Tropical Medicine and Infectious Disease

Crimean-Congo haemorrhagic fever virus (CCHFV) causes a viral zoonotic disease transmitted through tick bites and direct contact with infected blood or tissue of infected animals. Socio-ecological and behavioural risk factors for CCHFV exposure in Uganda remain poorly understood, which can lead to the omission of key risk factors in quantitative survey design and limit our wider understanding. In this study, we explored human-animal-tick interaction transmission risks in Uganda. We conducted 24 focus group discussions (FGDs) and 31 key-informant interviews (KIIs) across six environmentally and socio-ecologically diverse districts, between October 2023 and March 2024. Study sites were selected using K-prototype analysis, which combined environmental and socio-ecological variables to identify distinct clusters within Uganda. FGDs were conducted separately with groups of community leaders, men, women and teenagers with stratified purposive sampling. Medical doctors, veterinarians, traditional healers, district surveillance officers, and herdsmen were individually interviewed as key informants and purposively sampled. Data were transcribed and translated into English, and analysed thematically using iterative categorisation in NVivo 14. Most participants reported tick bites, some as frequently as every day. Close contact with animals was common, including sleeping next to them in the same building, largely due to concerns about animal theft. Less frequent but notable practices included slaughtering animals for consumption or sacrifice and interactions with wild animals during hunting. Slaughtering and butchering an animal which was sick or had died was reportedly performed by participants in most districts. Plucking and roasting engorged ticks was a practice described in the Kaabong and Arua districts of Northern Uganda. These practices and behaviours highlight potential key risks of CCHFV transmission and underscore the need for future studies to address specific behaviours, to quantify if, and to what extent, they present an exposure risk. Further work should include underlying reasons for the behaviours, which would help ensure that culturally appropriate interventions are targeted.

Abstract Introduction Onchocerciasis is targeted for elimination with community-directed treatment with ivermectin (CDTI). Alternative strategies are needed in areas where transmission persists despite long-term CDTI and/or are co-endemic with loiasis. This study assessed the efficacy of 35-day treatment with 100mg doxycycline on Wolbachia density at 6 months and microfilaridermia and palpable nodules at 30 months post-treatment. Methods A treatment follow-up study was conducted in 20 high-transmission onchocerciasis communities in a co-endemic loiasis area of South-West Cameroon. Community-based directly observed treatment with 100mg doxycycline was administered to community members aged [≥]9 years. Wolbachia clearance at 6-months and treatment efficacy on microfilaridermia and palpable nodules were assessed at 30-months post treatment. Factors associated with reductions in microfilaridermia post treatment, including adherence to doxycycline treatment were assessed with mixed-effects logistic regression. Results Over 92% (2835/3080) of eligible participants took 35 days of 100mg doxycycline over 5 or 6 weeks. This regimen achieved a 62.8% microfilaridermia reduction and 99% palpable nodule reduction in the 720 participants included at follow-up. Wolbachia depletion was observed in 92% of skin samples at 6 months post treatment. The most important factor associated with microfilaridermia after 30 months was having missed at least 7 doxycycline consecutive doses (OR 3.11, 95%CI: 1.17-8.26). Incomplete treatment to a lesser extent was not associated with reduced efficacy at follow-up. Conclusion This large-scale community intervention shows that a 5-week treatment with 100mg doxycycline is feasible and has high curative efficacy against adult O. volvulus as measured by the dramatic reduction in the proportion of palpable nodules at 30-months post treatment. The high efficacy shows the tremendous potential of anti-Wolbachia drugs as part of the arsenal for onchocerciasis elimination and paves the way for the next generation of anti-Wolbachia drugs with shorter treatment courses, which will facilitate the implementation of alternative strategies to accelerate onchocerciasis elimination.

