Tropical Medicine & International Health

BackgroundDengue virus (DENV) is an increasingly recognized cause of febrile illness in sub-Saharan Africa, yet its epidemiology in Nigeria remains incompletely characterized due to fragmented surveillance and diagnostic variability. We conducted a systematic review and meta-analysis to estimate marker-specific seroprevalence and to evaluate geographic variation, seasonal patterns, and environmental risk factors associated with DENV infection in Nigeria between 2014 and 2024. MethodsFollowing PRISMA guidelines, we searched PubMed, Scopus, Web of Science, EMBASE, Google Scholar, and African Index Medicus for studies reporting laboratory-confirmed dengue infection in Nigeria. Random-effects meta-analysis was used to estimate pooled prevalence and pooled odds ratios (ORs) with 95% confidence intervals (CIs). Between-study heterogeneity was quantified using the I{superscript 2} statistic. Subgroup analyses explored variation by diagnostic marker and geographic region. ResultsThirty-three studies met inclusion criteria. The pooled random-effects IgM seroprevalence was 20.9% (95% CI: 13.0-30.1; I{superscript 2} = 98.6%), while pooled IgG seroprevalence was 19.9% (95% CI: 11.6-29.7; I{superscript 2} = 97.7%). NS1 antigen positivity was 8.9% (95% CI: 2.2-19.4), and PCR-confirmed infection was 7.0% (95% CI: 1.2-16.2; I{superscript 2} = 25.8%). Significant differences were observed across diagnostic markers (p = 0.0002). Regional subgroup analysis demonstrated statistically significant geographic variation for both IgM (p = 0.0179) and IgG (p = 0.0030), with highest pooled prevalence observed in the Southeast and lowest in the Southsouth region. Environmental and behavioral exposures were strongly associated with seropositivity, including proximity to refuse dumpsites (OR = 9.39, 95% CI: 7.44-11.84), non-use of mosquito nets (OR = 8.70, 95% CI: 5.73-13.21), malaria positivity (OR = 5.54, 95% CI: 3.84-7.98), and open household water storage (OR = 2.18, 95% CI: 1.65-2.89). All four DENV serotypes were identified across reporting studies. Transmission intensity increased during rainy seasons. ConclusionsDengue virus transmission in Nigeria is widespread and geographically heterogeneous, with evidence of both recent and cumulative exposure. Strong associations with modifiable environmental and household-level factors underscore the importance of integrated vector control and improved diagnostic capacity. Enhanced surveillance and climate-informed public health strategies are essential to mitigate future outbreak risk. Author SummaryDengue is a mosquito-borne viral infection that is increasing globally but remains underrecognized in much of sub-Saharan Africa. In Nigeria, many febrile illnesses are presumed to be malaria, which can obscure the contribution of dengue virus infection. In addition, limited surveillance systems and inconsistent diagnostic testing have made it difficult to determine the true extent of dengue transmission. To address this gap, we conducted a systematic review and meta-analysis of studies published between 2014 and 2024 to evaluate patterns of dengue exposure, geographic variation, and environmental risk factors in Nigeria. We found evidence of both recent infection (IgM antibodies) and past exposure (IgG antibodies) across multiple regions of the country. Transmission intensity varied geographically, with higher levels observed in some regions, particularly in the Southeast, and lower levels in the Southsouth. Infection risk increased during the rainy season, consistent with enhanced mosquito breeding conditions. Living near refuse dumpsites, storing water in open containers, not using mosquito nets, and having malaria were all associated with higher odds of dengue infection, highlighting the importance of household and environmental conditions in shaping transmission risk. All four dengue virus serotypes were identified, indicating sustained viral circulation. These findings demonstrate that dengue virus infection is widespread in Nigeria and influenced by modifiable environmental and behavioral factors. Improving diagnostic capacity, strengthening routine surveillance, and implementing targeted vector control strategies are essential to reduce transmission and improve outbreak preparedness.

BackgroundDiarrheal disease is the second leading cause of under-five mortality and morbidity in Sub-Saharan Africa. The World Health Organization (WHO) has developed treatment guidelines to support clinicians in the management of pediatric diarrhea; however, adherence to, and the impact of, these guidelines are not well described in low- and middle-income countries. MethodWe conducted a secondary analysis of data from the Enterics for Global Health study to determine whether adherence to WHO diarrhea management guidelines, specifically zinc supplementation and antibiotic administration (when appropriate), shortened the duration of diarrhea among children aged 6-35 months who presented to selected health facilities with diarrhea. ResultsThis analysis includes 9,397 children aged 6 to 35 months with diarrhea enrolled across all seven EFGH sites. The majority (63.3%) of participants were under 18 months of age and 54.4% were male; 1,214 children (12.9%) presented to care with dysentery. Zinc was frequently administered (96.6%), with over 10 days of mean prescribed treatment duration. Of 5,061 children (53.9%) offered antibiotics, 3,082 (60.9%) received a WHO recommended regimen. Among participants who presented with dysentery, 67.6% were prescribed a WHO-recommended antibiotic. Among participants with watery diarrhea without dysentery, 72.4% were not prescribed any of the recommended antibiotics and were thus considered guideline-adherent. Overall, 6,302 (67.1%) children received guideline-adherent care when combining the zinc and appropriate antibiotic use indicators. In children with dysentery, providing WHO-recommended antibiotics was associated with 1.08 (95% CI: 0.53, 1.53) fewer days of diarrhea than those with dysentery who did not receive antibiotics. Children who were given 10+ days of zinc had on average 0.36 (95% CI: 0.03, 0.70) fewer days of diarrhea. ConclusionWe found that two-thirds of children in this study received guideline adherent care in terms of zinc and appropriate antibiotic use for the treatment of childhood diarrhea, and that adherent treatment was associated with shorter duration diarrhea.

