Tropical Medicine and Infectious Disease

Background Onchocerciasis (river blindness), caused by the filarial nematode Onchocerca volvulus and transmitted by Simulium blackflies, remains a public health challenge in sub-Saharan Africa. Following the transition from vector control to large-scale ivermectin distribution, microfilariae (mf) prevalence has declined substantially across Ghana. The World Health Organization targets onchocerciasis elimination, defined as sustained mf prevalence below 1%. This requires identifying areas of persistent or resurgent transmission to guide targeted mapping surveys and interventions. Methods A Bayesian spatiotemporal, multilevel, generalized additive model with a zero-inflated beta-binomial outcome was fitted to mf prevalence data from 1353 surveys across 671 villages and environmental and socio-economic predictors. Temporal prevalence trends for ecozones within operational transmission zones (OTZ) were modelled using a 2D spatial smooth to account for residual spatial autocorrelation. Temporal autocorrelation in prevalence was accounted for using a random effect for village nested within ecozone. Results Runoff probability and surface wetness were positively associated with prevalence, consistent with Simulium breeding in fast-flowing water. Despite high initial mf prevalence, by 2015 the median prevalence across all OTZs in Ghana was estimated to be between 0.43 and 1.97%. The probability that prevalence was <1% in 2015 ranged from 0.15 to 0.87. Assuming testing rates and mass drug administration have remained consistent (twice a year and >80% coverage), linear extrapolation predicted that the three OTZs have some probability of exceeding the elimination threshold by 2030, while two were predicted to have near-zero prevalence. The Tano-Ankobra OTZ, which includes both savanna and forest agro-ecological zones, was a persistent hotspot. Conclusions This first comprehensive spatio-temporal analysis of onchocerciasis in Ghana reflects the well-documented challenge of onchocerciasis control in forested riverine environments. Persistent transmission foci in eastern and southern Ghana, particularly in forest zones with sustained vector habitat, warrant targeted investigation and intensified intervention to meet WHO elimination thresholds.

Background On the Zanzibar islands, Tanzania, mass drug administration (MDA) with praziquantel against Schistosoma haematobium infections has been implemented regularly since the early 2000s. Elimination of schistosomiasis as a public health problem has been achieved in most areas, with the goal of interruption of transmission. The RESIST project investigates the extent to which MDA-driven selection for praziquantel resistance is occurring and contributing to persistent transmission hotspots. Methodology As part of RESIST, the efficacy of praziquantel treatment was assessed in two schools on Pemba between October 2024 and March 2025. Longitudinal parasitological surveys were conducted before and two weeks after school-based MDA with praziquantel (40 mg/kg). Up to six urine samples per study participant were collected on different days pre- and post-MDA and examined for S. haematobium eggs by urine filtration microscopy. In a per-protocol analysis, drug efficacy was categorised as adequate, inconclusive, or reduced, based on hypothesis testing. A generalized linear mixed model was used to assess the association between pre-MDA infection intensity and drug efficacy at the individual level. Principal findings Pre-MDA, S. haematobium prevalence was 14.3% (62/434) in School 1 and 37.8% (233/617) in School 2. Post-MDA prevalence was 0.5% (2/434) and 9.6% (59/617), respectively. Egg reduction rates were 99.8% (90% confidence interval (CI): 99.2-100%) in School 1 and 94.8% (90% CI: 88.6-98.6%) in School 2, which were classified as adequate and inconclusive, respectively. In School 2, drug efficacy at the individual level was negatively associated with pre-MDA infection intensity. Conclusion/significance The efficacy of praziquantel on Pemba remains higher than the 90% threshold for optimal drug efficacy set by the World Health Organization. While the inconclusive efficacy results for School 2 can at least partially be explained by the variation in the participants pre-MDA infection intensities, further investigations are warranted to account for the disparity in praziquantel efficacy on Pemba. Trial registration: ISRCTN, ISRCTN59331501. Registered 24 October 2024, https://www.isrctn.com/ISRCTN59331501.

