Tropical Medicine & International Health

Background: Anaemia in women of reproductive age is a persistent contributor to maternal morbidity and adverse birth outcomes in sub-Saharan Africa. Ghanaian surveys have repeatedly placed national anaemia prevalence in the World Health Organization's severe public health problem range, yet the geographical distribution of this burden, and the socioeconomic factors that may account for it after geographical adjustment, remain insufficiently elucidated. Methods: This cross-sectional study analysed the women's and geospatial files of the 2022 Ghana Demographic and Health Survey. Anaemia was defined as altitude- and smoking-adjusted haemoglobin below World Health Organization thresholds among 7,557 women aged 15-49 years with a valid measurement. Survey-weighted multivariable logistic regression, accounting for clustering, stratification, and sampling weights, was used to elucidate socioeconomic and demographic correlates. Cluster-level prevalence was tested for spatial clustering with global Moran's I and local Getis-Ord Gi* statistics (k-nearest neighbour weights, k = 8). Results: Weighted anaemia prevalence was estimated at 41.1% (mild: 22.6%, moderate: 17.3%, and severe: 1.1%). Pregnant women appeared to have higher adjusted odds of anaemia than non-pregnant women (adjusted odds ratio [AOR] 1.71, 95% CI 1.38-2.12), as did women in the Northern (AOR 1.54, 95% CI 1.16-2.06) and Savannah (AOR 1.35, 95% CI 1.04-1.76) regions relative to Greater Accra, while the Ahafo region showed lower odds (AOR 0.64, 95% CI 0.43-0.94). Associations with rural residence, education, and wealth that were significant in crude analysis appeared substantially attenuated after adjustment. Moran's I suggested significant positive spatial autocorrelation (I = 0.156, p = 0.001); Getis-Ord Gi* identified 109 hotspot and 117 cold spot clusters among 618 clusters, with hotspots concentrated in the north and cold spots in the mid-southern forest belt. Conclusion: Two in five women of reproductive age in Ghana were estimated to have been anaemic in 2022. Risk appeared to be shaped more by region and pregnancy status than by household wealth or education once geography was accounted for. Anaemia-control programming may benefit from prioritising the identified northern hotspot areas alongside routine antenatal supplementation.

Background: Sickle cell anaemia (SCA) is characterised by chronic haemolysis, inflammation, platelet activation, and recurrent vaso-occlusive complications. Mean platelet volume (MPV) is a readily available platelet index, but evidence regarding its relationship with disease severity in paediatric SCA remains limited and inconsistent, particularly in African populations. Objective: To evaluate the relationship between MPV and disease severity among children with SCA in Kwara State, North-Central Nigeria. Methods: This hospital-based cross-sectional study included 51 clinically stable children with confirmed SCA consecutively recruited from the paediatric haematology clinic of Children Emergency Specialist Hospital, Ilorin. Complete blood count, including MPV, was performed using a Rayto RT-7600 automated haematology analyser. Disease severity was assessed using a composite clinical and laboratory scoring system based on a previously described method. Pearson's correlation, Spearman's rank correlation, simple linear regression, and the Kruskal-Wallis test were used as appropriate. Statistical significance was set at p < 0.05. Results: Of 51 participants, 14 (27.5%) had mild, 33 (64.7%) moderate, and 4 (7.8%) severe disease. Mean MPV was 9.34 +/- 0.76 fL (range, 8.0-11.2). Pearson's correlation showed a weak positive, non-significant linear relationship with severity score (r = 0.231, p = 0.103), whereas Spearman's analysis showed a weak positive monotonic association (rho = 0.286, p = 0.042). Regression explained 5.3% of severity-score variation (R2 = 0.053, p = 0.103). MPV did not differ significantly across severity categories (H = 2.163, p = 0.339). MPV correlated inversely with haemoglobin (r = -0.556, p < 0.001) and positively with platelet count (r = 0.307, p = 0.029). Conclusion: MPV showed a weak relationship with disease severity but inconsistent statistical evidence across analyses. The limited explained variance and absence of significant differences between severity categories do not support MPV as a standalone severity marker. Larger longitudinal studies are warranted. Keywords: Sickle cell anaemia; Mean platelet volume; Disease severity; Platelet indices; Paediatric haematology; Cross-sectional study; Nigeria.