AbstractsO_ST_ABSBackgroundC_ST_ABSAccurate dengue forecasting is vital for public health preparedness. Despite a surge in forecasting approaches, a quantitative ranking of the relative performance and practical utility of dengue forecasting is lacking. MethodsA systematic review and Network Meta-Analysis (NMA) of studies comparing dengue forecasting methods (2014-2024) was conducted. Models were categorised into five groups: Time Series, Deep Learning (DL), Machine Learning (excluding DL), Hybrid, and Ensembles. NMA was applied to the logarithm of the most common forecast error metric to rank relative performance--an "Implementability Score" quantified analyst and data requirements, and computational costs. Results59 studies were included. NMA of Root Mean Squared Error identified k-Nearest Neighbour (k-NN) models as achieving the highest predictive accuracy, followed closely by Vector Autoregression, Kalman Filtering, Generalised Linear Model and Autoregressive Neural Network (ARNN). While DL models showed high potential, they scored lowest in implementability due to poor interpretability and high data requirements. Most studies utilised meteorological covariates, with significant gaps in the use of socio-economic and entomological predictors. ConclusionsAlthough there was some trade-off between accuracy and implementability, traditional statistical models were often comparable in accuracy to machine learning approaches, with advantages in interpretability and data needs. Under-explored areas for future research include the use of ensemble models and the use of socio-economic and entomological data. RegistrationPROSPERO CRD420251016662. Author SummaryDengue is a critical global health threat affecting the worlds population. While many forecasting models exist to help officials prepare for outbreaks, there has been no standardised way to compare their performance. This leaves health experts in resource-limited areas uncertain about which tools are truly reliable or easy to use under their specific local conditions. We conducted a network meta-analysis of studies comparing dengue forecasting methods accuracy, grouping them into five categories: Machine Learning, Deep Learning, Time Series, Ensemble, and Hybrid. Beyond ranking their accuracy, we developed an "Implementability Score" to evaluate the practical feasibility of each model, accounting for technical complexity, data requirements, and software accessibility. Our analysis identified the top-performing models. Notably, traditional statistical models often performed as well as complex Deep Learning algorithms. While advanced models show potential, they are often difficult to implement or explain to decision-makers. There is no "one-size-fits-all" solution; the best model depends on capacity and data in each setting. This study provides a roadmap for public health officials to select tools that are both accurate and feasible.

Background Antibiotic pricing is a key determinant of access and stewardship in low- and middle-income countries (LMICs), yet empirical evidence on how prices are formed within pharmaceutical markets remains limited. However, there is little longitudinal evidence on how antibiotic prices behave within national pharmaceutical supply systems. This study evaluated the patterns and determinants of systemic antibiotic pricing in Tanzania using national regulatory import permit data. Methods We conducted a retrospective analysis of antibiotic importation records from the Tanzania Medicines and Medical Devices Authority for 2010-2016. Systemic antibiotics for human use imported via oral or parenteral routes were included. Unit prices (USD per smallest unit of measure) were summarized using the median and interquartile range (IQR). Prices were compared by route of administration, supplier country, and product naming practice (INN-named versus brand-named) using Mann-Whitney U and Kruskal-Wallis tests with false discovery rate adjustment. Results Of the 14,301 records, 10,894 (76.2%) met the inclusion criteria. Oral antibiotics predominated (89.6%). Although the median oral antibiotic prices declined over time, substantial price dispersion persisted across all study years. Parenteral antibiotics were consistently more expensive (USD 0.755-3.370) and more variable than oral antibiotics. Importation was concentrated in a few medicines, with amoxicillin-clavulanate (16.7%) and amoxicillin (11.4%) accounting for over one-quarter of records, and in a few supplier countries, with India representing 44.9% of the records. Significant price differences between INN-named and branded products were observed for amoxicillin (adjusted p<0.001) and ciprofloxacin (adjusted p=0.018), whereas prices differed significantly by supplier country across major medicines (adjusted p<0.05). Across medicines and years, wide within-product price distributions indicate persistent market segmentation rather than price convergence. Conclusions Antibiotic import prices in Tanzania exhibit systematic and reproducible variations associated with formulation type, supplier origin, and product naming practices. The findings indicate that procurement structure and supplier participation strongly influence pricing in the import-dependent pharmaceutical market. Monitoring import-level prices can serve as an upstream indicator of market conditions and support evidence-informed procurement, pricing regulations, and antimicrobial stewardship policies in LMIC settings.