Introduction: Hantavirus disease is an emerging and potentially severe zoonosis of global distribution. In Uruguay, it is transmitted by rodents inhabiting peridomestic, suburban, and rural areas. Global incidence is estimated at 150,000 to 200,000 cases per year, with up to 300 annual cases in the Americas. Since 1997, Uruguay's Ministry of Public Health (MPH) has monitored Hantavirus cardiopulmonary syndrome (HCPS), the most common clinical presentation in the region. By 2019, a total of 271 cases had been identified in the country, with an estimated mortality rate of nearly 50%. Objectives: To describe the clinical, epidemiological, and occupational characteristics of patients with Hantavirus disease in Uruguay during the pre-pandemic (2018-2019) and pandemic (2020-2021) periods. Methods: A descriptive, cross-sectional, observational study was conducted, including all serologically confirmed cases of Hantavirus infection reported to the MPH between 2018 and 2021. Clinical and demographic data were extracted from the mandatory reporting form for zoonotic diseases. Incidence and case fatality rates were calculated, and factors associated with fatal outcomes were analyzed. Results: A total of 58 confirmed cases were identified between 2018 and 2021. Most patients were male (62%), with a mean age of 36.5 years (SD 16). A decline in incidence was observed during 2020-2021, with no significant change in case fatality. Direct rodent exposure was the most frequently associated risk factor. Montevideo and Canelones were the most affected departments. Renal and pulmonary involvement were significantly associated with mortality. Conclusion: Hantavirus remains a relevant public health concern in Uruguay. Although a decrease in incidence was observed during the COVID-19 pandemic years, case fatality rates remained high. The findings underscore the need for sustained surveillance and early recognition, particularly in urbanizing regions.

Introduction Reducing delays in leprosy case detection is essential for achieving global leprosy targets. Accurate measurement of these delays and their determinants relies largely on patient-reported data, as routine health records are often inadequate. The leprosy case detection delay (CDD) questionnaire, developed under the Post Exposure Prophylaxis for Leprosy (PEP4LEP) project, has been validated in Ethiopia, Mozambique, Tanzania, and Indonesia. However, it has not been adapted or validated for Nigeria or any major Nigerian indigenous language. This study aimed to culturally adapt and validate the CDD questionnaire for Igbo-speaking populations in Nigeria. Methodology/Principal Findings The CDD questionnaire underwent a standardized cross-cultural adaptation process. Content validity was assessed using item- and scale-level content validity indices, while construct validity was evaluated through hypothesis testing. Reproducibility was assessed using test-retest and inter-rater reliability; agreement using the Bland-Altman method and the Wilcoxon Signed-Rank test; reliability using Spearmans rank correlation coefficient and the Intraclass Correlation Coefficient (ICC); and internal consistency using Cronbachs alpha. Data were collected through face-to-face interviews with persons affected by leprosy at two time points separated by at least two weeks. Participants (n=100) had a mean age of 45.1 years (SD=18.7). Mean CDD was 77.2 months at baseline and 77.9 months at retest. The instrument demonstrated excellent content validity (I-CVI/S-CVI: 0.90-1.00), good internal consistency (Cronbachs =0.77), and excellent test-retest reliability (ICC=0.996, 95% CI: 0.994-0.997). Test and retest measurements were highly correlated ({rho}=0.985, p<0.001), with no evidence of systematic change over time (p=0.864). Seventy-two percent of participants reported identical CDD values across assessments. All items from the original English version were retained without modification. Conclusion/Significance The Igbo version of the CDD questionnaire demonstrated good validity and reliability and is suitable for assessing leprosy case detection delay among Igbo-speaking populations in Nigeria

Use of fungal mycelia, which has antiviral properties, constitutes a novel strategy for addressing existing and newly emerging viral diseases. We evaluated safety and feasibility of fungal mycelia (Fomitopsis officinalis and Trametes versicolor, FoTv) for treatment of COVID-19 and assessed its antiviral effects and potential to reduce symptoms. In a randomized, double-blind, placebo-controlled, dual site (UCSD/UCLA medical centers) clinical trial we examined non-hospitalized patients who contracted mild-to-moderate COVID-19 [&le;] 96 hours, and experienced symptom onset [&le;] nine days, before enrollment. FoTv was safe, well-tolerated, and feasible for COVID-19 treatment. Minor differences in biochemical markers were observed between groups (26 FoTv, 24 Placebo). FoTv significantly reduced the number and severity of symptoms, particularly sore throat/cough, and in vitro SARS-CoV-2 (pseudovirus) cellular infection. In conclusion, FoTv was safe and reduced COVID-19 symptoms and cellular viral infection. Future studies should investigate therapeutic benefits of fungal mycelia for SARS-CoV-2 and other viruses. Clinicaltrials.gov registration:NCT04667247.

