Multi-level tuberculosis of the spine identified by 18 F-FDG-PET/CT and concomitant urogenital tuberculosis: a case report from the spinal TB X cohort

BACKGROUND

Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and typically infects the lungs. However, extrapulmonary forms of TB can be found in approximately 20% of cases. It is suggested, that up to 10% of extrapulmonary TB affects the musculoskeletal system, in which spinal elements (spinal tuberculosis, STB) are involved in approximately 50% of the cases. STB is a debilitating disease with nonspecific symptoms and diagnosis is often delayed for months to years. In our Spinal TB X Cohort, we aim to describe the clinical phenotype of STB using whole-body 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) and to identify a specific gene expression profile for the different stages of dissemination on PET/CT. Here we report on the first patient recruited into our cohort who underwent PET/CT before treatment initiation, at 6-months and at 12-months - time of TB treatment completion.

CASE PRESENTATION

A 27-year-old immunocompetent male presented with severe thoracolumbar back pain for 9 months with severe antalgic gait and night sweats. Magnetic resonance imaging (MRI) of the whole spine revealed multilevel spinal disease (T5/6, T11/12, L3/4) in keeping with STB. After informed consent and recruitment into the Spinal TB X Cohort, the patient underwent PET/CT as per protocol, which revealed isolated multilevel STB (T4-7, T11/12, L3/4) with no concomitant lung or urogenital lesion. However, sputum and urine were Xpert MTB/RIF Ultra positive and Mtb was cultured from the urine sample. CT-guided biopsy of the T11/12 lesion confirmed drug-sensitive Mtb on Xpert MTB/RIF Ultra and the patient was started on TB treatment according to local guidelines for 12 months. The 6-month follow-up PET/CT revealed new and existing spinal lesions with increased FDG-uptake despite significant improvement of clinical features and laboratory markers. After 9 months of treatment, the patient developed an acute urethral stricture, most likely due to urogenital TB, and a suprapubic catheter was inserted. The 12-month PET/CT showed significantly decreased PET/CT values of all lesions, however, significant persistent spinal inflammation was present at the end of TB treatment. Clinically, the patient was considered cured by the TB control program and currently awaits urethroplasty.

CONCLUSIONS

In our case, PET/CT emerged as a valuable imaging modality for the initial assessment, surpassing MRI by revealing more comprehensive extensive disease. Subsequent PET/CT scans at 6-month uncovered new lesions and increased inflammation in existing ones, while by the end of TB treatment, all lesions exhibited improvement. However, the interpretation of FDG avidity remains ambiguous, whether it correlates with active infection and viable Mtb. or fibro- and osteoblast activity indicative of the healing process. Additionally, the absence of extraspinal TB lesions on PET/CT despite positive microbiology from sputum and urine maybe explained by paucibacillary, subclinical infection of extraspinal organs. The Spinal TB X Cohort endeavours to shed light on whole-body imaging patterns at diagnosis, their evolution midway through TB treatment, and upon treatment completion. Ultimately, this study aims to advance our understanding of the biology of this complex disease.

Moving on from clinical animal-derived surfactants to peptide-based synthetic pulmonary surfactant

Research on lung surfactant has exerted a great impact on newborn respiratory care and significantly improved survival and outcome of preterm infants with respiratory distress syndrome (RDS) due to surfactant deficiency because of lung immaturity. Current clinical, animal-derived, surfactants are among the most widely tested compounds in neonatology. However, limited availability, high production costs, and ethical concerns about using animal-derived products constitute important limitations in their universal application. Synthetic lung surfactant offers a promising alternative to animal-derived surfactants by providing improved consistency, quality and purity, availability and scalability, ease of production and lower costs, acceptance, and safety for the treatment of neonatal RDS and other lung conditions. Third-generation synthetic surfactants built around surfactant protein B (SP-B) and C (SP-C) peptide mimics stand at the forefront of innovation in neonatal pulmonary medicine, while nasal continuous positive airway pressure (nCPAP) has become the standard noninvasive respiratory support for preterm infants. nCPAP can prevent the risk of chronic lung disease (bronchopulmonary dysplasia) and reduce lung injury by avoiding intubation and mechanical ventilation, is a relatively simple technique, and can be initiated safely and effectively in the delivery room. Combining nCPAP with noninvasive, preferably aerosol, delivery of synthetic lung surfactant promises to improve respiratory outcomes for preterm infants, especially in low- and middle-income countries.

EEG background activity, seizure burden and early childhood outcomes in neonatal encephalopathy in Uganda: a prospective feasibility cohort study

Background

Intrapartum-related neonatal encephalopathy (NE) is a leading cause of childhood mortality and morbidity. Continuous electroencephalography (EEG) is gold standard for neonatal brain monitoring; however, low-income country data is lacking. We examined EEG in a Ugandan cohort with NE to describe feasibility, background activity, seizure prevalence and burden, and associations with clinical presentation and outcome.

Methods

Neonates with NE were recruited from a single hospital referral centre in Kampala, Uganda (Oct 2019-Oct 2020) and underwent EEG monitoring. Feasibility was assessed as to whether EEG monitoring of diagnostic quality could be achieved from days 1-5. Evolution of clinical presentation was assessed by Sarnat classification and daily Thompson score was performed. EEG background severity was graded at 12, 24, 48 and 72 h after birth, and at time of Thompson score. Seizures were annotated remotely by experts and assessed for frequency, duration, burden, and status epilepticus. Early childhood outcome was assessed at follow up, and adverse outcome defined as death or neurodevelopmental impairment (NDI) at 18-24 months of age.

Findings

In this prospective feasibility cohort study, diagnostic quality EEGs were recorded for 50 of 51 recruited neonates (median duration 71.4 h, IQR 52.4-72.2), indicating feasibility. Of 39 participants followed to 18-24 months, 13 died and 7 had NDI. Daily Thompson score and EEG background grade were strongly correlated across all timepoints (days 1-5). Thompson score of ≥7 was most predictive of moderate-severe EEG background abnormality (AUC 0.83). Prognostic accuracy of moderate-severe EEG background grade to predict NDI was high (AUC 0.74). Electrographic seizures were seen in 52% (26); median seizure burden was high at 264 min (IQR 27.8-523.7, range 1.3-1374.1); half (13) had status epilepticus.

Interpretation

EEG monitoring was feasible as a research tool in this sub-Saharan Africa setting. EEG background activity correlated strongly with scored neurological assessment and predicted adverse early childhood outcome. Seizure prevalence and burden, including status epilepticus, were high in this uncooled cohort with important potential longer-term implications for survivors.

Funding

Bill & Melinda Gates Foundation grant number OPP1210890; Wellcome Trust Innovator award (209325/Z/17/Z).

Effects of a Simulation-Based Care After-Death Mentoring Program for New Nurses: Augmented Reality End-of-Life Experience

Background: Nurses who provide person-centered care even after death must possess essential competencies to perform their duties effectively. Therefore, it is imperative to develop educational programs to enhance the capabilities of new nurses in care after death. Objective: To develop a care after-death mentoring program that includes an augmented reality (AR) end-of-life experience for new nurses and to describe its effectiveness. Design: A quasi-experimental pre- to post-test design was followed to evaluate program outcomes. Setting/Participants: The participants (n = 18) were nurses with <12 months of experience working at a tertiary general hospital in South Korea. Measurements: A pre-post survey was conducted on comfort in bereavement/end-of-life care, death anxiety, and compassion competency. Data were analyzed using the SPSS program, employing descriptive statistics and paired sample t-tests. Results: Significant improvements were observed in both comfort during bereavement/end-of-life care and compassion competency (t = -8.43, p < 0.001; t = -4.90, p < 0.001). Conclusions: This study demonstrated enhancements in participants' comfort levels regarding bereavement and end-of-life care, as well as their ability to exhibit compassion after participating in the program. Consequently, it was confirmed that simulation-based care after-death mentoring education utilizing an AR app helped enhance the capabilities of new nurses.

Urine-Xpert Ultra for the diagnosis of tuberculosis in people living with HIV: a prospective, multicentre, diagnostic accuracy study

BACKGROUND

Diagnostic delays for tuberculosis are common, with high resultant mortality. Urine-Xpert Ultra (Cepheid) could improve time to diagnosis of tuberculosis disease and rifampicin resistance. We previously reported on lot-to-lot variation of the Fujifilm SILVAMP TB LAM. In this prespecified secondary analysis of the same cohort, we aimed to determine the diagnostic yield and accuracy of Urine-Xpert Ultra for tuberculosis in people with HIV, compared with an extended microbiological reference standard (eMRS) and composite reference standard (CRS) and also compared with Determine TB LAM Ag (AlereLAM, Abbott).

METHODS

In this prospective, multicentre, diagnostic accuracy study, we recruited consecutive inpatients and outpatients (aged ≥18 years) with HIV from 13 hospitals and clinics in seven countries (Malawi, South Africa, Tanzania, Thailand, Uganda, Viet Nam, and Zambia). Patients with no isoniazid preventive therapy in the past 6 months and fewer than three doses of tuberculosis treatment in the past 60 days were included. Reference and index testing was performed in real time. The primary outcome of this secondary analysis was the diagnostic yield and accuracy of Urine-Xpert Ultra compared with the eMRS and CRS. Diagnostic accuracy was compared with AlereLAM and diagnostic yield was compared with both AlereLAM and Sputum-Xpert Ultra. This study was registered with ClinicalTrials.gov, NCT04089423, and is complete.

FINDINGS

Between Dec 13, 2019, and Aug 5, 2021, 3528 potentially eligible individuals were screened and 1731 were enrolled, of whom 1602 (92·5%) were classifiable by the eMRS (median age 40 years [IQR 33-48], 838 [52·3%] of 1602 were female, 764 [47·7%] were male, 937 [58·5%] were outpatients, 665 [41·5%] were inpatients, median CD4 count was 374 cells per μL [IQR 138-630], and 254 [15·9%] had microbiologically confirmed tuberculosis). Against eMRS as reference, sensitivities of Urine-Xpert Ultra and AlereLAM were 32·7% (95% CI 27·2-38·7) and 30·7% (25·4-36·6) and specificities were 98·0% (97·1-98·6) and 90·4% (88·7-91·8), respectively. Against CRS as reference, sensitivities of Urine-Xpert Ultra and AlereLAM were 21·1% (95% CI 17·6-25·1), and 30·5% (26·4-34·9), and specificities were 99·1% (98·3-99·6) and 95·1% (93·5-96·3), respectively. The combination of Sputum-Xpert Ultra with AlereLAM or Urine-Xpert Ultra diagnosed 202 (77·1%) and 204 (77·9%) of 262 eMRS-positive participants, respectively, in incompletely overlapping groups; combining all three tests diagnosed 214 (81·7%) of 262 eMRS-positive participants INTERPRETATION: Urine-Xpert Ultra could offer promising clinical utility in addition to AlereLAM and Sputum-Xpert Ultra. In inpatient settings where both AlereLAM and Urine-Xpert Ultra are possible, both should be offered to support rapid diagnosis and treatment.