ObjectiveCongenital syphilis remains a preventable cause of fetal and neonatal morbidity and mortality, despite the availability of inexpensive diagnostics and effective treatment. We aimed to evaluate the maternal and congenital syphilis burden at the Instituto Nacional Materno Perinatal, Perus national referral center for maternal and perinatal care. MethodsWe conducted a retrospective analysis of aggregated, de-identified surveillance data from January 2023 to December 2025. Maternal prevalence and congenital syphilis incidence were calculated and compared with World Health Organization (WHO) elimination benchmarks. FindingsAmong 59,568 pregnant women screened, maternal syphilis prevalence ranged between 1{middle dot}0% and 1{middle dot}2% of all women screened. Across 36,094 live births, congenital syphilis incidence ranged between 191 and 259 per 100,000 live births, consistently exceeding the WHO target of 50 per 100,000 live births. More than half of maternal infections were diagnosed at outside facilities before referral. Reported treatment coverage exceeded 90% among mothers and 100% among infants in all years. ConclusionThe prevalence of congenital syphilis exceeded WHO elimination benchmarks despite stable maternal prevalence, highlighting gaps in timely diagnosis and linkage between diagnosis and treatment.

BackgroundRespiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections in children, often leading to hospitalisation in infants. In low-resource settings where routine RSV diagnostics are unavailable, clinical overlap with bacterial pneumonia frequently results in unnecessary antibiotic use, contributing to antimicrobial resistance. ObjectiveTo evaluate the frequency and clinical determinants of antibiotic use among RSV-positive children under two years at a tertiary hospital in Ghana. MethodsThis cross-sectional study was conducted from June to November 2023 at the Department of Child Health, Korle Bu Teaching Hospital. Children with acute respiratory illness were enrolled and tested for RSV using molecular point-of-care and reverse transcriptase-polymerase chain reaction methods. Antibiotic use and clinical characteristics were analysed among RSV-positive cases. ResultsOf 128 children enrolled, 72 (56.2%) tested positive for RSV. Among these, 48 (66.7%) received antibiotics. Antibiotic use was significantly associated with markers of disease severity, including hypoxia (p = 0.009), tachypnea (p = 0.015), dyspnea (p < 0.001), and hospital admission (p < 0.001). Only 11 (23%) had suspected or confirmed bacterial co-infections. ConclusionA substantial proportion of RSV-positive children received antibiotics. These findings underscore the importance of antimicrobial stewardship programs, rapid diagnostics, and preventive interventions, such as maternal RSV vaccination. Strengthening diagnostic capacity and clinical decision-making in pediatric care is crucial for reducing inappropriate antibiotic use and addressing antimicrobial resistance in low-resource settings.

Iron deficiency (ID) is the most common nutritional deficiency worldwide, often caused by insufficient dietary intakes. Oral supplementation is one of the means to improve iron status. This study evaluated the efficacy and safety of two low-dose iron supplements - >Your< Iron Forte Capsules (YIFC) and Ferrous Sulfate Capsules (FSC) - in individuals with dietary ID. One hundred and one participants (mean age 30.6 years; 98% women) with low iron stores (mean serum ferritin 16.1 {micro}g/L) were randomized to receive either YIFC or FSC once daily for 12 weeks. Changes in blood indices and iron-related parameters were assessed at four and 12 weeks of intervention relative to baseline. The primary outcome was the change in hemoglobin (Hb) after 12 weeks. Eighty-seven participants completed the study. Both supplements significantly increased Hb at 12 weeks (YIFC: mean 6.52 g/L, p<0.001; FSC: mean 5.71 g/L, p<0.001). Product-related adverse events (AEs) were few (17% of all AEs) and of mild to moderate intensity only. One participant receiving FSC withdrew due to a probable product-related AE. The frequencies of product-related AEs were similar between study arms, however, statistically significantly more AEs judged to be definitely related to the product occurred in in the FSC arm. While product-related AEs were confined to the gastrointestinal tract in the YIFC arm, they affected multiple organ systems in the FSC arm. Supplementation with either YIFC or FSC proved as an effective, well-tolerated, and safe strategy for improving iron status in non-anemic dietary iron deficiency. In terms of the AE profile, supplementation with YIFC may offer advantages over supplementation with FSC.

BackgroundMalaria, transmitted by female Anopheles mosquitoes, remains a major public health challenge in Nigeria, where approximately 97% of the population is at risk. Despite large-scale investments, Nigeria continues to bear the worlds highest malaria burden. Long-lasting insecticidal nets (LLINs) are central to prevention, yet their effectiveness is increasingly undermined by non-usage, delayed replacement, and growing outdoor biting activity. National surveys (MIS, PMI) consistently report gaps in LLIN use, irregular implementation of the three-year replacement strategy, and persistent outdoor biting. This study quantifies the relative contributions of these behavioural and entomological factors to sustained malaria transmission across five Nigerian states. MethodsA deterministic compartmental model of malaria transmission was developed and calibrated using Bayesian inference with MCMC in CmdStanR. The model incorporated heterogeneous mosquito biting behaviour, LLIN effectiveness decay, and distribution cycles. Calibration used monthly malaria case data (2015-2024), demographic and entomological data (2015-2022), and DHS/MIS prevalence surveys (2015, 2018, 2021) for Akwa Ibom, Ebonyi, Kebbi, Oyo, and Plateau states. Counterfactual scenarios quantified malaria cases attributable to (i) outdoor mosquito biting, (ii) LLIN usage gaps, and (iii) delayed replacement. Parameter sweeps were used to assess how LLIN effectiveness changes with varying outdoor biting intensities. ResultsEliminating outdoor biting yielded the largest reductions in malaria incidence--Akwa Ibom (82.4%, 95% CrI: 74.0-89.6), Ebonyi (92.0%, 95% CrI: 87.5-95.5), Kebbi (76.4%, 95% CrI: 51.0-92.6), and Oyo (83.0%, 95% CrI: 74.9-89.6). LLINs sub-stantially reduced malaria transmission only under low outdoor biting intensities--below 1 bite per mosquito per month in Akwa Ibom and Ebonyi, below 0.2 in Kebbi and up to 0.8 in Oyo. In Plateau, outdoor biting contributed minimally (5.8%, 95% CrI: 4.8-6.3), while the gap between LLIN ownership and use was the dominant factor (23.1%, 95% CrI: 22.5-23.8), rising to 36.5% (95% CrI: 35.5-37.6) when combined with delayed replacement. ConclusionOutdoor mosquito biting is a dominant driver of persistent malaria transmission in Akwa Ibom, Ebonyi, Kebbi, and Oyo states, whereas low LLIN usage is the leading factor in Plateau. Although maintaining high LLIN coverage, adherence, and timely replacement remains critical, these efforts alone are insufficient where outdoor biting is widespread. Strengthening Nigerias malaria control strategy will require integrating LLIN deployment with targeted outdoor vector control and state-specific behavioural interventions to achieve sustained reductions in malaria burden.