Objective: This study aimed to determine TB incidence, median duration of Isoniazid Preventive Therapy protection (PLHIV), and factors associated with TB among adult People living with HIV (equal or above 15 years) on ART who completed IPT Methodology: This secondary analysis examined adult PLHIV who completed IPT using data from the CTC2 database (Jan 2019 to Dec 2023, mainland Tanzania). Statistical analysis was conducted in STATA 15, with Cox regression used to identify factors associated with tuberculosis diagnosis. Proportional hazard assumptions were tested using Schoenfeld residuals scatter plots. Results: A total of 38,407 adults living with HIV (equal or above 15 years) were included in the analysis. The mean age was 36.7 years, with 63.0% female. The median follow-up time was 17.9 months, during which 901 incident TB cases were identified over 682,252.63 person-months, yielding an incidence rate of 1.40 per 1,000 person-months. The median time to TB development was 10.12 months. Female sex (aHR = 1.23; 95% CI: 0.86,1.75; p = 0.025), being unmarried (aHR = 1.20; 95% CI: 0.71,1.51; p = 0.034), and breastfeeding status (aHR = 1.12; 95% CI:1.02,1.56; p = 0.034) had higher risk of TB. Those aged 25 to 34 years (aHR = 0.55; 95% CI: 0.33,0.89; p = 0.015) and [&ge;]45 years (aHR = 0.56; 95% CI: 0.32,0.95; p = 0.031) had a lower risk of TB. Geographically, those in Eastern (aHR = 0.21; 95% CI: 0.11,0.42; p < 0.001), Western (aHR = 0.37; 95% CI: 0.19,0.73; p = 0.004), and Lake zones (aHR = 0.78; 95% CI: 0.18,0.50; p < 0.001) had lower TB risk compared to the Northern zone. At Health centres (aHR = 0.57; 95% CI: 0.40,0.81; p = 0.002) and hospitals (aHR = 0.20; 95% CI: 0.11,0.39; p = 0.001) had reduced TB risk compared to dispensary Conclusion: Among adults living with HIV on ART who completed IPT in mainland Tanzania, the incidence of TB remained low, confirming the protective benefit of IPT in reducing TB occurrence. Evidence shows IPT protection among PLHIV may last only about 10 months rather than the 18 months stated in the Tanzania HIV treatment guidelines, underscoring the need for earlier and intensified TB screening, revision of IPT guidelines, and consideration of alternative TB preventive therapy regimens.

Introduction: The treatment of multidrug-resistant tuberculosis (MDR-TB) remains challenging due to the toxicity of second-line medications and suboptimal treatment outcomes. This study aimed to determine the incidence of adverse events and identify factors associated with these events in patients undergoing treatment for MDR-TB with second-line all-oral drugs in Ghana. Methods: This retrospective cohort study reviewed the medical records of 384 MDR-TB patients treated with second-line all-oral drugs at selected health facilities in Ghana, including the Greater Accra Regional Hospital, Eastern Regional Hospital, and Kumasi South Hospital. Data were extracted using the Kobo Collect tool, capturing patient demographics, baseline clinical and laboratory characteristics, treatment regimens, and adverse events. The study period spanned from 2020 to August 2024. Results: The study included a total of 384 MDR-TB patients, with a mean age of 45 years (SD = 15). The majority of patients were male (65.78%), and most were within the 45-64 years age group (33.85%), followed by those aged 25-44 years (31.25%). Regionally, the highest number of cases were reported from the Greater Accra Region (39.06%), followed by the Eastern Region (31.25%) and Kumasi South Hospital (29.69%). Approximately one in four patients (25%) presented with comorbidities, with HIV being the most common (19.5%). The most frequently reported adverse events were diarrhea (14%), dizziness (13.7%), and vomiting (12.3%). Most of these were mild to moderate in severity and tended to decrease as treatment progressed. Severe adverse events, such as leukopenia and acute kidney injury, were rare, occurring in less than 5% of patients. Over the course of treatment, gastrointestinal adverse events such as vomiting and nausea showed a significant decline, indicating possible patient adaptation or improved clinical management. Results from the multivariate Poisson regression analysis revealed that age and comorbidities were significant predictors of adverse events. Patients aged 65 years and above had a 56% lower risk of developing adverse events compared to younger patients (Adjusted Risk Ratio [aRR] = 0.44, 95% CI: 0.25-0.79, p = 0.005). Conversely, patients with comorbid conditions such as diabetes or hypertension were approximately 2.6 times more likely to experience adverse events compared to those without comorbidities (aRR = 2.65, 95% CI: 1.58-4.43, p < 0.001). The effect of sex was not statistically significant after adjustment (aRR = 1.03, 95% CI: 0.70-1.50, p = 0.86). At the end of the treatment period, 74.9% of patients achieved successful outcomes, including both those who were cured and those who completed treatment without being classified as cured. However, 25.1% had unsuccessful outcomes, which included treatment failure, relapse, or death. Conclusion: In conclusion, adverse events are common in the treatment of MDR-TB with second-line All-Oral drugs, with gastrointestinal adverse events being the most prevalent. These findings highlight the importance of monitoring and managing adverse events to optimize treatment outcomes for MDR-TB patients in Ghana.