FUNDING

Global Health Innovative Technology Fund, KfW Development Bank, Commonwealth of Australia represented by the Department of Foreign Affairs and Trade, and the Netherlands Enterprise Agency.

A character-strengths based coaching intervention to improve wellbeing of rural community health workers in Madhya Pradesh, India: Protocol for a single-blind randomized controlled trial

Background

There is scarce knowledge on the use of structured positive psychology interventions for reducing work-stress and improving wellbeing of rural community health workers in India, particularly the Accredited Social Health Activists (ASHAs) who are village-level (resident women, incentivised) lay health workers. This trial will test the effectiveness of a 'character-strengths' based coaching intervention compared to routine supervision on wellbeing ('authentic happiness') of ASHAs.

Methods

This protocol is for a single-blind, parallel group randomized controlled trial comparing the effectiveness of a five-day residential workshop focusing on the use of character-strengths and subsequent 8- to 10-week remote telephonic coaching (weekly) to individually support ASHAs to improve their wellbeing, against routine health system support. The arms are intervention added to routine ASHA supervision (weekly, by the ASHA supervisor), and routine supervision alone (control arm). The target sample comprises 330 rural ASHAs in Madhya Pradesh, India. The primary outcome of mean Authentic Happiness Inventory (AHI) scores will be compared between arms at 3-month follow-up. Secondary outcomes will include an assessment of ASHA's self-reported affect, self-efficacy, flourishing, burnout, motivation, physical health symptoms, quality of life, and routine work performance indicators, and the consequent patient-level outcomes [e.g., service satisfaction and depression remission rates after receiving brief psychological treatment by trained ASHAs]. We will also evaluate the costs of developing and delivering the intervention.

Discussion

This trial will determine whether a character-strengths based coaching intervention is an effective and scalable approach for reducing work-stress and improving wellbeing of rural ASHAs in low-resource settings.

Evaluation of Wolbachia infection in Aedes aegypti suggests low prevalence and highly heterogeneous distribution in Medellín, Colombia

Dengue virus, transmitted mainly by Aedes aegypti mosquitoes, is a significant public health challenge in tropical and subtropical countries, with an incidence that is growing at an alarming rate. The release of Wolbachia-carrying mosquitoes has been suggested as a strategy to reduce the incidence of multiple arboviruses. In Medellín, Colombia, large-scale releases of Wolbachia-infected Ae. aegypti mosquitoes were performed between 2017 and 2022 by the World Mosquito Program to facilitate population replacement. In this study, we evaluated the prevalence and distribution of Wolbachia-infected Ae. aegypti two years after completion of these releases. We conducted the sampling across 19 communes in Medellín, using 416 ovitraps to collect Ae. aegypti eggs from epidemiological weeks 26 to 41 in 2023. Upon hatching the collected eggs, we identified and pooled adult female Ae. aegypti for DNA extraction. Subsequently, we conducted PCR assays for the detection of Wolbachia infection in these mosquitoes. We used maximum likelihood estimation (MLE) and Bayesian methods to estimate the prevalence of Wolbachia infection, while using QGIS to analyze spatial distribution of infection in the region. A total of 774 female Ae. aegypti mosquitoes from 182 pools were evaluated. We detected Wolbachia in 33.5 % of pools, with an estimated individual minimum infection rate of 9.5 % and a maximum of 33.2 %. The prevalence varied significantly across communes, with the highest rates observed in the northeastern and southwestern areas. Spatial analysis revealed a highly heterogeneous island-like distribution of Wolbachia across Medellín with a few hotspots. The observed Wolbachia prevalence in this work was lower than previously reported. We suspect a decline in the prevalence of Wolbachia-infected Ae. aegypti mosquitoes in Medellín following the completion of their release.

Burnout, working alliance, and ward atmosphere: A multisite study of mental health professionals and patients with schizophrenia

This study examined the association between burnout, psychological distress, ward atmosphere, and working alliance (WA) among mental health workers treating patients with schizophrenia spectrum disorder (SSD). Data were collected from 345 patients with SSD and 151 mental health workers across 98 residential facilities (RFs) as part of the DiAPAson project from October 2020 to October 2021. Participants were excluded from the study if they exhibited patient-operator matching errors, dropped out, or had many missing Maslach Burnout Inventory (MBI) scores. The final sample included 282 patients and 155 healthcare workers. Burnout was assessed using the MBI. Psychological distress was evaluated with the 12-item version of the General Health Questionnaire. WA and ward atmosphere were evaluated with the WA Inventory and the Ward Atmosphere Scale, respectively, in both staff and patients. Sociodemographic and clinical data was also collected and analysed. Burnout was associated with a less supportive ward atmosphere, a weaker WA, and higher staff distress. Severe psychiatric symptoms evaluated with Brief Psychiatric Rating Scale in patients were also linked to staff burnout levels. Discrepancies in the perceptions of the ward atmosphere and the WA were observed between staff and patients, with patients reporting better perceptions in both domains. Our findings highlight the complex dynamics of well-being within psychiatric care settings, emphasizing the importance of role clarity, professional autonomy, and a positive ward atmosphere in mitigating burnout. Interventions focused on such factors may help support mental health professionals involved in SSD patient care. ISRCTN registry ID ISRCTN21141466.

Heterogeneous mosquito exposure increases Plasmodium vivax and Plasmodium falciparum co-infections: a modelling study

In malaria-endemic regions, Plasmodium vivax and Plasmodium falciparum coexist and may interact. For instance, fevers induced by P. falciparum might activate dormant P. vivax parasites and concurrent radical cure of both species has been proposed to prevent relapses. Heterogeneous mosquito exposure may contribute to the dependence of both parasites. We conducted a literature review on their respective prevalence and that of co-infections. The data revealed a positive correlation between P. vivax and P. falciparum prevalence, and co-infection prevalences exceeding expectations assuming infections occur independently. We used the review data to fit a compartmental model of co-infections that features heterogenous mosquito exposure. The fit suggests that heterogeneous exposure sufficiently explains the observed departure from independence. Finally, we performed simulations under the model assessing the impact on P. vivax prevalence of the activation-by-fever hypothesis and the radical cure proposition. We demonstrated a moderate impact of allowing P. falciparum fevers to reactivate P. vivax and a substantial impact of treating P. falciparum cases with radical cure. Our model highlights dependence between P. falciparum and P. vivax and emphasizes the influence of heterogeneous mosquito exposure. This simple framework can inform the design of more complex models assessing integrated malaria control strategies in coendemic regions.

Prevalence and Trends of Not Receiving a Dose of DPT-Containing Vaccine Among Children 12-35 Months: An Analysis of 81 Low- And Middle-Income Countries

Not receiving a DPT-containing vaccine in early childhood indicates an absence of routine immunization, which puts children at an elevated risk of mortality, morbidity, and worse human development over the life course. We estimated the percentage of children 12-35 months who did not receive a dose of DPT-containing vaccine (termed zero-dose children) using household surveys from 81 low- and middle-income countries conducted between 2014 and 2023. For 68 countries with more than one survey (with the earlier survey conducted 2000-2013), we estimated the average annual percentage point change in prevalence of zero-dose children between the earliest and latest surveys. We also explored the association of zero-dose prevalence with postneonatal and child mortality, health expenditure, and Gavi-eligibility. Overall, 16% of children in our pooled sample had not received a dose of DPT-containing vaccine. There was a 0.8% point decline in zero-dose prevalence per year on average across the period studied. A single percentage point average annual decline in zero-dose prevalence was associated with an average annual decrease of 1.4 deaths in the postneonatal and childhood period per 1000 live births. Gavi-eligible countries had a much faster decline in zero-dose prevalence than other countries. Large gains have been made in reducing the percentage of children who did not receive a DPT-containing vaccine. Efforts to reduce the number of zero-dose children should focus on countries with high prevalence to achieve the Immunization Agenda 2030. Healthcare spending could be prioritized so that the prevalence of zero-dose children is reduced.

Experiences of Pregnant and Parenting Adolescents and Young Women During COVID-19 Pandemic: A Mixed-Methods Study Among Girls and Women in Kenya

PURPOSE

This study examines the experiences of pregnant/parenting adolescents and young women during the first two years of the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This explanatory sequential mixed-methods study leverages quantitative data collected among a cohort of adolescents and young people aged 15-22 years in three Kenyan counties; Nairobi, Kisumu, and Kilifi at three time points (2020, 2021, 2022), and two rounds of qualitative interviews in the same settings conducted in 2020 and 2022.

RESULTS

Among 2337 (2020), 1438 (2021), and 1669 (2022) respondents, pregnant/parenting adolescents and youth comprised 140 (6%), 101 (7%), and 83 (5%) individuals, respectively. Across the three time points, the experience of depressive symptoms was similar between pregnant/parenting adolescents and those not pregnant/parenting. Pregnancy and parenting was associated with twice the odds of skipping health services (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.43-3.35), in 2020, and 85% higher odds (aOR 1.85, 95% CI 1.14-3.02) in 2021, and 90% higher odds of skipping meals (aOR 1.90, 95% CI 1.19-3.03) in 2022. Qualitative findings indicated experiences of psychological distress, food insecurity, and inadequate access to health care services among pregnant/parenting young people during the pandemic.

DISCUSSION

The pandemic increased pre-existing challenges associated with adolescent and young people's health, predisposing young pregnant/parenting women to greater adversity than their nonpregnant/parenting counterparts. Targeted and responsive approaches during emergencies and crises such as social protection, food security, and mental health programs for this group of vulnerable people are required and need to be integrated into disaster response plans.

Etiologies and comorbidities of meningitis deaths in children under 5 years in high-mortality settings: Insights from the CHAMPS Network in the post-pneumococcal vaccine era

BACKGROUND

The role of meningitis in causing deaths and in children under 5 is unclear, especially since widespread use of vaccines to prevent common causes of meningitis. Child Health and Mortality Prevention Surveillance (CHAMPS) uses post-mortem minimally invasive tissue sampling (MITS) and ante-mortem data to explore death causes. We aimed to assess meningitis's contribution to mortality and identify causative pathogens in children under 5 within CHAMPS Network sites.

METHOD

In this observational study, we analyzed deaths in live-born children <5 years of age that occurred between December 16, 2016, and December 31, 2023, in CHAMPS catchments in six sub-Saharan African countries (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, South Africa) and Bangladesh. MITS was conducted within 24-72 h of death, including blood and cerebrospinal fluid (CSF) culture, multi-organism targeted nucleic acid amplification tests on blood, CSF and lung tissue, and histopathology of lung, liver and brain. Expert panels at each site reviewed data to attribute causes of death following ICD-10 standards.