Introduction: Malaria, primarily transmitted by Anopheles mosquitoes, remains a major public health concern in Maiduguri, Borno State, Nigeria. While conventional control methods (e.g., ITNs) face challenges due to insecticide resistance and accessibility constraints, many communities rely on locally sourced natural products. This study aimed to assess the prevalence, usage patterns, and associated factors of these natural alternatives. Methods: A cross-sectional survey was conducted across three purposefully selected communities in Maiduguri (Mairi, Furi, Lagos Street). A total of 450 household heads were interviewed using a structured questionnaire, collecting data on socio-demographics, specific natural products used, method of application, frequency, and perceived efficacy. Data were analyzed using descriptive statistics and binary logistic regression. Results: Overall usage prevalence of natural products was high at 68.4%. The most common products identified were Neem (Azadirachta indica) extract (45.9%) and burnt Lemon Grass (Cymbopogon citratus) (31.2%). Usage pattern was predominantly indoor fumigation (burning), and over 70% of users prepared the products crudely at home. Logistic regression revealed that rural residence (Odds Ratio (OR): 2.1; p<0.01) and low education level (OR: 1.8; p<0.05) were significant independent predictors of higher natural product reliance. Conclusion: Natural products constitute a widely adopted, community-driven vector control method in Borno State. The high prevalence and association with vulnerable populations suggest an urgent need to standardize the preparation and application of these products for potential integration into regional malaria control programs. Keywords: Anopheles, Adulticides, Borno State, Malaria, Natural Repellents, Vector Control, Usage Pattern.

Purpose: The purpose of this study was to examine the barriers and facilitators experienced by non-U.S. born persons during the diagnosis and treatment of latent tuberculosis infection (LTBI) in primary care settings, including the impact of culturally and linguistically congruent care navigation. Design: 25 interviews with non-U.S. born patients, along with focus groups and surveys with 31 primary care team members and leadership, were conducted. Setting: The study was conducted within a network of Federally Qualified Health Center (FQHC) clinics. Participants: Participants were adult non-U.S. born patients with LTBI and FQHC care team members. A purposefully selected subsample of randomized participants was interviewed. Intervention: Care navigators followed participants randomized to receive care navigation after a positive test for tuberculosis (TB) infection and offered health navigation and education about the importance of TB screening and treatment. Method: Data collection was followed by thematic analysis guided by a critical ideological paradigm. Results: Culturally and linguistically congruent navigation emerged as central to potentially reducing barriers, fostering trust, and improving treatment continuity. Participants without navigation support reported confusion and disengagement from care, while those with culturally aligned navigators described clarity and comfort, with influence overall by intrinsic motivation, relational support, and culturally shaped beliefs about care. Conclusion: Care navigation that includes culturally and linguistically congruent navigators whenever possible may help increase LTBI treatment completion among non-U.S. born populations. Limitations of the study include the potential influence of cultural norms, power dynamics, and selection bias.

Background: Leprosy reactions (LR) are immune-mediated complications associated with disability, emotional distress, and social isolation. We identified a gap in affected-individual-informed interventions that aim to improve the management of LR in healthcare settings. To address this gap, we assessed the acceptability of three peer-support interventions co-created with people affected by LR in Indonesia. Methods: Using an interactive learning and action approach, we co-created peer counselling, telesupport groups, and participatory video interventions which were piloted in an urban hospital and 13 rural community clinics. A mixed-methods design was applied with interviews, focus group discussions, and pre-post assessments involving four participant groups. Data were analyzed thematically using an acceptability framework. Results: One hundred participants were enrolled, and 92 completed the pilot intervention between November 2022 and July 2023. Qualitative findings showed that all interventions were acceptable. Peer counselling provided emotional reassurance through shared experiences and was perceived as trustworthy and supportive. Perceived burdens differed by setting, with time constraints in urban facilities and geographical barriers in rural clinics. Knowledge improved significantly among participants of peer counselling and telesupport groups in rural settings. Telesupport groups facilitated connection, information exchange, and continuity of care. Digital access and literacy limited participation for some, particularly in rural areas. The participatory video was perceived as reassuring and informative. Improvements in knowledge, attitude, practices, and mental well-being domain scores were observed among urban participants, but responses in rural settings showed less change. Participants and co-implementers reported increased self-efficacy, participants confidence to perform required behaviors within peer support interventions, with effects shaped by intervention and setting. Conclusions: The three co-created peer-support interventions were acceptable for individuals with LR in diverse healthcare settings. These outcomes highlight the importance and effectiveness of selective, and context-sensitive implementation of one or more peer-support modalities.

