Tropical Medicine & International Health

Female Genital Schistosomiasis (FGS) is a gynaecological condition, arising from complication from schistosomiasis - a neglected tropical disease (NTD). FGS shares overlapping symptoms with several sexually transmitted infections, making it challenging to diagnose and manage especially in primary health care settings where diagnostic tools are often unavailable. In response to this challenge, an FGS screening tool (COUNTDOWN screening tool) was developed to support primary health care workers in identifying persons at risk of FGS. We investigated the sensitivity and specificity of adapted versions of the COUNTDOWN screening tool and evaluated the costs associated with providing these services in two Nigerian schistosomiasis endemic states (Ondo and Kebbi). Using three adapted versions of the screening tool against colposcopy and unit costs of activities, performance of the tool and cost-effectiveness analysis were evaluated. Compared to the colposcopy, the performance of the FGS screening tool varied using different screening definitions. When only direct and indirect contact with surface water was considered it demonstrated a sensitivity of 66.7% (95%CI: 60.1-72.8) and specificity of 35.4% (30.2-40.9); and when water contact together with any self-reported urogenital symptom was considered, the sensitivity and specificity were 50.2% (95%CI: 43.5 - 56.9) and 48.0% (95%CI: 42.5 - 53.6) respectively. Activity based micro-costing, showed that the FGS screening tool could screen individuals for approximately US$11 per woman, compared with US$20 per woman when using colposcopy. The screening tool detected far fewer true positive cases than the reference standard, assuming colposcopy did not miss true positives. The sub-optimal performance of the screening tool indicates the need for further refinement, to balance cost and effectiveness.

Background: In malaria-endemic tropical regions, the overlapping coagulopathy in COVID-19 and malaria poses diagnostic and prognostic challenges, particularly with potential sex differences. This study evaluated sex-specific variations in platelet indices and fibrinolytic markers and assessed the utility of Platelet Distribution Width (PDW) and D-dimer in mild/asymptomatic cases. Methods: A case-control study was conducted with 220 participants (55 each in healthy controls, malaria-positive, COVID-19-positive, and COVID-19+malaria co-infected groups), aged 20-65 years, in Port Harcourt, Nigeria. Platelet indices were analysed using Sysmex XP-300 haematology analyser, while D-dimer and fibrinogen were measured by ELISA. Data were analysed using SAS 9.4 with ANOVA, Tukey's HSD, Pearson correlation, and sex-stratified comparisons. Results: PDW was significantly elevated in all infected groups compared to controls (malaria: 15.21 +/- 0.22 fL; COVID-19: 15.21 +/- 0.22 fL; co-infection: 15.61 +/- 0.21 fL vs. control: 13.26 +/- 0.17 fL; F=25.850, p < 0.001). D-dimer levels were highest in the co-infected group (553.42 +/- 59.74 ng/ml, F=2.816, p = 0.040). No significant changes were observed in other platelet indices or fibrinogen across groups. No significant correlation existed between platelet indices and the fibrinolytic markers. Males exhibited significantly higher D-dimer levels across all infected groups (p < 0.05) and higher fibrinogen in COVID-19 subjects (p = 0.036). Sex exerted a stronger influence on parameters than age. Conclusion: Males show heightened fibrinolytic activation in COVID-19 and malaria co-infection. PDW and D-dimer are promising, cost-effective biomarkers for screening mild infections in resource-limited tropical settings.