RESULT

Meningitis was in the causal pathway for 7.0% (270/3857) of deaths; in 4.8% (13/270) meningitis was considered the underlying condition. Neonates accounted for 65.9% (178/270) and infants or children 34.1% (92/270). Among neonatal meningitis deaths, 55.6% (99/178) occurred ≥72 h post-hospital admission; and common pathogens were Acinetobacter baumannii (49.5%, 49/99; mainly from South Africa) and Klebsiella pneumoniae (40.4%, 40/99). Forty-four percent (79/178) of neonatal meningitis deaths were community-associated, primarily due to K. pneumoniae (35.4%, 28/79) and Escherichia coli (13.9%, 11/79). Among infant and child meningitis deaths, 43.5% (40/92) occurred ≥72 h post-admission; and common pathogens were K. pneumoniae (42.5%,17/40) and A. baumannii (17.5%, 7/40). Among community-associated meningitis deaths in infants and children (56.5%, 52/92), Streptococcus pneumoniae (34.6%, 18/52) and K. pneumoniae (19.2%, 10/52) were common pathogens. Pathogen prevalence varied by region.

CONCLUSION

Our study highlights meningitis as a significant contributor to under-5 mortality in low-middle-income countries. The prominent role of K. pneumoniae and A. baumannii, particularly in healthcare settings and specific regions, highlights the need for better infection control, targeted interventions, and more effective treatment strategies.

In-hospital unfavorable outcomes of MIS-C during 2020-2022: a systematic review

Studies on the severity in multisystem inflammatory syndrome in children (MIS-C) show heterogeneous results and may not reflect a global perspective. This systematic review aims to estimate the frequency of in-hospital unfavorable outcomes in patients with MIS-C over the 3 years since the onset of the SARS-CoV-2 pandemic. A systematic search was conducted in Medline, Scopus, Embase, Cochrane, Web of Science, Scielo, and preprint repositories until December 15, 2022. Study selection and data extraction were evaluated independently. The primary outcomes were intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and death. Additionally, we evaluated cardiovascular-related outcomes. We performed a random-effects model meta-analysis and assessed the certainty of the evidence. Fifty-seven studies (n = 13 254) were included. The frequency of ICU admission was 44.7% (95% CI 38.8-50.7), 11.9% for IMV (95% CI 9.6-14.4), and 2.0% for death (95% CI 1.3-3.0). The requirement of vasoactive/inotropic drugs was 40.1% (95% CI 35.9-44.4), 7.9% for coronary aneurysm (95% CI 4.1-12.7), 30.7% for decreased left ventricle ejection fraction (LVEF) (95% CI 26.3-35.4), and 29.7% for myocarditis (95% CI 18.4-42.4). We assess the included evidence as being of very low certainty. Finally, excess COVID-19 mortality by country and the diagnostic criteria for MIS-C (CDC compared to WHO) were associated with a higher frequency of ICU admissions. The year of study conduction (2022 compared to 2020) was associated with a lower frequency of IMV.

CONCLUSION

The frequency of in-hospital unfavorable outcomes in patients with MIS-C was high. Well-designed studies are needed to explore other heterogeneity sources.

PROTOCOL REGISTRATION

CRD42021284878.

WHAT IS KNOWN

• Multisystem inflammatory syndrome in children (MIS-C) is a serious post-infectious condition linked to SARS-CoV-2. Studies on the severity of MIS-C show heterogeneous results. These findings may not be representative of the reality in other regions, making it challenging to draw generalizable conclusions.

WHAT IS NEW

• Over the 3 years since the onset of the SARS-CoV-2 pandemic, our systematic review has shown that the frequency of in-hospital unfavorable outcomes in patients with MIS-C is high, with a very low certainty of the evidence. Our results reflect the reality from a global perspective, across different countries with varying income levels. • The main sources of heterogeneity in the frequency of severe outcomes could be explained by the excess mortality due to COVID-19 in each country, the type of diagnostic criteria for MIS-C, and the year the study was conducted.

MicroRNAs secreted by the parasitic nematode Brugia malayi disrupt lymphatic endothelial cell integrity

Lymphatic filariasis (LF) is a neglected tropical disease affecting over 51 million people in 72 endemic countries. Causative agents of LF are mosquito-borne parasitic nematodes Wuchereria bancrofti, Brugia malayi, and Brugia timori. The adult parasites impact the integrity of lymphatic vessels and damage valves, leading to a remodeling of the lymphatic system and lymphatic dilation. Chronic infections can develop into severe clinical manifestations, primarily lymphedema, hydrocoele, and elephantiasis. Mechanistic studies on the underlying pathology due to the parasite are necessary to better manage human filariasis. Since parasite molecules, such as microRNAs (miRNAs), can be found in secreted extracellular vesicles (EVs) and are transported between parasite and host cells, we hypothesized that these could also play a role in the development of pathology in LF. In this study, we tested two B. malayi miRNAs previously detected in vitro in the culture media of microfilarial stages of worms. While one is Brugia-specific (bma-miR-5864) and the other nematode-specific (bma-miR-86), both miRNAs are secreted in high abundance. We first examined the in vitro response by transcriptomic profiling of human lymphatic endothelial cells to treatment with these miRNAs, which allowed us to identify genes involved in maintaining the integrity of the lymphatic endothelium. We then measured the effect of these miRNAs on the regulation of proteins necessary for cell integrity, demonstrating downregulation leading to a significant increase in the permeability of the endothelium monolayer. With this study we identify parasite miRNAs involved in undermining the integrity of endothelial cells, thus potentially contributing to the development of pathology. These findings could pave the way for a novel treatment strategy where the inhibition of parasite-secreted molecules could slow the progression of LF pathology. From a broader perspective, the miRNAs secreted by filarial parasites could potentially be used in the future for diagnosing and monitoring disease progression or treatment efficacy.

Postpartum maternal and infant haematological effects of second-trimester ferric carboxymaltose versus standard-of-care oral iron in Malawi: longitudinal follow-up of a randomised controlled trial

BACKGROUND

Anaemia is common in mothers and infants in the first year postpartum, especially in sub-Saharan Africa. We evaluated whether treating anaemia in the second trimester of pregnancy with a single dose of intravenous iron, ferric carboxymaltose, compared with standard-of-care oral iron could alleviate anaemia in postpartum women and their infants.

METHODS

REVAMP (ACTRN12618001268235), an open-label, individually randomised, controlled trial done across nine urban and five rural health centres in Malawi, recruited women if they were in the second trimester of singleton pregnancy, had a capillary haemoglobin concentration of less than 10·0 g/dL, and had a negative malaria rapid diagnostic test. Once enrolled, women were randomly assigned (1:1) to receive intravenous ferric carboxymaltose (20 mg/kg up to 1000 mg) or standard of care (60 mg oral elemental iron twice daily for 90 days); all women received preventive malaria treatment. The primary endpoint of REVAMP was anaemia prevalence at 36 weeks of gestation, with follow-up of mothers and infants until 1 month postpartum. In REVAMP-EXTENDED, women from REVAMP who gave consent, and their infants, were followed up at 3, 6, 9, and 12 months postpartum, and venous blood was collected for haemoglobin, ferritin, and C-reactive protein measurement. Maternal postpartum outcomes comprised prevalence of anaemia (venous haemoglobin concentration <11 g/dL up to and including delivery and <12·0 g/dL postpartum) and haemoglobin concentration, as well as iron status (iron deficiency, defined as serum ferritin <15 μg/L, or <30 μg/L if C-reactive protein >5 mg/L, and iron deficiency anaemia [both iron deficiency and anaemia]). Infant outcomes comprised cord ferritin concentration, and haemoglobin and ferritin concentrations at 1, 3, 6, 9, and 12 months of age.

FINDINGS

Between Nov 12, 2018, and March 2, 2021, 862 women were randomly assigned in REVAMP, of whom 793 (393 in the ferric carboxymaltose group [376 liveborn infants] and 400 [379 liveborn infants] in the standard-of-care group) provided consent for REVAMP-EXTENDED. At 12 months postpartum, ferritin concentrations were higher (geometric mean ratio 1·47 [95% CI 1·29-1·66], p<0·0001), and prevalence of iron deficiency was lower (prevalence ratio 0·65 [0·48-0·88], p=0·0050), in mothers receiving ferric carboxymaltose than in those receiving standard of care. Anaemia was less common in women who received ferric carboxymaltose than in those who received standard of care at 1 month (prevalence ratio 0·84 [95% CI 0·71-0·98], p=0·027), 3 months (0·75 [0·62-0·91], p=0·0029), and 6 months (0·78 [0·63-0·96], p=0·018) postpartum but not thereafter. There was no evidence of a difference between groups regarding cord ferritin, infant ferritin, or infant haemoglobin concentrations at any timepoint. Benefits on postpartum anaemia were restricted to mothers with baseline iron deficiency.

INTERPRETATION

Ferric carboxymaltose treatment in the second trimester protected women from postpartum anaemia and iron deficiency but did not affect infant haematological or iron status.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Chichewa translation of the abstract see Supplementary Materials section.

Nutritional interventions for indigenous adults in Canada - opportunities to sustain health and cultural practices: a scoping review

Indigenous People in Canada possess rich cultural traditions, intertwined with a strong connection to nature. However, colonisation and contemporary challenges have given rise to changes in lifestyle and culture, resulting in health and nutrition disparities within these communities. The goal of this review was to explore the available literature of existing Indigenous nutrition programs for adults in Canada. Arksey and O'Malley's scoping review protocol was used to conduct the search between July 2020 and February 2023. Articles were obtained from MEDLINE (Ovid), PsycInfo, Embase (Ovid), CINAHL (EBSCO), Web of Science, Scopus (Elsevier), Canadian Business and Current Affairs (Proquest), and Google Scholar. We identified 24 publications, with 19 being unique interventions. Common themes among programs included integrating traditional foods and cultural values, adapted programming to local needs, empowering community members, using a multidisciplinary collaboration, and leveraging social activities, all of which highlight the need for holistic strategies amid complex historical, social, and environmental factors. Overall, this review emphasises the need for continued support and development of Indigenous-led nutritional initiatives to promote health and well-being among Indigenous adults in Canada. Ensuring culturally relevant and sustainable solutions is crucial for addressing nutritional health disparities and fostering long-term positive outcomes.

Assessing the direct and spillover protective effectiveness of Wolbachia-mediated introgression to combat dengue

BACKGROUND

Dengue remains a global health challenge with limited treatment options, highlighting the need for effective vector control strategies. The introduction of Wolbachia pipientis into Aedes aegypti populations has shown success in reducing dengue transmission across global field trials. However, the spillover effectiveness of the technology on untreated areas is not well-known. This study estimates the spillover protective effectiveness (PE) of Wolbachia-mediated introgression on dengue.

METHODS

We used the synthetic control method (SCM) under assumption of partial interference to evaluate the direct and spillover PEs of Wolbachia-mediated introgression in a long-running operational trial of the intervention in Malaysia. Synthetic controls (SCs), which comprise of a weighted sum of non-spillover controls, were constructed for each directly-treated and spillover site in the pre-intervention period to account for historical imbalances in dengue risk and risk trajectories. SCs were compared to directly/spillover-treated sites to estimate the impact of Wolbachia-introgression on dengue incidence across each site, calendar year and intervention time. Robustness checks, including visual inspections, root-mean-square error (RMSE) calculations, in-space and in-time placebo checks, and permutation tests, were used to inspect the model's ability in attributing dengue incidence reductions to the Wolbachia interventions.

