Uganda faced its sixth reported Ebola outbreak between September 2022 and January 2023, the fifth to be recorded as Sudan Virus Disease (SVD) in the country. In response to this, the Ugandan Ministry of Health (MoH), rapidly deployed a mobile laboratory from the National Health Laboratory and Diagnostics Services (NHLDS) within one week of the declared outbreak. Here we describe the deployment of the mobile laboratory to Mubende, the outbreak epicentre, as part of the national response. This provided (1) efficient diagnostics and characterization of Sudan virus cases to support national data reporting (2), greater insight into Sudan virus kinetics, including viral clearance and risk factor analysis and (3) evaluation of the integration of the mobile laboratory into the national outbreak response. The mobile laboratory was deployed to the Mubende Regional Referral Hospital and positioned next to the established Ebola Treatment Unit (ETU). The laboratory was deployed for 177 days, in continuous operation by a team of 18 trained personnel. Molecular testing, using reverse-transcriptase polymerase chain reaction (RT-PCR) was carried out on all samples received in the laboratory for both Sudan virus diagnosis and differential diagnosis for other viral haemorrhagic fever (VHFs). All results from the mobile laboratory were fed directly into the national database, to enable a coordinated response to the outbreak and analysis of the outbreak data on a national level. Nationwide, there were 142 confirmed cases, 55 deaths and 22 probable cases reported in the outbreak. During the mobile laboratory deployment, 3282 samples were tested and 72 SVD cases confirmed by RT-PCR, with an average turn-around-time (TAT) of 6 h. In addition to molecular diagnostic confirmation of suspect cases, the mobile laboratory functioned to support follow-up surveillance of Sudan virus survivors (4 breast feeding mothers and 22 males). Sudan virus RNA was found in the breast milk a median of 135 days after initial test positivity and in the semen of male survivors median 176 days later. We observed the highest risk for contracting the disease in health care workers and a significant correlation between patient viral load at initial diagnosis and patient outcome. Differential diagnosis of other VHFs in the mobile laboratory and at the Uganda Virus Research Institute (UVRI) identified 6 Rift Valley fever (RVF) and 7 Crimean-Congo haemorrhagic fever (CCHF) cases co-circulating in the current SVD outbreak. Having the mobile laboratory stationed next to the ETU at the epicentre of the outbreak, markedly reduced diagnostic turn-around-time (TAT) and improved interoperability between the laboratory and the ETU, supporting containment and treatment. Furthermore, integration of the mobile laboratory into existing national outbreak systems, ensured rapid data provision for daily decision making by the national task force. The data from this study contributes to a greater understanding of Sudan virus. Not applicable.

Abstract Background The COVID-19 pandemic has highlighted the need for more effective immunization programs, including in limited resource settings. This paper presents outcomes and lessons learnt from a COVID-19 vaccination campaign (VC), which used a tailored adaptive strategy to optimise vaccine uptake in the Boeny region of Madagascar. Methods Guided by the Dynamic Sustainability Framework (DSF), the VC implementation was regularly reviewed through multi-sectoral stakeholder feedback, key informant interviews, problem-solving meetings, and weekly monitoring of outcome indicators to identify and apply key adaptations. Qualitative data on processes were collected and analysed using a rapid assessment approach. Outcome indicators, including pre- and post-VC vaccine hesitancy and trends in vaccine doses administered, were analysed using generalized linear models. Additionally, vaccination coverage, geographic reach, and target population characteristics, and sustainability indicators, such as staff trained, facilities equipped, and degree of integration of operational and educational materials were also tracked. Results Key strategy adaptations included using a proactive campaign approach, community-led awareness and outreach, particularly in remote areas, and addressing cold chain, waste management, vaccine transport, and information technology (IT) equipment gaps. Over six months, 24,888 COVID-19 vaccines were administered. The adapted strategy led to an 8% increase in doses administered weekly (RR = 1.08, CI 95%: 1.01-1.15). However, vaccine hesitancy among the unvaccinated population remained unchanged (∆ = 0.02, CI 95%: -0.04-0.08). In terms of sustainability, 340 staff were trained, and 10 primary healthcare facilities were equipped and refurbished. Conclusions Implementing collaborative, multi-sectoral vaccination strategies that integrate healthcare services with proactive outreach and community-driven campaigns are effective in increasing vaccine coverage in resource-limited settings. It demonstrates how theory-based adaptive strategies can enhance vaccination rates, even if they do not significantly impact COVID-19 vaccine hesitancy within the community. More generally, this initiative has important implications for adult vaccination programmes other than those related to COVID-19.