BackgroundSix multi-month dispensing (6MMD) of antiretroviral therapy (ART) for HIV treatment clients has expanded rapidly in the past decade, but its effect on individual outcomes in routine (non-trial) care is still poorly documented and based on observational programmatic data. Malawi launched 6MMD in April 2019 and scaled-up implementation in 2020. We compared retention in care for clients who received 6MMD to those who did not using a target trial emulation (TTE) approach to minimize bias. MethodsWe used routine clinical data from Malawis Electronic Medical Record (EMR) system to identify ART clients eligible for 6MMD in 27 districts from 01/2020-12/2021. Eligible participants were non-pregnant adults ([&ge;]18 years), on ART for [&ge;]6 months, clinically stable as evidenced by a dispensing duration of 3 months (3MMD), and with no prior 6MMD exposure. We created four six-month trials, defined eligibility at the start of each trial period, and classified participants as either receiving 6MMD or non-6MMD (dispensing duration of 1-3 months) within the six-month interval. Follow-up started at 6MMD enrollment for the 6MMD arm or the first visit in the trial enrollment period for the non-6MMD arm. Retention at 12 and 24 months was defined as having a clinic visit within 12-24 (trial 1-4) and 24-36 (trial 1-2) months from trial enrollment. Using an intention-to-treat approach, we estimated adjusted risk differences (aRD) with 95% confidence intervals (CI) using a Poisson regression model with an identity link function and robust standard errors adjusting for age, sex, duration on ART, facility type, regional location, WHO clinical stage at ART initiation. Pooled RDs were estimated by accounting for within-subject variation in a Poisson regression model using data from all trials. ResultsOf the 159,801 unique patients eligible for this study (65% female, median age 37 years), 74% (118,910) were ever enrolled in 6MMD. Retention rates at 12 months (trials 1-4) and 24 months (trials 1-2) were consistently higher in the 6MMD group than the non-6MMD group. The pooled risk for retention was 3% higher in the 6MMD vs non-6MMD groups (aRD 3.0%; 95% CI: 2.8%-3.3%) at 12 months and 2.0% higher (aRD: 2.0%; 95% CI: 1.7%-2.4%) at 24 months. ConclusionsWe observed slightly higher retention in care rates in Malawi at 12 and 24 months among patients on 6MMD compared to those receiving shorter medication dispensing intervals. Future work to assess the impact of 6MMD on visit burden and resource use would offer a comprehensive view of the benefits to both ART clients and the health system.

BackgroundCervical cancer, generally induced by human papillomavirus (HPV) infection remains one of the most prevalent and deadly female cancers in sub-Saharan Africa (SSA). In Cameroon, the impact of prevention strategies is limited by systemic challenges, and insufficient evidence base to guide effective interventions. This study aimed to synthesize available evidence on the prevalence and key determinants of HPV infection among Cameroonian women. MethodsA comprehensive search was conducted across PubMed, Scopus, Web of Science, Embase, Cochrane electronic databases and local online publishers. Quality assessment of included studies was performed using the Joanna Briggs Institute (JBI) critical appraisal tool. The random effect model was used to pooled the estimates. Heterogeneity was evaluated using the I2 statistics. Statistical significance was set at p <0.05 and all analyses were conducted using R Statistics version 4.5.2. The protocol was registered on PROSPERO (CRD420261279093). ResultsThirty-six studies (20,033 participants) were included. The pooled prevalence of HPV infection 36.10 (95% CI: 27.28-45.97) with high heterogeneity (I2 = 98.4%). Higher estimates were observed among female sex workers 62.10% (95% CI: 58.08-66.00%, 1 study, n = 599) and women with pre-cancerous genital lesions 85.53% (95% CI: 61.72-95.59%, 4 studies, n = 673). Significant determinants of HPV infection included age below 40 (OR = 1.31; 95% CI: 1.14-1.49; 7 reports), unmarried status (OR = 1.43; 95% CI: 1.24-1.64; 15 reports), having five or more sexual partners (OR = 1.26; 95% CI: 1.05-1.51; 2 reports), parity below four (OR = 1.29; 95% CI: 1.09-1.52; 2 reports), HIV infection (OR = 1.92; 95% CI: 1.24-2.98; 6 reports), CD4 count below 500 cells/mm3 (OR = 2.00; 95% CI: 1.02-3.95; 2 reports), and viral load below 1000 copies/mL (OR = 2.12; 95% CI: 1.27-3.53; 2 reports). ConclusionsOur study demonstrates a high and persistent burden of HPV infection in Cameroon, with a greater impact on younger women and women living with HIV. These findings highlight an urgent public health need to strengthen and expand prevention strategies to effectively reduce and eliminate cervical cancer incidence in the country.