Background Malaria remains a major public health challenge in Indonesia, with transmission concentrated in several eastern regions. A systematic overview of national research activity is needed to show how scientific priorities have changed and whether the evidence base is aligned with elimination needs. Methodology/Principal findings We conducted a scoping review and bibliometric analysis of Scopus-indexed malaria publications from 2015 to 2025 following PRISMA-ScR guidance. Records were screened for an Indonesian institutional affiliation or an explicit Indonesia-specific study component. Publication trends, co-authorship, keyword networks, citation patterns, thematic evolution, and exploratory forecasts were analysed. Keyword text was represented using term frequency-inverse document frequency and grouped with K-means clustering. The initial candidate set contained 592 publications; four false-positive records were excluded, leaving 588 eligible Indonesia-related publications. Of these, 583 had an Indonesian affiliation identifiable in the exported Scopus metadata and 586 had usable keyword metadata for thematic analysis. Ten clusters were identified. Environmental and Community-Based Studies was the largest theme (110/586, 18.77%), followed by Plasmodium Species and Clinical Parasitology (85/586, 14.51%), Molecular Diagnostics (76/586, 12.97%), Treatment and Antimalarial Drugs (69/586, 11.77%), and Health Systems and Malaria Control Programs (67/586, 11.43%). Treatment-related research had the greatest total and mean citation impact. Publication output accumulated continuously without a clear plateau. Forecasts suggested the strongest continued growth in environmental and community-based research, while treatment and health-system themes were comparatively stable. Conclusions/Significance Indonesian malaria research became more diverse while retaining strong clinical and treatment foundations. Future research planning should balance biomedical priorities with environmental, community, diagnostic, and implementation research. Forecasts are exploratory and should not be interpreted as precise predictions.

Background Malaria and HIV remain major causes of illness in sub-Saharan Africa, accounting for 94% of the global malaria burden and over two-thirds of the global HIV burden. HIV-related immunosuppression increases susceptibility to malaria, with a higher malaria burden of up to 47% and severe malaria complications compared to HIV-negative individuals. Socio-demographic factors, individual knowledge, attitude, and perception are recognized determinants of malaria prevention behaviours, but no study has modelled their combined contribution, and there is scant research on these factors among people living with HIV. We assessed the level of knowledge, attitudes, and perceptions towards malaria, and identified the predictors of malaria prevention practice among HIV-positive individuals in Kampala, Uganda. Methods This cross-sectional study enrolled 620 HIV-positive patients attending the ART clinic of China-Uganda Friendship Hospital, Naguru, selected by systematic random sampling. Data collection was conducted from 21st July 2025 to 18th August 2025 using a structured, interviewer-administered questionnaire that measured socio-demographic characteristics, knowledge, attitude, perception, and the practice of malaria prevention. Associations were assessed using Mann-Whitney U, Kruskal-Wallis H, and Spearman correlation. The independent predictors of good malaria prevention practice were identified using binary logistic regression. Results Participants had a mean age of 34.8 years, were predominantly female (68.9%), Baganda (38.1%) by tribe, and the majority had a secondary level of education(46.0%). Most had good knowledge of malaria (97.3%) and a positive attitude (90.5%), while 57.3% held a positive perception of malaria risk and prevention; only 62.6% reported good malaria prevention practice, and most prevention methods used were sleeping under a mosquito net (71.1 3%) and closing windows early in the evening (70.3%). In regression analysis, knowledge (adjusted odds ratio [AOR] 1.198, 95% CI 1.03-1.40, p = 0.023) and attitude (AOR 1.101, 95% CI 1.04-1.17, p = 0.001) independently predicted good practice, while perception did not (AOR 1.00, 95% CI 0.96-1.04, p = 0.994). Scores of Attitude, perception, and malaria prevention practices varied significantly, though non-linearly, by education level, and were highest among non-educated participants. Conclusions Despite near-universal knowledge and predominantly positive attitudes in this study, more than a third of HIV-positive participants did not practice adequate malaria prevention, and perception did not independently predict malaria prevention practice once knowledge and attitude were accounted for. Programmes seeking to close this know-do gap should pair health education with structural support for prevention tools rather than education alone.

