BackgroundAntimicrobial-resistant (AMR) Salmonella Typhi (S. Typhi) is a persistent public health threat in India. We conducted a systematic review and meta-analysis to estimate the prevalence and temporal trends of AMR S. Typhi across Indian states to inform prevention and treatment strategies.MethodsWe systematically reviewed antimicrobial resistance in S. Typhi isolates from India, including studies published up to March 31, 2025, with no start-date restriction. We screened eligible articles from PubMed-MEDLINE, EMBASE, Scopus, Web of Science, and AMR surveillance networks and excluded studies on chronic carriers and travellers. We assessed risk of bias using the Risk Of Bias In Non-randomised Studies - of Exposures (ROBINS-E) tool. We conducted meta-analysis using a random-effects model to estimate the prevalence of multidrug resistance (MDR; resistance to chloramphenicol, ampicillin, and co-trimoxazole) and resistance to fluoroquinolones, third-generation cephalosporins, and azithromycin across five-year periods, Indian states, and age groups (<18 versus all ages).ResultsWe analysed data from 188 of 4,430 identified studies. MDR declined from 65% (95% CI 63-67) in 1990-94 to nearly 0% (95% CI 0-1) ≥2020. Fluoroquinolone resistance rose from 2% (95% CI 1-2) in 1990-94-85% (95% CI 84-86) in 2015-19, then declined slightly, with similar trends in children but marked variation across Indian states. Resistance to third-generation cephalosporins, azithromycin, and carbapenems remained below 5%, 8%, and 2%, respectively. Our meta-analysis of studies with samples collected from 2015 onwards showed a pooled summary resistance estimate of 82% (95% CI 74-87) for fluoroquinolones, 3% (95% CI 2-4) for third-generation cephalosporins, and 3% (95% CI 1-6) for azithromycin.ConclusionFluoroquinolone resistance in S. Typhi in India is high but is declining, while resistance to third-generation cephalosporins and azithromycin is low. As many isolates originated from major cities, caution is warranted when generalising nationally. Continued AMR surveillance is crucial to guide vaccination strategies and treatment decisions.

Abstract Enteric fever caused by Salmonella enterica serovars Typhi and Paratyphi A, B and C remains a major public health burden in endemic regions. Existing molecular assays frequently demonstrate limited specificity due to cross-reactivity with non-typhoidal Salmonella (NTS). In this study, we developed and validated a genomics-informed multiplex PCR assay capable of simultaneously differentiating all four typhoidal Salmonella serovars. A curated dataset of 3,239 Salmonella genomes, including S . Typhi (n=361), S . Paratyphi A (n=453), S . Paratyphi B (n=511), S . Paratyphi C (n=62), and NTS genomes (n=1,853), was used for comparative genomic analysis. Thirty published PCR targets were evaluated in silico , followed by pangenome and SNP analyses to identify discriminatory loci for mismatch amplification mutation assay (MAMA)-based primer design. Candidate primers were validated using in silico PCR, BLASTn analysis, and laboratory testing against a panel of typhoidal Salmonella, clinical NTS isolates, and non-Salmonella bacterial pathogens. In silico evaluation demonstrated substantial cross-reactivity among many published targets, whereas SNP-informed primer design targeting staG ( S . Typhi), SPA0152 ( S . Paratyphi A), SPAB_03490 ( S . Paratyphi B), and SPC_0571 ( S . Paratyphi C) achieved predicted specificities of 98–100% while retaining high analytical sensitivity (>97%) across target genomes. Combined with a pan-Salmonella invA target, the multiplex assay precisely identified all target serovars in vitro with minimal cross-reactivity. These findings demonstrate that genomics-informed SNP-based primer design enables reliable multiplex differentiation of typhoidal Salmonella serovars and provides a scalable framework for improving enteric fever diagnosis and surveillance in endemic settings. Importance Typhoidal Salmonella serovars remain major causes of enteric fever in endemic regions, yet molecular differentiation from non-typhoidal Salmonella (NTS) remains challenging because of extensive genomic conservation and cross-reactivity of commonly used diagnostic targets. In this study, we combined large-scale comparative genomics of 3,239 Salmonella genomes with SNP-informed primer design to develop a multiplex PCR assay capable of simultaneously differentiating all four typhoidal serovars ( S . Typhi, S . Paratyphi A, B, and C) from NTS and other non-Salmonella pathogens. Unlike conventional gene-content-based assays, this approach incorporated lineage-specific SNPs and mismatch amplification strategies to improve specificity while maintaining high analytical sensitivity. In silico evaluation demonstrated high diagnostic performance across diverse global lineages, while in vitro testing confirmed accurate serovar-level discrimination with minimal cross-reactivity. These findings demonstrate the value of population-scale genomics for molecular assay development and provide a scalable framework for improving diagnosis and surveillance of enteric fever in endemic settings.