FINDINGS

The direct and spillover PEs of Wolbachia on dengue incidence were expressed as a percentage reduction of dengue incidence, or the absolute case reductions, by comparing SCs to actual intervention/spillover sites. Findings indicate a direct reduction in dengue incidence by 64.35% (95% CI: 63.50-66.71, p < 0.05 using permutation tests) in directly treated areas, corresponding to 1802 (95% CI: 1768-1932) cases averted. Meanwhile, spillover effects contributed to a 37.69% (95% CI: 36.45-38.49, p < 0.05) reduction in adjacent non-intervention areas, accounting for 115 (95% CI: 104-132) absolute cases averted. Tracking PEs by intervention time revealed a dose-response relationship, where PEs increased concomitantly with Wolbachia frequency. Model checks confirmed the robustness of these results, and ascertained that these PEs were not an artefact of poor control selection, pre-trends in dengue incidence or poor predictive ability of the fitted SCs.

INTERPRETATION

Wolbachia-introgression effectively diminished dengue incidence in directly-treated and surrounding spillover regions. This dual effectiveness highlights the potential of Wolbachia-infected mosquitoes as a sustainable, cost-effective strategy against dengue.

FUNDING

This research is hosted by CNRS@CREATE and supported by the National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise (CREATE) program, and is funded by the Lee Kong Chian School of Medicine-Ministry of Education Start-Up Grant. The original Hoffmann et al. (2024) study was funded by the Wellcome Trust Awards 226166, 108508, 202888 and the Ministry of Health Malaysia NMRR-16-297-28898.

Adolescent reproductive health in a post- Dobbs landscape: a review

PURPOSE OF REVIEW

To summarize notable recent research in adolescent reproductive health, particularly with respect to a rapidly changing legal landscape surrounding health services that significantly impact adolescent health.

RECENT FINDINGS

Approval of the first over-the-counter contraceptive pill represented a major advance in adolescent reproductive health, which relied on research regarding its safety, efficacy, and potential to increase access for vulnerable groups. Despite this approval, disparities persist in equitable contraceptive access for adolescents of color and those from sexual and gender identity minorities. Legal changes in access to abortion care and parental involvement in reproductive health decision-making have presented significant challenges for young people across the U.S. Recent research points to the promise of telehealth abortion care and parental acceptance of confidentiality in adolescent reproductive healthcare. Misinformation remains a barrier to advancing adolescent reproductive health and points to continued opportunities for providers to create evidence-based online content.

SUMMARY

In this review, we discuss recent research regarding adolescent reproductive health and laws impacting the reproductive health of adolescents. As the legal landscape evolves, further research surrounding the effect of policy changes that both expand and restrict access to adolescent reproductive health services will be critical to advancing adolescent health.

Patient-Centred Counselling Tools for Dispensing Contraceptives in Community Pharmacy Settings: A Systematic Review

Background

The patient-centred counselling tools are a comprehensive resource to assist community pharmacists in providing effective treatment choices and assisting with decision-making.

Aim

To identify and select suitable tools community pharmacists use with targeted patient-centred outcomes for dispensing contraceptives.

Methods

Five electronic databases, Web of Science, Cochrane Library, PubMed, Scopus, and Google Scholar as additional sources for published and unpublished studies, were searched to identify literature for contraceptive tools or strategies for pharmacists to decide on contraceptive choice and dispensing by pharmacist. Studies involving pharmacists or tools suitable for pharmacists from any country, published since 1990 were considered.

Results

A total of 21 publications met the inclusion criteria. Robvis' tool was used for visualizing the risk of bias for each result. There were three studies that used the tools specifically by community pharmacists and others focused on general family planning users and pharmacists. The suitability of patient-centred interventions in community pharmacy settings was further evaluated.

Conclusion

The evidence for special tools for pharmacists for dispensing contraceptives in community settings is limited and further research is needed to develop and evaluate novel interventions for pharmacists in community settings.

Fine particulate matter and ovarian health: A review of emerging risks

Fine particulate matter (PM2.5) pollution has raised significant public concerns, especially for vulnerable populations. Studies have indicated the association between PM2.5 and ovarian disorders, although the mechanisms underlying the effects have not yet been fully elucidated. In this review, we elucidated three main conditions pertaining to ovarian function that may result from exposure to PM2.5: diminished ovarian reserve, polycystic ovary syndrome, and infertility. Specific effects of ovarian disorders caused by PM2.5 are discussed, including reactive oxygen species, apoptosis, DNA damage, and inflammation.

Beyond policy: perspectives of school health practitioners about providing contraception services to school-going adolescents in South Africa

BACKGROUND

Providing contraception to adolescents is a critical intervention in reducing adolescent and early pregnancy. However, many adolescents, including those attending school, still lack access to contraception. We adapted Baroudi's ecological framework of access to healthcare to explore the perspectives of school health practitioners about providing contraceptive services to school-going adolescents.

METHODS

This is an exploratory qualitative research study. We employed purposive sampling to recruit school health practitioners directly involved in implementing sexual and reproductive health policies or interventions in public secondary schools. From September to October 2023, we conducted semi-structured interviews with forty-nine participants. We followed Braun and Clarke's approach of thematic analysis and adhered to the Consolidated Criteria for Reporting Qualitative Studies checklist for qualitative research reporting.

RESULTS

In our study, participants highlighted the importance of having access to accurate information about contraception and being knowledgeable about school health policies. They also identified socio-cultural norms, denialism and misconceptions as potential barriers to contraception access. Notably, they suggested that strengthened parental involvement and the presence of nurses in schools could significantly improve the provision of contraceptive services to school-going adolescents.

CONCLUSIONS

Our study offers valuable insights into the perspectives of school health practitioners about providing contraception to adolescents. These findings highlight the implications of implementing the Integrated School Health Policy and the Policy on the prevention and management of learner pregnancy in schools. The results of this study could provide valuable insights to policymakers, decision-makers, nurses, and teachers from the Departments of Education and Health. Those insights could enhance the development of school health policies and the implementation of contraception-related programmes for adolescents in secondary schools. This, in turn, would contribute to reducing adolescent pregnancies in South Africa.

Effect of a Reduced PCV10 Dose Schedule on Pneumococcal Carriage in Vietnam

BACKGROUND

After pneumococcal disease and colonization have been controlled through vaccination campaigns, a reduced pneumococcal conjugate vaccine (PCV) schedule may be sufficient to sustain that control at reduced costs.

METHODS

We investigated whether a single primary dose and booster dose (1p+1) of the 10-valent PCV (PCV10) would be noninferior to alternative dose schedules in sustaining control of carriage of pneumococcal serotypes included in the vaccine. In Nha Trang, Vietnam, an area in which PCV had not been used previously, a PCV10 catch-up campaign was conducted in which the vaccine was offered to children younger than 3 years of age, after which a cluster-randomized trial was conducted in which children received PCV10 at 2, 3, and 4 months of age (3p+0 group); at 2, 4, and 12 months of age (2p+1 group); at 2 and 12 months of age (1p+1 group); or at 12 months of age (0p+1 group). Annual carriage surveys in infants (4 to 11 months of age) and toddlers (14 to 24 months of age) were conducted from 2016 through 2020. The primary end point was protection against carriage of vaccine serotypes, evaluated in a noninferiority analysis in the 1p+1 group as compared with the 2p+1 and 3p+0 groups, 3.5 years after vaccine introduction (noninferiority margin, 5 percentage points). Noninferiority of the 0p+1 schedule was also evaluated.

RESULTS

In 2016, before the introduction of PCV10, vaccine-serotype carriage was found in 160 of 1363 infants (11.7%); in 2020, vaccine-serotype carriage was found in 6 of 333 (1.8%), 5 of 340 (1.5%), and 4 of 313 (1.3%) infants in the 1p+1, 2p+1, and 3p+0 groups, respectively, indicating noninferiority of 1p+1 to 2p+1 (difference, 0.3 percentage points; 95% confidence interval [CI], -1.6 to 2.2) and to 3p+0 (difference, 0.5 percentage points; 95% CI, -1.4 to 2.4). Similarly, 1p+1 was noninferior to 2p+1 and 3p+0 for protection against vaccine-serotype carriage among toddlers. In 2016, carriage of serotype 6A was found in 99 of 1363 infants (7.3%); in 2020, it was found in 12 of 333 (3.6%), 10 of 340 (2.9%), and 3 of 313 (1.0%) infants in the 1p+1, 2p+1, and 3p+0 groups, respectively. The 0p+1 schedule was also noninferior to the other three dose schedules among infants and toddlers, although cross-protection against serotype 6A was less common than with the other vaccination schedules. No PCV10-associated severe adverse effects were observed.

CONCLUSIONS

A reduced vaccination schedule involving a single primary dose and booster dose of PCV10 was noninferior to alternative schedules in protecting against vaccine-serotype carriage in infants and toddlers. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov number, NCT02961231.).

Recruitment for Voluntary Video and Mobile HIV Testing on Social Media Platforms During the COVID-19 Pandemic: Cross-Sectional Study

BACKGROUND

The COVID-19 pandemic prompted social distancing policies and caused misinformation that hindered in-person HIV screening for high-risk groups. Social media platforms provide additional options for voluntary counseling and testing (VCT) for HIV, overcoming these limitations. However, there is a lack of data on HIV testing recruitment through social media platforms and its outcomes during the pandemic.

OBJECTIVE

This study aimed to measure the rate of face-to-face mobile and video VCT conducted after recruitment through social media platforms and friend referrals during the pandemic and compare the geographic distribution, risk feature targeting, testing outcome, and cost between the 2 models.

METHODS

Data were collected from March 3 to December 31, 2021, during the COVID-19 outbreak in Taiwan. Participants engaging in unprotected sex were recruited. After one-on-one message discussions through the platforms, the well-trained research assistants provided mobile or video VCT based on the participants' availability. Primary outcomes were completion rate, testing results, and CD4 count. Secondary outcomes included demographic and HIV risk-taking and protective features from a questionnaire. Selection bias was controlled by adjusting for the testing site (Taipei vs non-Taipei) using univariable multinomial logistic regression.

RESULTS

This study gathered 5142 responses on the social media platforms, recruiting 1187 participants. Video VCT had a completion rate of 31.8% (207/651), higher than mobile VCT's 21.8% (980/4491). Both rates were higher than those before the COVID-19 pandemic. Recruitment through friend referrals, instant messaging apps (eg, Line [LY Corporation]), and geosocial dating apps (eg, Hornet [Queer Networks Inc], Grindr [Grindr LLC], and Gsland [Tien-Hao Tsai]) resulted in higher acceptance and completion rates than social networks (eg, Facebook [Meta], X [formerly Twitter], and Instagram [Meta]). Mobile VCT had higher recruitment among urban residents and screening density, while video VCT reached a broader geographic area. The mobile group was more likely to have had more than 10 sexual partners (odds ratio [OR] 1.92, 95% CI 1.05-3.50; P=.03), history of sex work (OR 4.19, 95% CI 1.68-10.43; P=.002), and sexually transmitted diseases (OR 2.23, 95% CI 1.18-4.23; P=.01) within the past 3 months. The video group was more likely to meet sexual partners through social media. The HIV-positive rate in the mobile group was 0.7% (7/973) with an average CD4 count of 460/μL, while in the video group, it was 1% (2/205) with an average CD4 count of 347/μL, indicating a later diagnosis. Both positivity rates were higher than those before the COVID-19 pandemic, with no significant difference between the groups. The video group cost US $54.68 per participant, slightly higher than the US $50.36 for the mobile group.