Background Inadequate water, sanitation, and hygiene (WASH) remain key risk factors for neglected tropical diseases (NTDs) in Nigeria. However, the complex, non-linear determinants of household WASH access are poorly understood, limiting targeted NTD control. Methods We conducted a cross-sectional secondary analysis of 30,045 households from the nationally representative 2024 Nigeria Demographic and Health Survey (NDHS). Four supervised machine learning models -- Logistic Regression, Decision Tree, Random Forest, and XGBoost -- were trained to predict improved household WASH access. Model performance was evaluated using accuracy, precision, recall, F1-score, and AUC. Explainability was achieved using SHAP values and feature importance. Results XGBoost achieved the highest performance: 83.3% accuracy, 86.9% precision, 92.3% recall, 89.5% F1-score, and AUC 0.877. Random Forest performed similarly with AUC 0.868. SHAP analysis identified household wealth index, improved sanitation, place of residence, and water availability at handwashing stations as the top predictors. Rural households in northern Nigeria and those in the lowest wealth quintiles had the lowest predicted probability of improved WASH. Conclusions Explainable machine learning effectively identifies populations most vulnerable to WASH inequities. Targeting low-wealth, rural households in northern Nigeria with integrated WASH interventions could yield the greatest gains for NTD control. Our open-source code provides a reproducible framework for evidence-based resource allocation.

Objectives: To examine the association between maternal media exposure and childhood anemia in three sub-Saharan African countries, and to develop a two-stage multiple imputation approach for substantial hemoglobin outcome missingness in Demographic and Health Survey (DHS) data. Design: Multi-country cross-sectional analysis of nationally representative DHS data. Setting: Community-based household surveys in Ghana (2022), Nigeria (2023-24), and Tanzania (2022). Participants: 42,944 children aged 6-59 months across 2,621 clusters. Primary and secondary outcome measures: The primary outcome was anemia (altitude-adjusted hemoglobin <11.0 g/dL, WHO criteria); the primary exposure was a composite maternal media score (0-4 channels). Given 61.5% hemoglobin missingness, we imputed altitude-adjusted hemoglobin using multilevel Gaussian models and derived anemia deterministically, then estimated associations using population-averaged generalized estimating equations (pre-specified primary analysis), with six sensitivity analyses and exploratory mediation analysis. Results: Media exposure was significantly associated with reduced anemia odds (OR 0.946, 95% CI 0.917 to 0.976, p<0.001; FMI 32.5%), a 5.4% reduction per additional weekly channel. Estimates were consistent across six sensitivity analyses (OR range 0.914-0.961), with no heterogeneity by country (I2=0%, p=0.482). Media exposure predicted antenatal care attendance and iron supplementation (both p<0.001), but neither mediated the anemia association. Conclusions: Maternal media exposure was consistently associated with reduced childhood anemia across three sub-Saharan African settings. A two-stage multiple imputation approach addressed substantial (61.5%) outcome missingness while maintaining stable estimates, offering a transferable framework for DHS-based analyses. Prospective and intervention studies are needed before media-based communication can be recommended as a complementary anemia-control strategy. Keywords: Anemia; Child Health; Mass Media; Health Surveys; Data Interpretation, Statistical

Background: Low birth weight remains a primary driver of neonatal and infant mortality in Ethiopia. Machine learning models can assist early risk identification, yet clinical adoption is often limited by black box algorithms and late pregnancy predictor variables. This study aimed to develop and validate interpretable machine learning models using early pregnancy and sociodemographic features from a national survey dataset. Methods: Secondary data from the nationwide Ethiopian Demographic and Health Survey were analyzed. Predictors were restricted to features accessible during early antenatal visits. Six machine learning algorithms were trained and evaluated on an independent holdout test set: Logistic Regression, Decision Tree, Support Vector Machine, Gradient Boosting, Random Forest and Extreme Gradient Boosting (XGBoost). Imbalance was addressed using synthetic oversampling on the training set. Model explainability was established through Shapley Additive exPlanations (SHAP). Results: Out of 12876 births, 4249 (33%) were categorized as low birth weight / small birth size. XGBoost achieved superior predictive performance with an AUC-ROC of 0.947 (95% CI: 0.910-0.938) on the test set, outperforming standard logistic regression (0.8088). Key global predictive drivers identified by SHAP values included maternal anemia status, short inter pregnancy interval (< 18 months), low maternal BMI (< 18.5 kg/m^2), rural residence, lowest household wealth quintile and delayed or non-attendance of first trimester antenatal care. Conclusion: Machine learning models trained on early pregnancy and demographic features can accurately predict low birth weight risk in Ethiopia. Integrating interpretable frameworks into primary healthcare decision support tools provides a viable strategy for early risk stratification and targeted interventions in resource-limited settings.