Maternal and newborn mortality in The Gambia remains high despite expanded coverage of essential interventions, and progress towards SDG targets 3.1 and 3.2 has stalled. The National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy (2017 to 2026) ends in 2026, and a successor plan is in development. We aimed to identify and rank nationally defined maternal and newborn health (MNH) research priorities in The Gambia to inform the successor RMNCAH plan and align research investment with national health system needs. We conducted a national, stakeholder-led MNH research prioritisation exercise in October 2023 using an adapted Child Health and Nutrition Research Initiative (CHNRI) method. Forty-six participants, including Ministry of Health policymakers and programme managers, clinicians, midwives, researchers, and development partners, took part in a two-day workshop. A starting set of 46 questions from the 2019 African Academy of Sciences (AAS) continental MNH prioritisation exercise and four questions from The Gambia's National Health Research Agenda was expanded through facilitated discussion to a final list of 61 questions, organised by MNH grand challenge area and CHNRI research domain. Participants independently scored each question against four weighted criteria, and national rankings were compared descriptively with AAS continental and West African subregional rankings. The priority list was dominated by delivery-focused research (49 of 61 questions, 80 percent), concentrated in better care during pregnancy and better postnatal care. The five highest-ranked priorities addressed management of obstetric emergencies before referral, retention and equitable distribution of the MNH workforce, neonatal resuscitation at peripheral facilities, maternal recognition of danger signs, and kangaroo mother care. Pre-transfer emergency obstetric management was the top national priority but was not prominent in AAS continental or West African subregional rankings. This first national MNH research priority-setting exercise in The Gambia identifies a coherent set of implementation and health systems research priorities and surfaces context-specific questions, particularly pre-transfer emergency management, that were under-emphasised in continental rankings. The agenda provides an evidence base for the successor RMNCAH plan and for partner alignment in The Gambia and comparable high-burden settings.

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 Socially Determined Diseases (SDDs) remain closely associated with health inequities and require coordinated responses from health systems, even in countries with universal healthcare coverage. In Brazil, the Brasil Saudavel Program (PBS) identified priority diseases and municipalities for elimination efforts, placing Municipal Health Plans (MHPs) at the centre of governance and policy implementation. Objective To analyse how and to what extent diseases prioritised by the PBS are incorporated into MHPs and translated into programmatic actions, considering municipal institutional capacity and service delivery organisation. Methods This descriptive documentary study analysed the MHPs of 175 municipalities prioritised by the PBS for the 2022-2025 planning cycle. Structured assessment instruments were developed based on the Programs National Guidelines to evaluate planning attributes, alignment with national priorities, and the operationalisation of disease-specific actions. Descriptive analyses were performed using absolute and relative frequencies. Pearsons chi-square test was used to assess associations between key planning attributes and regional differences. Results Although SDD-related goals were included in most plans, only 29.7% (n = 52) presented fully defined disease-specific targets, and 25.7% (n = 45) provided complete epidemiological information for all priority diseases. Dedicated funding was identified in 11.4% (n = 20) of municipalities, while fully structured awareness campaigns were described in only 4.0% (n = 7). Municipalities that incorporated epidemiological information into their plans were significantly more likely to describe structured prevention and control programmes than those without such information (76.7% versus 30.4%; {chi}2 = 29.8; p < 0.001). Regional differences were observed regarding the provision of disease-specific funding ({chi}2 = 12.0; p = 0.018), although planning profiles remained broadly similar across regions. Conclusions SDDs prioritised by the PBS are widely incorporated into MHPs at a declaratory level; however, their translation into structured programmatic actions remains limited. Weaknesses in financing, epidemiological intelligence, and operational planning constrain the implementation of national priorities. Strengthening municipal institutional capacity is essential to improve the operationalisation of health policies aimed at diseases shaped by social inequalities.

Background Insecticide-treated nets (ITNs) are effective for preventing malaria among children under five years, who bear a disproportionate burden of malaria. This study assessed the prevalence and determinants of ITN non-utilization among children under five in Rwanda using data from the 2024 Rwanda Malaria Indicator Survey (RMIS).Methodology This cross-sectional study utilized nationally representative data from the 2024 RMIS. Analyses were restricted to children under five residing in households that owned at least one ITN. The outcome was non-utilization of ITN, defined as not sleeping under an ITN the night preceding the survey. Survey-weighted descriptive statistics were used to estimate the prevalence of ITN non-utilization. Factors associated with non-utilization were identified using a survey-weighted Poisson regression model. Adjusted prevalence ratios (aPRs), 95% confidence intervals and p-values were reported.Results A total of 1,979 children were included in the study. The weighted prevalence of ITN non-utilization among children under five years was 20.11% (95% CI: 17.81 - 22.63). After adjusting for other factors, children aged 2 - 3 years were associated with an 83% higher prevalence of ITN non-utilization compared with those aged [&le;]1 year (aPR = 1.83, 95% CI: 1.423 - 2.352, p < 0.001). Compared with households that owned only one ITN, children in households with three or more ITNs were associated with a 76% lower prevalence of ITN non-utilization (aPR = 0.24, 95% CI: 0.171 - 0.332, p < 0.001). Children living in households with 5 - 7 members were associated with an 87% higher prevalence of ITN non-utilization compared with those in households with 1 - 4 members (aPR = 1.87, 95% CI: 1.476 - 2.358, p < 0.001).Conclusion The findings suggest that ITN utilization among children is influenced not only by household access to nets but also by household composition and dynamics that shape the allocation and use of available preventive resources.