Background. The objective was through an analysis of longitudinal data from the DepIST-H cohort to estimate the incidence, describe the dynamics and factors associated with CT/NG infection in MSM in Togo. Methods. A total of 200 MSM in Lome, Togo, were included in the ANRS I MIE 12400/DepIST-H cohort, half living with HIV. After inclusion in the study, participants received follow-up clinical visits at 6 and 18 months, and laboratory tests were performed at baseline (M0) and at 12 and 24 months (M12 and M24). PCR tests for CT and NG were performed from pharyngeal, anal and urine samples collected using the Xpert(R) CT/GC kit (Sunnyvale, CA, USA). To identify the factors associated with anal bacterial STIs, offset term Poisson regression models were performed. Results. Among 200 MSM (median age 24 years), CT and NG incidence rates were high ({approx}22 cases per 100 person-years), particularly at the anal site. Multiple partners significantly increased anal NG incidence (aIRR 2.35). Anal NG incidence was significantly lower among participants with income-generating activity (aIRR 0.57). Trends suggested higher anal CT and NG incidence in the presence of pharyngeal infection, but associations were not statistically significant Conclusion. This study confirms that MSM remain highly exposed to STIs in Togo and highlights the need to strengthen prevention efforts within this population. Postexposure doxycycline prophylaxis and multisite pooled-sample screening represent promising avenues to strengthen prevention efforts within these populations.

The effectiveness of malaria vector control is increasingly threatened by widespread insecticide resistance, particularly to pyrethroids. In response, the World Health Organization recommends dual-active ingredients (dual-A.I.) insecticide-treated nets (ITNs) in resistant settings. This study evaluated the efficacy of several dual-A.I. ITNs in two experimental hut trial sites an area with high insecticide resistant malaria vectors in Tanzania with differing vector species composition and bionomics. Five ITNs were evaluated: a pyrethroid-only net (MAGNet(R)), three pyrethroid-piperonyl butoxide (PBO) nets (OlysetTM Plus, Veeralin(R), and PermaNet(R) 3.0), one dual-A.I. net (Interceptor(R) G2; chlorfenapyr + alpha-cypermethrin), and an untreated control net. Mosquitoes were collected from huts, morphologically identified, and monitored for mortality up to 72 h. WHO cone and tunnel tests using susceptible An. gambiae s.s. were conducted for quality control, while field-collected mosquitoes were used for bio-efficacy monitoring. Molecular species identification was performed using PCR assays, and genomic DNA was extracted from An. funestus s.l. and An. gambiae s.l. collected from the trials. All ITNs met WHO bio-efficacy criteria in cone and tunnel tests. An. gambiae s.l. predominated in Mwagagala (77%) but was rare in Magu (4%), where An. funestus complex was dominant. In Magu, Interceptor(R) G2 and Veeralin(R) achieved significantly higher mortality than MAGNet(R) at 24 h (53% and 45% vs 24%) and 72 h (61% and 53% vs 24%). In contrast, no significant mortality differences were observed among ITNs in Mwagagala. High resistance intensity was detected in both vector groups (mortality <20% in bioassays). In An. funestus from Magu, the 4.3 kb-SV resistant genotype was fixed, while G454A-CYP9K1 resistance was highly prevalent (RR: 0.70-1.00). Interceptor(R) G2 and Veeralin(R) outperformed the pyrethroid-only reference net against An. funestus complex but not against predominantly An. arabiensis populations.

Background: The World Health Organization proposes that elimination of onchocerciasis transmission (EOT) be verified in 12 endemic countries by 2030. In sub-Saharan Africa (SSA), where most cases occur, Niger is the only country that has been verified to date. Despite decades of ivermectin mass drug administration (MDA), infection persists in West and Central Africa. Alternative treatment strategies (ATS) are necessary to accelerate progress towards EOT by 2030 and beyond. Methods: We used the EPIONCHO-IBM transmission model to project the number of years, from 2026, to reduce microfilarial (mf) prevalence below 1% across 1,634 implementation units (IUs) in 19 SSA countries. We fitted the model to geostatistically-derived mf prevalence in 1975, 2000 and 2018, and projected mf prevalence through to 2025. We classified IUs according to their baseline endemicity, intervention history programmatic performance, and current (2025) MDA frequency (annual or biannual). For those IUs that would not reach < 1% mf prevalence by 2030 if current strategies were continued, we simulated ATS (increasing treatment frequency, improving coverage, and adopting moxidectin MDA) from 2026 to 2040. Results: Of the 1,486 IUs currently under annual ivermectin MDA, 45% would require ATS. In those low-moderate endemicity IUs, biannual ivermectin would have a comparable impact to that of switching to annual moxidectin; in those with high endemicity, adopting biannual moxidectin would be more impactful. Of the 148 IUs currently receiving biannual ivermectin, 24% would benefit from ATS, switching to biannual moxidectin being the best option. Conclusion: This work brings into sharper focus which IU profiles are most likely to require ATS across SSA. In highly-endemic IUs with long intervention histories, biannual moxidectin MDA may be required under our modelling assumptions, with substantial uncertainty surrounding the permanent sterilising effect, of the two drugs under comparison, upon adult female worms. National programmes aiming to reach EOT will have options that need to be balanced against financial considerations. Implementation studies will also be important for translating these modelling projections into national policy decisions, particularly where different intervention strategies generate similar epidemiological benefits. Economic and epidemiological evaluations of repeated moxidectin MDA are needed to inform these decisions.