BackgroundSevere Plasmodium falciparum malaria is a leading cause of death in sub-Saharan Africa, with most deaths occurring in children younger than five years of age. The RTS,S/AS01E (RTS,S) malaria vaccine delivered seasonally with Seasonal Malaria Chemoprevention (SMC) led to a two-third reduction in severe malaria and malaria deaths compared with either intervention given alone. The aim of this study was to assess the seasonal distribution and clinical presentation of children admitted in hospital with severe malaria who received RTS,S with or without SMC, and whether seasonal vaccination with RTS,S affected their distribution and clinical presentation. MethodsWe conducted a secondary ad-hoc analysis of hospital admissions in children aged 5 to 17 months of age when enrolled in the RTS,S + SMC trial in April 2017 in Hounde, Burkina Faso, and Bougouni, Mali, and who were followed until they reached five years of age. ResultsThree hundred and thirtythirty-seven serious adverse events were reported during the trial with 222 (65.9%) in Burkina Faso and 115 (34.1%) in Mali, and 48.1% (162/337) were due to severe malaria. The mean age of children with severe malaria was 2.9 years; 79.0% (128/162) of the cases occurred in children aged 3 years or less and 21.0% (34/162) in those aged 4 to 5 years. The most common presentation was severe anemia reported in 50% (81/162) of children, followed by repeated convulsions 25.3%, (41/162), prostration 11.1%, (18/162), hyperparasitaemia 8.0%, (13/162) and cerebral malaria 6.2%, (10/162). Severe malaria anemia was a more frequent form of severe malaria in children in the SMC alone arm 62.1%, (36/58) and lower in children in the SMC+ RTS,S arm 37.1%, (13/35), p=0.048. There was no significant difference in frequency of other clinical presentations between the study arms. Most severe malaria cases, 85.8% (139/162) occurred during the transmission season (July to December). ConclusionsSevere anaemia was the most common presentation of severe malaria and was most frequent in the SMC alone arm. Children aged 3 years or less were the most affected and almost all the cases occurred between July and December. Trial registrationClinicalTrials.gov, NCT04319380

BackgroundDengue fever is an emerging public health concern in Burkina Faso, with increasing outbreaks and data gaps in population awareness. This study assessed knowledge, attitudes, and practices (KAP) related to dengue fever in all health regions of the country. Methodology/Principal FindingsA nationwide cross-sectional household survey was conducted in May 2022 using a stratified two-stage cluster sampling design. One rural and one urban area were selected per region. Heads of households or their representatives were interviewed using a structured questionnaire. Data were collected electronically and analyzed using Stata. A total of 1,568 participants were enrolled (52.0% male; 48.0% female). Overall, 66.3% had heard of dengue, with higher awareness in urban than rural areas. Only 49.0% correctly identified mosquito bites as the mode of transmission, and 29.9% did not know what dengue is. Most respondents (88.3%) stated that dengue can affect everyone. Regarding prevention, 80.2% reported sleeping under a mosquito net, 49.0% eliminated stagnant water, and 45.4% used mosquito repellents. In practice, 67.6% consistently slept under mosquito nets and 82.6% used repellents. Almost all respondents (98.6%) reported that they would consult a health professional if they had symptoms of dengue. However, knowledge about treatment and vaccination was limited, with 46.5% and 56.6% respectively reporting not knowing whether drugs or vaccines exist. Conclusions/SignificanceThis study highlights moderate awareness but substantial knowledge gaps and urban-rural disparities in dengue-related KAP in Burkina Faso. Strengthening community-based education and integrated vector control strategies is essential to improve prevention and reduce dengue transmission. Author SummaryDengue fever is a mosquito-borne disease that is spreading in many parts of the world, including West Africa. In Burkina Faso, outbreaks have been reported in recent years, but little is known about what communities understand about the disease or how they protect themselves. In this study, we conducted a nationwide household survey covering all health regions of the country to explore peoples knowledge, perceptions, and prevention practices related to dengue. We found that while many people had heard about dengue, important gaps remain. A significant proportion did not know how the disease is transmitted or whether treatments or vaccines exist. Preventive actions such as sleeping under mosquito nets and removing standing water were reported, but these practices were not consistent everywhere, especially between urban and rural areas. Encouragingly, almost all respondents said they would seek care from a health professional if they developed symptoms. Our work provides the first national picture of community awareness and behaviors related to dengue in Burkina Faso. These findings highlight the need for strengthened health education and community engagement to improve prevention and support ongoing efforts to control mosquito-borne diseases.