Background: Cervical cancer is the fourth most common cancer in women worldwide and remains a major public health challenge. In Ethiopia, it is the second leading cause of cancer deaths, with around 8,000 new cases and 6,000 deaths each year. Region?specific data on the prevalence and predictors of precancerous lesions remain scarce, yet such information is vital for guiding targeted reproductive health strategies. This study therefore examined the prevalence and predictors of cervical precancerous lesions among women aged 21-60 years undergoing Pap smear screening in public hospitals in Hawassa City, Sidama Region. Methods: An institution-based cross-sectional study was conducted among 241 women attending Pap smear screening at public hospitals in Hawassa City from March to August 2025. Sociodemographic and clinical data were collected via interviews and medical records. Lesions were classified based on the standardized international framework for reporting cervical cytology results from Pap smears per the Bethesda system. Multivariable logistic regression identified predictors p<0.05). Result: Of 241 women screened (mean age 35.3 years), cervical epithelial abnormalities were detected in 52 (prevalence 21.6%). Atypical squamous cells of undetermined significance was the most common abnormality (16.6%). Multivariable analysis showed HIV infection was significantly associated with precancerous lesions (AOR = 3.7, 95% CI: 1.69-8.12, p<0.05), while hormonal contraceptive use was protective (AOR = 0.27, 95% CI: 0.11-0.67, p<0.05). Conclusion: These results underscore the urgent need to strengthen cervical cancer prevention through targeted screening and early intervention. Integrating routine HIV testing with Pap smear programs would be especially valuable. Health authorities should expand accessible screening for women aged 21-60, with particular attention to those living with HIV, to help reduce the burden of precancerous lesions.

Background: Rising antibiotic resistance challenges empirical therapies for urinary tract infections (UTIs). This study evaluated the microbial etiology, susceptibility profiles, and multidrug resistance (MDR) patterns of uropathogens among outpatients at the Berekum Holy Family Hospital, Ghana. Methods: This cross-sectional study (February to August 2021) screened 263 symptomatic outpatients. Mid-stream urine samples underwent quantitative culture, biochemical identification, and antimicrobial susceptibility testing via the Kirby-Bauer disc diffusion method following the 2021 CLSI guidelines. Results: Significant bacteriuria prevalence was 22.8% (60/263). UTIs predominated in females (78.3%, 47/60; p = 0.1501) and individuals [&ge;]45 years (33.3%, 20/60). Gram-negative rods accounted for 90.0% of isolates, primarily Escherichia coli (26.7%), Citrobacter spp. (25.0%), and Enterobacter spp. (21.7%); Staphylococcus aureus (10.0%) was the only Gram-positive pathogen. Extreme phenotypic resistance was observed against piperacillin/tazobactam (98.3%), cefotaxime (93.3%), tetracycline (88.3%), and cefoperazone (85.0%). Conversely, highest therapeutic susceptibilities were retained by amikacin (78.3%), levofloxacin (61.7%), and gentamicin (58.3%). Conclusion: The high prevalence of MDR uropathogens against advanced beta-lactamase inhibitor combinations and cephalosporins necessitates an immediate re-evaluation of regional empirical protocols. Amikacin, levofloxacin, and gentamicin remain viable options prior to culture confirmation. These findings establish a crucial phenotypic baseline to guide localized prescribing policies and regional antimicrobial resistance tracking strategies.