Introduction Miltefosine is the only approved oral antileishmanial agent, but its use in women of childbearing potential (WOCBP) is restricted due to preclinical teratogenicity. Current labeling recommends contraception during treatment and for at least five months thereafter, based solely on its long terminal elimination half-life. This study re-evaluated the required contraceptive duration using an exposure margin-based approach. Methods Virtual populations were generated from anthropometric data of 382 Indian, 4,462 Eastern African, and 4,019 Brazilian WOCBP with leishmaniasis. Published population pharmacokinetic models were used to simulate miltefosine exposure following 14-42-day regimens for visceral leishmaniasis (VL), post-kala-azar dermal leishmaniasis (PKDL), and cutaneous leishmaniasis (CL). A developmental safety exposure threshold was derived from the rat no-observed-adverse-effect level (0.6 mg/kg/day for 10 days) and adjusted using a 10-fold safety margin. Contraceptive durations resulting in median residual post-contraception exposure (AUCEOC-{infty}) below this threshold were considered supportive of contraceptive discontinuation. Results The developmental safety exposure threshold was estimated at 2.5 mg{middle dot}day/L. Despite pharmacokinetic differences across geographical regions and disease manifestations, required minimum contraceptive durations were consistent: three months from treatment initiation for the 14-day regimen, four months for 21- and 28-day regimens, and five months for the 42-day regimen. For the 14-day regimen, a single dose of a long-acting injectable contraceptive administered at treatment initiation would provide sufficient coverage. Conclusion An exposure margin-based approach supports shorter contraceptive durations than current recommendations. For the 14-day VL regimen, three months of contraception may provide a practical alternative to current labeling.

Tuberculosis (TB) remains a major global public health threat, with an estimated 10.7 million incident cases and 1.23 million deaths in 2024. Treatment interruption undermines TB control efforts, yet the effectiveness of Community Health Promoters (CHPs) in tracing patients lost to follow-up (LTFU) is poorly understood. We assessed the proportion of LTFU TB patients successfully traced through CHP-led tracing strategy and explored challenges of implementation CHP strategy. We conducted a mixed-methods cross-sectional study in Kilifi County, Kenya, among adult TB patients recorded as LTFU between July 2022 and December 2023. Patients identified through the national electronic TB surveillance system were linked to their respective community health units and assigned to CHPs for tracing. CHPs attempted to contact patients by telephone and through repeated household visits and, where necessary, sought information from relatives, neighbours, and local administrative leaders. For successfully traced patients, quantitative data were collected using structured questionnaires. Qualitative data were collected through five focus group discussions with 30 traced TB patients and 30 in-depth interviews with CHPs, TB clinic staff, programme managers, and County Health Management Team members. Qualitative data were coded and analysed thematically using a primarily deductive approach guided by the study objectives, while allowing additional themes to emerge. Of 140 patients identified for tracing, 36 (25.7%, 95% confidence interval 18.7-33.8) were successfully traced; 90 (64.3%) had relocated outside Kilifi County and 14 (10.0%) had died. Qualitative findings indicated that treatment interruption was driven by financial hardship, including transport costs, medication side effects, stigma, and difficulties maintaining continuity of care after relocation. CHPs supported treatment adherence through health education, counselling, appointment reminders, and household follow-up. However, their ability to trace patients was constrained by patient mobility, limited financial support for community-based activities, shortages of health workers, competing responsibilities, and gaps in systems for tracking patients across administrative boundaries. CHP-led tracing reached only one-quarter of LTFU TB patients, largely because many had relocated outside the county. Health systems should strengthen patient tracking across county boundaries and equip CHPs with the resources, staffing, and support needed for effective community-based TB tracing.

