Tuberculosis

Background: Tuberculosis (TB) remains the leading infectious disease cause of mortality worldwide. A subset of individuals exposed to Mycobacterium tuberculosis (Mtb) remain TST/IGRA-negative despite sustained exposure, termed "TB resisters". The biological mechanisms underlying this resistance remain poorly understood. We applied untargeted high-resolution metabolomics to determine whether systemic metabolic profiles differ between TB resisters and matched Mtb-infected close contacts. Methods: We compared untargeted high-resolution plasma metabolomics using liquid chromatography mass spectrometry between 269 TB resisters and 269 matched Mtb-infected close contacts, enrolled across Brazil, India, and South Africa. TB resisters were defined as highly exposed close contacts who slept in the same room or spent at least 5 hours indoors per day with an infectious pulmonary TB index patient, but remained TST/IGRA-negative. Mtb-infected close contacts were those who were TST/IGRA positive. Metabolome-wide association studies (MWAS) were conducted using paired t-tests. Results: There were 1,787 features with nominal differences between TB resisters and matched Mtb-infected contacts (p < 0.05). Pathway enrichment identified fructose and mannose metabolism and bile acid biosynthesis in the overall cohort, while lipid-related pathways were enriched in Brazil. Among metabolites with confirmed chemical identities, glyceric acid concentrations were higher in TB resisters by 0.53 uM, whereas hydroxyproline was lower by 0.90 uM, butyrobetaine was lower by 0.06 uM, and homogentisate was lower by 0.0036 uM at false discovery rate of 0.2. Conclusions: Plasma metabolomic profiles differed between TB resisters and matched Mtb-infected close contacts. These findings indicate that systemic metabolic differences are associated with resistance to Mtb infection.

Interferon-gamma release assays detect Mycobacterium tuberculosis infection but cannot distinguish infection from active tuberculosis (TB). We evaluated the diagnostic information provided by QuantiFERON-TB Gold Plus (QFT-Plus) among adults investigated for active TB in Brazil and South Africa. Adults with presumptive TB were prospectively enrolled by convenience sampling. QFT-Plus was the index test, and diagnostic classification required microbiological confirmation of TB or an established alternative diagnosis. QFT-Plus results did not inform diagnostic classification. Accuracy was assessed among participants with determinate results, primarily using likelihood ratios. Of 723 participants tested, 48 (6.6%) had indeterminate results, all due to low mitogen responses. Among 675 participants with determinate results, 147 (21.8%) had confirmed TB. Sensitivity was 68.0% (95% CI, 60.1-75.0), specificity was 59.3% (95% CI, 55.0-63.4), and the negative likelihood ratio was 0.54 (95% CI, 0.42-0.69). At the observed prevalence, a negative result left a 13.1% probability of active TB. Negative likelihood ratio confidence intervals included 1 in both South African HIV strata. Specificity was higher among participants with HIV in both countries. Adding TB2 to TB1 alone identified 15 additional TB cases and generated 18 additional positive results among participants without active TB. HIV and active TB were independently associated with indeterminate results in exploratory regression. A negative QFT-Plus result provided insufficient information to exclude active TB. Higher negative predictive values among participants with HIV reflected lower disease prevalence and higher specificity rather than greater sensitivity. Negative or indeterminate results should not terminate diagnostic evaluation.

The COVID-19 pandemic substantially disrupted tuberculosis (TB) prevention, diagnosis, and treatment services worldwide. Despite increased TB notifications in Nepal during the post-pandemic recovery period, the geographic distribution and temporal clustering of notifications remain poorly understood. This study examined the spatial and temporal patterns of TB notifications across Nepal during the COVID-19 recovery period. We conducted a nationwide retrospective ecological analysis of district-level TB notifications across all 77 districts of Nepal from FY 2019/20 to FY 2023/24. Space-time, purely spatial, and purely temporal scan statistics were performed using a discrete Poisson model in SaTScan. Statistical significance was assessed using Monte Carlo simulation with 999 replications. A total of 172,155 TB cases were notified during the study period. TB notification rates increased by 51%, from 92 to 139 per 100,000 population between FY 2019/20 and FY 2023/24. Four statistically significant high-notification space-time clusters were identified (all p < 0.001). The primary cluster included Kathmandu, Lalitpur, Bhaktapur, Makwanpur, Bara, and Parsa districts during FY 2021/22-FY 2023/24 (RR = 1.60). Additional clusters were identified in western Nepal, the eastern Terai, and Rupandehi district. Purely temporal analysis showed a nationwide increase in notifications during FY 2022/23-FY 2023/24 (RR = 1.26, p = 0.001). TB notifications increased substantially during Nepals post-pandemic recovery period, with marked geographic and temporal heterogeneity. Integrating spatial and temporal surveillance may help identify areas requiring geographically targeted TB control strategies.

