Tropical Medicine & International Health

Background: Female genital schistosomiasis (FGS) is a neglected gynaecological manifestation of Schistosoma haematobium (S. haematobium) infection, resulting from the deposition of parasite eggs in the female genital tract. Although urogenital schistosomiasis is highly prevalent in parts of coastal Kenya, including Kilifi County, the burden of FGS among women of reproductive age remains poorly characterised. Routine diagnosis of S. haematobium infection relies largely on urine microscopy, which may underestimate genital involvement. This study aimed to assess the prevalence, diagnostic concordance, and risk factors for FGS among women of reproductive age in Kilifi County, Kenya. Methodology: In this cross-sectional study, 320 randomly selected women aged 15-50 years were recruited from rural Kilifi County; 261 provided complete data for analysis. A structured questionnaire was administered to collect sociodemographic and behavioural information. Urinary schistosomiasis was assessed using triplicate urine microscopy over three consecutive days, and FGS was evaluated using real-time polymerase chain reaction (PCR) targeting the S. haematobium Dra1 gene sequence on self-collected high vaginal swabs. Results: Overall, the prevalence of PCR-confirmed FGS was 36.0% (94/261), while urinary egg excretion was detected in 13.0% (34/261) of participants. Concordance between urine microscopy and genital PCR was 70.9%. Notably, 72% of women with PCR-confirmed FGS had no detectable parasite eggs in their urine. In bivariate analyses, factors such as urinary infection severity, water contact behaviours, haematuria, dysuria, age group, place of residence, and prior history of schistosomiasis were found to be associated with female genital schistosomiasis (FGS). However, in the multivariable logistic regression, only sub-location and urinary infection severity remained independently associated with the infection. Additionally, PCR cycle threshold (Ct) values showed a non-linear relationship with mean urinary egg counts, indicating that the detection of genital parasite DNA does not directly correspond to the urinary egg burden. Conclusion: FGS prevalence among women in Kilifi County was substantially higher than indicated by urine microscopy alone. The majority of women with genital schistosomiasis did not exhibit detectable urinary egg excretion, highlighting the limitations of routine parasitological screening for identifying genital disease. These findings underscore the need to incorporate genital sampling and molecular diagnostics into schistosomiasis control strategies targeting women of reproductive age in endemic settings.

Background Cutaneous leishmaniasis (CL) is highly prevalent in Ethiopia, including the Tigray region. However, there is a dearth of information on the levels of knowledge, attitude, and health seeking behavior among the communities in CL-endemic areas of Tigray region, northern Ethiopia. Objective This study aimed to investigate CL-related knowledge, attitude, treatment-seeking and prevention practices in disease-endemic areas of Tigray. Methods Between November and December 2022, a cross-sectional survey was conducted among communities living in seven districts of Tigray. A mixed sampling method was implemented. Data were collected using a pre-tested structured questionnaire and analyzed using SPSS 25 (IBM, Chicago). Results A total of 512 participants were included. Overall, 43%, 36% and 34% of participants had a good level of knowledge, a favorable attitude and a good treatment-seeking and prevention practices towards CL, respectively. However, nearly all participants did not know about CL transmission, about 25% perceived CL to be genetically acquired and about 67% believed it to be stigmatizing. Traditional medication was the preferred option over modern treatment for 63.3%. Rural dwelling participants (AOR = 1.60; 95% CI: 1.00-2.57) and participants living in households with CL episode (AOR = 10.19; 95% CI: 6.36-16.30) had good knowledge towards the disease. However, urban/ semi-urban residents (AOR = 2.17; 95% CI: 1.42-3.31) had favorable attitude towards CL. Gender (AOR = 1.49; 95% CI: 1.01-2.22) and education level (AOR = 0.39; 95% CI: 0.24-0.62) were significantly associated with treatment-seeking and prevention practices. Participants living in households with CL episode (AOR = 2.99; 95% CI: 1.96-4.57) had good treatment-seeking and prevention practices. Conclusion In this study, over one half of participants had poor knowledge about CL, nearly two-third of them had unfavorable attitude towards the disease and two-third of them had poor treatment-seeking and prevention practices. Residence and previous CL episode in households were determinants of respondents knowledge about CL and their attitude towards the disease. Level of education and living in households with CL episode were determinants of participants treatment-seeking and prevention practices. These findings support for an integrated intervention through health education focusing on CL transmission and preventive measures.

