-COVID (PRCC=-0.61), the probability of sputum testing in symptomatic individuals in the absence of NPOC/TS testing (PRCC=-0.39), and the efficacy of TB preventive therapy (PRCC=-0.35). TB mortality predictors are similar. Conclusions: Increasing testing among people with TB symptoms, including through new NPOC/TS technologies, is likely to have the largest impact on progress towards End TB goals in South Africa, though attainment by 2030 is unlikely.

BackgroundAnimal bites represent a significant public health concern due to the risk of injuries and transmission of zoonotic diseases such as Rabies, particularly in low and lower- middle-income countries (LMICs). Understanding the epidemiological characteristics of animal bite incidents is essential for improving the prevention and control strategies. This study aimed to characterize the epidemiological patterns and characteristics of animal bite cases in Sylhet, Bangladesh. Methodology/Principal findingsWe conducted a retrospective analysis of 6,565 animal bite cases reported between January 1 and December 31, 2024, in Sylhet, Bangladesh. Data on demographic characteristics, type of biting animal, site of bite, and exposure category were collected and analyzed to determine associations using correlation analyses and chi-square tests. Among the victims, 3,917 (60%) were male and 2,648 (40%) were female and young adults aged 20-39 years comprised the largest group (39% of cases). The majority of cases (88.1%) originated from urban areas within Sylhet City Corporation. Cats were the leading cause of bites (56.6%), followed by dogs (35.0%) and monkeys (7.5%), suggesting a shift from the traditional dog-dominated pattern. The most frequently affected anatomical sites were the legs (50.3%) and hands (40.9%). Most exposures were classified as World Health Organization (WHO) Category II (98.2%). Bite incidents showed moderate seasonal variation, with peaks in spring and early autumn. A significant declining temporal trend was observed for monkey bites (R = -0.59, p = 0.044), whereas cat and dog bite patterns remained relatively stable throughout the year. Significant associations were identified between bite site and age group, as well as between biting animal and demographic characteristics (p < 0.05). Conclusion/SignificanceThese findings highlight the epidemiological patterns of animal bites in Sylhet and emphasize the need for strengthened public awareness, surveillance, and preventive strategies to reduce animal bite incidents and associated zoonotic disease risks. SynnopsisO_LIA large-scale retrospective analysis of 6,565 animal bite cases revealed a cat-dominant bite pattern (56.6%), contrasting with the traditional dog-dominant paradigm in South Asia. C_LIO_LIYoung adults (20-39 years) and males (60%) were disproportionately affected, reflecting occupational and behavioral exposure risks. C_LIO_LIUrban residents (88.1%) accounted for the majority of cases, highlighting the growing public health burden of animal bites in rapidly urbanizing settings. C_LIO_LIThe most frequently affected anatomical sites were the legs (50.3%) and hands (40.9%). Bite incidents showed moderate seasonal variation, with peaks in spring and early autumn. C_LIO_LICategory II exposures (98.2%) predominated, indicating a high burden of seemingly minor injuries that may be underestimated in rabies prevention strategies. C_LI

Abstract Background: To influence malaria-related behaviours, it is important to understand key behavioural drivers, encourage enablers and address barriers to individuals and communities adoption of interventions to prevent malaria. The capability(C), opportunity(O), and motivation(M) Behaviour(B) model (COM-B model) was used to inform development of perennial malaria chemoprevention (PMC) social, and behaviour change (SBC) message delivered through routine immunization (RI) platform. This paper presents how the COM-B model was used for designing the SBC messages for PMC using the findings from a qualitative study. Methodology The COM-B model provided the theoretical framework for designing the PMC SBC intervention by identifying, capability, opportunity motivation for PMC as well as the barriers, and possible enablers for PMC uptake. A qualitative study was conducted as key source of information. Twelve focus group discussions (FGDs) were conducted with the target audience comprising of mothers of children under two years, pregnant women, men, ward development committee members, community mobilizers and health workers. A total of 120 people participated in the study. An SBC workshop was conducted to develop key messages and content for a community dialogue flipbook and facilitators' guide. Results Knowledge of malaria signs that prompt mothers to seek health care for their children as well as awareness about malaria prevalence and severity, were identified as capabilities that could drive behaviour change, while forgetting the time to visit the health facility was noted as a hindrance. Opportunities and social influencers included spousal support, the positive influence of health workers, accessibility and affordability of the intervention, and the availability of transportation. Motivation was shaped by the perceived seriousness of malaria as a health problem that could lead to the death of children. Fathers were motivated when they observed reduced malaria burden and improved child health, although a lack of perceived urgency remained a demotivating factor for seeking care. Mothers' motivation was strengthened by encouragement from husbands, community mobilisers and health workers. Conclusion The COM-B model provided an effective framework for identifying and developing key messages that informed changes needed to improve capability, opportunities, motivation of individuals and communities towards increased uptake of PMC during PMC pilot study in Osun state Nigeria.

Numerous factors may influence the optimal rollout of new gonococcal antibiotics. We compared eight rollout strategies using a gonorrhea transmission model and ranked strategies by the number of gonococcal infections and clinically useful antibiotic lifespan. Rankings were most sensitive to the starting ceftriaxone resistance prevalence and screening frequency.