Background Cervical cancer remains a significant global public health challenge, ranking as the fourth most common cancer among women worldwide. According to The World Health Organization (WHO) 604,000 women were diagnosed with cervical cancer globally in 2020, with over 342,000 deaths amongst this group [1]. Despite its high mortality, cervical cancer is largely preventable through early detection and vaccination against human papillomavirus (HPV), which causes nearly all cases of cervical cancer [1,2] In Nigeria, it is the second most common cancer among women in Nigeria and a leading cause of cancer-related deaths, with low screening rates exacerbating late diagnoses and poor outcomes [1]. Despite global commitments to elimination with Pap smear screening and HPV vaccination, less than 10% of women in Nigeria have undergone screening due to misconceptions, stigma, and limited awareness. Educational interventions may improve awareness and promote screening behaviors. This global health quality improvement (QI) project aimed to enhance cervical cancer awareness and increase Pap smear uptake at the Central Bank of Nigeria (CBN) Clinic in Abuja, Nigeria. Methods In November 2024, we conducted a health education intervention at the Central Bank of Nigeria (CBN) through a structured educational session for male and female CBN staff members. The session focused on cervical cancer prevention, risk factors, and screening guidelines. Additionally, cervical cancer awareness was raised via email, social media, and electronic bulletin board. Participants completed pre and post-interventions surveys assessing cervical cancer knowledge across 10 key items and demographic characteristics. Pap smear uptake was assessed using the CBN clinic records for three months before and after the intervention. Institutional approval was obtained from CBN and external institutional review board approval was not required. Results 188 participants attended the health education session with 124 survey responses (70 pre-event, 54 post-event). Participants were mostly women aged 30-39. Post-intervention, eight of ten survey questions showed improved knowledge, with five demonstrating statistically significant gains: understanding Pap smear frequency (p<.001), HPV infection prevention (p=.042), early symptoms of cervical cancer (p=.019), smoking as a risk factor (p=.002), and availability of Pap smears at the CBN clinic (p=.035). Pap smear uptake increased from 5 screenings in three months pre-intervention to 32 screenings in the three months post-intervention. Participants reported that the sessions provided a safe space to ask questions and address cultural myths and misconceptions. Conclusion This QI initiative demonstrates the positive impact of targeted health education in improving awareness and screening uptake. Recommendations include increasing awareness through public health talks, updating clinicians on current guidelines, and removing unnecessary barriers to HPV vaccination. These findings align with global health efforts to reduce cervical cancer mortality and underscore the potential of QI projects to improve health outcomes in resource-limited settings.

Background Despite existing road safety regulations, commercial motorcycle riders commonly referred to as "Boda Bodas" in Uganda continue to experience high rates of injuries due to road traffic accidents resulting from unsafe riding behaviours, contributing significantly to morbidity and mortality among both riders and passengers. Safe riding behaviours are less well documented, as well as factors associated with the observance of those behaviours. This study aimed to determine factors associated with safe riding behaviors for both boda-boda riders and their passengers in Kampala Central Division. Methods A cross-sectional survey study design was conducted using a convergent parallel mixed-methods design guided by the PRECEDE model. Quantitative data were collected from 424 riders through structured questionnaires administered by trained research assistants. Binary Logistic regression was used to determine the independent predictors of safe road riding behaviors, and Adjusted Odds ratios (AORs) have been reported. Data were analyzed using descriptive and inferential statistics, with a p-value <0.05 considered statistically significant. Qualitative data were collected simultaneously with quantitative data through in-depth semi-structured interviews with 10 passengers to capture perceptions of rider behaviors and safety practices. Thematic analysis was applied, and results were triangulated to highlight convergences and divergences between quantitative and qualitative findings, providing a comprehensive understanding of safety determinants for both riders and passengers. Results Of the 424 riders (mean rider age was 29.56 {+/-} 5.71), overall, 276 (65.1%) of riders exhibited unsafe riding behaviors. In the bivariate analysis with Logistic regression, predisposing factors (education, marital status, religion, and willingness to obey traffic regulations), and reinforcing factors (family encouragement) were significantly associated with safe riding behaviors. However, in the adjusted model, secondary (AOR=0.50; 95% CI:0.30-0.85) and post-secondary education (AOR=0.57; 95% CI:0.33-0.98), being married (AOR=0.56; 95% CI:0.34-0.91), Christian religion (AOR=2.98; 95% CI:1.63-5.47), willingness to obey traffic regulations (AOR=0.41; 95% CI:0.24-0.70), union advocacy (AOR=1.76; 95% CI:1.03-3.01), and well-maintained roads (AOR=1.65; 95% CI:1.07-2.55) were significant predictors of safe riding behaviors. Qualitative interviews further highlighted barriers to safety, including a lack of helmets, over-speeding, disregard for traffic regulations, and poor road infrastructure. Conclusions Rider and passenger safety is still low, interdependent, and influenced by multiple factors. Integrated interventions focusing on education, stronger families, religious affiliations, union safety advocacy, and stricter enforcement of traffic regulations are vital for enhancing safety for both riders and passengers.