Mycobacterium tuberculosis has a flavin-intensive metabolism, with more than 180 proteins that require flavin or deazaflavin cofactors. M. tuberculosis requires riboflavin biosynthesis for growth in standard culture conditions in vitro, which can be overcome by providing exogenous riboflavin. It is unknown whether M. tuberculosis also requires riboflavin synthesis to grow or persist in infected host cells or tissues. Here we used a M. tuberculosis strain that conditionally expresses ribA2, which encodes a bifunctional enzyme that catalyzes the first steps in both branches of riboflavin biosynthesis, to determine whether M. tuberculosis requires riboflavin biosynthesis during infection. Transcriptional repression of ribA2 caused death of M. tuberculosis in vitro without riboflavin supplementation. RNAseq revealed that riboflavin starved M. tuberculosis induce a transcriptional program indicating decreased electron transport chain function and broad changes to central metabolism. Transcriptional repression of ribA2 prevented M. tuberculosis growth in cultured macrophages and caused clearance of M. tuberculosis from infected tissues at all stages of infection in both C57BL/6 mice that form cellular lung lesions and C3HeB/FeJ mice that develop necrotic lung granulomas. Our results demonstrate that M. tuberculosis requires RibA2 for viability at all stages of infection and support further characterization of the riboflavin biosynthesis pathway as a potential target for development of new anti-tubercular drugs.

Macrophages, alongside mammary epithelial cells, are major contributors to the innate immune response triggered by bacterial invasion of the mammary gland. To investigate breed-specific immune mechanisms, we stimulated monocyte-derived macrophages from Holstein and Normande cattle with Escherichia coli and Streptococcus uberis, two major mastitis pathogens. We monitored bacterial survival using [methode] and profiled gene expression via RNA-seq. E. coli exhibited significantly higher survival 6 hours post-infection compared to S. uberis (p < 0.05). Moreover, E. coli induced a robust transcriptional response, with 4403 differentially expressed genes (FDR < 0.05, |log2FC| > 1), versus only 813 for S. uberis. Qualitative differences were also observed: genes such as CCL2 and CSF1 were uniquely induced by S. uberis. Additionally, macrophages from Holstein and Normande cattle showed distinct expression profiles: 185, 45, and 174 genes were differentially expressed at steady state or after E. coli or S. uberis stimulation, respectively. These genes were enriched in immune-related pathways. Overall, our results demonstrate a stronger response to E. coli, although S. uberis specifically induces a subset of genes. The observed breed-specific differences may reflect underlying immune mechanisms that could influence disease susceptibility, warranting further functional validation.

Linezolid is a key component of the bedaquiline, pretomanid, linezolid (BPaL) regimen for rifampin-resistant tuberculosis, but dose- and duration-dependent mitochondrial toxicity frequently limits its use. TBD09 (formerly MK-7762) is a novel oxazolidinone developed to maintain antitubercular potency comparable to linezolid while reducing related adverse events. We evaluated the contribution of TBD09 to the bactericidal and sterilizing activities of BPa-based regimens in a murine tuberculosis model. BALB/c mice were aerosol-infected with Mycobacterium tuberculosis H37Rv and treated starting 2 weeks post-infection. In Experiment 1, dose-ranging bactericidal activity of TBD09 (50, 100, 200 mg/kg) was assessed alone and in combination with BPa, with comparison to linezolid and sutezolid. In Experiment 2, the sterilizing activity of TBD09 (200 mg/kg) in combination with BPa and BPa plus moxifloxacin (M) was assessed by evaluating relapse after treatment durations of 4-22 weeks. TBD09 monotherapy was bacteriostatic, similar to linezolid over the first 4 weeks of treatment. The addition of TBD09 to BPa significantly enhanced bactericidal activity comparable to the addition of linezolid. In relapse assessments, BPa+TBD09 resulted in significantly fewer relapses compared to BPa alone after 14 weeks of treatment, and BPaM+TBD09 resulted in significantly fewer relapses compared to BPaM after 10 weeks. Model-based analysis estimated the treatment duration to 95% cure for BPa+TBD09 at 2.7 weeks, compared to 3.2 weeks for BPaL, although the time to 50% cure was similar. These results demonstrate that TBD09 provides bactericidal and sterilizing activity similar to linezolid in combination with BPa(M), supporting further clinical development of TBD09 for tuberculosis.