Abstract Background: Cervical cancer is a leading malignancy and mortality cause among Ethiopian women. Despite screening expansions coverage remains low. Traditional models miss complex determinants. This study aimed to develop machine learning models to predict cervical cancer screening utilization and identify drivers using the 2024 to 2025 Ethiopian Demographic and Health Survey. Methods: A secondary analysis of the 2024 to 2025 Ethiopian Demographic and Health Survey was conducted among women aged 15 to 49. Six algorithms Logistic Regression, Decision Tree, Support Vector Machine, Random Forest, Gradient Boosting Machine and Extreme Gradient Boosting were trained. Synthetic Minority Over-sampling Technique handled class imbalance with a 4.2 percent screening prevalence. Models were evaluated on a holdout set using Area Under the Receiver Operating Characteristic curve, Area Under the Precision-Recall Curve, Brier score and Decision Curve Analysis. SHapley Additive exPlanations explained model predictions. Results: Extreme Gradient Boosting achieved superior discrimination with an Area Under the Receiver Operating Characteristic curve of 0.896 and Area Under the Precision-Recall Curve of 0.781 outperforming baseline Logistic Regression at 0.772. Isotonic calibration optimized prediction loss with a Brier score of 0.038. Decision Curve Analysis confirmed clinical net benefit across thresholds from 5 percent to 55 percent. Explanatory analysis identified cancer awareness, education, autonomy, wealth quintile, recent health visits and urban residence as primary screening drivers. Conclusions: Probability-calibrated Extreme Gradient Boosting with explainability provides an accurate tool for identifying un-screened women in Ethiopia. Public health programs can deploy these tools in primary care applications to target outreach, optimize community engagement and accelerate World Health Organization elimination targets.

Background Urogenital schistosomiasis control programmes have traditionally focused preventive chemotherapy (PC) on school-aged children (SAC, 5 -14 years). However, the burden of infection among pre-school-aged children (Pre-SAC) and the extent to which infection patterns differ from those of adults remain poorly documented in the Lake Chad Basin. This study presents a secondary analysis of routinely collected programme data from the Dawa Mobile Health schistosomiasis control programme to characterise the burden, age distribution, and determinants of urogenital schistosomiasis among children and adolescents (1 - 20 years) in the Ngouri Health District, Chad. Methods We conducted a retrospective cross-sectional secondary analysis of routinely collected data collected during a community-based schistosomiasis control programme implemented in the Ngouri Health District, Lac Province, Chad, between February 2024 and April 2025. All individuals screened during routine programme activities were eligible for inclusion. Children and adolescents aged 1- 20 years (n = 1,946) constituted the primary population of interest, while adults aged [&ge;]21 years (n = 2,570) served as a comparison group. Urogenital schistosomiasis was diagnosed by urine membrane filtration, with infection defined as the detection of at least one Schistosoma haematobium egg per 10 mL of urine. Multivariable logistic regression was used to identify factors independently associated with infection among children and adolescents. Results Among 4,516 programme participants, children and adolescents represented 43.1% of those screened and accounted for 43.9% of the 880 confirmed infections. During programme implementation, the observed prevalence was 19.8% (95% CI: 18.1 - 21.7%) among children and adolescents, 18.2% (95% CI: 14.7 - 22.2%) among Pre-SAC (1 - 10 years), and 20.3% (95% CI: 18.3 - 22.4%) among SAC (11 - 20 years), with no significant difference compared with adults (19.2%; p = 0.633). Both child age groups remained within the WHO moderate-endemicity category, indicating continued eligibility for annual preventive chemotherapy. In multivariable analysis, neither age subgroup, sex, education level nor occupation was independently associated with infection (all p > 0.05), suggesting broadly distributed community exposure. Conclusions Pre-school-aged children experienced a burden of urogenital schistosomiasis comparable to that of school-aged children and adults in this agro-pastoral setting. Although the reported prevalence reflects infection observed during programme implementation rather than baseline district prevalence, moderate endemicity persisted after 15 months of community-based screening and treatment, supporting the continuation of community-wide preventive chemotherapy, including Pre-SAC. These findings also suggest that chemotherapy alone may be insufficient to interrupt transmission and highlight the need to complement treatment with strengthened WASH interventions and adaptive surveillance strategies capable of identifying persistent transmission hotspots. Keywords: Schistosoma haematobium; urogenital schistosomiasis; pre-school-aged children; school-aged children; preventive chemotherapy; mass drug administration; community-based control; Lake Chad; Chad; Dawa Mobile Health.