CONCLUSIONS

Recruiting through social media platforms that facilitate one-on-one message discussions can effectively target high-risk groups for mobile and video VCT. This approach should be integrated into the current screening model to enhance HIV case finding.

Systemic biological mechanisms underpin poor post-discharge growth among severely wasted children with HIV

In sub-Saharan Africa, children with severe malnutrition (SM) and HIV have substantially worse outcomes than children with SM alone, facing higher mortality risk and impaired nutritional recovery post-hospitalisation. Biological mechanisms underpinning this risk remain incompletely understood. This case-control study nested within the CHAIN cohort in Kenya, Uganda, Malawi, and Burkina Faso examined effect of HIV on six months post-discharge growth among children with SM and those at risk of malnutrition, assessed proteomic signatures associated with HIV in these children, and investigated how these systemic processes impact post-discharge growth in children with SM. Using SomaScanTM assay, 7335 human plasma proteins were quantified. Linear mixed models identified HIV-associated biological processes and their associations with post-discharge growth. Using structural equation modelling, we examined directed paths explaining how HIV influences post-discharge growth. Here, we show that at baseline, HIV is associated with lower anthropometry. Additionally, HIV is associated with protein profiles indicating increased complement activation and decreased insulin-like growth factor signalling and bone mineralisation. HIV indirectly affects post-discharge growth by influencing baseline anthropometry and modulating proteins involved in bone mineralisation and humoral immune responses. These findings suggest specific biological pathways linking HIV to poor growth, offering insights for targeted interventions in this vulnerable population.

Quantifying Arm and Leg Movements in 3-Month-Old Infants Using Pose Estimation: Proof of Concept

BACKGROUND

Pose estimation (PE) has the promise to measure pediatric movement from a video recording. The purpose of this study was to quantify the accuracy of a PE model to detect arm and leg movements in 3-month-old infants with and without (TD, for typical development) complex congenital heart disease (CCHD).

METHODS

Data from 12 3-month-old infants (N = 6 TD and N = 6 CCHD) were used to assess MediaPipe's full-body model. Positive predictive value (PPV) and sensitivity assessed the model's accuracy with behavioral coding.

RESULTS

Overall, 499 leg and arm movements were identified, and the model had a PPV of 85% and a sensitivity of 94%. The model's PPV in TD was 84% and the sensitivity was 93%. The model's PPV in CCHD was 87% and the sensitivity was 98%. Movements per hour ranged from 399 to 4211 for legs and 236 to 3767 for arms for all participants, similar ranges to the literature on wearables. No group differences were detected.

CONCLUSIONS

There is a strong promise for PE and models to describe infant movements with accessible and affordable resources-like a cell phone and curated video repositories. These models can be used to further improve developmental assessments of limb function, movement, and changes over time.

Procedural legitimacy: co-developing a community agreement model for genetic approaches research to malaria control in Africa

With reductions in the malaria burden stalling in the past years, gene drive holds promise as a novel way of reducing disease transmission. Governance and decision-making processes are pivotal aspects of the legitimate adoption of this technology. Here, the authors explore Target Malaria's journey in developing a community agreement model for the release of non-gene drive genetically modified mosquitoes. They describe the iterative development of the model, including consultations with experts, stakeholder engagement, and alignment with principles of procedural justice. Several challenges were identified during its development, including defining communities, ensuring adequate information, consultation, monitoring, and achieving a common decision between dissenting and consenting viewpoints. They underscore the complexity of developing a legitimate model and emphasize the importance of transparency, procedural legitimacy, and adherence to ethical principles. This paper does not describe the model itself, which will be the subject of another paper. Instead it focuses on the process, to share this experience with other projects-those working with gene drive, or any other projects requiring a community-level decision-making process. The model builds on Target Malaria's experience with the release of genetically modified sterile male mosquitoes, to address the challenges posed by modified mosquitoes which are fertile and would therefore be expected to persist longer in the environment and spread further than the sterile male mosquito strains. While the level of spread and persistence of these non gene drive, but fertile, modified mosquitoes are expected to be substantially lower than those of the gene drive mosquitoes, the process is an essential advance in accommodating the broader geographical and temporal concerns associated with the more permanent spread of gene drive mosquitoes. The work described here constitutes part of the evolution of a community agreement process that could be applied to proposals for releases of gene drive mosquitoes for malaria control. In describing this process, Target Malaria hopes to contribute to the ongoing dialogue on good practices for community agreement engagement in research for genetic vector control approaches and to share the experience of building legitimacy while designing such agreement models.

Factors influencing provider deviation from national HIV and nutritional guidelines for HIV-exposed children in western Kenya: a qualitative study

BACKGROUND

Malnutrition and HIV interact in a vicious cycle for HIV-exposed infants (HEIs), increasing vulnerability and the severity of each condition and contributing to poor health outcomes. We identified multi-level factors influencing provider adherence to Kenyan HIV and nutrition guidelines for HEIs.

METHODS

We conducted six focus group discussions and seven in-depth interviews using a semi-structured question guide. Participants were selected through purposive maximum variation sampling of health workers involved in maternal and child health services and outpatient nutrition programs at two facilities in western Kenya. Data collection and analysis were guided by the Theoretical Domains Framework (TDF). Transcripts were coded by two primary coders using both deductive and inductive thematic analysis.

RESULTS

TDF domains that drove guideline adherence included: environmental context and resources, beliefs about capabilities, and social influences. While participants praised attempts to integrate HIV and nutritional services through teamwork and service colocation, challenges in the successful referral of patients between services persisted. Participants described siloed HIV and nutrition-related knowledge across staff, leading to missed or delayed care if certain providers were unavailable. Participants emphasized understaffing as a major contributor to gaps in care. Inconsistent material resource availability also disrupted linkages between HIV and nutrition services for patients. While participants frequently expressed high intention and internal motivation to link children between services, they described minimal structured supervision or positive reinforcement from supervisors and feeling demoralized when resource constraints interfered with care provision. Lastly, participants described patient-level factors that made it challenging for families to seek or remain in care, including poverty and HIV and malnutrition-related stigma. Participants made several recommendations, including training multiple cadres in the fundamentals of both HIV and nutritional care to address siloed services and understaffing.

CONCLUSIONS

This study details the factors that facilitate or hinder health workers as they implement national guidelines and link HEIs between HIV and nutritional services, including the impact of physical integration of service sites, human and material resource constraints, and health worker motivation. Future interventions can address these challenges by expanding access to needed resources, task sharing, and testing implementation strategies that increase the efficiency of service delivery to improve linkages in care for vulnerable infants.

Effective Coverage of Modern Contraceptive Use in Ethiopia: An Ecological Linking Analysis of Service Provision Assessment and National Health Equity Surveys

The increase in contraceptive prevalence rate (crude coverage) in Ethiopia over the past two decades does not necessarily reflect service quality, and although the proportion of women with unmet needs has decreased, it remains unacceptably high. Hence, this study aimed to estimate the effective coverage (EC) of modern contraceptive methods in Ethiopia, considering the quality of care. We used nationally representative surveys, such as health facility surveys (Ethiopia Service Provision Assessment, 2021/22) and household surveys (National Health Equity Survey, 2022/2023). The descriptive analysis and ecological linking of the two surveys were used to assess the relationship between service quality and utilization among married/in union women in need of limiting or spacing children. In 2022, about 78% of health facilities in Ethiopia were ready to provide Family Planning (FP) services using modern contraceptive methods. Met FP need was 48%, with the quality of services assessed at 36%. After accounting for both service quality and readiness, Ethiopia's effective coverage of family planning services using modern methods was estimated at 16%, with the highest coverage in the Sidama region (21%) and the lowest in the Somali region (2%). The EC of FP services in Ethiopia was low, largely attributed to the poor overall quality of the FP services provided. It is therefore important to ameliorate the quality of FP services in the country.

Socio-cultural practices and experience of mothers' post stillbirth and newborn death: a population-based perspective from India

INTRODUCTION

We report on post stillbirth and newborn death socio-cultural experience of women from a population-based representative sample in the Indian state of Bihar.

METHODS

A state-representative sample of 7,270 births between July 2020 and June 2021 was sampled, including 582 stillbirths and 831 newborn deaths. Detailed confidential interviews were conducted with the consenting women with stillbirth and newborn death to understand their post-birth experience.

RESULTS

A total of 501 (86.1% participation) women with stillbirth and 717 (86.3% participation) with neonatal death provided interview. Able to talk to someone about their baby and receiving support to cope with their loss were reported by 369 (74.2%) and 398 (80.2%) women with stillbirth; these proportions were 76.7% and 77.3% for women with newborn deaths, respectively. More than 80% of these women reported spouses as their main source of support. At least one negative experience was reported by 150 (30.9%) and 233 (32.5%) women with stillbirth and newborn death, respectively. The most commonly reported negative experience was receiving insensitive/hurtful comments about the baby (18.6% for stillbirth and 20.4% for newborn deaths), followed by being blamed for the baby's death (14.3% for stillbirths and 15.0% for newborn deaths). The majority of women reported being verbally abused by the mother-in-law for both stillbirth (24, 63.2%) and newborn death (49, 64.5%); while 48 (67.6%) and 66 (61.7%) women were blamed by the mother-in-law for stillbirth and neonatal death, respectively. Most women with stillbirth (72.7%) and with neonatal death (77.1%) were asked to forget about their babies as a means to cope with their loss. Naming, seeing, and holding the stillborn were reported by 56 (11.2%), 229 (45.9%), and 64 (12.8%) women with a stillborn.

CONCLUSION

With one-third women with adverse birth outcome reporting negative experience, this translates into a significant number of women in India as it accounts for high numbers of stillbirths and newborn deaths globally. These population-based data can facilitate in designing interventions to improve post-partum experience for women with adverse birth outcomes in India.