Background: In countries without functioning cancer registries, population-based cancer estimates are problematic, and the burden of all-sites and site-specific cancer mortality is hard to gauge. Objective: The study aimed to estimate cause-specific, age-and sex-specific cancer mortality burden using data from the Vital Registration System (VRS) in an urban complex with no cancer registry. Methods: The Ghana Vital Registration System (GVRS) is designed to be coterminous with the national political-administrative units, allowing for mortality reporting at the household level. Death records are stored centrally at the National Office in Accra, the capital of Ghana. We collected and analysed, using Binomial/Poisson, Hazard and Cox regression models, mortality records from Ghana’s VRS over a 14-year (1998-2011) period in order to estimate and study the relationship among sex, age, and the risk of dying of cancer. Results: Overall, the results showed an increase in cause-specific hazard rates with increasing age. The results also showed strong evidence of a difference in all-cause relative hazard rate between males and females (1.12, 95% CI 1.07 -1.19, p < 0.001). Finally, further cause-specific analyses showed that, while stomach cancers and lymphomas were more prevalent in males than females, the converse was true for bladder and pancreatic cancers (11.4%and 12.5%, respectively). Conclusion: The consistency of the findings reported here with results from similar analyses using data from standard cancer registries supports the view that routine data from vital registration systems can be used validly to estimate the burden of cancer mortality in resource-poor settings where cancer registries are unavailable.

Objective: Snakebite envenoming remains a public health threat in many tropical countries. While community knowledge of local snakes and snakebite first-aid and prevention are needed to reduce snakebite incidence and improve the outcomes for snakebite patients, it is poor in many communities. We assessed community health workers and community members regarding their knowledge on local snakes, snakebite first-aid and prevention in Neno district, Malawi. Methods: In November 2022, we conducted a cross-sectional survey among 312 community health workers and 379 community members in the Neno District of Malawi to assess their knowledge of snake identification, snakebite first-aid, and prevention. Different questions were asked in these sections and summarised as linear scores ranging from 0% to 100%. Scores of 0%-49%, 50%-70%, and >70% were considered inadequate, fairly adequate, and adequate, respectively. Along with data collected during knowledge assessments, the socio-demographic characteristics of participants were collected. To assess knowledge differences between community health workers and community members, Pearson's chi-square or Fisher's exact tests were used, and linear regression was calculated to investigate possible predictors of knowledge. Results: Overall, 66.6% of participants were females with a median age of 39 (IQR = 30-48) years. Of the 89% (n = 615) who agreed to view snake pictures, only 1.3% had adequate snake identification knowledge. Less than 5% (n = 33) had adequate knowledge of first aid measures, and 14.3% (n = 99) had adequate knowledge of prevention practices. Overall, less than 1% (n = 3) had adequate knowledge across the three assessment sections, with no significant difference between community health workers (n = 1, 0.3%) and community members (n = 2, 0.5%) (p > 0.949). Conclusion: Both community health workers and community members had inadequate knowledge regarding local snake species, first aid for snakebites and prevention measures. The effect of awareness campaigns and other education initiatives could be explored to help improve these gaps.