IntroductionAnaemia is one of the most prevalent global public health challenges, particularly among women of reproductive age and children. According to the World Health Organization, anaemia is defined as a hemoglobin concentration below 13.0 g/dL in adult men, 12.0 g/dL in non-pregnant women, and 11.0 g/dL in pregnant women. Hemoglobin measurement therefore plays a critical role in diagnosis, classification, and monitoring of anaemia at both clinical and public health levels. Hemoglobin estimation allows early identification and intervention in at-risk populations. MethodologyA cross-sectional study was conducted at Aniniwaa Medical Centre, Kumasi, involving 100 participants who visited the laboratory for a complete blood count. Venous blood samples were collected aseptically into EDTA tubes and analysed first with the fully automated analyser, followed by the two Hb meters. Data were analysed using Chi-square tests, Bland-Altman plots, and descriptive statistics. ResultsResults showed that the prevalence of anaemia varied across methods: 28% by the analyser, 60% by Urit, and 64% by Mission. Both meters demonstrated 100% sensitivity but lower specificities (55.6% for Urit and 50.0% for Mission). Bland-Altman analysis indicated negative biases (Urit = -1.665 g/dL; Mission = -1.55 g/dL), suggesting both underestimated hemoglobin values compared to the reference. ConclusionThe study revealed that while Hb meters offer convenience and portability for field screening, the fully automated analyser remains more accurate and reliable for diagnosing anaemia in clinical settings.

BackgroundUrogenital schistosomiasis is a major cause of preventable morbidity, primarily in rural, resource-limited regions. After decades of mass drug administration, changing epidemiologic landscapes, and ongoing resource limitations, test-and-treat models may be necessary to meet elimination goals. However, diagnostic capacity remains centralized and laboratory-dependent, and community-led, contextually adapted implementation strategies remain poorly defined. This study describes the accuracy and feasibility of a low-cost diagnostic toolkit and explores community-integrated implementation models. Methodology/Principal FindingsThis mixed-methods study enrolled 418 participants from five endemic sites near Oyan River Dam, Ogun State, Nigeria in July 2025. Urine samples underwent parallel analysis by community health extension workers utilizing the toolkit and by laboratory technicians using standard microscopy. The toolkit consisted of a reusable urine filtration device paired with a under-$2 paper microscope. Semi-structured interviews with community health extension workers and key informants were analyzed using the Consolidated Framework for Implementation Research. Prevalence was 27.5% (115/418). Community health extension workers demonstrated progressive improvement in diagnostic accuracy across five sequential communities (n=237), rising from 52.5% (95% CI 37.5-67.1) to 92.1% (79.2-97.3) over eight study days (Cochran-Armitage Z=3.08, p=0.002). Specificity improved from 53.6% to 96.3% (Z=3.00, p=0.003), final sensitivity reached 81.8% (52.3-94.9), and final Cohens kappa reached 0.803. In the hands of laboratory scientists, Foldscope microscopy achieved 91.0% sensitivity and 99.3% specificity. Conclusions/SignificanceCommunity-led diagnostic task-shifting for urogenital schistosomiasis control is accurate, feasible, and implementation-ready. Consolidated Framework for Implementation Research-guided analysis demonstrated strong end-user acceptability, with local ownership, collaboration, and trust-building as key implementation facilitators. This approach addresses diagnostic gaps in resource-limited endemic settings with relevance to other community health worker-led strategies. Author SummarySchistosomiasis is a parasitic infection that spreads through contact with freshwater and often goes undetected and untreated for years. Most common in sub-Saharan Africa, the disease damages the bladder and genitourinary tract, increasing risk of infertility, bladder cancer, and HIV transmission. It is most prevalent in rural communities where the snail intermediate host thrives in local water sources used daily for fishing, farming, and bathing. One such area is the Oyan River in Nigeria. Here, we found that barriers to diagnosis and treatment of the illness include distance and transportation. In this study, community health workers diagnosed their neighbors and community members using a low-cost toolkit: a <$2 / 2700 microscope, called the Foldscope paired with a small steel filter card we designed, called the SchistoFilter.. We enrolled 418 people across five villages along the Oyan River in Nigeria and trained eight community health workers to use this toolkit at the point of care. By the fifth community visite, they reached 92.1% accuracy. The study team interviewed community health workers and government officials to contextualize this approach, and they were enthusiastic: The tools can be used with confidence, the training is feasible, and what is most needed is a reliable supply chain and supportive oversight.