Background Madagascar has one of the highest burdens of schistosomiasis globally, yet epidemiological evidence from the South-east of the country remains limited. Existing surveillance estimates suggest relatively low prevalence in this region. This contrasts with the region's environmental suitability for transmission and its population's high occupational risk through rice farming. Methods A cross-sectional exploratory study was conducted across 13 villages around the Manombo Special Reserve, Farafangana District, between May and July 2025. Participants were surveyed for geographic, environmental and behavioural risk factors for schistosomiasis infection. Infection was diagnosed by Kato-Katz stool microscopy. Multivariable mixed-effects logistic and linear regression, with village as a random intercept, estimated associations with infection and intensity respectively, adjusting for the water catchment area of household water sources, sex, age group, recent praziquantel treatment and village-level open defecation rate. Results 227 participants were included. Overall S. mansoni prevalence was 53.3% (95% CI 46.8-59.8%); median infection intensity was 96 (IQR 48-288) eggs per gram of stool among those infected. Surface water contact was near-universal (97.3%). Prevalence varied markedly between neighbouring villages. No demographic, behavioural, or WASH variable was independently associated with infection. The water catchment area of household water sources was the primary predictor of infection. Conclusions Prevalence substantially exceeded current surveillance estimates, suggesting this population is underserved by existing control programmes. Water catchment area was the dominant determinant of transmission heterogeneity, possibly consistent with Biomphalaria habitat suitability. Water catchment area may represent a valuable and underutilised unit for targeting schistosomiasis surveillance and control in Madagascar.

Precision targeting is essential for maximising impact and cost-effectiveness of interventions at this stage of the HIV response in Malawi. We aimed to measure gaps in access to and use of condoms, HIV testing, pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision among HIV-negative individuals at public health facilities and social venues (bars, rest houses and liquor stores) in Blantyre, Malawi. We analysed cross-sectional data from 2,227 HIV-negative patients at government clinics and 1,634 patrons at social venues recruited in the Clinic vs Venue (CLOVE) study between January and March 2022. We estimated gaps in access to and use of condoms, HIV testing, PrEP and circumcision. Estimates were stratified by risk group, defined as reporting transactional sex, having multiple sex partners in the past 4 weeks, being female aged 15 to 24, or being male aged 30 and above. Access and use were based on self-reports. Overall, 30% of clinic and 60% of venue participants reported higher risk. Among men, we found a gap between access to condoms and condom use at last sex (76.7% vs 29.8% among clinic men; 75.4% vs 36.7% among venue men). Among women, the gap between access and use of condoms was 65.9% vs 18.0% at clinics and 79.9% vs 46.0% in the venues. Approximately 80-85% of participants reported knowing where to get an HIV test in Blantyre but less than half reported testing in the past 6 months. Use of PrEP was low (~2%). Comparable proportions of men who paid for sex and those with multiple partners (~77%) reported being circumcised, but this was lower among those aged 30 years or older (~57%). Despite expanded HIV prevention services in Blantyre, gaps remain in the uptake of prevention services among people reachable at public health facilities and social venues. Use of PrEP was particularly low across all groups. Condom and testing use remained suboptimal despite high reported access. Targeted efforts are needed to address barriers to uptake, particularly for PrEP among high-risk venue-based populations.

Histidine-rich protein 2 (HRP2)-based rapid diagnostic tests (RDTs) are central to malaria case management in Africa but fail when Plasmodium falciparum parasites lack the pfhrp2 or pfhrp3 genes. Widespread deletions have been reported in Eritrea, Ethiopia, and Djibouti, yet no systematic data have been available from Somalia. Between May and October 2023, we collected 7148 dried blood spot (DBS) samples from patients with suspected malaria attending eight health facilities across seven regions in Somalia. Field HRP2/pan-lactate dehydrogenase (LDH) RDTs and microscopy were performed, and DNA was extracted from 301 RDT-positive and 173 RDT-negative DBS samples. A multiplex quantitative PCR assay targeting pfldh, pfhrp2, and pfhrp3 was used to identify deletions in pfldh-positive samples lacking pfhrp2 or pfhrp3 amplification, with mixed infections inferred from delta cycle threshold ({Delta}Ct) differences. Of 474 analysed samples, 301 (4.2%, 95% CI 3.7-4.7) were RDT or microscopy positive, and 159 (33.5%) were confirmed pfldh-positive by qPCR. Among these, six (3.8%, 95% CI 1.4-8.1) carried pfhrp2 deletions and 59 (37.1%, 95% CI 29.6-45.1) carried pfhrp3 deletions. Eleven infections (6.9%, 95% CI 3.5-12.1) produced discordant RDT outcomes, HRP-/LDH+ or RDT-negative despite pfldh positivity. Deletions were most frequent in Dolow, Luq, and Bosaso. A single isolate carried the pfk13 R622I mutation, confirming the first report of the emergence of an artemisinin partial resistance-associated in Dolow, Gedo region, Somalia. Pfhrp2/3 deletions causing false RDT results remain low in Somalia and the confidence interval overlaps with the 5% policy threshold for changing RDTs, indicating uncertainty that warrants larger-scale assessment. Pfhrp3 deletions are widespread and compromise the diagnostic redundancy of HRP2-based tests. Most deletion-carrying parasites remain detectable through the pan-LDH line, minimising immediate clinical risk but leading to systematic misclassification of P. falciparum as non-falciparum malaria. These findings support the continued use of HRP2/Pan-LDH RDTs but highlight high risk areas and emphasise the need for periodic and expanded molecular surveillance for prevalence trends to guide timely future diagnostic policy.