Abstract Background Adequate knowledge and awareness regarding diseases are essential for appropriate, high-quality healthcare. Female Genital Schistosomiasis (FGS) is a non-sexually transmitted gynaecological disease that is caused by the presence of Schistosoma haematobium eggs in the female genital tract and the resulting immune response that causes tissue damage. It is estimated to affect 56 million women, mostly in sub-Saharan Africa (SSA), where healthcare workers (HCWs) have limited awareness and knowledge of FGS. Most migrants in Europe are female, often from SSA and therefore at risk of FGS. This study investigated awareness and knowledge of FGS among European HCWs with the aim of informing strategies to improve the management of migrant health. Methods We conducted a cross-sectional survey using a self-administered, closed, multilingual, anonymous online questionnaire between 1st June 2023 to 31st January 2024. Medical doctors (MDs) (n = 581) and nurses or midwives (NMs) (n = 341) working in infectiology, gynaecology, urology and general, travel, internal or occupational medicine in European countries were enrolled in the survey. A Poisson regression was used to identify factors associated with MDs’ knowledge and awareness of FGS and adjusted prevalence ratios (aPR) were estimated. Practices related to FGS were described using counts and proportions for a subsample of MDs aware of FGS. Results Among the 922 eligible participants, FGS awareness was 43.7% (CI95%: 39.6; 47.9) for MDs and 12.0% (CI95%: 8.8; 16.0) for NMs. FGS awareness among MDs was higher among men (50.0%; CI95%: 43.7; 56.3), working in clinics for migrants (72.0%, CI95%: 63.2; 79.7) and among infectiologists/travel medicine specialists (68.9%, CI95%: 62.2; 75.0). No knowledge was reported by 67.6% (95% CI 63.7–71.4) of MDs, while 25.3% (CI95%: 21.8; 29.0) had low and 7.1% (CI95%: 5.1; 9.5) medium knowledge. Working in healthcare for migrants was positively associated with medium knowledge (aPR = 3.49; CI95% 1.67;7.28), which was lower for general practitioners (aPR = 0.23, CI95%:0.07;0.81). Conclusions Our study highlights that HCWs in Europe might not be adequately prepared to manage FGS patients, resulting in a high risk of neglect. We believe that the promotion of existing medical networks could improve knowledge about FGS and thus the health of migrant women.

Introduction: There are limited data on dengue transmission across most of African countries, including Senegal, Ghana, and the Democratic Republic of the Congo (DRC). We aimed to assess the age-stratified dengue seroprevalence and estimate the force of infection (FOI, per-capita risk of dengue infection for a susceptible subject) in these countries. Methods: We surveyed 14 regions in Senegal, 3 cities in Ghana, and 2 cities in DRC, leveraging blood samples collected from previous SARS-CoV-2 serosurveys of individuals aged 0 to 94 years. An Enzyme-Linked Immunosorbent Assay (ELISA) was used to measure IgG antibody levels against purified dengue particles (ELISA-1). A subset of samples was tested by ELISA for IgG against the recombinant nonstructural protein (NS1) of dengue (ELISA-2) and using a Plaque Reduction Neutralization Test (PRNT) for all four dengue serotypes.We used a Bayesian approach to reconstruct results obtained in the study and estimated the force of infection of dengue assuming a time-constant transmission. Results: In total, 8203 samples were tested by IgG ELISA-1: 1486 in Ghana, 3137 in Senegal and 3580 in DRC. Based on the IgG ELISA results, there was significant heterogeneity in the annual per capita risk of dengue infection across regions of Senegal, ranging from 0.2% (95% CrI: 0.1-0.3%) in Dakar to 2.6% (95% CrI: 1.9 -3.6%) in Fatick, corresponding to overall seroprevalence estimates of 5% (95% CrI: 3-8%) and 39% (95% CrI: 32-47%), respectively. In DRC, the average yearly FOI obtained from the IgG ELISA-1 results was 2.9% (95% CrI: 2.2-3.9%) in Kinshasa and 1.4% (95% CrI: 0.9-2.0%) in Matadi, with an overall population seroprevalence of 41% (95% CrI: 34-48%) in Kinshasa and 23% (95% CrI: 17, 32%) in Matadi. There were large heterogeneities in dengue transmission intensity across locations in Ghana, with a higher average yearly FOI in Tamale at 7.1% (95% CrI 5.6-9.6%)] compared to Accra at 2.6% (95% CrI 2.1-3.3%) and Kumasi at 0.5% (95% CrI 0.1-0.8%)​. Based on these results, we estimated that 43%, 11%, and 70% of the Accra, Kumasi, and Tamale populations, respectively, had been exposed to dengue virus. Notably, we found that the integration of the IgG ELISA-2 and PRNT test generated consistent estimates to those obtained with the IgG ELISA-1 test across locations. Conclusion: This three-country seroprevalence study provides evidence that dengue has been circulating at different levels across Ghana, DRC, and Senegal and highlights the large heterogeneity in population immunity and transmission across regions. Dengue surveillance needs to be strengthened in these countries and across Africa to monitor transmission and respond to future outbreaks.