Background Urogenital schistosomiasis (UGS), caused by Schistosoma haematobium (S. haematobium), disproportionately affects women in sub-Saharan Africa and can lead to haematuria, anaemia, and urinary tract morbidity. Data on the prevalence in women of reproductive age remains limited in contrast to infection among school-aged children in Kenya. This study assessed the prevalence of UGS and its socioeconomic determinants among women in Kilifi County, Kenya. Methods: Urine samples (20-50 mL) were collected from each participant over three consecutive days. Day-one samples were tested for haematuria, proteinuria, nitrites, leukocytes, and pregnancy using dipsticks. On the other hand, 10 mL of urine was examined for S. haematobium eggs via urine filtration on all three days. Results: A total of 599 women aged 15-50 years were enrolled, with complete data available for 336. The mean age was 33 years; 57.7% were <35 years. Most participants were from rural Magarini Sub-county (63%) and engaged in crop farming (62.5%). Primary education was the highest level attained by 59.8% of participants. Frequent contact with stagnant water was reported by 92%. The overall prevalence of S. haematobium infection was 13.7% (95% CI: 10.2-17.8), higher in Magarini (14.9%) than in Rabai (12.0%), though not statistically significant. Younger age, primary education, and frequent water contact were associated with higher infection rates; however, after adjustment for covariates, haematuria showed the strongest independent association with infection. Women with haematuria were 25.2 times more likely to be infected (OR: 25.24, 95% CI: 7.07-82.63, p < 0.001); multivariate analysis confirmed haematuria as the sole significant predictor (OR: 20.83, 95% CI: 5.45-79.57, p < 0.001). Conclusion: UGS prevalence among women in Kilifi County is substantial, with variation between sub-counties. Haematuria demonstrated the strongest independent association with infection and may serve as a simple, non-invasive diagnostic marker. These findings underscore the pressing need for the integration of UGS screening into the reproductive health services and targeted interventions. Authors Summary UGS, caused by the parasitic worm Schistosoma haematobium, is a neglected tropical disease and remains a major public health problem in sub-Saharan Africa. Although control programmes in Kenya primarily target school-aged children, women of reproductive age are frequently exposed through daily water contact and may develop chronic urinary and reproductive health complications. However, data on the infection burden among adult women are limited. In this study, we assessed the prevalence of urogenital schistosomiasis and associated risk factors among women aged 15-50 years in Kilifi County, Kenya. Urine samples were collected over three consecutive days and examined for parasite eggs and indicators of urinary tract disease. We found that urogenital schistosomiasis affected more than one in ten women in the rural sub-counties where the study was conducted. Haematuria was strongly associated with infection and remained the most reliable predictor after accounting for other social and behavioural factors. These findings demonstrate that UGS is an under-recognised health issue among women and highlight the potential value of simple urine-based screening tools. Integrating UGS screening into existing reproductive health services could improve early detection and contribute to more inclusive disease control strategies.

BackgroundFamily planning (FP) is essential for improving maternal and child health. Despite Ethiopias national progress, regional disparities persist in underserved areas. This study assesses FP utilization and its determinants among women of reproductive age in the Oromia and Gambella regions. MethodsA community-based cross-sectional study was conducted from October 15-25, 2023, among 840 women of reproductive age selected from five districts in Oromia and Gambella Regions. Data were collected using a structured, interviewer-administered questionnaire adapted from the Demographic and Health Survey and implemented through SurveyCTO. Multivariable logistic regression analysis was performed to identify factors associated with FP utilization, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) reported. ResultsFP utilization was 60.9%, with injectables (48.2%) and implants (30.4%) being most common. Utilization was significantly lower among women lacking transport access (AOR=0.49, 95% CI: 0.36-0.67) and those in the poorest (AOR=0.48, 95% CI: 0.29-0.77) and poor (AOR=0.47, 95% CI: 0.29-0.74) wealth quintiles. Women whose partners had no formal education (AOR=0.46, 95% CI: 0.30-0.70) or only primary education (AOR=0.64, 95% CI: 0.44-0.92) were less likely to use FP compared to those with more educated partners. Additionally, farming women were more likely to use FP (AOR=1.64, 95% CI: 1.11-2.42), while those reporting unwanted pregnancies had lower utilization (AOR=0.54, 95% CI: 0.32-0.92). ConclusionFP utilization in these regions exceeds national averages, yet reliance on short-acting methods remains high. Limited transport, low household wealth, low partner education, and pregnancy unintendedness are critical barriers. Strengthening community-based services, addressing economic disparities, and promoting male involvement are essential for improving equitable FP access.