The pathogenicity of Mycobacterium tuberculosis relies on its ability to withstand hostile host environments. Coenzyme F420 is critical for redox metabolism in Mycobacterium tuberculosis an organism distinguished by its abundant use of this low-redox-potential cofactor and a repertoire of F420-dependent enzymes. While F420-dependent mechanisms are known to confer protection against antimicrobials and oxidative stress, the specific enzymes responsible remain largely unidentified. In this study, using the F420-dependent detoxification of malachite green as a phenotypic marker, we performed a genome-wide screen in Mycobacterium tuberculosis using transposon mutagenesis and whole genome sequencing. The results of transposon mutagenesis and whole genome sequencing revealed that, among the 28 genes encoding F420-dependent enzymes, only mutations in fgd (essential for F420H2 re-generation) and Rv2061c, a gene encoding a putative F420-dependent oxidoreductase, were highly susceptible to malachite green. Subsequent experiments confirmed that Rv2061c and its homolog MT2120 are required for detoxifying malachite green and crystal violet. Furthermore, the Rv2061c mutant exhibited increased susceptibility to isoniazid and pretomanid; as well as menadione-induced oxidative stress. We also identified mutations in the transcriptional repressor Rv0678 as a key determinant of resistance to malachite green and crystal violet. This study establishes Rv2061c as a pivotal F420-dependent oxidoreductase that protects Mycobacterium tuberculosis from malachite green and other antimicrobial compounds as well as oxidative stress and further supports Rv0678 as a master regulator of multidrug resistance. These findings expand our knowledge of Mycobacterium tuberculosis defense mechanisms and highlight F420-dependent pathways as a potential target for new drug development.

Tuberculosis (TB) disease consistently causes the highest number of annual deaths from infectious disease and is responsible for over 100 million disability-adjusted-life-years annually. Despite the dramatic impact on human health, TB treatments are intensive and moderately effective, while Bacille Calmette-Guerin (BCG), the primary TB vaccine strategy and the oldest vaccine in circulation, needs updating. One gap in knowledge is that the vaccine primed lung immune environment has not been systematically profiled following TB challenge, making it challenging to interpret how various vaccine strategies provide protection. Here we profiled the male and female mouse lung immune environment using Mass Cytometry by Time of Flight (CyTOF) and bacterial burden (colony forming units, CFU), to systematically identify immune cells contributing to Mycobacterium tuberculosis (Mtb) infection or vaccine-induced protection. We investigated the mouse immune system after various infection outcomes including primary Mtb infection, Mtb reinfection, Mtb challenge after BCG vaccination and Mtb challenge after vaccination with a live attenuated Mtb vaccine. Across all conditions we identified Thy1.2 expression on NK cells as a new candidate for a sex-specific correlate of protection. Our results further replicate and support known immune responses for vaccine-induced protection, such as T-cell activation and infiltration. These findings highlight the pan-immune response to vaccine-induced protection, showcase the importance of sex in rodent models of TB, and identify novel host immune candidates to protect the lung against TB disease.