Background: Campylobacter fetus causes reproductive diseases in livestock and zoonotic infections in humans, especially in immunocompromised individuals. Despite its significance, its genomic characteristics are poorly understood. This study analyzed 114 publicly available C. fetus genomes to provide global insights into its genetic diversity, antimicrobial resistance (AMR) patterns, and zoonotic risk. Results: A total of 32 distinct sequence types (STs), ranging from ST-1 to ST-74, were identified across 111 of the 114 C. fetus genomes, spanning six continents and diverse hosts (cattle, humans, sheep, and reptiles). ST-4 was the most prevalent (n = 45), followed by ST-3 (n = 8). A significant proportion (90.9%; n/N=40/44) of C. fetus subsp. venerealis (Cfv) and its biovar intermedius (Cfvi) were assigned to ST-4. Despite being isolated from five continents, Cfv and Cfvi genomes clustered closely, forming distinct branches at the biovar level; however, six Cfv genomes were located within Cfvi clades, suggesting a shared evolutionary lineage. In contrast, C. fetus subsp. testudinum (Cft) genomes, exhibiting 20 distinct STs, formed distinct clades from Cfv, Cfvi, and C. fetus subsp. fetus (Cff). While Cfv genomes from North America and Cfvi genomes from South America formed distinct geographic clusters, Cff genomes displayed no clear geographical patterns, with branches containing strains from multiple continents, indicating a globally dispersed distribution. Pangenomic analysis revealed pronounced clustering within Cft, characterized by unique gene presence/absence patterns. Five distinct AMR genes were detected, with tet(O) (n = 3) being the most common. Horizontal gene transfer analysis identified 140 genomic islands across 41 genomes, and virulence factor analysis revealed cheY as the sole conserved virulence gene across 35 genomes. Conclusion: These findings provide critical insights into the genomic diversity, zoonotic potential, and global distribution of C. fetus, emphasizing the need for integrated genomic and epidemiological strategies to assess its impact on human and animal health. ### Competing Interest Statement The authors have declared no competing interest.

Antibiotic resistant Salmonella enterica are on the increase, worldwide. Given the scarcity of data, this study aimed to investigate its occurrence, virulence, and antibiotic resistance in Costa Rica's food chain. In total, 65 chicken meat- and 171 chicken caecal samples were collected and examined for Salmonella. High frequencies of Salmonella were found in chicken meat (58.5%, n/N=38/65) and poultry farms (38.0%, n/N=65/171). The majority of Salmonella from chicken meat (89.5%, n/N=34/38) and caecum samples (93.6%, n/N=59/63) exhibited multidrug resistance (MDR). Serovar Infantis was the most prevalent (94%, n/N=67/71), followed by serovars Anatum and Kentucky (3%, n/N=2/71). A pESI-like plasmid (92%, n/N=65/71) containing virulence and resistance markers was found in S. Infantis. Given the high prevalence of MDR Salmonella, this study emphasizes the need to enhance surveillance systems for foodborne pathogens and antimicrobial resistance in Costa Rica's food production chain.