Background: Human Tungiasis is a neglected tropical skin disease caused by the sand flea Tunga penetrans, associated with pain, inflammation, secondary bacterial infections, and significant morbidity. Despite its health impact on school children, it remained understudied in Kamushoko Parish, Bubaare Sub-County, Mbarara District, Uganda. Objectives: To determine the prevalence and identify associated factors of human Tungiasis among primary school children in Kamushoko Parish, Bubaare Sub-County, Mbarara District. Methods: A school-based cross-sectional descriptive study was conducted among 415 primary school children (P1-P7) at Katooma II and Komuyaga Primary Schools in March 2026. A census sampling approach enrolled all eligible pupils. Data were collected through structured face-to-face questionnaires and clinical examination of exposed areas. Tungiasis diagnosis was based on clinical identification of characteristic lesions with microscopic confirmation of extracted specimens. Bivariate and multivariate logistic regression analyses identified independently associated factors. Results: Of 415 children examined, 22 had active Tungiasis lesions, yielding an overall prevalence of 5.3% (95% CI: 3.53%-7.90%). Katooma II Primary School recorded a slightly higher prevalence (6.29%) than Komuyaga Primary School (4.78%), though the difference was not statistically significant (p = 0.499). Male children had higher odds of infection than females (7.1% vs. 3.7%). Children aged 9-10 years had the highest prevalence (7.7%). In the multivariate logistic regression, walking barefoot at school was the only independently significant predictor of infection (aOR = 0.18 for home vs. school; 95% CI: 0.04-0.78, p = 0.022). Conclusion: The prevalence of Tungiasis among primary school children in Kamushoko Parish was 5.3%, confirming ongoing transmission in the community. Walking barefoot at school was the only independent predictor of infection, highlighting the school environment as a critical intervention site. School-based strategies including grounds improvement, routine classroom cleaning, enforcing no-barefoot policies, and health education are recommended.

We report an unusual mortality event affecting the isolated Egyptian fruit bat (Rousettus aegyptiacus) population in northern Cyprus, combining clinical admissions, microbiological findings, and roost surveys to assess magnitude and potential drivers. From January to June 2025, the Cyprus Wildlife Research Institute (CWRI) Wildlife Hospital received an unprecedented surge in admissions with 12 individuals (versus sporadic admissions in prior years), with high acute mortality: most bats arrived moribund and died within 12-24 hours. Clinical records noted localized purulent lesions and abscesses in a substantial fraction of cases. Bacteriological culture and PCR assays recovered Staphylococcus aureus from abscesses and skin swab samples in multiple individuals; isolates exhibited susceptibility to tested antibiotics. Necropsy sampling confirmed viable S. aureus in several specimens despite prolonged storage. Concurrent targeted surveys of ten known roosts in Feb-Mar 2026 documented marked declines at multiple historical sites, including reductions from hundreds to single-digit counts at formerly large colonies and the complete absence of bats at multiple roosts. No clear evidence of recent human disturbance, extreme weather anomalies, or reduced food availability was found; shotgun cartridges from historical hunting were present, but no direct anthropogenic cause was apparent. While S. aureus infections--seasonally concentrated in winter--are consistent with observed lesions and may have contributed to morbidity and mortality, causality for the population-level declines remains unknown, and other factors (toxins, unassessed pathogens, multi-factor stressors) cannot be excluded. Given the genetic isolation and conservation significance of the Cyprus Egyptian fruit bat population, these findings are concerning. We recommend urgent, coordinated longitudinal population monitoring, expanded pathogen surveillance including whole-genome sequencing of S. aureus isolates, toxicological screening, and development of a species recovery plan incorporating emergency response, habitat protection, and public outreach.