Salmonella enterica serovar Enteritidis is a leading cause of invasive non-typhoidal Salmonella (iNTS) disease globally, particularly in sub-Saharan Africa. In contrast, the epidemiology and population structure of invasive S. Enteritidis in South Asia remain poorly characterized. This study investigates the clinical presentation, phylogenetic relationships and genomic characteristics of S. Enteritidis bloodstream infections (BSIs) in India. Clinical data were collected from 101 patients with S. Enteritidis BSI between 2012 and 2022. Whole-genome sequencing was performed on representative bloodstream isolates together with isolates from non-blood clinical specimens and poultry sources. Comparative genomic analyses included phylogenetic reconstruction, invasiveness index prediction, and prophage characterization. Infants and immunosuppressed individuals were disproportionately affected by iNTS disease. Phylogenetic analysis identified four major lineages of S. Enteritidis. Most BSI isolates clustered in a previously unrecognized lineage, designated the Global Intermediate Clade, which occupied a phylogenetic position between the Global outlier and Global epidemic clades. Bayesian inference dated its most recent common ancestor to around 1789 AD (95% HPD: 1692-1941), with global circulation confirmed by European and Asian isolates. The Global Intermediate clade exhibited the second-highest invasiveness index (median 0.221, SD 0.013) after the West African clade; however, this index reflects genomic signatures associated with invasiveness and should not be interpreted as a direct measure of virulence. Poultry isolates clustered separately from the dominant bloodstream-associated lineage. Pan-genome analysis identified a lineage-specific mosaic prophage composed of modules homologous to prophages found in diverse Enterobacterales. This study provides the first detailed genomic insight into invasive S. Enteritidis in India and identifies a previously unrecognized Global Intermediate Clade associated with bloodstream infection. The distinct phylogenetic placement and genomic features of this lineage, including a lineage-specific mosaic prophage, warrant further investigation and support the need for expanded One Health genomic surveillance.

Climate change poses a significant threat to human health, necessitating the integration of sustainable practices across healthcare sectors. Dentistry contributes to environmental burden through resource-intensive procedures and waste generation, yet sustainability remains insufficiently addressed in dental education and practice, particularly in low- and middle-income countries. In Pakistan, existing efforts are largely limited to amalgam-related concerns, with minimal focus on comprehensive sustainability frameworks such as the Green Dental Model (GDM). This study aimed to assess the knowledge, attitudes, and practices (KAP) related to environmental sustainability among dental school personnel and students in Karachi, Pakistan. By identifying KAP levels, the study outlined the landscape of environmental sustainability. A cross-sectional quantitative study was conducted as part of an explanatory sequential mixed-methods project guided by the GDM framework. Data were collected using an adapted, validated structured questionnaire administered electronically to faculty, undergraduate and postgraduate students, and dental auxiliaries across 13 public and private dental schools in Karachi. Descriptive statistics were used to summarize KAP scores. One-way analysis of variance (ANOVA) and Pearson’s correlation analysis were applied to examine differences and associations, with significance levels set at p < 0.05 and p < 0.01, respectively. A total of 3,356 participants were included in the analysis. Knowledge scores were generally moderate to good, with undergraduate and postgraduate students demonstrating higher mean scores compared with other groups. Attitudes toward environmental sustainability were more favorable among clinical faculty and postgraduate students. Practice scores were fair across all groups, with domain-specific variation. Higher engagement was observed in energy and water conservation practices, while gaps persisted in green procurement and infection control. Significant differences in KAP were observed across institutional sectors and participant groups. This study identified variability in environmental sustainability-related knowledge, attitudes, and practices among dental school personnel and students in Karachi. While awareness is relatively established, translation into consistent sustainable practices remains limited. Targeted educational strategies, institutional policy support, and infrastructure development are required to strengthen sustainability integration in dental education and clinical practice. These findings provide baseline evidence to inform future interventions and policy development in environmentally sustainable dentistry.