Abstract Background Malaria remains a major public health challenge in Ghana, despite recent reductions in cases due to various interventions. The endemicity of the disease varies across regions, influenced by diverse seasonal and temporal factors that support mosquito proliferation and malaria cases. This study used a Generalised Additive Models to explore the impact of weather conditions on malaria cases in Ghana. Methods Generalised Additive Models were used to examine the nonlinear effects of weather conditions on malaria cases. Monthly aggregated malaria cases from the District Health Information Management System II and average monthly rainfall and temperature data from the Ghana Meteorological Agency were analysed, covering 2012 to 2023. Regional Generalised Additive Models incorporating weather variables were developed, fitted, and validated against observed data using model diagnostics to identify the most suitable model for each region. Results The analysis revealed complex temporal patterns in malaria cases across Ghana, influenced by seasonal and long-term trends. Regions constituting the Coastal and Transitional Forest zones exhibited bimodal peak malaria seasons, while the Guinea Savannah showed a unimodal peak. Significant interactions between rainfall and temperature were identified, particularly in the Eastern region, where higher rainfall combined with temperatures around 27-28 {degrees}C were associated with higher malaria cases, reflecting the complex and region-specific nature of meteorological influences. Conclusions The findings point to the dynamic and heterogeneous nature of malaria caseloads in Ghana, emphasising the need for region-specific control strategies tailored to local climatic conditions. A key recommendation is the systematic integration of meteorological data into the National Malaria Data Repository to enable continuous monitoring of climatic influences and support timely, evidence-based intervention decisions. Future research should incorporate socio-economic factors, intervention coverage data, vector surveillance, and demographic characteristics into mathematical modelling frameworks for a more comprehensive understanding of malaria cases in Ghana.

Abstract Background Evaluating antenatal care (ANC) quality is critical to reducing maternal and neonatal mortality. In Zambia, despite high basic ANC attendance, comprehensive national evidence on the clinical content and quality of services remains limited. This study assessed the coverage of WHO-recommended ANC interventions and identified factors associated with care quality using the latest national data. Methods A cross-sectional analysis was conducted using data from the 2024 Zambia Demographic and Health Survey. The final analytic sample comprised 4,829 women aged 15-49 with a live birth in the preceding 5 years. A composite index of 15 selected, equally weighted WHO-recommended components evaluated clinical assessment, counseling/screening, preventive interventions, and utilization. Survey-weighted Poisson regression estimated adjusted incidence rate ratios (aIRRs) for the count of ANC components received. Results The mean ANC quality score was 12.5 out of 15 (95% CI: 12.4-12.6), and 78.5% (95% CI: 77.0-80.0) of women achieved adequate ANC ([&ge;] 12/15 components). While individual clinical and counseling coverage generally exceeded 90%, only 47.2% (95% CI: 45.3-49.0) of women initiated care during the first trimester, and just 4.8% (95% CI: 4.1-5.6) achieved [&ge;] 8 ANC contacts. Maternal education was the strongest and most stable predictor of quality across all models. Compared to no education, higher education was associated with an 8.0% higher expected quality score (aIRR = 1.080, 95% CI: 1.051-1.110). Lower ANC quality was significantly associated with unwanted pregnancies (aIRR = 0.970, 95% CI: 0.956-0.993) and with residence in Western (aIRR = 0.923, 95% CI: 0.897-0.951) and North Western (aIRR = 0.966, 95% CI: 0.937-0.996) provinces. Absence of distance barriers and residence in Eastern, Luapula, and Copperbelt provinces were associated with higher quality scores. Conclusion While average ANC component coverage in Zambia is high, critical gaps persist in early initiation and total contact frequency. Care adequacy is strongly influenced by maternal education, relationship status, pregnancy intention, and regional inequities. These findings underscore the need for interventions targeted at uneducated women, preventing unintended pregnancies, and underserved regions such as Western and North Western Provinces. Keywords: Antenatal care quality, ANC content, Zambia, maternal education.