Therapeutic Hypothermia and Its Role in Preserving Brain Volume in Term Neonates with Perinatal Asphyxia

Background: Perinatal asphyxia is a major cause of neonatal morbidity and mortality, often resulting in hypoxic-ischemic encephalopathy (HIE) with long-term neurodevelopmental impairments. While therapeutic hypothermia has emerged as a promising intervention to reduce brain damage, its specific impact on key brain structures and long-term neurodevelopmental outcomes remains underexplored. This study aims to evaluate the effects of therapeutic hypothermia on brain volumetry, cortical thickness, and neurodevelopment in term neonates with perinatal asphyxia. Methods: This prospective cohort study enrolled 34 term neonates with perinatal asphyxia, with 12 receiving therapeutic hypothermia and 22 serving as controls without hypothermia. Brain MRI data were analyzed using Infant FreeSurfer to quantify the basal ganglia volumes, gray matter, white matter, cerebellum, cortical gyri, and cortical thickness. Neurodevelopmental outcomes were assessed at 18 and 24 months, using the Bayley Scale III, evaluating the motor, cognitive, and language domains. Genetic analyses, including next-generation sequencing (NGS) and microarray testing, were performed to investigate potential neurodevelopmental markers and confounding factors. Results: Neonates treated with hypothermia demonstrated significantly larger gray and white matter volumes, with a 3.7-fold increase in gray matter (p = 0.025) and a 2.2-fold increase in white matter (p = 0.025). Hippocampal volume increased 3.4-fold (p = 0.032) in the hypothermia group. However, no significant volumetric differences were observed in the cerebellum, thalamus, or other subcortical regions. Moderate correlations were found between white matter volume and cognitive outcomes, but these associations were not statistically significant. Conclusions: Therapeutic hypothermia appears to have region-specific neuroprotective effects, particularly in gray and white matter and the hippocampus, which may contribute to improved neurodevelopmental outcomes. However, the impact was not uniform across all brain structures. Further research is needed, to investigate the long-term benefits and to optimize therapeutic strategies by integrating advanced neuroimaging techniques and genetic insights.

Long-lasting residual efficacy of a new indoor residual spraying product, VECTRON™ T500 (broflanilide), against pyrethroid-resistant malaria vectors and its acceptance in a community trial in Burkina Faso

BACKGROUND

The WHO Global Malaria Programme advocates for a comprehensive, strategic approach to managing insecticide resistance, highlighting the importance of using multiple insecticides with different modes of action through rotations and combinations. To slow the spread of resistance, it is essential to develop and evaluate new formulations that feature unique modes of action and extended residual effects. Addressing this need, Mitsui Chemicals Crop & Life Solutions, Inc., developed VECTRON™ T500, a new indoor residual spraying (IRS) formulation using broflanilide, applied at a dosage of 100 mg AI/m2. This formulation was tested in a Phase III community trial, alongside Actellic® 300CS, a commonly used IRS product containing pirimiphos-methyl, applied at the recommended dosage of 1000 mg AI/m2.

METHODS

Monthly WHO wall cone bioassays were performed to assess the efficacy of the interventions using three mosquito strains: the laboratory-bred, insecticide-susceptible Anopheles gambiae s.s. Kisumu strain, the insecticide-resistant Anopheles coluzzii VKPer strain, and wild Anopheles gambiae s.l. mosquitoes from the Vallée du Kou, where the study was conducted. Vector surveillance was carried out to compare the results between sites treated with VECTRON™ T500, Actellic® 300CS, and an untreated control site. In addition, any reported adverse effects were closely monitored to evaluate the community's acceptance of VECTRON™ T500.

RESULTS

VECTRON™ T500 consistently achieved 100% mortality across all wall types for both susceptible and resistant mosquito strains over the 12-month period. In comparison, Actellic® 300CS induced < 80% mortality for both strains, irrespective of the wall substrate. When assessing delayed mortality in An. gambiae s.l. mosquitoes collected from sites treated with Actellic® 300CS (VK1) and VECTRON™ T500 (VK3), a statistically significant difference was noted after a 72-h holding period compared to the control site (RR = 0.51, CI95% = [0.31-0.6], P = 0.0026). Additionally, no adverse events were reported in households sprayed with VECTRON™ T500.

CONCLUSIONS

The residual efficacy of VECTRON™ T500 extended for 12 months post-spraying, effectively covering the full malaria transmission season while maintaining high mortality rates in pyrethroid-resistant malaria vectors. VECTRON™ T500 demonstrated non-inferiority in performance compared to Actellic® 300CS, the standard reference product. This new IRS formulation has the potential to play a crucial role in managing insecticide resistance by being integrated into a rotational strategy alongside other IRS products containing insecticides with different modes of action.

Perceived Stress, Resilience and Emotional Intelligence in Romanian Healthcare Professionals

BACKGROUND

Occupational stress and burnout in the medical field are common factors that can have a negative impact on the quality of clinical care. In the Romanian healthcare environment, there exists important financial difficulties contributing additionally to stress in this study, we aimed to investigate if resilience and emotional intelligence would prove to be protective factors against stress.

METHODS

In our cross-sectional study, we investigated 189 medical professionals, using convenience sampling, from July 2022 to September 2022 in two university centers. We applied a self-reported questionnaire that included socio-demographic characteristics and three scales that measured perceived stress (the Perceived Stress Scale), resilience to stress (the Connor-Davidson Resilience Scale), and emotional intelligence (the short-form Trait Emotional Intelligence Questionnaire).

RESULTS

Age was positively associated with resilience levels, meaning that resilience increases with age. While specialist physicians had the highest emotional intelligence score, nurses and other healthcare workers had the highest resilience scores. Perceived stress level was negatively correlated with resilience to stress and with emotional intelligence levels. Resilience to stress was positively correlated with emotional intelligence.

CONCLUSIONS

The major strength of this study is the finding that resilience to stress mediated the association between perceived stress and emotional intelligence. Because resilience is negatively associated with burnout, resilience to stress and emotional intelligence are potential targets for training aimed at improving the working environment and reducing current levels of burnout in the Romanian Health System and beyond.

Supporting contraceptive self-care and reproductive empowerment with a digital health game in Barbados: Development and Pre-implementation study for What's My Method?

Effective contraceptive education is essential to reducing unwanted pregnancy, increasing uptake of modern contraceptive methods, and thoughtfully planning desired births. New World Health Organization (WHO) and family planning organization guidelines recommend situating contraceptive education and counseling within a broader context of self-care that emphasizes individual agency and reproductive empowerment. Digital health interventions, and games for health specifically, have been validated as effective and scalable tools for self-guided and interactive health education, especially among younger tech-savvy individuals. Barbados currently supplements provider-based contraceptive counseling with analog materials (pamphlets and posters) and informational videos that play on a screen in the waiting room. As part of an implementation framework, this study seeks to conduct a formative evaluation of the What's My Method? (WMM) game intervention as a tool to support contraceptive counseling and increase reproductive empowerment among childbearing persons in Barbados. We test-deployed the WMM game in Bridgetown, Barbados, conducting playtests and unstructured discussions with prototypes of the WMM game among three groups of stakeholders (youth contraception ambassadors: n=8; healthcare providers: n=7; and nursing students: n=27) to determine acceptability of the intervention, efficacy of the game as a learning tool, and willingness to adopt the tool in their healthcare context. Feedback on acceptability of the game was largely positive. Detailed constructive comments informed modifications and improvements to the game. The questionnaire used to assess contraceptive knowledge gain did not prove effective. Results indicate that the WMM game is well-received and accepted by the healthcare professionals who would be deploying it. This pilot testing has informed the design of the modified WMM for a randomized controlled trial (RCT) to test the deployment of the game in a healthcare setting.

Post-release monitoring pathway for the deployment of gene drive-modified mosquitoes for malaria control in Africa

BACKGROUND

Gene drive-modified mosquitoes (GDMMs) have been promoted as one of the innovative technologies that may control and eliminate malaria and other mosquito-borne diseases. Several products are in early stages of development, targeting either population suppression or population modification of the mosquito vector. However, there is no direct experience of conducting risk assessment for environmental releases and subsequent policies regarding conditions for post-release. This study was carried out to gain additional insights on the possible post-release concerns that may arise, as they may inform future risk assessment and planning for deployment.

METHODS

This study involved desktop reviews on post release monitoring experiences with previously released biological control products. Stakeholder consultations involving online surveys, and face to face workshop with experts from selected African countries from Eastern, Western, and Southern African regions was then carried out to establish post-release monitoring concerns for GDMMs.

RESULTS

Review of genetic biocontrol technologies showed only limited lessons from post-release monitoring regimes with a focus largely limited to efficacy. For genetically modified organisms general surveillance and case-specific monitoring is expected in some of the regions. A number of post-release monitoring concerns in relation to the protection goals of human and animal health, biodiversity, and water quality were identified.

CONCLUSION

Based on established- protection goals, several post-release monitoring concerns have been identified. Subject to a rigorous risk assessment process for future GDMMs products, the concerns may then be prioritized for post-release monitoring.

Enhancing childhood immunization coverage in Mozambique and Malawi: Study protocol of a mixed methods evaluation of the 'Let's talk about vaccines' multisite community-based participatory project

BACKGROUND

Full coverage of childhood vaccines is a persistent challenge in low- and middle-income countries, suggesting the presence of specific contextual barriers. The emergence of the COVID-19 pandemic further worsened the situation. The complementary use of community-based participatory research (CBPR) and human-centered design (HCD) approaches has the potential to effectively create tailored interventions for improving public health outcomes. This protocol provides examples of methods to evaluate the use of these novel approaches in low- and middle-income countries. The 'Let's talk about vaccines' project is a multisite community-based participatory project by VillageReach that uses the CBPR and HCD approaches to identify the barriers and co-create interventions/solutions to address under two routine immunization access and uptake in Malawi and Mozambique.

METHODS

Guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, this evaluation prospectively evaluates the effectiveness (on under-two immunization coverage and related outcomes) of VillageReach's co-created interventions and processes of implementation (reach, adoption, implementation and maintenance) in two districts in Mozambique and two in Malawi. This paper will also describe the theory of change for VillageReach's project. Thematic analysis will be used to analyze the qualitative data, and interrupted time series analysis used to analyze the co-created interventions' effectiveness on specific under two immunization outcomes. The analysis will integrate complex systems thinking and constructs inherent in health systems strengthening.

DISCUSSION

This evaluation is an opportunity to share the use of novel and best practices, opportunities and challenges for improved community-responsive programming in routine immunization. It will be fundamental in providing evidence on the impact of interventions, evidence on mechanisms behind improvements in under- two immunization outcomes due to codesigned community-driven solutions and informing their scalability in similar contexts. Findings will inform the development of a comprehensive framework to guide the scalability of community-based approaches on childhood immunization uptake and access into similar contexts.

HIV phylogenetic clusters point to unmet hiv prevention, testing and treatment needs among men who have sex with men in kenya

BACKGROUND

The HIV epidemic in Kenya remains a significant public health concern, particularly among gay, bisexual, and other men who have sex with men (GBMSM), who continue to bear a disproportionate burden of the epidemic. This study's objective is to describe HIV phylogenetic clusters among different subgroups of Kenyan GBMSM, including those who use physical hotspots, virtual spaces, or a combination of both to find male sexual partners.

METHODS

Dried blood spots (DBS) were collected from GBMSM in Kisumu, Mombasa, and Kiambu counties, Kenya, in 2019 (baseline) and 2020 (endline). HIV pol sequencing was attempted on all seropositive DBS. HIV phylogenetic clusters were inferred using a patristic distance cutoff of ≤ 0.02 nucleotide substitutions per site. We used descriptive statistics to analyze sociodemographic characteristics and risk behaviors stratified by clustering status.