Gaps in India’s routine dengue surveillance have led to an underestimation of its actual burden and could adversely affect funding for preventive public health measures. In this study, we report the incidence of symptomatic dengue and the associated direct medical costs in a large urban population-based cohort in Vellore, Tamil Nadu. Surveillance for febrile illnesses was conducted in 30 urban wards in Vellore as part of the Vellore Typhoid Vaccine Impact Trial. Participants seeking healthcare for febrile illnesses called the trial helpline, triggering active surveillance until fever defervescence. Febrile episodes lasting ≥ 3 days were diagnosed as dengue based on either laboratory tests or a physician-assigned diagnosis. From May 2023 to January 2025, 74,587 participants aged 1–30 years contributed 124,018.4 person-years (PYs) of follow-up. We identified 188 laboratory-confirmed and 107 physician-assigned diagnoses of dengue. From May 2023 to April 2024, the incidence of laboratory-confirmed dengue was 150.3 per 100,000 PYs (95

OBJECTIVES:Global populations are ageing rapidly, especially in Asia. The Ageism Scale for Dental Students (ASDS) was developed in 2018 to assess ageism among dental students. This study aims to validate the ASDS in a multicultural, multi-center Asian context to establish a robust tool for future educational and interventional research in gerodontology education. METHODS:The original 27-items ASDS was distributed to dental students from five dental schools in Cambodia, India, Indonesia, Malaysia, and Philippines. Data were randomly split for Exploratory Factor Analysis (EFA; n = 400) and Confirmatory Factor Analysis (CFA; n = 355). Sampling adequacy and Bartlett's test were assessed. EFA employed Oblimin rotation, polychoric correlation matrix and maximum likelihood extraction with iterative item removal. Reliability and internal consistency were evaluated with Cronbach's alpha; convergent and discriminant validity were also examined. RESULTS:EFA revealed 20-items five-factor structure explaining 55.2% of the variance namely therapeutic nihilism, empathy and advocacy, perceived noncompliance and oral health neglect, perceived clinical burden, and confidence and competence. Cronbach's alpha values ranged from 0.742 to 0.839. CFA of the modified model, with 2 items removed, confirmed the five-factor structure with 2-6 items per factor distribution, and good model fit indices (χ2/DF = 3.717, CFI = 0.968, GFI = 0.993, SRMR = 0.055, RMSEA = 0.088). Four factors demonstrated strong convergent validity (AVE ≥ 0.50), while discriminant validity was supported for all factors (HTMT < 0.85). CONCLUSION:The modified 18-item ASDS demonstrated robust reliability and validity across the five Asian countries, confirming its utility as a cross-cultural tool for assessing ageism in dental education and guiding the development of culturally sensitive strategies to prepare students for geriatric care.

BACKGROUND:With the global rise in ageing populations, dental education must prepare students to care for older adults with empathy and competence. Ageism, defined as negative bias towards older individuals, can hinder quality care and meaningful dentist-patient relationships. OBJECTIVE:This study aimed to explore whether documenting and narrating oral health-related life experiences of older adults could promote positive intergenerational attitudes and enhance empathy among dental students. METHODS:A reflective qualitative study was conducted among 3rd-year dental students enrolled in a Social and Behavioural Sciences module. A subgroup of students participated in an enhanced learning session that involved biographical interviews with older adults, focusing on their oral health journeys and related life stories. Students documented these narratives and produced reflective essays. Thematic analysis of the essays was performed to identify key domains of learning and professional development. RESULTS:Engagement with older adults' life stories fostered greater understanding of the psychosocial dimensions of ageing and oral health. Thematic analysis revealed enhanced empathy, improved communication skills and increased cultural sensitivity. Students recognized the importance of preparation, clear communication and digital tools for engagement. They also identified barriers such as financial constraints and access inequalities, demonstrating growing social awareness for older patients. CONCLUSION:Documenting and reflecting on oral health-related life experiences provided dental students with meaningful intergenerational learning opportunities that strengthened empathy, cultural sensitivity and readiness for geriatric dental care. Narrative-based reflection represents a valuable pedagogical tool to reduce ageist perceptions and promote inclusive care within dental education.