Background Estimation of prevalence of Strongyloides stercoralis infection is required in endemic areas, in order to identify areas in need of control programmes. Data on prevalence of strongyloidiasis in Madagascar are scant. Aim of this work was to estimate prevalence of S. stercoralis in four districts of Madagascar. Methods Fecal and serum samples collected in the context of a previous study on schistosomiasis were tested with S. stercoralis real-time PCR and serology, respectively. A multiplex real-time PCR for Ascaris lumbricoides, Ancylostoma duodenalis, Necator americanus, and Trichuris trichiura was done on fecal samples collected in the areas demonstrating higher prevalence of strongyloidiasis. Comparisons between proportions were made using Fisher exact test, with false discovery rate correction used for post-hoc comparisons. A multivariable Firth logistic regression model was used to assess potential risk factors for S. stercoralis infection. Results Overall, 1775 serum samples were tested, of which 102 of 487 (20.9%) and 104 of 296 (35.2%) were serological-positive in Marovoay and in Vatomandry districts (both coastal areas), respectively, compared to 28 of 496 (5.6%) and 30 of 496 (6.1%) in Tsiroanomandidy and in Ambositra districts (both highlands), respectively (adj. p < 0.001). PCR for S. stercoralis was positive in 15 of 210 (7.1%) and in 11 of 296 (3.7%) samples from Marovoay from Vatomandry, respectively, while was negative for all samples tested in the other two districts. High prevalence of A. lumbricoides (45.9%), hookworm (44.6%) and T. trichiura (32.1%) was found in Vatomandry. In the multivariable analysis, strongyloidiasis was associated with hookworm infection. Hookworm infection was also associated with male sex and lower education level. Conclusions S. stercoralis prevalence proved higher in coastal areas compared to highlands. Different climatic conditions may explain this distribution, along with previous rounds of anthelminthics distributed in the country, which may have reduced the parasite load in the population. The high prevalence of the other soil-transmitted helminths (STH) in Vatomandry was unexpected, given the good coverage with benzimidazole in control campaigns. Further studies are needed to explore the risk factors for STH and S. stercoralis infections in Madagascar, in order to align with the WHO recommendations.

Abstract Background Dengue fever is a major public health problem because it is a widespread and rapidly transmitted mosquito-borne viral disease. We developed a framework for early detection of dengue outbreaks in Tanzania, starting with detection of suspected and/or confirmed cases, followed by site-specific risk characterization, both useful for planning and prioritizing outbreak interventions or epidemic preparedness. Methods Our initial focus was on the identification and categorization of indicators that are specifically tailored to the early detection and classification of outbreak events. The framework was then evaluated using (i) available cases with syndromic and laboratory-confirmed disease information from ProMED emails using decision tree analysis, and (ii) available historical dengue epidemic data at the local level from 2019 with 6,795 confirmed cases using negative binomial regression analysis adjusted for month and area. Results The laboratory-confirmed diagnosis (dengue yes or no) was consistent with the results of the suspected case classification algorithm for clinically defined syndromic cases. There was strong evidence of an increase in dengue cases with higher site-specific risk (rate ratio = 2.51 (95% CI = [1.76, 3.58])) when regressing confirmed dengue cases in 2019 as the dependent variable and site-specific risk as the independent variable. Conclusions The rapid dengue outbreak risk assessment developed may be useful in controlling the epidemic in Tanzania. The suspected case classification algorithm can be a very useful tool to better assess whether a potential dengue case is present and thus requires laboratory confirmation. The framework can be used to rapidly predict the risk of dengue outbreaks, which is useful for planning and prioritizing interventions or for epidemic preparedness. Key messages • Framework for a novel rapid risk assessment for early detection of dengue outbreaks in Tanzania. • Framework relevant to epidemic preparedness.

The East African Community (EAC) is experiencing an unprecedented, emerging mpox outbreak since July 2024 in five of eight partner states. We highlight rapid regional response measures, initiated August 2024 coordinated by EAC: field deployment of six mobile laboratories in Burundi, Rwanda, Uganda, Tanzania, Kenya, South Sudan to high-risk areas, donation of one mobile laboratory to Democratic Republic of the Congo and genomic monkeypox virus (MPXV) surveillance support. These interventions aim to limit local mpox spread and support international containment.

Reduced susceptibility to ART, the first-line treatment against malaria, is common in South East Asia (SEA). It is associated with point mutations, mostly in kelch13 (k13) but also in other genes, like ubp1. K13 and its compartment neighbors (KICs), including UBP1, are involved in endocytosis of host cell cytosol. We tested 135 mutations in KICs but none conferred ART resistance. Double mutations of k13C580Y with k13R539T or k13C580Y with ubp1R3138H, did also not increase resistance. In contrast, k13C580Y parasites subjected to consecutive RSAs did, but the k13 sequence was not altered. Using isogenic parasites with different k13 mutations, we found correlations between K13 protein amount, resistance, and fitness cost. Titration of K13 and KIC7 indicated that the cellular levels of these proteins determined resistance through the rate of endocytosis. While fitness cost of k13 mutations correlated with ART resistance, ubp1R3138H caused a disproportionately higher fitness cost. IMPORTANCE:Parasites with lowered sensitivity to artemisinin-based drugs are becoming widespread. However, even in these "resistant" parasites not all parasites survive treatment. We found that the proportion of surviving parasites correlates with the fitness cost of resistance-inducing mutations which might indicate that the growth disadvantages prevents resistance levels where all parasites survive treatment. We also found that combining two common resistance mutations did not increase resistance levels. However, selection through repeated ART-exposure did, even-though the known resistance genes, including k13, were not further altered, suggesting other causes of increased resistance. We also observed a disproportionally high fitness cost of a resistance mutation in resistance gene ubp1. Such high fitness costs may explain why mutations in ubp1 and other genes functioning in the same pathway as k13 are rare. This highlights that k13 mutations are unique in their ability to cause resistance at a comparably low fitness cost.