RESULTS

Of the 2,450 participants (baseline and endline), 453 (18.5%) were living with HIV. Only a small proportion of seropositive DBS specimens were successfully sequenced (n = 36/453; 7.9%), likely due to most study participants being virally suppressed (87.4%). Among these sequences, 13 (36.1%) formed eight distinct clusters comprised of seven dyads and one triad. The clusters mainly consisted of GBMSM seeking partners online (n = 10/13; 76.9%) and who tested less frequently than recommended by Kenyan guidelines (n = 11/13; 84.6%).

CONCLUSIONS

Our study identified HIV phylogenetic clusters among Kenyan GBMSM who predominantly seek sexual partners online and test infrequently. These findings highlight potential unmet HIV prevention, testing, and treatment needs within this population. Furthermore, these results underscore the importance of tailoring HIV programs to address the diverse needs of GBMSM in Kenya across different venues, including both physical hotspots and online platforms, to ensure comprehensive prevention and care strategies.

Person-centered contraceptive counseling and associations with contraceptive practices among a nationally representative sample of women in Ethiopia

Objectives

To estimate levels of person-centered contraceptive counseling among current and recent contraceptive users, assess for whom counseling differs, and examine the relationship between counseling and contraceptive practices, specifically use of provider-dependent methods and use of one's preferred method, among women in Ethiopia.

Study design

This cross-sectional study uses nationally representative data collected by the Performance Monitoring for Action Ethiopia project among current and recent contraceptive users (n = 2731) aged 15-49 between October and November 2021. Descriptive analyses estimated person-centered counseling levels via the recently validated quality of contraceptive counseling short scale (QCC-10). Bivariable and multivariable logistic regression estimated associations with contraceptive practices.

Results

Contraceptive users in Ethiopia receive moderate quality counseling (mean QCC-10 score = 2.69, range: 1.1-4.0) with significant social inequities in the receipt of person-centered care. Women who are younger, uneducated, not in union, from poorer households, or who sourced their method from a non-public facility reported less person-centered care. Strong relationships were observed between higher quality counseling and women's contraceptive practices. Those receiving highest quality counseling had nearly double the odds of using provider-dependent methods compared to those reporting lowest quality counseling (AOR: 1.92; 95% CI: 1.16-3.18). Among current users, women reporting highest quality counseling had 62% higher odds of using their preferred method relative to women receiving poorest quality care (95% CI: 1.06-2.48).

Conclusion

Poorer quality care is associated with use of non-preferred methods and reliance on provider-independent methods. Efforts to reduce reproductive health disparities and promote contraceptive autonomy should prioritize a person-centered approach to contraceptive counseling for all.

Implications

Inequitable delivery of person-centered contraceptive care based on individuals' sociodemographic characteristics, such as education or marital status, undermines women's reproductive autonomy and hinders contraceptive experiences. Person-centered contraceptive counseling should be provided to all women in Ethiopia, regardless of their background, to support individuals in achieving their reproductive goals.

The impact of group antenatal care on newborns: Results of a cluster randomized control trial in Eastern Region, Ghana

BACKGROUND

Maternal recognition of neonatal danger signs following birth is a strong predictor of care-seeking for newborn illness, which increases the odds of newborn survival. However, research suggests that maternal knowledge of newborn danger signs is low. Similarly, maternal knowledge of optimal newborn care practices has also been shown to be low. Since both issues are typically addressed during antenatal care, this study sought to determine whether group antenatal care (G-ANC) could lead to improvements in maternal recognition of danger signs and knowledge of healthy newborn practices, as well as boosting postnatal care utilization.

METHODS

This cluster randomized controlled trial of G-ANC compared to routine individual antenatal care (I-ANC) was conducted at 14 health facilities in Ghana, West Africa, from July 2019 to July 2023. Facilities were randomized to intervention or control, and pregnant participants at each facility were recruited into groups and followed for the duration of their pregnancies. 1761 participants were recruited: 877 into G-ANC; 884 into I-ANC. Data collection occurred at enrollment (T0), 34 weeks' gestation to 3 weeks postdelivery (T1) and 6-12 weeks postpartum (T2). Comparisons were made across groups and over time using logistic regression adjusted for clustering.

RESULTS

Overall, knowledge of newborn danger signs was significantly higher for women in G-ANC, both in aggregate (13-point scale) and for many of the individual items over time. Likewise, knowledge of what is needed to keep a newborn healthy was higher among women in G-ANC compared to I-ANC over time for the aggregate (7-point scale) and for many of the individual items. Women in G-ANC were less likely to report postnatal visits for themselves and their babies within 2 days of delivery than women in I-ANC, and there was no difference between groups regarding postnatal visits at one week or 6 weeks after birth.

CONCLUSION

This study illustrates that group ANC significantly improves knowledge of newborn danger signs and healthy newborn practices when compared to routine care, suggesting that the impact of G-ANC extends beyond impacts on maternal health. Further research elucidating care pathways for ill newborns and maternal behaviors around healthy newborn practices is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04033003, Registered: July 25, 2019 Protocol Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9508671/ .

Increased measles and rubella seroprevalence in children using residual blood samples from health facilities and household serosurveys after supplementary immunization activities in two districts in India

Residual blood specimens provide a sample repository that could be analyzed to estimate and track changes in seroprevalence with fewer resources than household-based surveys. We conducted parallel facility and community-based cross-sectional serological surveys in two districts in India, Kanpur Nagar District, Uttar Pradesh, and Palghar District, Maharashtra, before and after a measles-rubella supplemental immunization activity (MR-SIA) from 2018 to 2019. Anonymized residual specimens from children 9 months to younger than 15 years of age were collected from public and private diagnostic laboratories and public hospitals and tested for IgG antibodies to measles and rubella viruses. Significant increases in seroprevalence were observed following the MR SIA using the facility-based specimens. Younger children whose specimens were tested at a public facility in Kanpur Nagar District had significantly lower rubella seroprevalence prior to the SIA compared to those attending a private hospital, but this difference was not observed following the SIA. Similar increases in rubella seroprevalence were observed in facility-based and community-based serosurveys following the MR SIA, but trends in measles seroprevalence were inconsistent between the two specimen sources. Despite challenges with representativeness and limited metadata, residual specimens can be useful in estimating seroprevalence and assessing trends through facility-based sentinel surveillance.

Describing the effect of COVID-19 on sexual and healthcare-seeking behaviours of men who have sex with men in three counties in Kenya: a cross-sectional study

BACKGROUND

While the COVID-19 pandemic disrupted HIV preventative services in sub-Saharan Africa, little is known about the specific impacts the pandemic has had on men who have sex with men (MSM) in Kenya.

METHODS

Data were from an HIV self-testing intervention implemented in Kisumu, Mombasa and Kiambu counties in Kenya. Baseline data collection took place from May to July 2019, and endline in August-October 2020, coinciding with the lifting of some COVID-19 mitigation measures. Using endline data, this study characterised the impact the pandemic had on participants' risk behaviours, experience of violence and behaviours related to HIV. Logistic regression was used to understand factors related to changes in risk behaviours and experiences of violence; adjusted AORs (AORs) and 95% CIs are reported.

RESULTS

Median age was 24 years (IQR: 21-27). Most respondents (93.9%) reported no change or a decrease in the number of sexual partners (median number of male sexual partners: 2, IQR: 2-4). Some participants reported an increase in alcohol (10%) and drug (16%) consumption, while 40% and 28% reported decreases in alcohol and drug consumption, respectively. Approximately 3% and 10% reported an increase in violence from intimate partners and police/authorities, respectively. Compared with those with primary education, those with post-secondary education were 60% less likely to report an increase in the number of male sexual partners per week (AOR: 0.4, 95% CI: 0.2 to 0.9), while those who were HIV positive were at twofold the odds of reporting an increase or sustained levels of violence from intimate partners (AOR: 2.0, 95% CI: 1.1 to 4.0).

CONCLUSION

The results of this study demonstrate heterogeneity in participants' access to preventative HIV and clinical care services in Kenya after the onset of the COVID-19 epidemic. These results indicate the importance of responding to specific needs of MSM and adapting programmes during times of crisis.

Intimate Partner Violence during the Index Pregnancy and its correlates among a panel of pregnant women in Ethiopia, evidence from performance, and monitoring for action (PMA) 2021 cohort two baseline survey

INTRODUCTION

Current intimate partner violence (IPV) in Ethiopia is considerably high. This study aimed at determining the prevalence of IPV among a panel of pregnant women during their index pregnancy and identify its correlates using Performance Monitoring for action (PMA) cohort 2 baseline data. Documenting the magnitude of IPV thus far during the index pregnancy and identifying factors affecting it contributes its share for the ministry and relevant developmental partners in tracking progress towards eliminating all forms of violence against women and girls by 2030.

METHODS

We conducted a further analysis of national level follow up secondary data sets from Performance Monitoring for action Ethiopian (E_PMA). This study used PMA cohort two baseline data which enrolled pregnant and recently postpartum women and collected real time data on various sexual, reproductive, maternal and new born nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using standard pretested questionnaire prepared in three local languages (Amharic, Afan Oromo and Tigrigna) by well experienced resident enumerators. This study was restricted to 1,796 pregnant women at the enrollment. Frequency was computed to describe the study participant's characteristics, and chi-square statistics was used to assess cell sample size adequacy. Multilevel binary logistics regression model building process was employed to identify correlates of IPV. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using p-value of 0.25. Statistical significance was declared at p-value of 0.05.

RESULTS

One in six; 16.7% (14.81%, 18.76%) pregnant women have reported experiencing at least one form of physical and/or sexual IPV thus far in their index pregnancy. The prevalence of encountering at least one form of sexual violence was 12.53% (10.91%, 14.35%) while 7% (5.5%, 8.3%) of them experienced at least one form physical intimate partner violence thus far during their index pregnancy. Women perceived risk about contraceptive use ((AOR: 95% CI: 1.66 (1.10, 2.47)), higher birth order ((AOR: 95% CI: 1.88 (1.05, 3.34)), unhappy emotional fertility intention when learned their index pregnancy ((AOR: 95% CI: 1.7 (1.02, 2.84)) and a family size of 4 to 5 ((AOR: 95% CI: 1.87 (1.11. 3.14)) were the fixed effects factors found to increase the odds of IPV significantly and positively. On the contrary, being in the third trimester of gestation at enrollment was another fixed effect variable which contributed for the 44% lower odds ((AOR: 95% CI: 0.56 (0.34, 0.92)) of experiencing IPV thus far in their index pregnancy.

