Background Asymptomatic Plasmodium vivax infections undermine malaria control by sustaining transmission. This study aimed to validate an eight-marker serological panel (selected from 14 antigens) of P. vivax exposure to detect individuals likely harbouring hypnozoites in rural Cambodia, and to compare it with molecular surveillance for identifying at-risk populations in low-transmission settings. Methods Two studies were conducted in Mondulkiri, Cambodia. In a longitudinal cohort (N = 471), participants were tested monthly for one year for P. vivax using qPCR. At 12 months, IgG responses to 14 antigens were assessed, and Random Forest models (‘Cambodia-specific’ and ‘global’) were used to classify previous infection, with PCR as the reference standard. In a cross-sectional survey (N = 3538), risk factors for sero- and PCR positivity were assessed using generalized linear mixed-effects models. Findings PCR detected P. vivax in 29.9% (141/471) of participants over the 12-month follow-ups, while 31.8% (150/471) were classified as seropositive at month 12. Of 141 PCR-confirmed cases, 95 were seropositive (67.4%) and 46 seronegative (32.6%) under the 8-antigen panel. The ‘global’ model achieved an AUC of 0.81, with 83.3% specificity and 69.5% sensitivity for infections within nine months, increasing to 82% sensitivity for last-month infections. In the cross-sectional study, serology identified more positives than PCR, reflecting detection of exposure not captured by PCR. Interpretation This study provides the first validation of serological markers of P. vivax exposure in Cambodia, showing that such tools can identify recent and asymptomatic infections, though sensitivity was below target. Serology-based surveillance and strategies such as PvSeroTAT could accelerate malaria elimination. Funding NIH/NIAID, ICEMR Asia-Pacific U19AI129392.
Background Cardiovascular disease (CVD) is the leading cause of death globally, with the Asia–Pacific region home to over two-thirds of the world's population, bearing over half of this burden. This study aims to characterise historical trends and forecast CVD burden in the Asia–Pacific from 1990 to 2050, identifying disparities by geographic subregions, sociodemographic index (SDI), and age-sex strata. Methods Historical (1990–2023) and forecasted (2025–2050) trends in CVD disability-adjusted life years (DALYs) and mortality across 39 Asia–Pacific countries were examined using Global Burden of Disease Study 2023. Findings In the Asia–Pacific, CVD accounted for 241.2 million DALYs (55.3% of global) in 2023. Crude DALYs rose by 51.3% from 1990 to 2023, despite 36.2% reduction in age-standardised DALYs. Crude DALYs will rise further by 10.7% from 2025 to 2050. Atherosclerotic CVD is the key driver of morbidity, with stroke (1255.0 DALYs per 100,000 population) projected to plausibly surpass ischaemic heart disease (1148.7 DALYs per 100,000 population) by 2050. Disparities in CVD burden exist across SDI (low and low-middle SDI bearing the highest burden), geography (Oceania bearing the highest burden), and age-sex categories (DALYs peaking earlier in males by at least 5 years). Interpretation The net effect of gains in CVD prevention is offset by the rising crude CVD burden owing to the growing and ageing population. The heterogeneity in CVD burden across countries of different socioeconomic development poses unique challenges in tackling CVD in the Asia–Pacific. Funding SingHealth Duke-National University of Singapore Cardiovascular Sciences Academic Clinical Programme, the National Medical Research Council of Singapore, and the Stafford Fox Foundation.