BackgroundCurable sexually transmitted infections (STIs), including Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, remain highly prevalent among pregnant women in South Africa. Despite poor diagnostic performance in pregnancy, syndromic management remains standard care. Point-of-care (POC) screening enables aetiological diagnosis and same-visit treatment but is not yet included in national guidelines. We conducted a mixed-methods process evaluation to examine determinants of antenatal POC STI screening implementation in public facilities. MethodsThis evaluation was embedded within the three-arm Philani Ndiphile randomized trial (March 2021-February 2025) across four public clinics in the Eastern Cape. Screening used a near-POC, electricity-dependent nucleic acid amplification test with a 90-minute turnaround time. Reach, Adoption, Implementation, and Maintenance were assessed using the RE-AIM framework. Quantitative indicators included uptake of screening, treatment, and follow-up attendance. Qualitative data included in-depth interviews with 20 pregnant women and five focus group discussions with 21 research staff and government healthcare workers. The Consolidated Framework for Implementation Research guided qualitative analysis. Findings were integrated using narrative weaving. ResultsScreening uptake was high (99.0%), with treatment coverage of 95.2% at baseline and 93.5% at repeat screening. Same-day treatment was lower (50.7% and 69.8%) and varied substantially by facility, reflecting operational constraints including turnaround time, patient volume, infrastructure, and electricity. Attendance was higher when screening was integrated into routine ANC. Women valued screening for infant health, while providers recognised advantages over syndromic management but highlighted workforce, resource, and maintenance constraints. Socioeconomic factors, including transport costs, hunger, and work commitments, influenced retention and waiting. ConclusionsAntenatal POC STI screening was acceptable and achieved high treatment coverage in a research setting. However, same-day treatment was constrained by operational requirements of the testing platform. Scale-up will require workflow integration, strengthened health system capacity, and faster diagnostics suited to routine antenatal care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSSyndromic management remains standard antenatal care in many low-resource settings despite failing to capture up to 89% of infections that remain asymptomatic. Point-of-care aetiological screening has demonstrated feasibility, acceptability, and potential clinical benefit in research settings, yet has not been widely adopted into national policy. Limited evidence exists on the health system requirements and contextual determinants influencing scale-up within routine public facilities. What this study addsThis mixed-methods process evaluation demonstrates high uptake and treatment coverage of antenatal POC STI screening in a trial setting, while identifying facility-level, structural, and socioeconomic factors shaping same-day treatment and retention. We show that implementation success varies substantially across clinics and depends on assay characteristics, workflow integration, human resources, infrastructure reliability, and follow-up capacity. How this study might affect research, practice or policyThese findings provide implementation-relevant evidence to inform national policy deliberations on integrating POC STI screening into antenatal care. Sustainable scale-up will require context-adapted delivery models, strengthened workforce and supply systems, faster diagnostics, and alignment with existing ANC workflows to ensure equitable and durable impact.

Background Use of oral cholera vaccine (OCV) is globally recommended as a public health response to cholera outbreaks, alongside water, sanitation and hygiene (WASH) interventions. Estimating vaccine effectiveness during emergencies in low-and middle-income countries is challenging because vaccination campaigns are often implemented over short time frames, while individual-level data are frequently incomplete due to constraints in infrastructure, resources and data systems. There is a need for pragmatic approaches that can generate timely, policy-relevant evidence using routinely collected data. Methods We analysed routine surveillance data from a large 2022-2023 cholera outbreak in Blantyre District, Malawi. The EpiEstim framework was used to generate estimates of the time-varying reproduction number (Rt) from line-listed case data. We modelled changes in Rt as a function of cumulative OCV coverage using a log-linear framework and propagated uncertainty through posterior sampling. Lagged WASH exposure variables were incorporated in the model to generate adjusted vaccine effectiveness estimates and to explore potential interaction effects. Sensitivity analyses assessed robustness to alternative lag structures. Findings The Blantyre outbreak was characterised by an initial period of low-level transmission followed by a sharp increase in cases from late November 2022, after which transmission declined steadily through April 2023. This decline coincided with the implementation of a reactive OCV campaign. The majority of the cases were among middle-aged men living in urban Blantyre. The unadjusted vaccine-associated reduction in transmission was estimated at 53.52% (95% credible interval (CrI):42.5-64.1%). After adjusting for a 7-day rolling average WASH activity, total vaccine effectiveness increased to 62.1% (95% CrI: 49.3-74.9%). Sensitivity analyses using alternative lag structures for WASH exposure produced comparable adjusted estimates. Interpretation Implementation of OCV contributed to a substantial reduction in cholera transmission during the outbreak. This study demonstrates a feasible approach for estimating vaccine-attributable impact whilst accounting for public health and social measures, such as WASH interventions. The methods described will be useful in outbreaks where classical observational designs are not possible, providing actionable evidence to policy makers for outbreak response in resource-limited settings.

Background: Spotted fever is caused by spotted fever group rickettsiae (SFGR) belonging to the genus Rickettsia. Transmission to humans is primarily via the bite of infected ticks. Being a vector-borne disease, the occurrence of spotted fever is related to factors that allow the vector to thrive. This spatio-temporal analysis gives an insight into the distribution of cases and correlation with seasonality. Methodology: A suspected AFI patient was considered spotted fever positive if either serology (ELISA/IFA) or molecular assay (Nested PCR/qPCR) was tested positive. Demographic data of confirmed cases were included for the analysis. Results: In the 18-year dataset, a total of 2153 suspected patients were tested for spotted fever, of which 516 (24%) were positive. On spatio-temporal analysis, Vellore district reported 39.9% of cases, Chittoor 38.8%, Tirupattur 12.5%, Ranipet 4.5%, and Tiruvannamalai 4.3%. Maximum spotted fever cases were reported between the months of September to March, with a peak in January. Children below 10 years and housewives were at risk of spotted fever. Conclusion: The findings of this retrospective analysis highlight the importance of considering spotted fever group rickettsioses in patients presenting with acute undifferentiated febrile illness, particularly children aged <10 years, from areas with higher spatial clustering, during or following the monsoon season.