Background. Increasing evidence indicates that Ebola virus disease (EVD) survivors can remain a source of infection long after clinical recovery. Confirmed survivor-associated transmission events and genomic evidence linking the 2021 Guinea outbreak to viral lineages from the 2013-2016 West African epidemic have demonstrated that persistent infection in survivors can contribute to post-epidemic re-emergence. However, the population-level conditions under which survivor reservoirs may sustain recrudescence remain poorly understood. Methods. We developed an age-structured Bayesian transmission model to quantify survivor-driven recrudescence risk using historical Ebola outbreak data (1976-2022) and empirical viral persistence data from male survivors. Age-specific viral clearance probabilities were estimated for three age groups (less or equal to 25, 26-35, and >35 years). The recrudescence reproduction number (Rc) was derived using the next-generation matrix approach. Sensitivity analyses examined alternative assumptions regarding viral clearance and the potential contribution of female survivors. Results. The posterior mean recrudescence reproduction number remained below the persistence threshold (Rc=1) across all viral-clearance scenarios under the assumption of no female survivor contribution. Only by assuming the slowest rate of viral clearance and maximal female survivor contribution did the posterior mean for Rc exceed one (1.052; 95% CrI: 0.428-2.229), suggesting that survivor-driven transmission alone is unlikely to sustain Ebola re-emergence given our current understanding of recrudescence dynamics. Simulations showed that survivor-driven outbreak pressure (rate of survivor-initiated outbreaks) was driven primarily by outbreak size and clustering. Outbreaks involving less or equal to 5,000 EVD cases generally produced outbreak pressure below the estimated natural spillover rate, whereas outbreaks comparable in size to the 2013-2016 West African epidemic generated transient survivor-driven outbreak rates up to 7.8-fold higher than the natural spillover rate before declining to comparable levels within 3-7 years. Moreover, across all viral-clearance scenarios, older (>35 years) male survivors consistently exhibited the longest effective persistence durations and made the largest contribution to the recrudescence reproduction number. Conclusions. The human survivor reservoir represents a plausible complementary pathway for Ebola re-emergence, particularly following large epidemics and should be considered alongside zoonotic spillover as an important source of future outbreaks. Age-dependent viral clearance strongly shapes recrudescence dynamics, with older survivors contributing disproportionately to transmission potential. These findings support age-stratified survivor monitoring, extended persistence surveillance, and improved characterization of viral persistence in both male and female survivors to strengthen post-epidemic preparedness.

Background Paragonimiasis is a neglected tropical disease (NTD) and of significant public health concern in northeastern India where it is frequently misdiagnosed as pulmonary tuberculosis. Transmission occurs through consumption of raw or undercooked freshwater crustaceans, a widespread dietary practice in this region. Accurate diagnosis will ensure cheap, effective treatment with praziquantel and avoid unnecessary prolonged tuberculosis therapy. This study determines the prevalence, specific risk factors for infection, and showcases a clinical scoring model to screen for active paragonimiasis in endemic areas. Methodology/Principal Findings A community-based cross-sectional survey was conducted in Medziphema block, Nagaland, in northeastern India screening 2,942 residents aged over 10 years. Participants reporting chronic cough ([&ge;]2 weeks) provided sputum and serum samples (93,3.16%). Sputum examination was screened for Paragonimus ova and acid-fast bacilli, and serum samples were tested for IgG antibodies against Paragonimus heterotremus using anti-Extra Secretory antigen by ELISA (positive case defined as titre [&ge;]0.5 IU). IgG-confirmed paragonimiasis was detected in 30 individuals, yielding a population prevalence of 1.02% (30/2942) and 32.3% (30/93) amongst symptomatic participants. Sputum microscopy demonstrated limited sensitivity (3.3%), detecting cysts in only one confirmed case. Tuberculosis co-infection was documented in 6.7% of sero-positive cases. Multivariable regression identified significant associations with increasing age (adjusted (aOR) 1.04) previous tuberculosis history (aOR 4.62), monthly snail consumption frequency (aOR 1.05), ever smoking (aOR 3.51), and education beyond middle school (aOR 2.93). Haemoptysis (aOR 9.86) was the strongest symptomatic predictor. Clinical scoring models were developed, with haemoptysis consistently emerging as the most robust predictor across all models. Conclusions/Significance Pulmonary paragonimiasis constitutes a prevalent yet under-recognised condition in several southeast-Asian communities, necessitating systematic screening as a differential diagnosis for pulmonary tuberculosis. The clinical scoring model facilitates early case identification in resource-constrained settings. Public health interventions must address dietary practices, particularly consumption of raw or undercooked freshwater crustaceans, to interrupt transmission.