Background: Postpartum anemia (PPA) is defined as a hemoglobin concentration below 11 g/dL within the first week following delivery, or below 12 g/dL at eight weeks postpartum. It constitutes a major yet under-addressed public health burden in sub-Saharan Africa, contributing substantially to maternal morbidity and mortality. In Ethiopia, anemia prevalence among women of reproductive age has been increasing despite national nutrition strategies, yet aggregated, nationally representative data on PPA remain scarce. This systematic review and meta-analysis aimed to estimate the pooled prevalence of anemia among postpartum mothers attending public health facilities in Ethiopia and to identify significantly associated factors. Methods: A comprehensive literature search was conducted across PubMed/MEDLINE, Cochrane Library, Google Scholar, African Journals Online (AJOL), and HINARI from inception to December 2024. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines were followed. Observational studies (cross-sectional, cohort) conducted in public health facilities in Ethiopia, reporting hemoglobin-confirmed PPA prevalence and/or associated factors, were included. Two reviewers independently performed study selection, data extraction, and quality assessment using a modified Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies. Heterogeneity was quantified using the Cochran Q statistic and I-squared index. Pooled prevalence estimates and odds ratios were computed using a random-effects (DerSimonian-Laird) model with 95% confidence intervals. Subgroup analyses were performed by geographic region (Eastern vs. Western/Central Ethiopia), study period, and facility type. Publication bias was assessed via Egger weighted regression test and funnel plot asymmetry. Results: Six primary studies, encompassing 2,819 postpartum mothers, fulfilled the eligibility criteria and were included in the meta-analysis. The pooled prevalence of anemia among postpartum mothers in Ethiopian public health facilities was 35.4% (95% CI: 27.6-43.6%; I2 = 89.2%), classified as a severe public health problem per WHO thresholds. Subgroup analysis revealed higher prevalence in Eastern Ethiopia (Dire Dawa and Harari regions: 27.5%) compared to Western/Central Ethiopia (Gondar and Debre Markos: 24.3-47.1%), though marked heterogeneity was observed. Factors significantly associated with higher odds of PPA included: fewer than four antenatal care (ANC) visits (pooled OR = 2.72; 95% CI: 2.14-3.30), history of postpartum hemorrhage (OR = 2.49; 95% CI: 1.08-3.98), cesarean section delivery (OR = 4.04; 95% CI: 3.43-4.67), instrumental delivery forceps/vacuum (OR = 3.96; 95% CI: 2.99-4.95), poor adherence to iron and folic acid (IFA) supplementation (OR = 2.80; 95% CI: 2.31-3.30), low pre-delivery hemoglobin < 11 g/dL (OR = 4.20; 95% CI: 1.77-6.67), low dietary diversity (OR = 4.20; 95% CI: 1.77-6.67), and lack of formal education (OR = 3.50; 95% CI: 2.64-4.41). Conclusions: Nearly one in three postpartum mothers attending public health facilities in Ethiopia is anemic, constituting a severe public health emergency. The burden is driven by modifiable clinical and behavioral factors particularly inadequate ANC utilization, poor IFA adherence, hemorrhagic complications, and nutritional deficiencies as well as structural determinants including low educational attainment. Evidence-based, multi-sectoral interventions are urgently needed, including strengthening ANC quality and coverage, universal IFA supplementation monitoring, active postpartum hemorrhage management, and targeted nutritional counseling. Policy frameworks must address regional disparities and integrate anemia screening into routine postpartum care protocols.