Objectives: To evaluate whether on-site molecular point-of-care testing (POCT) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is associated with reduced antibiotic overtreatment for presumed sexually transmitted infections (STIs) among adults living with HIV in rural Uganda. Methods: We conducted a single-site quasi-experimental pre-post intervention study at Kumi Hospital, comparing syndromic management (April-August 2024) with CT/NG POCT-guided management (September 2024-January 2025). Adults living with HIV presenting with symptoms suggestive of an STI were included. Overtreatment in the pre-intervention phase was estimated by comparing antibiotic prescribing with the expected number of CT/NG infections based on positivity observed during the intervention phase. Results: A total of 404 participants were included (203 pre-intervention, 201 intervention). During the intervention phase, CT and/or NG were detected in 14 individuals (7.0%). Median test turnaround time was 95 minutes, enabling same-day treatment in 93% of positive cases. Antibiotic prescribing decreased from 99.0% to 11.4% following POCT implementation (P < 0.001), corresponding to an absolute reduction of 87.6 percentage points. Estimated overtreatment declined from 30.0% to 5.0% for NG and from 74.9% to 6.0% for CT (both P < 0.001). Conclusions: Implementation of CT/NG POCT in routine HIV care was associated with a marked reduction in antibiotic prescribing and estimated overtreatment for presumed STIs. These findings support the potential of POCT-guided, aetiology-based STI management to reduce unnecessary antimicrobial exposure in settings where syndromic management remains standard practice.

Adolescent girls and young women face significant sexual and reproductive health (SRH) challenges. We assessed the preliminary effectiveness of a community-based, peer-led SRH education intervention on risky sexual behaviors and comprehensive SRH knowledge among adolescent girls and young women aged 15-24 years in Moroto District, northeastern Uganda. From October 2024 to January 2025, we conducted a pre-post quasi-experiment study without a comparison group across six villages. Participants were selected through multi-stage sampling and assessed at baseline. They subsequently received the community-based peer-led SRH education intervention; each participant served as her own control in the absence of a comparison group. Risky sexual behavior was the primary outcome, and comprehensive SRH knowledge was the secondary outcome. The intervention effect was assessed using a generalized estimating equation with a Poisson distribution, log link function, and exchangeable correlation structure. We reported adjusted risk ratios (aRR) with 95% confidence intervals (CI). Of 389 participants who completed both the pre- and post-intervention evaluation, the mean ages were comparable (19.29 {+/-} 2.94 years vs. 19.31 {+/-} 2.91 years; p = 0.922, respectively). After the intervention, there was a significant decline in the proportion of participants who engaged in risky sexual behavior (57.1% before vs. 37.8% after, p<0.001) and a significant improvement in comprehensive SRH knowledge (85.6% before vs. 99.5% after, p<0.001). In cause-effect analysis, there was a 33% reduction in risky sexual behavior (aRR 0.67, 95% CI: 0.57-0.75), and a 16% improvement in comprehensive SRH knowledge (aRR 1.16, 95% CI: 1.12-1.20). A community-based, peer-led SRH education intervention reduces risky sexual behavior and improves comprehensive SRH knowledge. These findings should be considered preliminary, as robust studies are needed, including a need for nuanced strategies to address contextual factors that contribute to risky behavior despite improved comprehensive SRH knowledge.