Human Papillomavirus (HPV) infection among men who have sex with men (MSM) has become a significant public health concern, particularly in countries where male vaccination is unavailable. Given the high susceptibility of MSM to HPV and anal cancer, and the unavailability of HPV vaccination for males in low- and middle-income countries (LMICs), there is a need to identify alternative interventions for reducing disease transmission and burden in this population. The novel mathematical model presented in this article couples smoking behavior dynamics with HPV transmission and anal cancer progression among MSM. Smoking reduction is introduced as an intervention to assess its effects on disease transmission and burden. The basic reproduction number (R0) is derived using the next-generation matrix method, and a global sensitivity analysis is performed using partial rank correlation coefficients (PRCC) to identify the influence of model parameters on RR0. Further, the theoretical analysis of the model reveals a backward bifurcation, implying that RR0 < 1 is necessary but not sufficient to eradicate the disease. The study finds that smoking reduction among MSM reduces HPV infection and anal cancer burden relative to baseline projections without intervention. The joint effect of smoking reduction and vaccination shows that the critical vaccination coverage needed to achieve RR0 <1 decreases as the level of smoking reduction increases. A similar outcome is observed for contact reduction. These findings highlight the importance of concurrent interventions, which can significantly curtail the spread of HPV and reduce disease burden in both the high-risk group and the general population.

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 New swab-based near-point-of-care (NPOC) tests offer a potentially lower-cost, simpler alternative to Xpert MTB/RIF Ultra (Xpert-Ultra) testing for tuberculosis (TB) diagnosis. However, it is critical to understand how their performance may differ across diverse populations to inform programmatic rollout and real-world clinical decision-making. Methods We modeled the performance of testing sputum swabs with the MiniDock MTB assay and the Xpert MTB/RIF (Xpert) using positive percentage agreement (PPA) with Xpert-Ultra, disaggregated by semi-quantitative grade. PPA for MiniDock MTB was derived from a random-effects meta-analysis of three diagnostic accuracy studies. PPA for Xpert was derived from data from an early diagnostic study. PPA estimates were applied to 1,248 positive Xpert-Ultra test results from Phase 1 of the Start4All study across seven countries, disaggregated by facility-based (n=1,033) and community-based (n=215) participant recruitment, comparing a single overall PPA to an Xpert Ultra semi-quantitative grade-stratified model (from Trace to High). Results Pooled overall PPA was 84.8% (95% CI: 67.1-93.8%) for MiniDock MTB and 93.1% (90.3-95.2%) for Xpert. Grade-stratified modeling revealed lower PPAs at "Very Low" and "Trace" semi-quantitative grades: MiniDock MTB 56.5% and 33.8%; Xpert 66.7% and 23.1%, respectively. When grade-stratified estimates were applied to the Start4All data, both tests performed similarly, missing 241/1,248 and 228/1,248 positive Xpert-Ultra results, respectively. The single-value model overestimated performance most markedly in community settings, predicting 10.8% and 19.1% more positive results than the grade-stratified model for MiniDock MTB and Xpert, respectively. Conclusion MiniDock MTB sputum swabs perform comparably to Xpert when assessed using grade-stratified modeling. Both tests are likely to miss a greater proportion of people with Xpert-Ultra positive results in community settings, where paucibacillary disease is more common. Using single point estimates for diagnostic accuracy can substantially overestimate real-world performance, highlighting the importance of evaluating diagnostics across the full spectrum of TB disease.

Introduction: Most people with tuberculosis (TB) reside in countries with limited resources for prompt TB diagnosis, resulting in diagnosis and treatment delays and ongoing community transmission. Current TB diagnostics rely on sputum, while some people with presumptive TB cannot produce adequate sample. A new generation near-point-of-care (NPOC) tests using sputum or tongue swabs may provide more accessible TB diagnosis. Methods: In this pragmatic cluster randomised controlled trial (cRCT) in Indonesia, a multi-component public health intervention will include: (a) introduction of NPOC MiniDock MTB test (Guangzhou Pluslife Biotech, China) on sputum, tongue swab, or both specimens, (b) optimisation of clinical algorithms incorporating the new test, (c) a promotional package to encourage patient attendance and test utilisation, and (d) TB household contact investigation, including the new test, by community health volunteers. We will randomly stratify 40 community health centre (CHC) areas into intervention and control arms (1:1) in Bandung District. The intervention will be administered in healthcare facilities (HCFs) and in the community of the intervention areas. The control areas will continue standard of care with no intervention, except TB notification refresher training, which will be delivered in both areas before intervention roll-out. The primary outcome is the number of TB cases diagnosed and notified by HCFs per population attending them. It will be measured by abstracting data on TB case notification and the number of HCF attendees over 12 months following completion of the intervention roll-out, compared to 12 months preceding any trial activities. Discussion: This trial will evaluate the effect of an intervention package incorporating the first-in-class NPOC on TB diagnosis and notification. The trial results will inform policy to improve TB diagnostic efforts in Indonesia and other high burden TB countries. Trial Registration: ClinicalTrials.Gov, NCT07293455.