Background:The risk stratification of sudden cardiac death (SCD) in patients with heart failure (HF) with mildly reduced ejection fraction (HFmrEF) remains suboptimal. This study aims to evaluate the role of late gadolinium enhancement (LGE) and T1 mapping in predicting SCD in patients with HFmrEF and to provide an improved clinical risk stratification algorithm. Methods:A total of 1855 patients with HFmrEF from five tertiary medical centers were enrolled in this study, all of whom underwent echocardiography and cardiovascular magnetic resonance (CMR). Data analysis utilized a multicenter development cohort (n = 1417) and a multicenter external validation cohort (n = 438). The primary endpoints were sudden cardiac death, appropriate ICD shocks, and resuscitated cardiac arrest. Secondary endpoints were a composite of HF death, unplanned HF hospitalization, or cardiac transplantation. Based on validated MRI predictors, a risk algorithm and corresponding clinical workflow were developed for SCD risk assessment. Findings:During a median follow-up of 42 months in the development cohort, 142 and 140 patients experienced primary and secondary endpoints, respectively. Adjusted analyses identified the following as significant predictors of SCD-related events: LGE ≥6.3% (HR 5.33, 95% CI: 3.74-7.60; P < 0.001), ECV ≥28.4% (HR 3.44, 95% CI: 2.32-5.11; P < 0.001), and a native T1 z-score ≥2.7 (HR 2.40, 95% CI 1.67-3.48; P < 0.001). Patients with ECV >28.4% and no LGE showed higher SCD risk compared to those with ECV <28.4% and LGE <6.3% or mid-wall LGE. Conversely, patients with ln (NT-proBNP) <6.2, LGE <6.3%, and ECV <28.4% had a lower SCD risk, with an annual event rate of 0.4%. Notably, LGE ≥6.3% was associated with a high annual SCD event rate of 7.9%, irrespective of ECV, NT-proBNP levels, and LGE distribution. Interpretation:In HFmrEF, at least 6.3% of LGE serves as a strong predictor of SCD risk, irrespective of its distribution. ECV significantly enhances risk stratification, particularly in patients with negative or mid-wall LGE. Funding:This study was supported by the National Natural Science Foundation of China (Grant Nos. 81871354, 81571672) and Key R&D Program of Shandong Province, China (2025CXPT106, 2025CXGC020305).
Diabetes-related foot disease (DFD) is the leading contributor to the global diabetes disease burden. The largest DFD burden in the world is in the Western Pacific region. The Western Pacific is one of the most diverse global regions in the world, comprising around 2.2 billion people, 37 countries, and many different ethnicities, national incomes and geographies spread across three sub-regions: East Asia, Southeast Asia, and Oceania. To address such a large DFD burden it is critical to better understand the DFD burdens, care and strategies occurring across the region. We reviewed the burdens, current care, and future strategies for DFD in countries of the Western Pacific, and found the region had comparatively high DFD rates but lower amputation rates. Countries and sub-regions with lower rates tended to have better current DFD care and future strategies. We proposed eight key recommendations to reduce the largest DFD burden in the world.
Over 1-million people with Type 1 diabetes (T1D) live in the Western Pacific Region (WPR). Generally, estimated T1D incidence (range 0.26–15.60/100,000 persons p.a.) and prevalence are increasing. Based on the T1D index estimated healthy-life-years lost due to T1D ranges 20.6–46.0 years. Modulating factors regarding T1D epidemiology and health outcomes include ethnicity, genetics, healthcare and socioeconomic aspects. Whilst insulin pumps and continuous glucose monitors are available in many WPR countries/regions they are subsidised in only a few. Adjunct glucose drugs, developed for Type 2 diabetes if used in T1D are mainly used off-label. Regional research includes diabetes care, adjunct drugs, technology and stigma and discrimination. Stigma is common and advocacy and human rights to mitigate it are discussed. Advances will be facilitated by engaging all stakeholders, including people with diabetes, their carers and communities, clinicians, the healthcare system, payers, researchers, Non-Government Organisations, industry, government and policy-makers. Funding None.
Nasopharyngeal carcinoma (NPC) is a human malignancy with well-established association with Epstein-Barr virus (EBV) infection. Due to the concealed anatomical location of nasopharynx and the absence of early-stage clinical symptoms, most patients are diagnosed at a relatively advanced stage. EBV-related biomarkers, such as plasma EBV DNA and serum EBV antibodies, demonstrate outstanding sensitivity and specificity in the early detection of NPC. Moreover, plasma EBV DNA also serves as a useful tool for prognostic prediction of patients with NPC. Although current standard therapies have significantly improved the survival of patients with locoregionally advanced NPC, the establishment of personalized treatment plans remains challenging, and a subset of patients still experience disease progression even after definitive treatment. Plasma EBV DNA has shown great potential in guiding adaptive treatment of NPC, enabling optimum efficacy while minimizing treatment associated adverse effects. Additionally, EBV-targeted therapies, including cell therapies and small-molecule drugs activating anti-virus immune response or directly targeting EBV life cycle, represent promising approaches for these patients. In this review, we systematically summarized recent advances in EBV-targeted screening, prognostic prediction, adaptive treatment, and novel treatment strategies for NPC, discussed the strengths and limitations of these approaches and outlined future research directions in these fields.