Background: Urogenital schistosomiasis caused by Schistosoma haematobium remains a major public health concern in the Lake Chad region. This study aimed to estimate the cumulative prevalence of S. haematobium infection and to identify factors associated with test positivity within an intervention zone of the Ngouri health district, Lac Province, Chad. Methods: A cross-sectional analytical study was conducted using routinely collected data from the Dawa Mobile Health system between February 2024 and April 2025. A total of 4,504 individuals were included after data cleaning and biological consistency correction (22 haematuria cases recoded as positive). Bivariate analysis (Chi-square test) and multivariable logistic regression were performed. Results: The overall prevalence was 19.5% (95% CI: 18.4% - 20.7%). No statistically significant association was found for age (p=0.163), sex (p=0.939), marital status (p=0.858), occupation (p=0.704), or urine appearance in the binary model (p=0.116). Education level approached significance (p=0.078), with the highest prevalence observed at the primary level (23.0%). In multivariable analysis, only primary education was independently associated with positivity (adjusted OR=1.29, 95% CI: 1.06 - 1.57; p=0.011). Conclusion: Nearly one in five participants tested positive, confirming the high endemicity of the Ngouri district. The homogeneous distribution across demographic subgroups suggests widespread community exposure, supporting mass drug administration beyond school-aged children, strengthened WASH interventions, and consolidation of mobile health surveillance. Keywords: Schistosoma haematobium; urogenital schistosomiasis; prevalence; Lake Chad; Chad; mobile health; logistic regression.

Eastern and southern Africa are highly affected by drought, and projections indicate that droughts will become more common in the coming decades. Whilst there has been research on the impact of drought on HIV, attributable to its effect on food insecurity and increased risky sexual behaviour, the link between drought and other sexually transmitted infections (STIs), particularly syphilis, remains largely unexplored. This study therefore assesses the association between drought and active syphilis, history of syphilis, and recovery from syphilis in Zambia, Uganda, and Tanzania, while examining disparities between urban and rural settings. It uses data on 75,225 people from Population-based HIV Impact Assessment surveys (2016-17), which include biomarker information, combined with rainfall data from the Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) dataset to define drought in the two years prior to the survey. Multivariate logistic regression models with country-level fixed effects show that in urban areas, drought was associated with a significant increase in the probability of having active syphilis (average marginal effects (AME) = 0.5%, 95% confidence interval (CI): 0.2%-1.0%) and of having ever had syphilis (AME = 2%, 95% CI: 0.8%-4%). No significant association was found in rural areas. Exposure to drought was not associated with recovery from syphilis in either setting, though confidence intervals were wide. Our results underscore the importance of strengthening healthcare systems to make them more resilient to drought shocks in urban areas, and the need to reinforce syphilis prevention and treatment programmes in those areas when such shocks occur.

Objectives: Estimate fertility rate ratios (FRR) of HIV-positive relative to HIV-negative women in sub-Saharan Africa (SSA) by age group, CD4 stage, ART status, and country. Design: Analysis of nationally representative household surveys with HIV serological testing. Methods: We analysed current pregnancy and births in the past three years by HIV status from 72 nationally-representative household surveys in SSA between 2003 and 2017. Spectrum 2018 estimates for the distribution by CD4 stage and ART status were used to infer fertility of women on ART from changes in fertility of all HIV-positive women as ART coverage increased. We allowed regional differences in the age pattern of relative fertility and estimated country-specific random effects. Results: The ratio of fertility in untreated HIV-positive women with CD4 [&ge;]500 to HIV-negative women was 1.6 to 1.8 for age 15-19, relatively similar to 10% times lower for age 20-29, and 15-50% lower above age 30. Among age 15-19, each 15-point increase in percent sexually active reduced relative excess fertility by 24%. Fertility decreased with lower untreated CD4 count stages, consistent with previous estimates. Women on ART >6 months had fertility closer to that of HIV-negative women for ages 15-29, but still 25-40% lower above age 30. There was substantial variation across countries. Conclusions: Fertility differences for HIV-positive women compared to HIV-negative women are smaller than previous estimates, but vary substantially across countries. Recent data suggest fertility of women on ART is greater than that of untreated HIV-positive women, but remains lower than HIV-negative women. This conclusion should be reviewed as new evidence becomes available.