INTRODUCTION:Schistosomiasis is a parasitic infection highly prevalent in sub-Saharan Africa (SSA) with Madagascar being among the countries with highest burden of the disease worldwide. Despite WHO recommendations, suggesting treatment of pregnant women after the first trimester, this group is still excluded from Mass Drug Administration programs. Our study, had the objective to measure the prevalence of schistosome infection among pregnant women in Madagascar in order to inform public health policies for treatment in this vulnerable population. METHODS:Women were recruited for this cross-sectional study between April 2019 and February 2020 when attending Antenatal Care Services (ANCs) at one of 42 included Primary Health Care Centers. The urine-based upconverting reporter particle, lateral flow (UCP-LF) test detecting circulating anodic antigen was used for the detection of schistosome infections. To identify factors associated with the prevalence of schistosome infection crude and adjusted prevalence ratios and 95% CIs were estimated using mixed-effect Poisson regression. RESULTS:Among 4,448 participating women aged between 16 and 47 years, the majority (70.4%, 38 n = 3,133) resided in rural settings. Overall, the prevalence of schistosome infection was 55.9% (n = 2486, CI 95%: 53.3-58.5). A statistically significant association was found with age group (increased prevalence in 31-47 years old, compared to 16-20 years old (aPR = 1.15, CI 95%: 1.02-1.29) and with uptake of antimalaria preventive treatment (decreased prevalence, aPR = 0.85, CI 95%: 0.77-0.95). No other associations of any personal characteristics or contextual factors with schistosome infection were found in our multivariate regression analysis. DISCUSSION AND CONCLUSION:The high prevalence of schistosome infection in pregnant women supports the consideration of preventive schistosomiasis treatment in ANCs of the Malagasy highlands. We strongly advocate for adapting schistosomiasis programs in highly endemic contexts. This, would contribute to both the WHO and SDGs agendas overall to improving the well-being of women and consequently breaking the vicious cycle of poverty perpetuated by schistosomiasis.

In malaria-endemic areas of Sub-Saharan Africa, overlap of clinical symptoms between malarial and non-malarial febrile illnesses can lead to empiric use of antibiotics among children. Our study aimed to illustrate the potential impact of decreasing malaria prevalence from malaria control efforts on antibiotic use. We constructed a probabilistic decision tree model representing antibiotic prescription in febrile children<5 years. This model was used to predict change in absolute antibiotic use compared to baseline under levels of decreasing malaria prevalence. Model parameters were based on data from a hospital study in Ghana and validated via literature review. The baseline prevalence of malaria diagnoses was 52% among all hospitalized children. For our main results, we reported outcomes for a scenario representing a 50% decrease in malaria prevalence. Compared to baseline, absolute antibiotic prescription decreased from a baseline of 639 doses (95% CI 574-694) to 575 (95% CI 502-638). This reflected a 10% (95% CI 7%-13%) decrease in absolute antibiotic use. Our findings demonstrate that effective malaria control can reduce pediatric antibiotic use. However, until substantial progress is made in developing accurate diagnostics for non-malarial febrile illnesses, further reductions in antibiotic use will remain a challenge.