Introduction Neonatal mortality remains disproportionately high in sub-Saharan Africa, where an estimated 27 neonatal deaths per 1,000 live births occur annually. Infections, including sepsis and meningitis, account for a substantial proportion of these deaths, while neural tube defects (NTDs) contribute significantly to both neonatal mortality and long-term disability. Existing surveillance systems in the region are predominantly facility-based, missing the substantial proportion of births and deaths that occur in the community. Population-based surveillance platforms that capture community-level data are urgently needed to generate accurate incidence estimates, identify modifiable risk factors, and guide evidence-based interventions. Cohort Description The Consortium to Reduce Infant Mortality (CONRIM) is a multi-institutional partnership among Ugandan physicians and scientists, Yale University, Penn State University, Boston Children's Hospital/Harvard Medical School, and Uganda's National Planning Authority. CONRIM conducts prospective, community-based neonatal surveillance within the Busoga Kingdom in eastern Uganda. A network of 813 trained Village Health Team members conducts household-level visits using a structured Open Data Kit (ODK)-based mobile questionnaire to capture every birth, assess for danger signs of possible serious bacterial infection (pSBI), screen for NTDs, and record maternal nutrition and folic acid use, water, sanitation and hygiene (WASH) conditions, and health care utilization. Findings to Date Since surveillance began in June 2025, the platform has registered approximately 22,200 household submissions and over 5,700 newborn encounters across the Jinja District (population 660,000). Early data have identified higher than expected rates of infants with NTDs including encephalocele and spina bifida; documented folic acid non-use in before and during most pregnancies; characterized WASH conditions in birthplaces; and mapped geospatial hotspots of neonatal infection risk in northeastern rural subcounties. Prospective 28-day follow-up of all live births has demonstrated a neonatal mortality rate of 21.5 per 1000 live births. A real-time data quality monitoring system with 21 automated quality control flags maintains a 99% clean-record rate. Future Plans Ongoing and planned activities include laboratory-based confirmation of neonatal sepsis via blood culture and cerebrospinal fluid analysis with polymerase chain reaction capacity, portable neuroimaging for NTDs, environmental sampling, genomic studies of folate metabolism pathway genes, linkage with facility-based records at Jinja Regional Referral Hospital and Mulago National Referral Hospital, and community-level interventions informed by surveillance findings.

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.

Introduction: Despite major progress in antiretroviral therapy (ART) scale-up, viral suppression (VS) among children living with Human Immunodeficiency Virus (HIV) remains below global targets in Mozambique. Evidence on determinants of virological non-suppression (VNS) in decentralized rural settings is still limited. Objective: This study aimed to analyse factors associated with VNS among children receiving ART in Chokwe District, Gaza Province, Mozambique. Methods: We conducted a retrospective cohort study including children younger than 15 years who initiated ART between 2022 and 2024 in 27 health facilities in Chokwe District. Sociodemographic, clinical, laboratory, and health care data were extracted from paper medical records and electronic databases. VNS was defined as viral load (VL) [&ge;]1,000 copies/mL of blood after at least 6 months of ART initiation. Kaplan-Meier methods and Cox proportional hazards regression models, adjusted for key sociodemographic, clinical, and health care characteristics, were used to identify factors associated with time to VNS. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were estimated.We conducted statistical analyses using the STATA 15 and R 4.5.1 software packages. Results: A total of 285 children were included. At 6 months after ART initiation, 28.2% of children presented VNS, while 23.3% presented VNS at 18 months. In the adjusted analysis for the first 6 months of follow-up each additional year of age at ART initiation was associated with lower risk of VNS, whereas not initiating treatment on the same day of diagnosis increased the risk of VNS. At 18 months of follow-up, age at ART initiation showed evidence of a non-linear association with VNS. Tuberculosis co-infection and undernutrition at 6 months were also associated with a higher risk of VNS. Conclusion: VNS remains frequent among children receiving ART in Chokwe District. Younger age during early follow-up, delayed ART initiation, tuberculosis co-infection, and undernutrition were important determinants of poor virological outcomes. Strengthening early HIV diagnosis, timely ART initiation, integrated management of TB and undernutrition, and age-responsive follow-up strategies may improve long-term virological outcomes among children living with HIV in resource-limited settings.