The WHO recently endorsed two commercial culture-free targeted next-generation sequencing (tNGS) assays for detecting drug resistant Mycobacterium tuberculosis. These proprietary tNGS platforms present a black box. We developed an in-house tNGS assay using Oxford Nanopore Technology sequencing to detect an expanded range of resistance mutations directly from clinical specimens. The assay targeted 44 genomic loci; hsp65 for Mycobacterium tuberculosis complex (MTBC) identification; 12 loci for MTBC lineage classification; and 31 drug resistance loci predicted resistance to 16 anti-TB drugs. In total, 98 amplicons were distributed across three PCR pools. Analytical sensitivity was assessed using M. tuberculosis H37Rv, and proof-of-concept performance was evaluated in 63 archived clinical specimen extracts and one real-life sputum specimen in comparison with Illumina whole genome sequencing (WGS). All amplicons were successfully amplified and sequenced from M. tuberculosis H37Rv genomic DNA. At [&ge;]100 genome copies/L, 71.4% of amplicons met [&ge;]20x; mean depth across six replicates, including all loci for rifampicin, ethambutol, pyrazinamide, fluoroquinolone and bedaquiline resistance. In 63 clinical specimens, [&ge;]90% of amplicons achieved a mean depth of [&ge;]20x in specimens with IS6110 PCR cycle threshold (Ct) values [&le;]24. With Ct value [&le;]27 lineage classification was concordant with WGS in 94.7% (18/19) of specimens and drug-susceptibility prediction showed 94.7% (18/19) agreement with both phenotypic and genotypic (WGS) testing. In a single clinical case (Ct 26.5), lineage and resistance-associated mutations were accurately identified directly from sputum. The findings provide new insights into rapid culture-independent tNGS approaches for rapid M. tuberculosis drug resistance detection with lineage assignment.

Background: Age is an important determinant of tuberculosis (TB) risk, but population-level age patterns in TB prevalence have not been systematically quantified across settings. We conducted a systematic review of surveys conducted in low- and middle-income countries to quantify trends in TB prevalence across age groups. Methods: We collated age-stratified TB prevalence data for individuals aged 15+ years, from population-based surveys reported between 1993 and 2025. We analyzed data using Bayesian meta-regression models, estimating trends in bacteriologically confirmed pulmonary TB prevalence across age groups. We extended models to understand how age trends varied with alternative outcome definitions and data subsets, and examined correlations between TB age trends and sociodemographic determinants. We also estimated age-stratified notification-to-prevalence ratios as a measure of diagnostic delays for untreated TB. Findings: We included 82 unique surveys reporting age-stratified TB prevalence, spanning 30 countries and 4.6 million participants. These data demonstrated a pattern of increasing bacteriologically confirmed TB prevalence with older age, with each 10-year increase associated with a 30% (95% credible interval: 22, 38) increase in prevalence. TB prevalence for the oldest age group (75+: 796 per 100,000 [522, 1178]) was 6.4 (4.0, 10.4) times higher than the youngest (15-19: 127 per 100,000 [79, 186]), and positive age gradients were estimated for all countries (interquartile range: 23-40% increase per 10-year increase in age). Age gradients were lower in Africa compared to other regions, and for smear-positive compared to bacteriologically confirmed TB. Countries with HIV prevalence [&ge;]5% had flatter age gradients above 40 years of age. Age gradients declined slowly over the study period. Notification-to-prevalence ratios demonstrated a negative age gradient, declining by 10% (7, 14) per 10-year increase in age. Interpretation: The prevalence of untreated TB disease increases substantially throughout adulthood, and lower notification-to-prevalence ratios suggest poorer case detection among older individuals.

Background: TB vaccine development is hampered by the natural history of M. tuberculosis: most infected people rarely progress to disease, so trials must be very large and long to accrue sufficient disease endpoints. Current trials enrol IGRA-positive participants (IGRA: Interferon-Gamma Release Assays), but IGRAs remain positive for many years and cannot distinguish recent from remote infection. Tests for recent infection are now in development, and we argue they could make trials substantially more efficient. Here, we investigate how screening participants prior to enrolment with a test for recent M.tb infection could impact the total number of enrollees required for an adequately-powered TB vaccine trial. Methods: Using a statistical model of vaccine trial recruitment, we estimated the number needed to contact, test, and enrol to achieve an 'effective' trial (defined as 50 disease endpoints), under IGRA-gated enrolment (life-long duration of positivity) vs. enrolment with a test for recent infection. We considered five recruitment strategies: non-test-based enrolment for ages 15-49, ages 12-34, and household contacts of recent cases; and test-based enrolment using IGRA, and a test for recent infection with two-year duration of positivity. The model explored trial recruitment in South Africa, Kenya, and India. Results: Compared with an extended-positivity test, a test for recent infection reduced the median number needed to enrol by 4.2- to 6-fold under favourable conditions. It also outperformed non-test-based strategies, including enrolling household contacts. This comes at the cost of substantially more testing, but crude estimates suggest recency-based enrolment would still be cheaper overall provided the new test does not cost more than roughly 5-10 times an IGRA. Conclusions: Diagnostics for recent M.tb infection have the potential to improve vaccine trial efficiency, but more research is now needed to understand test characteristics and to evaluate their use in this setting. Our Viewpoint sets out the test attributes that would need to be established, such as time to positivity, duration of positivity, sensitivity, and specificity, before such tests could be used in vaccine trials.