Seasonal Malaria Chemoprevention (SMC) is a promising intervention for Turkana, Northern Kenya, where malaria transmission is highly seasonal. Traditional malaria control methods, such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs), are impractical due to the populations semi-nomadic lifestyle, temporary dwellings, sparse settlements, and limited access to health facilities. In 2024, following the WHOs updated guidance on SMC use, this intervention was implemented in Turkana Central for the first time, involving five monthly cycles of sulphadoxine-pyrimethamine with amodiaquine (SPAQ). To assess the programs feasibility, a mixed-methods study was conducted at the end of the campaign. Survey data from a randomly selected, representative sample of 449 households with 680 eligible children were analyzed using multi-level logistic regression to compare partial versus complete SMC adopters, accounting for clustering. It was supplemented by qualitative interviews involving 45 caregivers to explore barriers and facilitators to SMC adoption. The campaign achieved notable success, with 97% of children receiving at least one SMC cycle (95% CI: 94-99%), and 71% receiving all 5 cycles (95% CI: 66-75%), primarily through door-to-door delivery. The quality of delivery was evident, as 99% of caregivers reported direct observation of the first dose and proper instructions for subsequent days. Adherence to day 2 and 3 medication remained high at 95% (95% CI: 93.5-98.1). Regression analysis suggested that households familiar with their Community Health Promoter (CHP) and who communicated SMC information had lower odds of missing cycles. In contrast, children from wealthier families showed a 93% higher odds of missing cycles. Qualitative findings revealed that positive caregiver experiences with SMC effectiveness drove continuation, while late adoption was linked to illness/ineligibility, uncertainty, and rumors. Overall, these findings indicate that high and sustained SMC coverage is feasible in marginalized settings through adaptive delivery strategies and leveraging of trusted CHP networks, establishing a scalable model for similar mobile populations.

BackgroundRotavirus remains a leading cause of childhood diarrhoeal hospitalisation globally. Malawi introduced the monovalent G1P8 rotavirus vaccine (Rotarix(R)) in October 2012 and in April 2016 switched from trivalent to bivalent oral poliovirus vaccine (tOPV to bOPV). More than a decade after Rotarix(R) introduction, evidence on sustained vaccine effectiveness and population-level impact in high-transmission, low-income settings remains limited, and it is uncertain whether programme changes such as the OPV formulation switch have influenced Rotarix(R) performance over time. MethodsWe estimated the long-term impact and effectiveness of Rotarix(R) on diarrhoea hospitalisation in Malawi and explored whether OPV type changes Rotarix(R) effectiveness. We used interrupted time-series and test-negative case-control analyses to assess the impact and effectiveness of Rotarix(R), respectively, over seven years post vaccine introduction using data from diarrhoeal surveillance studies in children under five years hospitalised with acute gastroenteritis at Queen Elizabeth Central Hospital, in Blantyre, Malawi, between 1997 and 2019. Stool samples from these children were collected and tested for rotavirus A antigen using enzyme immunoassay (EIA). To assess the effect of concurrent vaccination with OPV, we used a test-negative case-control study to estimate the interaction between the two vaccines. FindingsThe interrupted time-series was based on 7,952 hospitalisations and showed a 23% (95% confidence interval (CI): 10 - 34%) reduction in rotavirus hospitalisations rates among children under five years in the post-vaccine introduction period (January 2013 - December 2019) compared with the pre-vaccine period (July 1997 - December 2012). There was a stronger effect among infants under one year (37%; 95% CI: 25 - 47%). Protection declined with age, with little measurable impact beyond infancy. The test-negative analysis enrolled 1,909 children and Rotarix(R) effectiveness for two doses was 52% (95% CI: 18 - 71%) overall, 67% (95% CI: 36 - 82%) among infants and 29% (95% CI: -136 - 74%) in those older than one year. Analyses of the tOPV to bOPV switch (n = 1,622) showed no measurable interaction with Rotarix(R) performance (aOR 1.07; 95% CI: 0.85 - 1.34). InterpretationRotarix(R) provides moderate protection for Malawian infants, and the transition from tOPV to bOPV did not influence vaccine effectiveness. The lower effectiveness of rotavirus vaccination with increasing child age highlights the need to evaluate alternative vaccination strategies alongside strengthened WASH interventions to sustain vaccine impact in LMICs. FundingMRC Discovery Medicine North (DiMeN) Doctoral Training Partnership (UKRI) and National Institute for Health and Care Research (NIHR) Research in contextO_ST_ABSEvidence before this studyC_ST_ABSMultiple reviews have evidenced variable vaccine effectiveness by setting and age. A recent global review and meta-regression of efficacy and effectiveness data by the authors (https://doi.org/10.1016/j.eclinm.2025.103122), updated to October 2024, highlighted lower rotavirus vaccine effectiveness and impact in high-burden, low- and middle-income countries (LMICs) compared with high-income settings. Studies in LMICs including those in sub-Saharan Africa (SSA) consistently indicate that protection is strongest in infants, with impact and effectiveness declining in older children. Multiple factors have been implicated for this variability in effectiveness, including interference from co-administration of oral polio vaccines. We also conducted a systematic review of post-licensure rotavirus vaccine impact and effectiveness studies from sub-Saharan Africa (CRD42023436851). We also assessed the principal study designs used and the extent to which they adjusted for concurrent public health and social measures (PHSMs). We searched PubMed, EMBASE, MEDLINE, CINAHL, and Google Scholar for studies of vaccine impact or effectiveness in children under five years and screened reference lists of included studies. Across all eligible studies, none measured or adjusted for concurrent public health or social measures. To date, most SSA evaluations have focused on the early post-introduction period, with limited evidence on longer-term vaccine performance and no epidemiological evaluation of the potential effect of co-administration of oral polio vaccines on rotavirus vaccine effectiveness. Added value of this studyWe provide a long-term evaluation of the monovalent rotavirus vaccine (Rotarix(R)) in Malawi using a single hospital-based surveillance platform spanning the pre-vaccine and post-vaccine periods. We combine interrupted time-series analyses of population-level impact with test-negative estimates of individual-level effectiveness using consistent age strata. We also examine whether the national switch from trivalent to bivalent oral poliovirus vaccine modified rotavirus vaccine effectiveness, addressing a programme change that has rarely been assessed in rotavirus vaccine evaluations. Implications of all the available evidenceThe available evidence indicates modest rotavirus vaccine benefit in sub-Saharan Africa, with protection concentrated in infancy and little measurable effect in older children. Our findings highlight the need to interpret long-term vaccine impact estimates alongside changes in other PHSMs that influence rotavirus disease burden, including water and sanitation and access to care. The absence of an effect associated with OPV formulation change suggests that modifying OPV valency alone is unlikely to improve rotavirus vaccine performance. Extending protection beyond infancy may require alternative vaccine schedules alongside sustained improvements in broader public health conditions.