Urogenital schistosomiasis, caused by Schistosoma haematobium, remains a major public health challenge among school-aged children in rural Ghana. Although urogenital indicators are well-established, systemic hepatic biomarker alterations in post-mass drug administration pediatric settings remain poorly characterized. This cross-sectional study evaluated point-of-care urinalysis profiles alongside a panel of serum hepatic and renal biomarkers in 174 children (aged 3 to 16 years) from the Sene West District, Ghana. Active infection (urine microscopy egg detection) was identified in 84 participants (48.3%, median egg count = 4.50 eggs/10 mL, IQR: 1.00 - 9.25). Active infection was strongly associated with microhematuria (57.1% vs. 11.1%, p < 0.001), proteinuria (42.9% vs. 22.2%, p = 0.004), and leukocyturia (27.4% vs. 4.4%, p < 0.001). Children with active infection also demonstrated a higher frequency of composite categorical hepatic biomarker alterations (60.7% vs. 37.8%, p = 0.002), whereas categorical renal alterations showed no significant difference (p = 0.332). Controlling for age and sex, multivariable logistic regression confirmed active infection as a significant independent predictor of composite hepatic biomarker alterations (aOR = 2.54, 95% CI: 1.37 - 4.69, p = 0.003), but not renal alterations (aOR = 1.40, p = 0.359). Continuous medians for individual serum biomarkers showed no significant differences between groups. Combining composite hepatic biomarker thresholds with routine dipstick screening improves the detection of subclinical morbidity in pediatric field settings.

Quantitative measurement of fetal hemoglobin (HbF) using high-performance liquid chromatography (HPLC) is standard but expensive and widely unavailable in low-income settings. The newer Gazelle method, which employs single-use alkaline electrophoresis cartridges, provides a portable and relatively inexpensive potential alternative. In the current study, we tested 3055 venous blood samples collected from 1780 children with sickle cell anemia who were enrolled into the H-PRIME trial by both Gazelle and the Bio-Rad D-10 HPLC instrument, before and during hydroxyurea treatment. Data reinterpretation was required to quantify accurately high HbF values derived using the D-10. Mean (standard deviation) baseline HbF values by HPLC and Gazelle (N=2042) were 11.4% (SD 5.9%) versus 16.3% (SD 7.5%), respectively, while mean on-treatment HbF values (N=1013) were 18.9% (SD 9.0%) versus 25.4% (SD 11.5%), respectively. While overall agreement was good (Lins concordance 0.76, 95% CI 0.75-0.78), HbF values derived using Gazelle were modestly higher than HPLC values (Bland-Altman agreement mean +5.4%, 95%CI -2.4% to +13.2%), with the difference between measures increasing at higher HbF percentages. With strong concordance and more easily interpretable HbF values, Gazelle represents an attractive and inexpensive alternative to HPLC for HbF quantification in the low-income settings where most patients with sickle cell anemia live.

BackgroundFebrile neutropenia requires rapid empirical antibiotic therapy, with regimen selection shaped by local prescribing practice and pathogen patterns. We described starting treatment, later drug changes, microbiological findings, and inpatient outcomes. MethodsThis ambispective cohort comprised 96 episodes from 90 patients admitted to a tertiary-level teaching hospital. Treatment and outcome analyses used each episode as the unit of observation. Recorded variables included the starting antibiotics, later regimen modification, microbiology, hospitalization length, invasive fungal infection (IFI) as captured in study records, and disposition. Comparisons based on escalation status were exploratory. ResultCefoperazone-sulbactam appeared in 62/96 initial regimens (64.6%), amikacin in 42 (43.8%), teicoplanin in 28 (29.2%), and meropenem in 14 (14.6%). Eighteen episodes (18.8%) required a change that broadened or substituted antibacterial therapy. Among 31 microbiologically documented infections, 22 (71.0%) yielded Gram-negative organisms and 9 (29.0%) were polymicrobial. Median length of admission was 18.5 days in the escalation group and 9 days in the remainder (p<0.001). Mortality was 27.8% (5/18) with escalation and 5.1% (4/78) without it (p=0.011), with nine inhospital deaths overall (9.4%). ConclusionAntibacterial management differed within this cohort, with treatment escalation required in 18 of 96 episodes. Gram-negative organisms comprised most microbiologically confirmed infections. Escalation marked a clinically complex course with prolonged hospitalization and greater observed mortality; the observational design does not establish comparative efficacy or causation.