Introduction: Tuberculosis (TB) care is typically organised around biomedical and public health priorities, including diagnosis, infection control, treatment adherence, and prevention of transmission. Although qualitative research has described the burden of TB, lived experience is often treated as descriptive rather than as knowledge that can inform care. We examined how Aboriginal people in remote northern Australia experienced TB, and what these experiences reveal about how TB care can be strengthened in practice. Methods: We conducted an inductive qualitative study involving in-depth interviews with Aboriginal people with lived experience of TB. Interviews were supported by Aboriginal community health workers. Data were analysed using reflexive thematic analysis, with Aboriginal contributors involved in interpretive workshops to refine themes and guide culturally safe representation. Results: Twenty-one Aboriginal people contributed across 13 interviews. Three interrelated themes described the TB journey. Illness often challenged dominant biomedical expectations: symptoms were commonly normalised, which fear, ambivalence, and endurance were shaped by experiences of compromised health and cumulative loss. Distance from family, community, and Country was experienced as both protection and sacrifice; separation was endured to protect others but carried substantial costs, particularly when its purpose and duration were unclear. Recovery involved rebuilding strength, connection, and identity. Clear explanation, continuity, and opportunities for choice supported engagement in care, while survivors and community health workers provided important sources of trust, support, and shared responsibility. Conclusion: Lived experience is practice-relevant knowledge for TB programmes. Care should minimise avoidable harms of separation, support continuity and choice, and recognise survivors, Aboriginal health workers, and communities as partners in the design and delivery of care.

Introduction: Thyroid diseases are major health problems and among the most common endocrine disorders worldwide, including in Ethiopia. They are characterized by alterations in hormone secretion, enlargement of the thyroid gland, or both. Fine needle aspiration cytology is an important initial screening tool, and histopathologic examination is essential for the definitive diagnosis of thyroid disease. This study aimed to compare the diagnostic accuracy of fine needle aspiration cytology with histopathology in identifying thyroid diseases. Methods: A cross-sectional study was conducted at three health facilities in Hawassa City, Ethiopia, involving 304 patients who underwent both thyroid fine needle aspiration cytology and histopathologic examination of the same site between 30th October 2024 and 29th October 2025. FNAC results were classified using the Bethesda system, with histopathology as the gold standard. Data were entered into Kobo Toolbox, exported to SPSS version 27, and analyzed using cross-tabulation and chi-square ({chi}{superscript 2}) tests to determine diagnostic accuracy. Result: 304 patient records were included in the study. The fine needle aspiration cytology was determinate/diagnostic in 81.6% of cases. The study revealed the sensitivity and specificity of fine needle aspiration cytology to be 88.2% (CI 77.6-95.1%) and 94.4% (CI 90.6-97.1%), respectively. The false negative and false positive rates in this study were 2.4% and 4.4%, respectively. The positive predictive value was 80.3% (CI 68.7-89.3%), and the negative predictive value was 96.8% (CI 93.8-98.7%). The accuracy of fine needle aspiration cytology in differentiating benign from malignant thyroid lesions was 93.1%. Conclusion: FNAC demonstrated strong agreement with histopathology and remains a reliable, cost-effective first-line diagnostic tool for thyroid disease, particularly in resource-limited settings. Strengthening sample handling, ultrasound guidance, and adherence to Bethesda criteria may further improve diagnostic precision

BackgroundTuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), remains a leading global public health challenge. Malnutrition is a major, modifiable driver of this vulnerability to the disease, creating a lethal, bidirectional link with TB. This s review aims to synthesize available evidence to estimate the pooled prevalence of TB and identify associated factors among malnourished children in Ethiopia, providing critical data to guide targeted, integrated public health interventions. MethodsA systematic review and meta-analysis were conducted on studies reporting the prevalence of TB and associated factors among malnourished children in Ethiopia. Electronic databases including PubMed/Medline, EMBASE, CINAHL, ScienceDirect, Academic Search Complete, and Google Scholar were searched. In addition, bibliographies of relevant articles were reviewed, and a search for relevant conference abstracts was performed. Eligible studies were those published in peer-reviewed journals that specifically addressed TB prevalence among malnourished children. A random-effects model was employed to estimate the pooled prevalence of TB and its associated factors. ResultsA total of 746 studies were initially identified through database and catalog searches. Following screening and eligibility assessment, 12 studies were included in the final systematic review and meta-analysis. These studies, published between 2017 and 2024, collectively involved 5,749 participants. The smallest sample size (133) was reported in a study from the Oromia region, while the largest (1,201) was from the Amhara region. The pooled prevalence of TB among malnourished children was estimated at 16%. The highest prevalence (95%) was reported in a study conducted in Addis Ababa, while the lowest (6%) was from Harar. Considerable variation in prevalence was noted across the included studies. ConclusionThis review resulted in the substantial prevalence of TB among malnourished children in Ethiopia, with a pooled prevalence of 16%. This finding highlights the urgent need for integrated healthcare interventions targeting both TB and malnutrition

Introduction. Histoplasma capsulatum is an important fungal pathogen of humans, especially in immunocompromised patients, and the World Health Organisation has listed Histoplasma as a High Priority fungal pathogen. The taxonomy of the genus Histoplasma is still under development, but its only species H. capsulatum has at least of seven lineages, and a range of sublineages. Gap Statement. Allelic multilocus sequence typing (MLST) has been very successfully applied for typing and epidemiology of pathogenic bacteria, but its adoption for fungal pathogens is more limited. Genome sequence-based MLST approaches promise much a higher resolution for comparative phylogenetics, but there are only a small number of genome assemblies available for H. capsulatum. Aim. To develop and validate genome-based MLST typing for H. capsulatum. Methodology. A total of 406 genome assemblies were generated from publicly available Illumina short-read sequencing samples. Selected genome assemblies were subsequently used to generate MLST schemes with chewBBACA, based on whole genome sequences (wgMLST), NCBI-obtained annotations (annMLST) and annotations obtained with Funannotate (fanMLST), and used for lineage identification, and comparative analyses of population structure. Results. Genome assemblies were successfully generated for 406 H. capsulatum samples, with BUSCO completeness scores of over 98%. A subset of 60 genome assemblies was used to generate and validate MLST schemes based on the 60 genome assemblies, 5 genome annotations obtained from Genbank, and 13 genome annotations generated using Funannotate, resulting in schemes with > 8,000 markers. Each of the MLST schemes allowed reproducible separation of all 7 lineages and 6 H. capsulatum Suramericanum sublineages, without the need for high-performance clusters or powerful computing equipment. Comparison of the different schemes using tanglegrams and scatter plots showed good reproducibility (r2 values of 0.8-1.0). Comparison of total sizes of genome assemblies showed significant lineage-dependent size differences, with the Suramericanum, LAmB, India, Capsulatum and Mississippiense lineages averaging a total genome size of 30-33 million bp, and the Africa and Ohiense lineages averaging at 39 million bp. Conclusion. Genome sequence- and especially genome annotation-based MLST analyses are a promising approach that can be adapted as a rapid, high-throughput method for genomic clustering and epidemiological tracing of pathogenic fungi.