The World Health Organization recommends biannual azithromycin mass drug administration (MDA) to infants aged 1-11 months to reduce mortality, following promising results from trials in West Africa. High coverage seen in well-resourced trials may decline as the intervention transitions to a real-world program. As a result, the most vulnerable children facing the highest risk of mortality may be missed. We aimed to identify predictors of non-participation in an azithromycin MDA program to inform programmatic delivery strategies to improve coverage. We conducted a coverage evaluation survey after azithromycin MDA to children aged 1-11 months in Nigers Tahoua region. Data collection teams visited households to assess caregiver-reported participation, reasons for participation and non-participation, and adverse events. Mixed effects logistic regression models were used to analyze community-, household-, and child-level predictors associated with non-participation in azithromycin MDA. Among 40 communities with 811 unique households and 871 children ages 2-12 months old included in analyses, 76% of eligible children received treatment based on caregiver report compared to 96% community health worker-reported coverage. The most frequently stated reasons for non-receipt of treatment were absence (34%), nobody coming to the house (31%), and not receiving enough information (17.2%). In an adjusted model, older children experienced higher odds of receiving treatment (aOR 1.22, 95% CI 1.15 - 1.30, P [&le;] 0.0001), as did children living in more densely populated areas (aOR 1.15, 95% CI 1.04 - 1.28, P = 0.01). Adverse events were reported among 6.8% of children who received treatment, with fever being the most reported symptom. Strengthening community sensitization and preparation activities before MDA is essential to address common reasons for non-participation. Future research to understand why younger children and those living in sparsely populated communities were less likely to be included may help target specific interventions in these populations.

BackgroundPerformance-based financing (PBF) aims to improve healthcare quality by offering financial incentives to service providers. This study evaluated PBFs impact on obstetric care quality in Nkambe Health District, Cameroon. MethodsWe employed a cross-sectional mixed-methods study from December 2016-July 2017 in PBF-implementing facilities. We surveyed 315 women attending prenatal and postnatal visits and 23 service providers using structured questionnaires. Quantitative data were analyzed with SPSS v20, and quality was assessed via WHO standards. Results99.7% of women attended [&ge;]5 antenatal visits; 93% delivered institutionally; 93% had postnatal care. Partogram use was 88%; 96% women reported satisfaction. Providers knowledge was high (97% for ANC/intrapartum care). Schooling (p<0.05), [&ge;]4 ANC visits (p=0.017), and proximity predicted quality. Providers (71%) were satisfied with pay. ConclusionsPBF significantly enhanced obstetric care utilization and quality. Scale-up recommended with attention to costs, staffing, and attitudes.

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.

IntroductionPersistent infection with high-risk Human Papillomavirus (hr-HPV) in women is a leading cause of cervical cancer, and its co-infection among people living with HIV (PLHIV) increases the risk of HPV-associated cancer, including oropharyngeal and anogenital cancers. In sub-Saharan Africa, awareness of HPV is limited, screening and vaccine adoption are critically low, undermining efforts toward sexually transmitted infection (STI) elimination. MethodsFrom Awareness to ACTion (FACT) study assessed HPV knowledge, screening, and vaccine uptake in adolescent-mother pairs participating in the HOMINY (HPV, Human Immunodeficiency Virus, and Oral Microbiota Interplay in Nigerian Youths) prospective cohort study. Participants were enrolled, including adolescents aged 9-18 years (N=636) and mothers aged 29-59 years (N=385). FACT was conducted at the University of Benin Teaching Hospital, Nigeria, with adolescent participants grouped as perinatally acquired HIV, HIV-exposed without acquisition and HIV-unexposed, and mothers by HIV serostatus. In line with the national immunisation programme protecting girls in Nigeria, sensitisation programmes were integrated into the research study to promote awareness and adoption of screening and vaccination practices. Knowledge and attitudes regarding HPV and its vaccination benefits were assessed through thematic discussions, field notes, interactive sessions, and questionnaires administered over the study period. ResultsAt baseline, HPV awareness was low, with 34.5% of mothers and 1.4% of adolescents being aware of HPV. Post-sensitisation, awareness increased significantly to 64.4% and 19% in mothers and adolescents, respectively. Vaccination uptake rose from 0% to 3.4% in adolescents, and the proportion of mothers who underwent HPV-related screening (Visual Inspection with Acetic Acid and/or Papanicolaou test) increased from 38.7 % at baseline to 52.4 % after a year (p < 0.0001). Barriers to the adoption of preventive services included misconceptions, healthcare provider gaps, myths, misinformation, mistrust, skepticism, and limited access. ConclusionsHPV awareness programmes significantly improved knowledge, vaccination uptake, and screening practices in this vulnerable population. As part of comprehensive STI elimination strategies, integrating HPV education and vaccination initiatives into HIV care and research will enhance prevention and address significant barriers. Lessons from a unique programmatic science framework provide critical insights for scaling vaccine delivery, and the design of future vaccine programmes.