Use of zooprophylaxis as a malaria control strategy has been recommended historically, but a complex relationship exists between animal ownership and malaria infection, with mixed associations described in the literature. We sought to characterize this relationship spatially and temporally in malaria-endemic regions of Africa. We used data from 392,843 individuals from 66 Demographic and Health surveys from countries within Africa to investigate the association between household animal ownership and Plasmodium infection. We used Bayesian models with Integrated Nested Laplace Approximation to incorporate spatially varying coefficient processes, allowing the association of interest to vary over space, time, and within strata of vector species occurrence, land cover, and number of animals owned by households. Spatially varying intercept models showed that ownership of cattle, chickens/poultry, goats, horses/donkeys/mules, pigs, and sheep was broadly associated with malaria infection, with odds ratios ranging from 1.55 to 1.67. However, spatially varying slope models revealed considerable heterogeneity, with odds ratio estimates for all animal types demonstrating both protective and harmful effects varying from 0.33 to 3.33 both subnationally and across time. We found no evidence that modification by vector species, number of animals owned, and land cover fully explained the variation in estimates. Unobserved localized cultural, behavioral, or ecological factors likely modify the association between animal ownership and malaria prevalence. Further exploring the nature of this relationship over space and time will be important to understanding how context-specific One Health dynamics between humans, animals and the environment affect malaria prevention and control efforts.

Reducing inequality in health-service coverage is central to universal health coverage, but the evidence base on how to design successful equity-oriented policies is inadequate to inform decision makers and tends to rely on case studies. Further, conventional measures of inequality capture a single timepoint, one service at a time; this obscures how inequity evolves as coverage increases. We reframe equity as a trajectory and ask how it evolves as total coverage rises, comparing systematically across countries and health areas. Using 132 Demographic and Health Surveys from 22 low- and middle-income countries (1990-2023), we estimated coverage at the subnational (admin1) level by wealth quintile for six representative maternal and child health indicators. For each country-indicator pair, we fit a natural cubic spline of the wealthiest-poorest gap against total regional coverage, extracted features describing each curve, and grouped them using hierarchical clustering. This yielded three archetypes: large rollout gaps (mean peak ~58%), modest but persistent inequality (~30%), and minimal inequality that sometimes reversed to favor the poor (~17%). Most trajectories traced an inverted U pattern, widening early, then closing only near 100% regional coverage. How a service is delivered, more than where, drove its path: institutional delivery was the most inequitable (15 of 20 countries with large gaps), whereas one-touch and campaign-delivered services such as bed nets and vaccines rarely produced large gaps and were sometimes pro-poor. Despite this, some countries achieved equity across nearly all services, indicating that proactive governance may be able to overcome structural challenges to achieve equitable outcomes. For policy, these archetypes let programs anticipate which groups will be left behind and when, replace assumed scenarios with empirical ones in impact models, and target investment early to ensure that new services achieve more equitable coverage.