Multimorbidity - the co-existence of two or more long-term health conditions (LTCs) - is increasingly common in low- and middle-income countries. Yet, in the African region, its prevalence in people with tuberculosis (TB) and its impact on treatment outcomes remain poorly characterised. We sought to determine the prevalence and patterns of multimorbidity and its impact on health and treatment outcomes in people with TB in Kampala, Uganda, and to evaluate cascades of care for hypertension, diabetes mellitus, HIV and mental health conditions. This was a prospective cohort study of adults ([&ge;]18 years) commencing anti-TB treatment at four clinics in Kampala between June 2024-June 2025. LTCs were identified through self-report, validated screening tools, clinical examination and blood analysis, using definitions informed by the Ho et al. Delphi consensus. Multimorbidity was defined as TB plus two or more LTCs. Participants were followed to month six to assess health-related quality of life (HRQoL), physiological status (National Early Warning Score (NEWS)), sputum bacillary clearance (TB-Molecular Bacterial Load Assay (TB-MBLA)) and WHO-defined treatment outcomes. Descriptive statistics were used to examine the prevalence and patterns of multimorbidity and evaluate cascades of care. The effect of multimorbidity on health and treatment outcomes was assessed using regression models. Among 254 adults with TB, the prevalence of multimorbidity was 39.4% (95% CI 33.3-45.7%); only 22.4% had TB with no co-existing condition. The most prevalent LTCs were HIV (44.1%), undernutrition (39.8%) and depression (16.1%). Care cascades revealed substantial gaps in screening and diagnosis (HIV, diabetes mellitus and mental health conditions) and treatment (hypertension). At enrolment, multimorbidity was associated with worse NEWS (adjusted mean difference 0.88, 95% CI 0.36 to 1.42) and HRQoL (adjusted mean difference in HRQoL score -10.75, 95% CI -16.77 to -4.73). Multimorbidity was associated with a higher risk of a positive sputum TB-MBLA at month 2 and a higher risk of an unsuccessful TB treatment outcome (adjusted risk difference 9.88%, 95% CI 2.59 to 17.17). All deaths occurred among participants with multimorbidity. Multimorbidity affected two in five adults with TB in this cohort and was associated with worse health at diagnosis and poorer treatment outcomes. National TB programmes are well placed to identify and manage co-existing LTCs, but care cascades show gaps at different stages for different conditions, underscoring the need for tailored, integrated approaches.

ABSTRACT Background: Trachoma remains the leading infectious cause of blindness. Over 100M people are at risk, and 1.9M already live with visual impairment or blindness. Ethiopia bears the greatest burden of disease with ~61M or 59% of the known affected global population. Although Chlamydia trachomatis (Ct) infection initiates disease, infection alone fails to explain why inflammation resolves in some but progresses to irreversible scarring and vision loss in others. Previous studies have largely examined gene expression or limited protein panels, leaving the conjunctival immune protein environment poorly characterized. We hypothesized that distinct conjunctival immune states capture these pathogenic processes and could reveal biomarkers for selecting treatment and surveillance strategies. Methods and Findings: We conducted a cross-sectional study of 667 participants residing in the hyperendemic Amhara region of Ethiopia at least one year after the most recent azithromycin mass drug administration to treat Ct. The upper tarsal conjunctivae was graded for TF and TI, trachomatous inflammation-follicular or intense, respectively; I-TS/TT, inflammation with scarring with or without trichiasis, defined as one or more eyelashes touching the globe of the eye; and TS and TT, scarring with or without trichiasis but no inflammation. T0 represented no trachoma. The protein concentrations of 41 immune mediators were quantified using Meso Scale Discovery electrochemiluminescence immunoassays. Associations with infection and grade were evaluated using covariate-adjusted models with false discovery rate correction. Bernoulli mixture modeling (BMM) revealed four distinct Immune State Types (ISTs). Both approaches supported a shared biological framework characterized by selective immune activation in Ct infection, broad inflammation in TF/TI, and chemokine remodeling versus immune quiescence in the scarred conjunctiva. Ct infection was associated with a focused IFN-{gamma}-centered response. IST1 captured this immune response where 51.9% of the participants had Ct; we therefore termed IST1 Quiescent Infection. In contrast, TF/TI was associated with higher concentrations of proinflammatory, Th1/Th17, chemokine, regulatory, and remodeling pathways mediators. This profile fit well within IST2, termed Broad Inflammation, where 72.4% of the participants had TF/TI. TS/TT retained considerable chemokine activity, whereas I-TS/TT showed a narrower, IL-17A-dominant inflammatory profile. BMM separated scarring into two states characterized by distinct profiles: IST3, Conjunctival Remodeling, with significantly stronger chemokine and T-cell maintenance signals; and IST4, Quiescent Scarring, with the majority of chemokines being significantly downregulated. This suggests that scarred conjunctiva can retain substantial immune activity or shift toward a more attenuated state. Conclusions: This study establishes the first IST framework for trachoma, revealing biologically distinct immune states with different potential clinical implications. IST1 indicates the need for antibiotic treatment, whereas IST2 suggests that novel immunotherapeutics might be effective in thwarting disease progression. The upregulated chemokines in IST3 may indicate risk of progression to TT necessitating prospective studies and potential novel antifibrotic interventions. Together, our findings provide a strong biological foundation for stratifying patients by immune state and matching them to preventive and therapeutic care. Prospective validation and streamlined biomarker panels will support the translation of this framework into field settings to help avert disease progression and blindness.