PurposeAntibiotic use (ABU) is a major driver of antimicrobial resistance (AMR), but ABU patterns are poorly understood in low-income countries where the burden of AMR is great and ABU is insufficiently regulated. Here, we report ABU from ten sites ranging from rural villages to small cities in Madagascar, a country with high AMR levels, and present results from modeling to identify factors that may be associated with ABU in this setting. MethodsWe conducted surveys of 290 individuals from ten sites in the SAVA Region of northeast Madagascar to gather data on sociodemographic characteristics, agricultural and animal husbandry practices, recent antibiotic use, the antibiotics that participants recalled using in their lifetimes, and the sources of their antibiotics. Using these data, we conducted statistical analyses with a mixed-effects logistic model to determine which characteristics were associated with recent antibiotic use. ResultsNearly all respondents (N=283, 97.6%) reported ABU in their lifetimes, with amoxicillin being the most widely reported antibiotic (N=255, 90.1% of those reporting ABU). All recalled antibiotics were classified as frontline drugs except for ciprofloxacin. Most respondents who reported antibiotic use also reported obtaining antibiotics without prescriptions from local stores (N=273, 96.5%), while only 52.3% (N=148) reported obtaining antibiotics through a prescriptive route, such as from a health clinic or private doctor. Of the 127 individuals (44.9%) who reported recent ABU, men were found to be significantly less likely to have recently taken antibiotics than women. ConclusionsOur findings provide new insights into ABU in agricultural settings in low-income countries, which have historically been understudied in AMR and pharmacoepidemiologic research. Knowledge of ABU patterns supports understanding of AMR dynamics and AMR control efforts in these contexts, such as interventions on inappropriate antibiotic dispensing. Key pointsO_LIAntibiotic use (ABU) in Madagascar is largely unstudied despite its role in antimicrobial resistance (AMR), which Madagascar faces a high burden of. C_LIO_LIABU was widespread among livestock owners in northeast Madagascar, with the majority of study participants reporting ABU in their lifetimes and most people reporting ABU also having taken antibiotics in the previous three months. C_LIO_LIMost respondents reported obtaining their antibiotics from non-pharmaceutical stores, indicating high levels of unregulated ABU, though more than half also reported sourcing their antibiotics through prescriptive means (like doctors and health clinics). C_LIO_LIMen were less likely than women to have taken antibiotics in the previous three months. C_LIO_LIThese findings support the development of interventions to mitigate the burden of AMR in Madagascar and similar contexts while underscoring the need for more comprehensive research on the drivers and patterns of ABU. C_LI Plain language summaryIn this study, we provide basic information on antibiotic use (ABU) patterns in Madagascar, a country that experiences high levels of resistance but has been particularly understudied in AMR and pharmacological research. We surveyed 290 farmers with livestock from ten sites across northeast Madagascar about their ABU and found that nearly all study participants (N=283, 97.6%) have used antibiotics in their lifetimes, while a little under half of those who reported ABU also reported using antibiotics in the previous three months (N=127, 44.9%). The most used antibiotic was amoxicillin (N=255, 90.1%). Most people obtained their antibiotics from sources that do not require prescriptions, like general stores, indicating that most ABU is unregulated. Through modeling, we also found that men were less likely than women to have taken antibiotics in the previous three months (OR=0.50, CI 0.30-0.82). These findings help us better understand the dynamics of ABU in low-income countries, which have historically been understudied in AMR and pharmacological research. They also support efforts to mitigate the burden of AMR by revealing ABU dynamics that may contribute to the emergence and spread of AMR, as well as identifying targets for intervention to curb inappropriate ABU.

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.

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.