Background Timely access to essential health technologies depends on aligning evidence-informed adoption with financing, procurement, delivery, monitoring, and learning. We examined how decision pathways shaped selected health technologies progression from prioritisation to implementation in South African public sector, and their implications for access, equity, sustainability, and learning. Methods We conducted a qualitative, retrospective, multi-case health policy analysis of twenty essential health technologies purposively selected to capture variation in technology type, disease area, delivery platform, adoption trajectory, and implementation outcome. Document review, process mapping, and key informant interviews were used to reconstruct decision pathways. Analysis was guided by the Policy Cycle Framework, Health Policy Triangle, and Health Technology Assessment (HTA) process domains. Results Decision pathways varied by technology and delivery platform but followed a common sequence from prioritisation and appraisal to policy endorsement, implementation, and limited reassessment. Medicines and vaccines were generally embedded within established national decision structures. Diagnostics required coordination across laboratory, programme, procurement, and service-delivery systems, while medical-device decisions were more decentralised. Upstream appraisal focused on safety, effectiveness, and public health needs; affordability, infrastructure, equity and sustainability were addressed inconsistently. System learning was evident when routine data, pharmacovigilance, programme review, and guideline revision informed post-adoption adaptation. Weak feedback loops limited reassessment of implementation barriers, equity effects, and sustainability, contributing to delays despite policy endorsement. Conclusion South Africa has formal structures for evidence-informed technology adoption. HTA would be strengthened by treating appraisal as part of lifecycle governance, with earlier alignment between adoption decisions, financing, procurement, implementation readiness, monitoring, and reassessment.

Background The COVID-19 pandemic was associated with reported disruptions to healthcare delivery and malaria control activities in remote, malaria-endemic indigenous communities with limited access to healthcare. Remote indigenous communities in the Peruvian Amazon may have been especially vulnerable due to interruptions in malaria surveillance, diagnosis, and treatment. We investigated the impact of the COVID-19 pandemic on malaria burden, healthcare access, and community perceptions in hard-to-reach indigenous communities in the Amazonas region of Peru. In malaria-endemic regions, these lessons are particularly important because future health emergencies may similarly affect surveillance, diagnosis, prevention, and treatment activities, potentially reversing gains achieved through malaria control programs. Methods A convergent parallel mixed-methods study was conducted in 2021 and 2022 across four indigenous communities in the Rio Santiago district, Amazonas region, Peru. Quantitative data were collected through cross-sectional malaria surveys, and qualitative data were obtained through semi-structured interviews with inhabitants, community health workers, and local health personnel. Malaria infections were detected by microscopy and confirmed by PCR. Factors associated with the occurrence of malaria infection were studied based on a generalized estimating equation (GEE) approach applied to clustered binary outcome data and accounting for repeated observations within participants across study years. Qualitative data were analyzed thematically, and both components were integrated using the Pillar Integration Process framework. Results A total of 514 participants were included. PCR-based malaria prevalence was 17.6% in 2021 and 26.09% in 2022. P. falciparum prevalence was particularly high in the Alianza Progreso community (2021: 24.19%, 2022: 16.16%) compared to the other studied communities. Previous malaria infection and chills were associated with PCR-confirmed malaria infection. Qualitative findings indicated that COVID-19-related disruptions affected malaria control activities by interrupting diagnosis and treatment availability, reducing community follow-up, and prioritizing COVID-19 response activities over malaria control. Participants also described fear of COVID-19, temporary migration to farm areas, and reliance on herbal medicine during the pandemic. Conclusions The COVID-19 pandemic may have contributed to exacerbated pre-existing challenges to malaria control in remote indigenous communities in the Peruvian Amazon. Strengthening malaria surveillance, ensuring continuity of diagnosis and treatment, and improving healthcare access in geographically isolated communities will be critical to supporting malaria elimination efforts in Peru.

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.

Background: Non-invasive hemoglobin measurement offers a painless and rapid alternative to conventional blood-based testing. The Vivaray Hb pro is a handheld photoplethysmography-based device designed for point-of-care hemoglobin assessment without blood sampling. We evaluated the clinical performance of the Vivaray Hb pro by comparing device-generated hemoglobin values with those obtained from a calibrated laboratory blood cell counter. Methods: In this cross-sectional, non-randomized clinical performance study, participants aged [&ge;]8 years were prospectively recruited. Hemoglobin was measured non-invasively using the Vivaray Hb pro and compared with venous blood samples analyzed on a calibrated Coulter counter. Agreement between methods was assessed using Bland-Altman analysis, including regression-based evaluation for proportional bias. Mean absolute error (MAE) and proportions of measurements within tolerance limits were also calculated. Complete paired measurements were available for 763 individuals. Results: Bland-Altman analysis demonstrated hemoglobin-dependent bias, with overestimation at lower hemoglobin levels and underestimation at higher levels. Regression-based analysis showed proportional bias ({beta}? = -0.178), indicating decreasing difference with increasing hemoglobin concentration. The MAE was 1.5 g/dL but was lower (1.2) in the clinically predominant ranges of 8.1-13 g/dl. Comment: The results support the use of the Vivaray Hb pro as a noninvasive hemoglobin screening and point-of-care assessment tool, particularly in settings where rapid, painless, and repeatable measurements are desirable.