Rationale: Tuberculosis preventive therapy (TPT) is essential for global tuberculosis control, yet estimated coverage remains well below global targets. Current World Health Organization (WHO)-recommended regimens require 1-9 months of treatment and are associated with suboptimal completion rates. Long-acting injectable (LAI) formulations offer the potential to improve TPT uptake and completion, with ideal products providing "one-and-done" options via a single administration. Sorfequiline, a second-generation diarylquinoline with superior potency over bedaquiline and lower QT prolongation risk, is a promising candidate for LAI TPT.

Skin ulcers, such as those observed in cases of the non-venereal disease yaws and the venereal disease syphilis, are traditionally diagnosed based on their anatomical location and visible appearance. Yet various evidence suggests that the pathogens that cause these ulcers may not be restricted to genital or non-genital body sites. We explored this by profiling the bacterial communities of genital and non-genital skin ulcers collected in Ghana using 16S rRNA gene amplicon sequencing. Swab samples were collected from 156 clinically diagnosed skin lesions (110 non-genital and 46 genital). The V1-V2 region of the 16S rRNA gene was sequenced to characterize bacterial communities. Microbial diversity, community composition, differential abundance, and associations between lesion diversity and common skin bacteria were analysed using bioinformatics and statistical methods. Following quality filtering, 135 samples were retained, revealing 23 bacterial phyla, 143 families, and 406 genera. Alpha diversity indicated similar bacterial richness and diversity in genital and non-genital skin lesions. Beta diversity analyses indicated differences between genital and non-genital lesions, accompanied by significant differences in within group dispersion. A log2 fold change analysis evidenced genital lesions were enriched in Gardnerella, whereas non-genital lesions showed more abundance of Staphylococcus, Streptococcus, Corynebacterium, Bradyrhizobium, and Pelomonas. Clinically important genera, including Treponema, Haemophilus, and Mycobacterium, were also detected, even in samples with low sequencing depths. Statistical modelling indicated that greater microbial diversity was associated with intermediate abundances of common skin taxa, particularly Corynebacteriaceae, Micrococcaceae, Cutibacterium, and Staphylococcaceae, thereby attesting the presence of polymicrobial communities in skin ulcers. Overall, genital and non-genital skin lesions showed similar microbial diversity but differed in composition. Our findings support the view of skin lesions as ecological niches containing diverse bacterial communities rather than being consistently dominated by a single bacterial taxon. They provide a basis for investigating possible polymicrobial interactions in skin ulcers.

Background: Bovine respiratory disease (BRD) is a major cause of antimicrobial use in cattle, raising concerns about antimicrobial resistance (AMR). This systematic review estimated pooled AMR proportions in BRD pathogens: Mannheimia haemolytica, Pasteurella multocida, and Histophilus somni, and assessed temporal and geographic trends in resistance. Methods: Five antimicrobials commonly used for BRD treatment were evaluated: penicillin G (PEN), tetracycline (TET), florfenicol (FLO), tulathromycin (TUL), and enrofloxacin (ENR). Following PRISMA guidelines, 1,097 records were screened and 24 studies met inclusion criteria. Study quality and risk of bias were assessed, and random-effects meta-analyses estimated pooled proportions of resistant isolates by antimicrobial, continent and period. Results: A total of 13,949 bacterial isolates were analysed including P. multocida (5,615), M. haemolytica (5,585), and H. somni (2,749). TET resistance was highest across all pathogens (12-30%), followed by TUL (6-11%), PEN (4-12%), FLO (0.5-1.6%) and ENR (0.2-1.1%). TET resistance in M. haemolytica and P. multocida, and FLO resistance in P. multocida were significantly more frequent in North America than in Europe (p[&le;]0.05). TUL resistance increased significantly in P. multocida after 2013 (p=0.038), with similar non significant trends in M. haemolytica and H. somni. FLO resistance decreased significantly in H. somni after 2013 (p=0.013). Egger's test identified significant funnel plot asymmetry for ENR resistance in H. somni and PEN resistance in M. haemolytica, suggesting possible small study effects. Conclusion: These results offer insights into distribution of phenotypic resistance across pathogens and regions, informing BRD antimicrobial treatment guidelines and One-Health antimicrobial stewardship aimed at preserving the effectiveness of medically important antimicrobials.