IntroductionThe long-standing disconnection of abortion legislation in Nigeria with the estimated incidence of 1.8 million terminations a year has contributed to systematic gaps in reliable abortion data for health policy. Any subnational monitoring under conditions of legal restraint tends to remain hidden beneath under-reporting and spatial instability such that policy makers are not left with a clear picture of where and why these decisions are being made. Methods and AnalysisTo address this ambiguity, this paper traces the path of state-level evolution of reproductive choices within the 2013, 2018 and 2024 NDHS. We detected the latent socio-demographic causes of terminated pregnancy using a Bayesian spatio-temporal framework, such as wealth, education, literacy, and contraceptive prevalence. ResultsThe rates were highly spatio-temporally intense and polarized in the region, with probabilistic evidence to justify state-specific reproductive health interventions between 2013 and 2024. Southern and coastal states (e.g., Lagos, Bayelsa) demonstrated sustained increases in prevalence in line with a high fertility transition, termination is more reproductive agency, access to services and reporting. Conversely, the unmet contraceptive need and structural vulnerability were the major causes of increased rates in the northern states (e.g., Yobe, Kano). Patterns of determinants also changed with time: in previous surveys, household wealth turned out to be a protective factor, as of 2024, education and literacy had become the strongest predictors. ConclusionsSuch findings affirm a dual reproductive regime in Nigeria--choice based in the South and vulnerability based in the North necessitating a shift from homogenous national approaches to state-specific reproductive health policies. What is already known on this topicStudies have noted the continuous disparities in the maternal and reproductive health indicators between northern and southern Nigerian states. Nevertheless, most of the studies done before were based on cross-sectional analysis and national-level summaries. Not many considered spatial dependence among states or studied how decisions on termination vary over time. What this study addsThrough shared modelling of spatial effects, temporal trends and space-time interactions, it establishes consistent high-risk conditions, arising hotspots and areas with decoding risk. The Bayesian model enhances the accuracy of the estimation since it takes into consideration the spatial correlation and the strength of borrowing on neighboring states. How this study might affect research, practice or policyIn the case of research, the study offers a methodological approach to the analysis of other maternal and public healthcare indicators by small-area estimation methods. Practically, with high-risk and emerging hotspots states identified, reproductive health more focused interventions can be implemented and limited resources can be efficiently allocated. To the policy, the study provides state-specifics evidence to inform subnational reproductive health planning and monitoring.

BackgroundZero-dose children, defined as those who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DPT1), are a key indicator of inequitable access to immunization services. Nigeria remains one of the largest contributors to the global burden of zero-dose children. This study estimated the prevalence of zero-dose children aged 12-23 months and identified individual-and community-level determinants using the 2024 Nigeria Demographic Health Survey (NDHS). MethodsA secondary analysis of cross-sectional analysis was conducted using data from 4,711 children aged 12-23 months in the 2024 NDHS kids recode dataset. A multilevel mixed-effects logistic regression model was fitted to account for the hierarchical structure of the data. Four models were compared: null, individual-level, community-level, and combined models. Adjusted odds ratios (AORs) with 95% confidence interval (CI) were used to identify significant determinants at p<0.05. ResultsThe weighted prevalence of zero-dose children was 37.3% (95% CI: 35.1-39.6%). Significant factors included birth order, maternal age, maternal occupation, parental education, household wealth, antenatal attendance, postnatal care utilization, place of delivery, religion, distance to health facilities, and geographical region. Children whose mothers had higher educational attainment, attending antenatal care, deliver in the health facilities, and received postnatal care were significantly less likely to be zero-dose status. Conversely, children from poorer households, those facing distance barriers to health facilities, those belongings to Muslim and traditional religion group and those residing in certain geographical regions had higher odds of zero-dose children, with significant regional variations observed. Conclusionzero-dose vaccination remains highly prevalent in Nigeria and is strongly influenced by socioeconomic disadvantage, maternal healthcare utilization, religion, and regional inequities. Strengthening integrated maternal and child health services and improving access in underserved regions are essential to achieving equitable vaccination coverage.