CONCLUSIONS

The overall burden of IPV reported was high; with nearly double the percentage of women experiencing sexual violence during the index pregnancy compared to physical IPV. More work needs to be done to achieve zero tolerance against any form of violence among women and girls in general and among pregnant women in particular. Efforts targeted in improving women perception on issue related with their contraceptive use, counseling women on how to prevent IPV during their antenatal care (ANC) visit along with advising the use of inter pregnancy contraception and empowering them to control on their fertility are hoped to mitigate such considerably higher odds of IPV among pregnant women. Further programs and intervention on awareness creation towards the misconception that women held about contraceptive use would contribute much. These activities and efforts need to target younger women. The implication of the findings calls key actors and the Federal Democratic Republic of Ethiopia Health Minster to design and implement programs on women emotional fertility readiness and empowering them to control over their fertility through diversified contraceptive provision which is critical in combating the reported substantial IPV experience during pregnancy. Creating institutional capacity in the health system through strengthening and expanding one stop centers to provide medical treatment, care, and psychosocial support for victims and survivors could play a pivotal role. In addition, installing rapid referral system and linkage to the legal system could play a vital role. Moreover, working on early marriage and counseling on childbirth; and spaced pregnancy for those young couples is imperative. Further implication of this study was installing contraceptive and violence related preconception care packages in the health system is very critical in the combat against IPV and any form of gender based violence.

Microfluidic qPCR for detection of 21 common respiratory viruses in children with influenza-like illness

Multiple respiratory viruses lead to high morbidity and mortality, yet global surveillance platforms focus primarily on seasonal influenza viruses. The COVID-19 pandemic and new RSV vaccines highlight the importance of a broader approach. Upper respiratory tract swabs from children aged 24-59 months presenting with influenza-like illness in The Gambia were collected during follow-up of a live-attenuated influenza vaccine randomised controlled trial in 2017-18. A microfluidic quantitative polymerase chain reaction (qPCR) assay was established and used to detect 21 respiratory viruses. 76.6% of samples had one or more viruses detected (n = 121/158). The viruses detected most frequently were rhinovirus (n = 37/158, 23.4%) and adenovirus (n = 34/158, 21.5%), followed by parainfluenza virus 3, influenza B and human metapneumovirus B. A third of positive samples had multiple viruses detected (two n = 31/121, 25.6%; three n = 9/121, 7.4%). Our data demonstrates how microfluidic qPCR is a useful tool for high-throughput, comprehensive detection of multiple respiratory viruses in surveillance platforms. Rapidly changing epidemiology exemplifies the need for new, broader approaches to virus surveillance in low-resource settings to respond to future epidemics and to guide the need for and use of new prevention and therapeutic measures.

Using an experience-based co-design approach to develop strategies for implementing an intravenous iron intervention to treat moderate and severe anemia in pregnancy in Malawi

BACKGROUND

In low- and middle-income countries, women experiencing anemia during pregnancy are recommended to take 30 mg to 60 mg of oral iron daily throughout pregnancy. However, oral iron tablets are often poorly tolerated and slow in correcting anemia, resulting in low adherence, prolonged anemia, and increased risk of adverse maternal and fetal outcomes. An alternative to oral iron is intravenous (IV) iron, commonly used in high-income countries to restore the body's iron stores rapidly. A randomized controlled trial was conducted to investigate the effectiveness and safety of IV iron compared to standard-of-care oral iron supplementation for pregnant women with moderate and severe anemia in the third trimester in Malawi (REVAMP-TT). Using an experience-based co-design approach, our study aimed to identify barriers and facilitators to IV iron use to treat anemia in pregnancy in the primary healthcare system of Malawi, and develop mitigating strategies for the successful implementation of REVAMP-TT.

METHODOLOGY

The co-design process involved two phases: i) We conducted an information-gathering exercise to identify barriers and facilitators to IV iron use to treat anemia in pregnancy in the primary healthcare system of Malawi. We interviewed key informants (n = 53) including the policymakers, government partners, healthcare managers, and healthcare providers. We also gathered previous research findings from a formative qualitative study on the perceptions and experiences of IV iron treatment for pregnant women experiencing anemia in Malawi (n = 29). ii) We conducted two co-design workshops with end-users (n = 20) and healthcare providers (n = 20) to confirm and identify the key barriers and facilitators and developed mitigating strategies to inform the successful implementation of the REVAMP-TT trial. We mapped the emerging barriers to the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0) and matched the mitigating strategies to the corresponding Expert Recommendations for Implementing Change (ERIC) compilation.

RESULTS

The following were identified as key barriers to IV iron use to treat anemia in pregnancy in the primary healthcare system of Malawi: the cost of IV iron, the lack of available resources and knowledge, local attitudes including myths and misconceptions about IV iron and keeping pregnancy a secret, local conditions, the lack of political will and buy-in from high-level leaders, the lack of capability of healthcare providers to deliver IV iron, and the lack of male involvement to support pregnant women's access to antenatal care. The proposed strategies to mitigate the barriers for the successful implementation of the REVAMP TT trial included providing financial strategy, developing stakeholder relationships, training and educating stakeholders, supporting clinicians, and engaging end-users.

CONCLUSION

The use of the experience-based co-design approach in our study provided a valuable method to expose the potential barriers and facilitators to IV iron use and develop mitigating strategies to successfully implement the REVAMP-TT trial. Engaging both the key informants and end users promoted ownership and consensus among stakeholders and ensured a collaborative environment for sharing deeply rooted real-world experiences and insights. Not only do these findings address the needs of this study, but they also, lay a groundwork for the possible integration of IV iron into routine care in Malawi and provide knowledge for policymakers to make informed decisions on the management of anemia in the primary healthcare systems of Malawi.

Biological control for One Health

Biological control has been effectively exploited by mankind since 300 CE. By promoting the natural regulation of pests, weeds, and diseases, it produces societal benefits at the food-environment-health nexus. Here we scrutinize biological control endeavours and their social-ecological outcomes through a holistic 'One-Health' lens, recognizing that the health of humans, animals, plants, and the wider environment are linked and interdependent. Evidence shows that biological control generates desirable outcomes within all One Health dimensions, mitigating global change issues such as chemical pollution, biocide resistance, biodiversity loss, and habitat destruction. Yet, its cross-disciplinary achievements remain underappreciated. To remedy this, we advocate a systems-level, integrated approach to biological control research, policy, and practice. Framing biological control in a One Health context helps to unite medical and veterinary personnel, ecologists, conservationists and agricultural professionals in a joint quest for solutions to some of the most pressing issues in planetary health.

Dengue virus genomic surveillance in the applying Wolbachia to eliminate dengue trial reveals genotypic efficacy and disruption of focal transmission

Release of Aedes aegypti mosquitoes infected with Wolbachia pipientis (wMel strain) is a biocontrol approach against Ae. aegypti-transmitted arboviruses. The Applying Wolbachia to Eliminate Dengue (AWED) cluster-randomised trial was conducted in Yogyakarta, Indonesia in 2018-2020 and provided pivotal evidence for the efficacy of wMel-Ae. aegypti mosquito population replacement in significantly reducing the incidence of virologically-confirmed dengue (VCD) across all four dengue virus (DENV) serotypes. Here, we sequenced the DENV genomes from 318 dengue cases detected in the AWED trial, with the aim of characterising DENV genetic diversity, measuring genotype-specific intervention effects, and inferring DENV transmission dynamics in wMel-treated and untreated areas of Yogyakarta. Phylogenomic analysis of all DENV sequences revealed the co-circulation of five endemic DENV genotypes: DENV-1 genotype I (12.5%) and IV (4.7%), DENV-2 Cosmopolitan (47%), DENV-3 genotype I (8.5%), and DENV-4 genotype II (25.7%), and one recently imported genotype, DENV-4 genotype I (1.6%). The diversity of genotypes detected among AWED trial participants enabled estimation of the genotype-specific protective efficacies of wMel, which were similar (± 10%) to the point estimates of the respective serotype-specific efficacies reported previously. This indicates that wMel afforded protection to all of the six genotypes detected in Yogyakarta. We show that within this substantial overall viral diversity, there was a strong spatial and temporal structure to the DENV genomic relationships, consistent with highly focal DENV transmission around the home in wMel-untreated areas and a near-total disruption of transmission by wMel. These findings can inform long-term monitoring of DENV transmission dynamics in Wolbachia-treated areas including Yogyakarta.

Approaches, enablers and barriers to govern the private sector in health in low- and middle-income countries: a scoping review

INTRODUCTION

The private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes across the health system, requires an understanding of the evidence base on private health sector governance. This paper reports on a scoping review, which synthesised evidence on the approaches used to govern private sector delivery and financing of healthcare in LMICs, the effectiveness of these approaches and the key enablers and barriers to strengthening governance.

METHODS

We undertook a systematic search of databases of published articles and grey literature to identify eligible papers published since 2010, drawing on WHO's governance definition. Data were extracted into a pretested matrix and analysed using narrative synthesis, structured by WHO's six governance behaviours and an additional cross-cutting theme on capacities.

RESULTS

107 studies were selected as relevant, covering 101 LMICs. Qualitative methods and document/literature review were predominant. The findings demonstrate the relevance of the WHO governance behaviours, but the lack of robust evidence for approaches to implementing them. Valuable insights from the literature include the need for a clear vision around governance aims; the importance of ensuring that policy dialogue processes are inclusive and transparent, avoiding interest group capture; the benefits of exploiting synergies between governance mechanisms; and the need to develop capacity to enact governance among both public and private actors.

CONCLUSION

Governance choices shape not just the current health system, but also its future development. Common barriers to effective governance must be addressed in policy design, stakeholder engagement, public and private sector accountability, monitoring and capacity. Achieving this will require in-depth explorations of governance mechanisms and more rigorous documentation of implementation and outcomes in diverse contexts.

Validation of a family planning self-efficacy measure with married women in Bihar, India: Findings from the Bihar Integrated Family Planning Survey

Objectives

Adapting and testing a novel measure of family planning self-efficacy (FPSE) and examining its association with fertility intention and contraceptive use in India.

Study design

Data were analyzed from 13,901 non-sterilized, currently married women of reproductive age (15-49 years) in the Bihar Integrated Family Planning Survey (BIFS) 2021. We adapted an FP Self Efficacy measure comprising women's agency to overcome barriers to accessing, discussing and using contraception, regardless of family pressure and social judgment. We used factor analyses to assess reliability and validity, and regression analyses to examine the associations of FPSE with key family planning outcomes.

Results

The study sample was relatively young (35% below 25 years of age), with 43% reporting no education and over half (52%) married before 18 years of age. The 9-item FPSE scale demonstrated high reliability (Cronbach's α=0.82) with two factors - self-efficacy to access and discuss contraception versus self-efficacy to use contraception in the face of resistance. Higher FPSE was associated with spousal communication [AOR: 2.35 (95% CI: 2.18, 2.54), traditional [AOR: 1.24 (95% CI: 1.12,1.36)] and reversible modern contraception [AOR: 1.58 (95% CI: 1.43,1.75)], and fertility intention [AOR: 1.13 (95% CI: 1.01,1.25)].

Conclusion

FP Self Efficacy was found to be a reliable and valid measure associated with spousal communication, reversible contraception use and fertility intention.

Implications

Measures to capture reproductive agency, such as family planning self efficacy within FP programs, place women's choice as central goals of FP programming and can help in meeting community needs and the demand for contraceptive use.