Introduction: The continuing high and inequitable global malaria burden requires improved methods to understand trends and target control. Current methods often involve infection prevalence surveys, but additional parasitological measures could increase precision in estimating infection burdens of communities. Methods: Focusing on the country with most malaria globally, examinations of slides from 10,651 children under five sampled in the 2021 national Malaria Indicator Survey in Nigeria were performed to measure asexual parasite densities in infected children and discriminate sexual stages and species. Variation in these indices among the six different geopolitical zones and 37 individual states including the Federal Capital Territory were compared with the variation indicated by infection prevalence alone. Results: Among the six major geopolitical zones, only one had significantly higher asexual parasite prevalence than others, but parasite densities within infected children revealed more significant variation among the different zones. Comparing results for 2021 with previous data from 2018, one zone showed lower asexual parasite prevalence and two had lower sexual parasite prevalence, but three had higher asexual parasite densities in infected children. Variation in parasite densities among individual states also highlighted significant geographical and temporal differences, extending the detection of heterogeneity within each geopolitical zone. Overall trends were driven by the predominant parasite species Plasmodium falciparum as prevalence and density of the other species were much lower. Conclusions: Findings indicate that understanding complex patterns of geographical and temporal variation is enhanced by including asexual parasite density measurement, providing opportunities for more precise targeting of malaria control within high burden countries.

Background Severe acute malnutrition (SAM) affects approximately 12 million children globally. The aim of this study was to assess the effectiveness of integrating a household water treatment and hygiene promotion intervention within the national protocol of Senegal for outpatient treatment of children aged 6-59 months of age with uncomplicated SAM. Methods This was a pragmatic cluster-randomised controlled trial with health centres allocated 1:1 to receive either the standard protocol alone or the standard protocol with the addition of the water treatment and hygiene intervention. The primary outcome of the trial was SAM recovery defined under the national protocol in Senegal, and the secondary outcomes were weight gain, referral to inpatient care, enteric pathogen detection, diarrhoea, and all-cause mortality. Participants were followed up over eight weeks. Findings Between 22 December 2021 and 20 February 2023, 2411 children were enrolled in the study with 777 defaulting outpatient treatment during eight weeks of follow-up. There was no difference between control and intervention groups in the proportion of children recovering from SAM eight weeks post admission (39.8% vs 41.2%; adjusted odds ratio [aOR]: 0.97, 95% Confidence Interval [CI]: 0.66, 1.48). There was no difference in weight gain, referral, enteric pathogen detection or mortality between groups. The prevalence of diarrhoea at eight weeks follow-up was higher in the control group (20.0%) than the intervention group (12.5%), with evidence for a large difference between arms, accounting for between-group differences at baseline (aOR: 0.36; 95%CI: 0.26, 0.50). Interpretation The integration of household water treatment and hygiene promotion in the standard national protocol did not improve SAM recovery nor the related outcomes of weight gain, referral, enteric pathogen detection or mortality but did reduce diarrhoea. Our results suggest that the integration of this intervention to the standard protocol would not improve SAM outcomes in this setting but would potentially reduce the burden of diarrhoea among this vulnerable group. Funding This study was supported by the Bureau of Humanitarian Assistance of the United States Agency for International Development and the ACF Foundation.

Introduction Reliable, well-maintained laboratory equipment is essential for timely, accurate and reliable laboratory results for patient care, surveillance, and health system resilience. Tanzania implemented the Standard Medical Laboratory Equipment Guideline (SMLEG-2018) to harmonise procurement and improve efficiency across a tiered laboratory system and network. However, equipment functionality gaps remain a critical challenge for healthcare delivery. This study determined the functionality status of standardised laboratory analysers in Tanzania mainland and identified the drivers of non-functionality. Methods We conducted a facility-based cross-sectional study to identify the causes of non-functionality of standardised chemistry, haematology, and urine analysers across mainland Tanzania. We assessed 3,044 analysers and used Pareto analysis to identify the primary drivers of non-functionality. Results Of the 3,044 standardised analysers assessed, 987 (32.4%) chemistry 1,308 (43.0%) haematology, and 749 (24.6%) urine) assessed; 397 (13.0%) were non-functional. Proportionally, urine analysers were the most non-functional (n=176/749, 23.5%), followed by chemistry (n=135/987, 13.7%), and haematology (n=86/1308, 6.6%) analysers, p<0.001. Urine analysers had significantly higher non-functional equipment (23.5%), followed by Chemistry analysers (13.7%), than Haematology analysers (6.6%), p<0.001. Equipment breakdown was the leading cause of non-functionality, accounting for 70.9% (61/86), 70.5% (124/176) and 60.0% (81/135) of the non-functional haematology, urine and chemistry analysers, respectively, among all causes identified for each analyser type. Conclusion Although the SMLEG 2018 implementation identified broad coverage of functional standardised laboratory equipment, persistent equipment breakdowns of more than 10% highlight a systemic, concerning gap that requires immediate corrective action to sustain high performance. Strengthening preventive maintenance, timely repair services and sustainable equipment lifecycle planning is critical to sustaining quality laboratory services for robust preventive and curative care.