Air pollution, particularly fine particulate matter, has emerged as a critical environmental determinant of diabetes mellitus. This review synthesizes global epidemiological evidence linking ambient pollutant exposure to impaired glycemic control and increased risk of diabetes, emphasizing the disproportionate burden and unique vulnerabilities of populations in the Western Pacific Region (WPR). While mechanistic pathways are universal, the WPR’s genetic predispositions, distinct metabolic phenotypes, rapid urbanization, and pollutant mixture profiles amplify diabetes risk, necessitating region-tailored interventions. This review also elucidates the key pathophysiological pathways, primarily oxidative stress, systemic inflammation, and endoplasmic reticulum stress, that underpin air pollution-induced insulin resistance. To mitigate the risks, integrated strategies encompassing health-oriented environmental governance and urban planning, individualized prevention, and AI-driven precision interventions should be prioritized. The convergence of high-resolution personal exposure tracking, longitudinal multi-omics validation of emerging mechanisms, and AI-integrated wearable systems may provide a strategic roadmap for translating scientific evidence into effective public health interventions.
Gastric, liver, and cervical cancers account for a disproportionate share of the global cancer burden, particularly in Asia, where infection-related cancers remain a major public health challenge. This narrative review aims to provide an overview of the epidemiological transition of these cancers and their implications for cancer control in Asia. Updated population-attributable fractions and other epidemiological evidence indicate a declining contribution of infections to overall cancer incidence, reflecting ongoing epidemiological transitions. While prevention of infection-driven cancers in Asia requires pathogen-specific strategies, they should be adapted to the changing epidemiological patterns. Population-wide Helicobacter pylori eradication combined with risk-stratified screening represents an effective strategy to reduce gastric cancer burden. Liver cancer prevention increasingly requires tackling viral and emerging metabolic risk factors. HPV- and HBV-related cancers are largely preventable through vaccination, although coverage remains uneven across Asia. EBV contributes substantially to nasopharyngeal cancer burden in East and Southeast Asia, highlighting persistent geographic disparities. Given substantial heterogeneity in the prevalence of major infectious agents and health-system capacity across countries, effective prevention strategies should be tailored to country-specific contexts, balancing benefits, risks, and cost-effectiveness. With equitable access to vaccination, antimicrobial therapy, and targeted screening, substantial reductions in infection-related cancer burden in Asia may be achievable.
Japan has seen a dramatic shift in liver cancer epidemiology, with hepatocellular carcinoma (HCC) declining after decades of comprehensive viral hepatitis control, illustrating the impact of sustained public health intervention. This review examines trends in liver cancer epidemiology in Japan in the context of long-term viral hepatitis control. National data indicate a substantial reduction in disease burden, with liver cancer mortality declining from 34,637 deaths in 2002 to fewer than 30,000 in 2014. The incidence of newly acquired infections is low, with HCV estimated at approximately 0.4 per 100,000 person-years and HBV at 2.38 per 100,000 person-years. These trends likely reflect population-based screening, universal health coverage, and expanded access to antiviral therapy. However, the aetiology of HCC is evolving, with non-viral causes increasing from 6.8% in 1991 to 41.1% in 2015 and accounting for 56.0% of HCC deaths in 2019. Overall, Japan's experience suggests progress in viral hepatitis control, while highlighting the need to address metabolic and lifestyle-related risk factors to sustain future prevention of liver cancer.