This study focuses on the relationship between access to Advanced Neonatal Care (ANC) and fertility across the regions in Ghana between 1988 and 2022. It builds on previous studies focused on inequity in maternal health across subnational levels and incorporates spatial analytics, machine learning, and a welfare-adjusted fertility care metric. Nine waves of the Ghana Demographic and Health Survey (DHS) were analyzed, with 94 region-by-year units across 8 to 16 regions in each survey wave in the 16 Ghana administrative regions. Skilled ANC along with the Total Fertility Rate (TFR) and demographic control variables were extracted for the analysis. The methodologies employed include decomposition of the Gini coefficient of inequality, bivariate z-score risk stratification, Random Forest (RF), and Decision Tree (DT) regression, partial dependence, Local Indicators of Spatial Association (LISA), global Moran's I with permutation inference and a novel Care Efficiency Index (CEI = ANC% / TFR). Care for the outcomes employed region aggregations along with district boundary geometries for the display of the choropleth maps. National skilled ANC coverage increased from 83.1% (1988) to 97.7% (2022), with inter-regional Gini declining 87.9% (0.070 to 0.008). The North-South gap narrowed from 32.4 to 0.9 percentage points. Northern region showed the greatest absolute gain (+43.0pp). Machine learning identified an exploratory RF partial-dependence inflection near TFR=5.90, above which predicted ANC coverage declined in the historical data. Survey year was the dominant RF predictor (43.7%), followed by TFR (38.8%). TFR spatial clustering intensified by 2022 (Moran's I=0.606, p=0.001). Greater Accra led the Care Efficiency Index (CEI=31.9); Northern Belt regions lagged (CEI=14.5-16.5). Risk stratification classified 23 observations as Critical (Low ANC/High TFR), predominantly from Northern Belt regions in earlier survey waves. ANC coverage converged substantially, yet fertility-related spatial inequities persisted, especially in the Northern Belt. The Care Efficiency Index and exploratory TFR inflection provide hypothesis-generating tools for targeting health-system investment. They should not be interpreted as causal thresholds.

Background: Human mobility is increasingly recognized as a key factor influencing malaria transmission dynamics, particularly in low-transmission settings approaching elimination. This study aimed to assess mobility patterns and their association with malaria risk in two hypoendemic communities in the Peruvian Amazon. Method: A longitudinal study was conducted in the communities of Libertad and Urcomirano (Mazan River basin). Monthly population screenings were combined with weekly active and passive case detection. A total of 678 individuals were enrolled. Mobility patterns were assessed through structured questionnaires, and social network analysis was used to characterize travel connections. Log-binomial regression analysis was applied to identify risk factors associated with malaria infection. Result: Internally, mobile individuals in Libertad showed a higher malaria incidence (>32.47 cases per 1,000 person-months) than those in Urcomirano (<10.15 cases per 1,000 person-months). Travel networks were mainly connected to Mazan district and Iquitos city, followed by local streams such as Armas and Arahuana. Mobility was primarily driven by family, administrative and occupational activities. Male sex (PR = 2.15, 95% CI: 1.37 - 3.37) and age [&ge;]15 years (PR = 1.98, 95% CI: 1.24 - 3.19) were significantly associated with malaria infection (p-value < 0.05). Conclusion: Internally mobile populations represent a key high-risk group sustaining malaria transmission in hypoendemic settings. Targeted interventions focusing on mobile individuals should be integrated into malaria elimination strategies in the Peruvian Amazon and similar endemic regions.

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.