Abstract Background Children under five continue to bear a disproportionate burden of malaria morbidity and mortality in endemic countries. While the link between socioeconomic position (SEP) and malaria is well established, the causal pathways remain poorly understood, hindering the design and implementation of more targeted structural interventions. This study examines the association between SEP and malaria among children in Ghana and explores the potential mediating role of behavioural and socio-structural factors. Methods Data from the Ghana Demographic and Health Survey (DHS) 2022 were analysed. As part of the survey, children were tested for malaria using a rapid diagnostic test (RDT), and SEP was measured using a household asset-based wealth index. Mediation analysis (MA) using a regression-based approach was performed to assess mediated effects between SEP and malaria in children under five in Ghana through housing quality, educational attainment (EA), long-lasting insecticidal net (LLIN) use, indoor residual spraying (IRS), and healthcare-seeking behaviour (HSB). Reported are the total natural indirect effects (TNIEs) and the proportion mediated (PM). Results Of the 3,884 children included in the survey, 19.4% (757) had malaria. Belonging to a household with high SEP was associated with a 43% lower risk of malaria (Prevalence Ratio, PR = 0.57; 95% Confidence Interval, CI 0.46–0.71). Regarding indirect (mediated) effects, maternal EA of secondary school or higher (OR = 0.68; 95% CI 0.60–0.77; PM = 17.5%), improved housing (OR = 0.80; 95% CI 0.68–0.91, PM = 9.2%), LLIN use (OR = 0.95; 95% CI 0.90–0.99, PM = 2.1%) partially mediated the association between SEP and malaria. The combined effect of all three mediators was higher than those in a single mediator or two sequential mediators (with EA as the initial mediator) (OR = 0.58; 95% CI 0.51–0.68, PM = 25.7%). No evidence of mediation was observed for HSB and IRS. Conclusion We found evidence of mediation by EA, housing, LLIN use and IRS, suggesting that current biomedical and behavioural malaria control efforts could be complemented with structural interventions, such as improved housing and education. Future studies that test the effect of different or joint effects of multiple mediators based on prospective designs are recommended to strengthen the evidence.

ObjectivesThis study aims to identify the factors influencing vaccine hesitancy, willingness and its variation over time in order to inform more responsive strategies for increasing vaccination uptake. The specific objectives are: (1) to describe and compare levels of COVID-19 vaccine hesitancy among the general population in rural and urban settings in West Africa over time and (2) to identify factors associated with COVID-19 vaccination willingness and hesitancy among the general population across five West African countries over time.DesignFollowing a baseline survey (Wave I), three serial cross-sectional surveys (Waves II-IV) were implemented.SettingThe study was conducted in Burkina Faso, Guinea, Mali, Senegal and Sierra Leone from November 2021 to July 2022.ParticipantsA total of 13 571 study participants were included in the study (n=4373, n=4593 and n=4605 for survey Waves II, III and IV, respectively). Inclusion criteria were being 18 years or older, living in the study area and willing to provide informed consent. A two-stage sampling strategy was used to select the sample from among the general population.Primary and secondary outcomesPrimary outcomes were the variability of vaccine hesitancy over time and across the five West African countries. Secondary outcomes were factors associated with vaccine willingness.ResultsA small but steady increase in hesitancy to COVID-19-vaccination can be observed across countries, with an upward trend of vaccine hesitancy reported by 952 participants (33.9 %) in Wave II, 1055 (37.3%) in Wave III and 1089 (38.1%) in Wave IV. Among the countries included, Senegal shows the highest level of vaccine hesitancy (‘Definitely no’ and ‘Probably no’ ranging from 50.2% to 56.0% and 26.2 to 28.3%, respectively). At the same time, Senegal has the lowest vaccination coverage overall. Across all five countries and survey waves, the primary factor associated with vaccination willingness is fear of experiencing severe COVID-19 disease (Wave II: OR 0.42, 95% CI 0.34 to 0.51, Wave III: OR 0.48, 95% CI 0.40 to 0.59 and Wave IV: OR 0.54, 95% CI 0.44 to 0.66). Perceived improved financial status seems to influence willingness to get vaccinated negatively (OR 0.57, 95% CI 0.40 to 0.81) and unlike in Western, Educated, Industrialised, Rich and Democratic countries, men seem more reluctant to get vaccinated than women (OR 0.77, 95%, CI 0.65 to 0.93).ConclusionsOur findings suggest that vaccine hesitancy should be monitored over time to inform communication strategies, which are responsive to changes in vaccination-related public sentiments. Additionally, a focus on social solidarity and the importance of women in vaccination advocacy can help improve COVID-19 vaccination coverage in West Africa.Trial registration numberThe general protocol is registered on clinicaltrial.gov (protocol number:NCT04912284).