Summary Background Persistent transmission from relapsing Plasmodium vivax infections threatens malaria elimination programs in the Asia-Pacific and Americas. Tools to identify people at risk of relapse are urgently required. We aimed to validate a panel of eight P. vivax serological biomarkers for predicting future relapses. Methods In this observational study, soldiers returning from malaria-endemic Papua to non-endemic East Java, Indonesia, were screened at enrolment using antibody measurement (Luminex) and trained random forest classification algorithms, then followed for 6 months. Active case detection was performed fortnightly by microscopy. Algorithms classified soldiers as recently infected (last nine months) and thus at risk of relapse, based on anti-vivax antibody measurements at enrolment. Findings Between December 2018 and July 2022, 592 soldiers were enrolled, with 553 completing follow-up; 119 experienced a P. vivax relapse. Of these, 102 were correctly classified as at risk of relapse at enrolment, corresponding to 86% sensitivity and 86% specificity, with an AUC of 0.92. Interpretation P. vivax serological biomarkers can identify people at risk of relapse with high sensitivity and specificity and could be used as a novel public health intervention, P. vivax serological testing and treatment (PvSeroTAT), to reduce relapse-driven transmission.

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.

Introduction: Differentiated service delivery (DSD) models aim to reduce time healthcare providers spend with DSD clients, increasing time available for non-DSD clients. We measured nurses' time allocation and explored their experiences with DSD models in South Africa. Methods: We conducted time and motion observations and surveyed nurses at 24 public primary healthcare facilities across two SENTINEL study rounds (09/2022-07/2023 and 11/2023-07/2024). We report median time nurses spent by activity, model of care, and interaction type. Log binomial regression investigated factors associated with high direct nurse-client interaction (above median minutes) and extended work-days ([&ge;]9 hours), and estimated adjusted risk ratios (aRR). Survey questions were related to client care, additional time availability, and policy changes post DSD implementation, with key themes presented alongside illustrative quotes. Results: 176 nurses (88% female, median age 44) were observed for 344 working days; of these, 60 (34%) participated in the provider survey. Nurses spent a median of 293 minutes (53% of their work-day) on direct nurse-client interaction, 89 minutes (22%) on client-support or facility-related tasks, and the remainder on other activities including personal breaks. Time spent per client was similar across conventional care clients (11 [IQR: 8-15] minutes) but ranged between 9 (7-13) to 11 (8-15) minutes for DSD clients; number of direct nurse-client interactions did not differ meaningfully. Nurses at facilities with 2,000-3,999 total remaining on ART (TROA) (aRR 1.56, 95% CI: 1.02-2.37) and in urban areas (aRR 1.43, [1.08-1.89]) had more direct nurse-client interactions than those at facilities with <1,999 TROA and in rural areas, respectively. Nurses at facilities with 4,000+ TROA (aRR 2.22, [1.36-3.63]) and those observed in SENTINEL 3.0 (aRR 1.53, [1.13-2.07]) were more likely to work standard or longer workdays than those at lower TROA facilities (<1,999), those in SENTINEL 2.0 and urban areas. Nurses reported DSD models improved client care (90%), freed up time (60%), and changed clinic procedures and policies (60%). Conclusions: While DSD models did not significantly reduce direct nurse-client interaction time, nurses reported improved client care and gained additional time. DSD impact may vary by facility context. As DSD implementation expands, effective time reallocation may enhance facility performance and provider productivity.

Tobacco control treaties were written for billboards and television, not for the people now selling lifestyles to young Africans. As mobile internet saturates East African cities, social media influencers have become an unmeasured channel, especially when it comes to tobacco promotion. We assessed the prevalence of tobacco use, its association with influencer exposure, and how urban youth interpret that exposure in two capitals with different tobacco laws. We conducted a comparative mixed-methods study among youth aged 18-29 years in Kampala, Uganda, and Nairobi, Kenya (January-August 2025), combining (i) a cross-sectional survey using systematic sampling at youth-dense venues (n=772), (ii) four online focus group discussions (FGDs; n=40), and (iii) content analysis of 30 tobacco-related posts from high-reach influencers (greater than 50,000 followers). We used chi-square tests and multivariable logistic regression, thematic analysis (Braun and Clarke), and descriptive engagement metrics. Ever tobacco use among urban youth in East Africa was 29.3% (226/772), similar in Kampala (30.7%) and Nairobi (28.0%; p=0.409). After adjustment, exposure to influencers promoting tobacco independently predicted ever use (adjusted odds ratio [aOR] 1.90, 95% confidence interval [CI] 1.29-2.82; p=0.001), alongside male sex (aOR 2.35) and age 26-29 years (aOR 1.99). Tertiary education (aOR 0.45) and never seeing tobacco content (aOR 0.26) were protective. Posts framed tobacco as aspirational lifestyle; 77% of sampled comments were positive and 47.5% expressed interest in trying the product. Influencer exposure behaved as a modifiable risk factor of a magnitude comparable to established demographic drivers. Tobacco control in the region must move from print-era advertising bans to platform governance, mandatory disclosure of paid promotion, and youth-led counter-marketing.