Background HIV testing is a key entry point for prevention and treatment in Nigeria, yet age-related disparities persist. Adolescent girls and young women (AGYW) are disproportionately affected by HIV but often demonstrate lower uptake of testing services. This study examined differences in HIV self-testing awareness, use, and antenatal HIV testing between AGYW and older women, the distribution of HIV testing service uptake, and identified multilevel factors associated with HIV self-test awareness and testing among AGYW. Methods This study analyzed cross-sectional data from the 2023-2024 Nigeria Demographic and Health Survey (NDHS), including women aged 15-49 years. Descriptive statistics were used to assess differences in HIV self-testing awareness, use, antenatal HIV testing, and place of HIV testing between Adolescent Girls and Young Women (AGYW) (15-24 years) and older women (25-49 years). Among AGYW, bivariate and multivariate logistic regression were conducted to identify socioecological factors associated with HIV self-testing, awareness and use. Results A total of 14,708 AGYW and 24,342 older women were included in the analysis. The median age of AGYW was 19 years (IQR: 17-22), compared to 35 years (IQR: 25-41) among older women. Older women reported significantly higher awareness of HIV self-testing (13.1%) compared to AGYW (8.8%). Use of the HIV self-testing kit was low overall but higher among older women (2.3%) than among AGYW (1.1%). Older women reported greater uptake of antenatal HIV testing (57.9%) than AGYW (48.4%). Education, wealth, and internet use were positively associated with awareness, while AGYW aged 15-19 had significantly lower odds of awareness than AGYW women aged 20- 24. Regional disparities were also observed in the awareness and use of HIV self-test kits. Conclusions Findings support that targeted, AGYW-centred strategies are needed to improve equitable access to HIV testing and achieve national and global HIV prevention goals.

Background: Dengue virus (DENV) and Chikungunya virus (CHIKV) are important mosquito-borne arboviruses with expanding global distributions. Although recurrent outbreaks have occurred in the Horn of Africa since the early 2000s, their epidemiology and burden remain poorly characterized. This systematic review and meta-analysis estimated the prevalence of DENV and CHIKV, their distribution by country, diagnostic methods, circulating DENV serotypes, and mosquito vectors. Methods: Following PRISMA guidelines, PubMed, Web of Science, Scopus, SpringerLink, Nature Portfolio, and Google Scholar were searched for studies published up to October 2025. Eligible studies reported DENV and/or CHIKV infections in humans or mosquitoes in Kenya, Ethiopia, or Somalia. Random-effects meta-analyses were performed, with subgroup analyses by country, population, setting, and diagnostic method. Results: Of 3,351 records, 65 studies met the inclusion criteria, most from Kenya (63.1%), followed by Ethiopia (30.8%) and Somalia (6.1%). Pooled DENV prevalence was 20% for IgG, 10% for IgM, 6% for NS1, and 4% by PCR. Corresponding CHIKV prevalence was 5% for IgG, 8% for IgM, and 4% by PCR. Significant differences between countries were observed for DENV NS1 (p<0.0001) and PCR-confirmed infections (p=0.01). DENV prevalence was highest in the general population (16%) compared with febrile patients (6%) and mosquito vectors (1%) (p=0.033), whereas CHIKV prevalence was highest in rural settings (15%) (p=0.0002). All four DENV serotypes circulated in Kenya and Ethiopia, while DENV-2 and DENV-3 were reported in Somalia. Aedes aegypti was the predominant vector, reported in 92.3% of vector studies. Conclusions: DENV and CHIKV are important and likely underrecognized arboviral threats to global public health and in the Horn of Africa, with evidence of ongoing transmission and widespread exposure. Strengthened surveillance, diagnostic capacity, vector control, and regional collaboration are needed to mitigate their growing public health impact.