Background:Cancer prevalence is the number of people alive with a past cancer diagnosis in a specified number of previous years (e.g., last 5 or 30 years). This study estimates 1- to 30-year cancer prevalence in Australia for each year in 2025-2050, for 24 cancer types, the group of remaining cancers, and for all cancers combined. Methods:We used validated methods to estimate prevalence as a function of incidence and survival, using tabulated data from the Australian Institute of Health and Welfare and incorporating the effect of influential cancer-specific factors. The number of people living with cancer (cancers not yet cured) is estimated using the time-to-cure method. Findings:The 30-year prevalence is projected to increase by 57.1% from 1,666,020 (95% uncertainty interval [UI]: 1,553,825-1,784,900) in 2025 to 2,617,016 (95% UI: 2,333,949-2,947,174) in 2050. For people aged 80+ years, 30-year prevalence is projected to increase by 111.0% from 481,079 (95% UI: 448,799-515,286) in 2025 to 1,015,061 (95% UI: 917,670-1,125,036) in 2050. Breast cancer is projected to be the most prevalent cancer in Australia in 2050, followed by prostate, melanoma and colorectal cancer. For 30-year prevalence in 2050, 43.9% of people (1,149,364; 95% UI: 1,103,165-1,238,377) are estimated to be living with cancer (cancers not yet cured) and requiring initial treatment or ongoing care. Interpretation:A substantial increase in the number of people with a past cancer diagnosis in Australia is expected in 2025-2050. Expansion of appropriate services to meet the demand will be a key challenge for the health system in Australia. Funding:This work was not supported by a dedicated research grant. This work and open access publishing were supported by the Cancer Council NSW, through funding to the Daffodil Centre. KC is a recipient of a Fellowship from the National Health and Medical Research Council of Australia (APP1194679). JS is a recipient of a Cancer Institute NSW Career Development Fellowship (2022/CDF1154).
Background:Post-bronchodilator (BD) spirometry is underused in primary care settings, limiting COPD diagnosis. This study aimed to derive and validate pre-BD thresholds that safely rule in COPD and enable immediate diagnosis. Methods:We derived pre-BD FEV1/FVC thresholds using a nationally representative derivation dataset (CPHS, n = 6360 with pre-BD ratio <0.7), with cross-sectional external validation in the China Kadoorie Biobank (CKB, n = 1890) and longitudinal validation in a national screening cohort (NSC, n = 7620 with 1-year follow-up). The optimal threshold was selected based on positive predictive value (PPV) for post-BD FEV1/FVC <0.7. One-year longitudinal follow-up assessed diagnostic stability and prognostic value. Findings:A pre-BD threshold of 0.56 was identified, yielding a PPV of 0.953 (95% CI, 0.939-0.965) in derivation set and 0.919 (95% CI, 0.875-0.940) in the CKB validation set. In subgroups with higher prior probability (male, age >60 years, smoking, and with respiratory symptoms), the PPV was further increased. At one-year follow-up in the NSC, 86.9% of participants with baseline pre-BD <0.56 still met the post-BD COPD criteria. Patients below 0.56 had significantly higher risks of acute exacerbation (OR, 3.34; 95% CI, 2.55-4.37) and respiratory hospitalization (OR, 3.42; 95% CI, 2.65-4.42). An alternative threshold of 0.62 gave a PPV of 0.891 (95% CI, 0.866-0.913) in CKB and allowed 33.8%-49.0% of participants across cohorts to bypass post-BD testing. Interpretation:A pre-BD FEV1/FVC threshold of 0.56 effectively "rules-in" COPD in primary care and identifies patients with poor prognosis. The alternative threshold of 0.62 offers a practical option to further reduce post-BD testing while maintaining an acceptable PPV. Both thresholds facilitate pragmatic triage and early diagnosis without routine post-BD testing. Funding:This work was funded by National High Level Hospital Clinical Research Funding (2025-NHLHCRF-JBGS-B-WZ-18), Noncommunicable Chronic Diseases-National Science and Technology Major Project (2023ZD0506003, 2023ZD0506306, 2023ZD0510101, 2023ZD0510100), Social Development Project of Yunnan Province (202403AC100006) and Beijing Nova Program (20250484849).