Background Artemisinin derivatives are central to first-line treatment of both uncomplicated and severe Plasmodium falciparum malaria. Emerging artemisinin partial resistance in East Africa threatens to spread across the continent. Methods In two cross-sectional studies in Zambia in 2024, we genotyped the artemisinin resistance-associated gene Pfkelch13. In Kaoma, western Zambia, we evaluated the percentage of patients with day-3 parasite positivity following treatment with artemisinin-based combination therapy, and ex vivo parasite susceptibility to dihydroartemisinin (the active metabolite of artemisinin). We also assessed longitudinal changes in Pfkelch13 mutation prevalence in Kaoma using isolates collected from 2018 through 2026. Results We identified a novel mutation, Pfkelch13 A724E, in 52% (113 of 217) of isolates from Western Province, 51% (94 of 184) of isolates from North-Western Province, and 11.7% (229 of 1,949) of isolates country-wide. In Kaoma, 28% (21 of 75) of patients carrying Pfkelch13 A724E mutant parasites before treatment were parasite positive on day 3, compared with 0% (0 of 23) of patients with the wild-type allele (P=0.003). Within day-3 positive patients, the proportion of A724E mutant parasites increased significantly after treatment (P = 0.013). The prevalence of Pfkelch13 A724E in Kaoma increased steadily from 0% (95% confidence interval [CI], 0 to 22%) in 2018 to 79% (95% CI, 73 to 85%) in 2026. Conclusions A novel Pfkelch13 mutation conferring partial resistance to artemisinin is spreading in Zambia. Additional clinical evaluations are urgently needed in the region. (Funded by the Gates Foundation, INV-048316).

Introduction Menopause is a central marker of reproductive ageing, but national evidence on menstrual cessation among Nigerian women in the late reproductive ages remains limited. This study examined the prevalence and socio-demographic correlates of prolonged amenorrhea/possible menopausal transition among Nigerian women aged 30-49 years. Methods The study used the women's individual recode file from the 2024 Nigeria Demographic and Health Survey. The analytic sample was restricted to women aged 30-49 years, excluding women who were currently pregnant, currently or postpartum amenorrheic, and those with invalid or special responses on time since last menstrual period. The final sample comprised 14,223 women. The outcome combined women whose last menstrual period occurred 12 or more months before the survey, and women reported as being in menopause. Weighted descriptive statistics, design-adjusted bivariate tests and survey-weighted binary logistic regression were used. Results The weighted prevalence of prolonged amenorrhea/possible menopausal transition was 7.6%. Prevalence rose from 1.2% among women aged 30-34 years to 23.6% among women aged 45-49 years. In the adjusted model, women aged 35-39 years (OR=1.64; p=0.030), 40-44 years (OR=6.20; p<0.001) and 45-49 years (OR=24.51; p<0.001) had higher odds than women aged 30-34 years. Primary education (OR=1.65; p=0.004), middle wealth status (OR=1.37; p=0.043) and poorest wealth status (OR=1.60; p=0.024) were associated with higher odds. Muslim affiliation (OR=0.72; p=0.024) and traditional contraceptive use (OR=0.24; p<0.001) were associated with lower odds. Conclusion Prolonged amenorrhea/possible menopausal transition among Nigerian women aged 30-49 is strongly age-patterned and socially differentiated. The findings support the need to make midlife menstrual health more visible within reproductive, family planning and primary healthcare services. Because the measure is based on survey-reported menstrual recency, it should not be interpreted as clinically confirmed natural menopause.