BackgroundMalawi has one of the highest incidences and mortality due to cervical cancer, which is caused by the human papillomavirus (HPV). Achieving high HPV vaccination coverage is critical for advancing the World Health Organization (WHO) cervical cancer elimination strategy. This study aims to describe the spatio-temporal uptake of the first and second doses of the HPV vaccine in Malawi and to investigate the covariates associated with the uptake. MethodsWe analysed HPV vaccination coverage data from routinely collected administrative data across 28 districts in Malawi from 2019 to 2024. We used spatio-temporal Bayesian models in R-INLA to investigate the association between environmental factors, such as urbanization and climatic conditions, and vaccination uptake. ResultsHPV vaccine uptake was 46.83% (95% Credible interval, CrI: 46.52%, 47.21%) for the first dose, and 32.44% (95% CrI: 32.09%, 32.96%) for the second dose, across the study period, with distinctive subnational heterogeneity. A negative relationship was observed between nighttime light intensity and vaccination coverage (first dose: posterior mean: -0.599, (95% CrI: -1.160, -0.040); second dose: posterior mean: -2.164, (95% CrI: -3.415, -0.967)). ConclusionsHPV vaccination uptake in Malawian districts remains below the WHO 90% vaccination target. These findings emphasise the need for decentralised planning to improve coverage. Targeted interventions, mobile outreach programmes, and strengthened community engagement, particularly in urban settings, may help close coverage gaps and accelerate progress toward cervical cancer elimination in Malawi.

BackgroundMeasles is a highly contagious infectious disease and a leading cause of childhood morbidity and mortality worldwide. In developing country like Ethiopia, effective immunization is a proven strategy for reducing measles related illness and deaths. However, measles second dose vaccination drop out has become a major public health concern. In a densely populated city such as Addis Ababa drop rate tends to be higher than the minimum acceptable threshold, leading to increased number of cases and recurrent outbreaks. Despite of this limited evidence exists on the determinants of second dose drop out and the problem is not well investigated, as a result this study will try to identify determinants of measles second dose vaccination dropout among children 24 - 35 months of age. ObjectivesTo identify determinants of measles second dose vaccination dropout among children 24 - 35 months of age Addis Ababa, Ethiopia in 2025. MethodCommunity based unmatched case control study was conducted in Addis Ababa from September 1/2024 to October /2025 with a total of 636 participants, consisting of 212 cases and 424 controls. Data were collected using structured Quesionariie and entered into EpiData 3.1 then StataSE 18 was used for detailed analysis including Descriptive statistics. Model fitness was checked using Hosmer-Lemeshow and multicollinearity were assessed using variance inflation factor. Furthermore, Bivariable and multivariable logistic regression analyses was employed and Adjusted odds ratio with 95% confidence intervals was used to identify significant variables. ResultsA total of 620 mothers/caregivers participants respond to the study, comprising 206 (97%) cases and 414(97.6%) controls, yielding a total response rate of 97.4%. In this study, waiting time longer than 30 minutes (AOR= 3.34, 95%CI: 1.86-5.9), Lack of counseling (AOR = 2.63, 95% CI: 1.60-4.30), Lack of reminders (AOR = 2.86, 95% CI: 1.89-4.30), Previous adverse event following immunization (AOR = 2.00, 95% CI: 1.39-3.00), postnatal care visit (AOR = 0.58, 95% CI: 0.40-0.85) and family size of greater than 3 (AOR = 1.96, 95% CI: 1.29-2.98) were significantly associated with measles second dose dropout. Conclusion and recommendationIn study shows measles second dose dropout is found to be associated with long waiting time, lack of counseling, lack of reminder, history of adverse event following immunization and postnatal visit. Which suggests Strengthening Immunization Counseling, reducing waiting time, establishing effective reminding system, integrating Immunization with postnatal services and promptly addressing concerns about adverse event following immunization can help reduce measles second dose dropout.