Background:Equity in health financing is essential for achieving universal health coverage (UHC), particularly in low- and middle-income countries (LMICs). As one of the largest middle-income countries, China has undergone substantial health financing reforms over the past decades and achieved near-universal social health insurance coverage. However, whether these achievements have translated into equitable distribution of health financing burdens and benefits remains unclear. We aim to provide updated national evidence on equity in health financing in China. Methods:We used data from three waves (2013, 2018 and 2023) of the Chinese Household Income Project, a nationally representative household survey. Financing incidence analysis was conducted to assess the progressivity of major health financing sources, and benefit incidence analysis examined the distribution of realised social health insurance (SHI) benefits. We further conducted counterfactual policy scenario analyses to explore the potential impact of policy reforms to mitigate inequities. All analyses were conducted at the household level and adjusted by adult equivalence. Sensitivity analyses using alternative household ability-to-pay measures, adult equivalence scales, private health insurance imputation approaches, and measures of health need were performed. Findings:The overall health financing system remained mildly regressive, with Kakwani indices (KIs) of -0.016 (-0.030, -0.002) in 2013, -0.034 (-0.044, -0.023) in 2018, and -0.071 (-0.080, -0.062) in 2023. Among the financing sources, direct tax payments and SHI contributions by employees remained progressive, while indirect tax payments, SHI contributions by non-employed residents, and out-of-pocket payments were regressive. In addition, SHI reimbursements were distributed pro-rich and did not align with measured health need. In 2013, the wealthiest 20% of households accounted for only 7.9% of the health burden but received 55.4% of SHI reimbursements, and this inequity persisted in 2023. Policy simulations suggest that reforming SHI financing mechanisms, capping out-of-pocket payments, and harmonising SHI benefit packages across schemes could improve overall progressivity to varying degrees, but require additional fiscal investments. Interpretation:Despite substantial increases in public health expenditure and near-universal health insurance coverage, China has not achieved significant improvements in equity of health financing. Lower-income households continue to bear disproportionately greater financing burdens relative to their ability to pay while receiving fewer SHI reimbursements relative to measured health need. These findings underscore the critical importance of equity-oriented design in health financing mechanisms, offering important lessons for other countries in the Western-Pacific region. Funding:Key Project of Philosophy and Social Sciences Research, Ministry of Education of China (24JZD035); Taikang Yicai Public Health and Epidemic Control Fund (XY240927100000); General Project of the National Social Science Fund of China (24BTJ054); Innovation Fund for Outstanding Doctoral Candidates of Peking University Health Science Center (BMU2026BSS001); Fundamental Research Funds for the Central Universities in China.
Background:The process of social transition, defined as outward changes in gender expression to align with and affirm one's gender identity, has been richly described in qualitative studies, but quantitative research often lacks the detail required to capture its full complexity. This study aimed to quantitatively examine how this process varies in transgender and gender diverse (trans) young people over time. Methods:Prospective longitudinal data (across 2-3 annual waves from 2017 to 2024) were obtained from 234 trans young people (aged 8-17 years) attending a specialist paediatric gender service in Australia. Social transition was operationalised using practices (name, pronouns, and appearance) across five contexts (home, school, online, with friends, and extended family). For each practice, we captured at each wave whether a change had been enacted or was desired in the future to determine longitudinal trajectories of social transition goal attainment. Findings:Four distinct trajectories were observed. The most common patterns were consistent goal attainment (meeting goals at every wave; 56.4%, n = 132) and progressive goal attainment (meeting goals by the final wave; 22.2%, n = 52). A small group of participants were initially meeting their goals at baseline, but not at the final wave (6.0%, n = 14). Even among participants consistently not meeting their goals (15.4%, n = 36), the majority were still actively progressing toward them. Additionally, most participants adjusted their goals over the study period (60.7%, n = 142). Goal attainment was associated with higher family functioning (p = 0.00075) and gender identity (p = 0.0034); specifically, trans boys were significantly more likely than trans girls to have met their social transition goals. Interpretation:Social transition is a dynamic, non-linear process driven by evolving personal goals rather than a uniform "all or nothing" milestone. These findings suggest that clinical, policy, and research frameworks should move away from rigid definitions of social transition to adequately reflect experiences of enactment and evolving goals. Funding:NHMRC GNT2006529 and GNT2006529, Hugh D. T. Williamson Foundation, and Royal Children's Hospital Foundation 2020-1314.