Introduction: Antibiotic misuse is a major driver of antimicrobial resistance (AMR), contributing to an estimated 1.27 million deaths globally. In Kenya, inappropriate antibiotic use is shaped by health-seeking behaviors and sociodemographic factors. However, little is known about how adults with productive coughs seek and use antibiotics, or how sociodemographic factors underpin these practices. This study explored antibiotic-seeking pathways, usage patterns, and the sociodemographic factors influencing these practices among adults with productive coughs attending selected chest and tuberculosis clinics in Nairobi County, Kenya. Methodology: A facility-based cross-sectional study was conducted among 400 adults ([&ge;]18 years) with productive coughs. Data were collected using a structured questionnaire on sociodemographic characteristics, antibiotic-seeking pathways, and use patterns. Results: Most participants were male (65.0%) and employed (67.0%), with 68.3% earning below Ksh 10,000 (approximately USD 80) monthly and 35.8% having basic education. A history of smoking (37.3%), tuberculosis (32.0%), or other comorbidities (29.8%) was common. Among 347 (86.7%) antibiotic users, 46.4% obtained antibiotics through general practitioners (GP) only, 31.4% via both GP and over-the-counter (OTC) sources, 15.3% from OTC only, and 6.9% through self-medication. Females were more likely to self-medicate (13.3% vs. 3.2%) and had higher odds of antibiotic use (cOR: 2.00; 95% CI: 1.04-4.10). Tuberculosis history was linked to greater GP reliance (61.7% vs. 37.4%). Low-income participants mainly used GP-only sources, while higher-income earners favored GP plus OTC routes (RRR: 2.67; 95% CI: 1.41-5.05). Empirical use was common (71.1%), dominated by Amoxicillin (90.8%), with multiple antibiotic use reported by 67.2% of the participants. Conclusion: Antibiotic use among adults with productive coughs in Nairobi was widespread and largely empirical, dominated by Amoxicillin and Amoxicillin/Clavulanic acid. Self-medication, unregulated antibiotic access, and inappropriate use highlight the urgent need for stricter prescription enforcement and strengthened stewardship programs to promote rational antibiotic use and curb AMR.

BackgroundCampylobacter is a major cause of childhood diarrhoea across Africa and asymptomatic carriage is frequently reported, however risk factors for Campylobacter presence remain poorly defined. This meta-analysis aimed to calculate the pooled prevalence of Campylobacter in diarrhoeic and non-diarrhoeic stool, assess its association with diarrhoea, identify risk factors for Campylobacter presence and antimicrobial resistance (AMR) patterns. MethodEnglish language studies on Campylobacter in children (<18 years) in Africa were searched. Prevalence of Campylobacter and AMR, Odds Ratios (OR) for Campylobacter presence in diarrhoeic stool and risk factors for Campylobacter were estimated. Heterogeneity was assessed using I2 and bias assessed via funnel plots and Eggers test. ResultsA total of 168 studies were included in the meta-analysis. The pooled prevalence of Campylobacter in diarrhoeic stool was 11.25% (9.41-13.23%), in non-diarrhoeic stool 12.56% (7.79-18.27%), and mixed stool types 33.47% (20.53-47.81%). The OR for Campylobacter presence in diarrhoeic stool versus non-diarrhoeic stool was 1.95 (95% CI: 1.62-2.33). Age affected the OR with children 0-6 months old having an OR 2.57 (1.74-3.81), 7-12 months old an OR 1.60 (1.07-2.40), 13-24 months old an OR 1.02 (0.68-1.52) and 25-60 months old an OR 1.76 (0.77-4.05). Risk factors for Campylobacter presence in stool were children living in rural areas (pooled Adjusted Odds Ratio (pAOR) = 2.59 95% CI 1.43-4.69) and having contact with animals (pAOR 4.28 95% CI: 2.40-7.61). AMR prevalence ranged from 54.85% for ampicillin to 9.85% for chloramphenicol. Heterogeneity was high across all analyses. ConclusionCampylobacter prevalence is high in symptomatic and asymptomatic children across Africa. Contact with animals and living in an urban environment are risk factors for Campylobacter presence. Risk factor identification in the African context would be strengthened with standardized risk factors. Further research is needed to clarify the public health significance of asymptomatic carriage. What is already known on this topic - Campylobacter is a significant cause of diarrhoea in children and asymptomatic carriage is common. However, the burden of asymptomatic carriage and risk factors are not well understood in Africa. What this study adds - This meta-analysis highlights the high burden of asymptomatic Campylobacter carriage, its relation to age, and identified risk factors for Campylobacter in children in Africa. How this study might affect research, practice or policy - Standardising risk factor assessments can guide future control strategies. Further research into the impact of asymptomatic carriage is warranted.

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.