BACKGROUND:Wastewater-based surveillance is a valuable tool for monitoring pathogen transmission in communities, especially in regions where formal surveillance systems are limited. AIM:The aim of this study was to implement and evaluate a wastewater-based monitoring system for viral pathogens in São Tomé and Príncipe. METHODS:A total of 122 water samples were collected bi-weekly from June 2022 to July 2023 at six locations in São Tomé city and analysed for molecular detection of Hepatitis A Virus (HAV), Enterovirus (EV), Poliovirus (PV), SARS-CoV-2, as well as JC-Polyomavirus (JCPyV) and pepper mild mottle virus (PMMoV) as indicators of human contamination. Prevalence was analysed per pathogen and across sampling locations. Results for SARS-CoV-2 were assessed together with notifications from national COVID-19 surveillance. Further, we estimated resources needed to establish a wastewater-based approach to assess community-level transmission of viral pathogens. RESULTS:All 122 and 117 samples were found positive for PMMoV and JCPyV, respectively, demonstrating a high level of human contamination at all sampling locations. The prevalence of HAV and EV ranged from 0 % to 59 % and 56 % respectively. Consistent with national surveillance data the highest proportion of SARS-CoV-2 positive water samples coincides with the highest number of COVID-19 cases reported during the study, demonstrating the potential of wastewater-based surveillance to identify signals. In addition, for SARS-CoV-2 this approach provided evidence of continuous circulation of the virus in the community, most importantly during weeks when no COVID-19 cases were reported. CONCLUSION:Our findings provide evidence of high transmission of HAV and EV in communities in São Tomé and continuous circulation of SARS-CoV-2, even in weeks without COVID-19 case notifications. This study demonstrates that monitoring of viral pathogens in humanly impacted open water streams and sewage tanks is a valuable tool to complement clinical surveillance in resource-limited settings.

Abstract Background Female Genital Schistosomiasis (FGS) is a gynaecological manifestation of persistent infection with Schistosoma haematobium, which can lead to severe consequences, such as miscarriage and infertility. It is estimated to affect 56 million women globally, mostly in sub-Saharan Africa (SSA). Most migrants in Europe are female, often from SSA and therefore at risk of FGS, hence healthcare workers (HCWs) knowledge of FGS is essential for the provision of adequate care. This study aims to assess awareness and knowledge of FGS among European HCWs to inform strategies to improve the management of migrant health. Methods In June 2023 - January 2024 we conducted a cross-sectional online survey targeting medical doctors (MDs), nurses and midwives (NMs) working in fields of infectiology, gynaecology, urology, family, travel, internal or occupational medicine. The prevalence of FGS awareness and knowledge was estimated, Poisson regression was used to identify factors associated with MDs’ awareness of FGS. Results Among 922 surveyed HCWs, 43.7% (CI95%: 39.6-47.9) of MDs and 12.0% (CI95%: 8.8-16.0) NMs have heard about FGS. FGS awareness among MDs was associated with work in clinics for migrants (prevalence ratio (PR)=1.33, CI95%: 1.10-1.59) and specialization, being lower for gynaecology (PR = 0.67; CI95%:0.51-0.88), and family medicine (PR = 0.42, CI95%:0.30-0.59). Among MDs, 7.1% (CI95%: 5.1- 9.5) had medium knowledge, while 25.3% (CI95%: 21.8-29.0) had low, and 67.6% (CI95%: 63.7-71.4) no knowledge on symptoms, complications or diagnostic tools for FGS. FGS knowledge was mostly acquired through academic curricula (34.7%), scientific literature (28.4%) and conferences (25.6%). Conclusions The study shows limited awareness of FGS among European MDs and NMs, and highlights that European HCWs may not be adequately prepared to deal with diseases that are gaining relevance on the European continent due to the global connectivity and the dynamic nature of our societies. Key messages • In Europe, the health specialities that are the first point of patient access to the health system show a low level of awareness and knowledge of Female Genital Schistosomiasis. • Rising knowledge of FGS among European HCWs through academic curricula and continuous medical education is important to ensure adequate diagnosis and management of disease in migrant populations.