BackgroundMalaria transmission in Uganda is heterogenous, so the national malaria program needs information about the distribution of malaria to develop appropriate policies. While population-based community surveys estimate Plasmodium falciparum parasite rate (PfPR), they are too infrequent and sparse for routine malaria management. Health facility data is routinely collected and covers a large geographic scope, but the data is collected passively, variable in quality, and potentially highly biased. We aimed to triangulate test positivity rate (TPR) from health facility data to survey estimated PfPR data in Uganda to create monthly, high-resolution PfPR estimates. MethodsUsing matched health facility and survey data, we fit a multi-level logistic regression model that accounted for clustering at the district and region level, to predict PfPR from TPR. Additional covariates were explored to select a final model that reduced bias while prioritizing its utility for programmatic tasks. Model predictions were validated against observed PfPR and used to generate monthly district-level prevalence estimates from 2016 to 2024. Regional and national level estimates were made by weighting district level estimates by population. ResultsThe final model included a smoothed TPR term and proportion of severe malaria cases at a district-month level. Predicted PfPR was strongly positively correlated with the observed survey PfPR (Pearsons rank correlation rho =0.79, p<0.001). National estimates derived from predicted PfPR aligned well with survey estimates from the same time and area. ConclusionHealth Management Information System (HMIS) data, when paired with research data, can be used to estimate malaria prevalence with high spatial and temporal resolution. Estimates can be tested and models can be updated to help malaria programs best leverage facility data. In the context of declining survey frequency, HMIS-based modeling offers a resilient and cost-effective alternative for malaria surveillance and programmatic decision-making in Uganda and similar high-burden settings.

Sepsis caused by drug-resistant pathogens remains a major contributor to under-five mortality in low- and middle-income countries, threatening progress toward Sustainable Development Goal (SDG) 3.2. Blood culture, the gold standard for sepsis diagnosis and antimicrobial stewardship, remains underutilised in routine pediatric care. This study assessed the extent and determinants of blood culture utilisation among hospitalised children under five years with suspected sepsis at four antimicrobial resistance (AMR) surveillance sites in Uganda. We conducted a cross-sectional mixed-methods study involving retrospective review of 384 pediatric patient records and in-depth interviews with 20 clinicians. Modified Poisson regression was used to identify factors associated with blood culture requests, while thematic analysis explored behavioral and contextual influences on diagnostic practices. Blood cultures were requested in 28.1% of suspected sepsis cases. Higher utilisation was independently associated with markers of clinical severity, including severe acute malnutrition (adjusted prevalence ratio [aPR] 1.3, 95% CI: 1.14-1.34), sickle cell disease (aPR 1.3, 95% CI: 1.19-1.40), and presence of WHO danger signs (aPR 1.1, 95% CI: 1.00-1.14). Senior clinician involvement (aPR 1.2, 95% CI: 1.08-1.32) and consultant review (aPR 1.4, 95% CI: 1.21-1.48) were also associated with higher use, while prior antibiotic exposure reduced the likelihood of blood culture request (aPR 0.9, 95% CI: 0.84-0.96). Qualitative findings identified four overarching themes influencing diagnostic behavior: motivation amid systemic constraints, institutional and environmental barriers, mentorship and teamwork, and emotional fatigue in the context of adaptive practices. Despite high clinician awareness, blood culture utilisation remains low, driven primarily by health system fragility, inefficient workflows, and emotional exhaustion rather than knowledge gaps. Improving utilisation will require integrated behavioral, workflow, and structural interventions, including clinical decision support and strengthened microbiology laboratory capacity, to enhance pediatric sepsis care, antimicrobial stewardship, and progress toward SDG 3.2.

We evaluated the probability of need for public health action against trachoma in Esmeraldas province, Ecuador. Compared to global references, seroconversion rates to Chlamydia trachomatis Pgp3 in children suggest high probability of action needed in rural villages (91%) and lower in more urban areas (32%), motivating further trachoma assessment.

Because of its recent regulatory approval in southern and eastern Africa, CAB PrEP represents a scientific advancement with unknown implementation costs in most African countries. To our knowledge, this paper is the first study comparing PrEP costs in health facilities where clients had a choice between three PrEP methods. We collected and analyzed the direct service delivery costs for each method using the same costing approach and assumptions at three facilities in Lesotho and six facilities in Zimbabwe. On average, in Lesotho, the direct costs of providing CAB PrEP were $57.22 for an initiation visit and $54.20 for a refill visit (same PrEP product dose dispensed in both visit types), while the direct costs of oral PrEP were $22.47 (initiation visit with one month of PrEP dispensed) and $31.98 (refill visit dispensing a three-month dose of medication), and the direct costs of the dapivirine ring were $34.27 (initiation visit with one month of PrEP dispensed) and $50.70 (refill visit dispensing a three-month supply). In Zimbabwe, the average per-visit direct costs to provide CAB PrEP were $48.26 (initiation visit) and $47.40 (refill visit), to provide oral PrEP were $13.47 (initiation visit with one month of PrEP dispensed) and $21.78 (refill visit dispensing a three-month dose), and to provide the dapivirine ring were $42.56 (refill visit dispensing a three-month supply). Initiation visits for the dapivirine ring were not observed in Zimbabwe. At a time when national governments are creating budgets for the HIV response with decreased financial support from bilateral and multilateral partners, this paper will inform HIV prevention planning by providing critical client-level data from the healthcare provider perspective.