Typhoid poses a significant challenge in India, which has one of the highest burdens of the disease globally, making the implementation of cost-effective vaccination strategies essential. The success of typhoid vaccination, whether through clinical trials or large-scale public health programmes, depends on community acceptance. In the post-COVID-19 period, vaccine hesitancy and scepticism have emerged as key challenges to both vaccine trials and mass vaccination efforts. This study examines the barriers to and motivations for vaccine uptake during a mass vaccination campaign. We conducted 15 focus group discussions (FGDs) and five in-depth interviews (IDIs) with participants and guardians from a cluster-randomised typhoid vaccine trial in Vellore, India. Data collection occurred two months after the vaccination campaign in purposively selected low- and high-coverage areas. FGD categories were determined a priori based on age, gender, and vaccination status, while IDIs were conducted when FGDs were not feasible. Data were collected until thematic saturation was achieved. The interviews were audio-recorded, transcribed, and analysed using thematic analysis. Vaccination decisions were shaped by a combination of safety concerns, risk perceptions, and social influences. Key barriers included fears of long- and short-term adverse events, low perceived disease risk and consequently a reduced perceived need for vaccination, shifting attitudes toward new and adult vaccination following COVID-19, sociocultural beliefs, objections from household decision-makers, perceived lack of visible government endorsement and participation, and trust in alternative systems of medicine. The motivators included increased disease salience after the COVID-19 pandemic, increased perceived disease risk, positive influence from family members and peers, and trust in healthcare providers and professional recommendations. Study-related benefits, such as access to vaccines, follow-up, and free vaccination, operated bidirectionally, motivating many participants while raising concerns about vaccine quality among a few. In the post–COVID-19 era, vaccine availability alone does not ensure uptake. Vaccination programmes should actively engage household decision-makers, leverage trusted healthcare providers, address safety concerns and misconceptions surrounding new and free vaccines, and strengthen community trust alongside logistical planning.

Background Typhoid fever incidence estimates are central to policy decisions on vaccine introduction and investments in non-vaccine prevention and control but are often unavailable. We explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local Salmonella Typhi (S. Typhi) incidence. Methods Using a previous systematic review (January 2018-December 2024), we identified studies reporting both typhoid incidence and prevalence of community-onset bloodstream infections from sentinel sites. From authors, we requested data on blood culture isolates and analysed four metrics: (i) S. Typhi prevalence among probable pathogens, (ii) S. Typhi rank order, (iii) S. Typhi to Escherichia coli ratio, and (iv) S. Typhi to "stably endemic" organisms ratio. Typhoid incidence was categorized as low (<10), medium (10-100) or high (>100) per 100,000 person-years. We used univariate ordinal regression to assess the association between each metric and typhoid incidence level. The model performance was evaluated by the c-statistic, sensitivity, and specificity. Findings Analysis of 29 study sites (20 Africa, 9 Asia) yielded 4,625 probable pathogens. The median (IQR) typhoid incidence was 140 (28-319) per 100,000 person-years. All metrics were associated with increased typhoid incidence level: for each 1% increase in S. Typhi prevalence OR 1.07 (95%CI 1.02-1.15); rank order OR 0.25 (95%CI 0.06-0.64); log S. Typhi to E. coli ratio OR 2.91 (95%CI 1.45-7.42); log S. Typhi to "stably endemic" organisms ratio OR 3.69 (95%CI 1.69-11.3). A parsimonious model using S. Typhi prevalence alone achieved c-statistics of 0.87 (0.58-0.97), 0.76 (0.51-0.91), and 0.88 (0.69-0.96) for low, medium, and high incidence, respectively. Interpretation Sentinel prevalence metrics from bloodstream infections, particularly S. Typhi prevalence among probable pathogens, could be useful for inferring local typhoid fever incidence where direct data are unavailable. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Gates Foundation (GF) grant INV-030857. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was a secondary analysis of published data and existing de-identified data and was approved by University of Otago Human Ethics Committee HD23/012. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The underlying data are available online at Dataverse: https://doi.org/10.7910/DVN/JTTFYL. This includes the underlying data to replicate all analysis and the supplementary material with detailed methods and results. Local ethical approvals did not include open posting of the isolate-level data. De-anonymised data regarding this study can be requested from the corresponding author. Proposals should be submitted by the study team via the corresponding author by email.

BACKGROUND:Typhoid fever incidence estimates are central to policy decisions on vaccine introduction and investments in non-vaccine prevention and control but are often unavailable. We explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local Salmonella enterica serovar Typhi (Salmonella Typhi) incidence. METHODS:Using a previous systematic review (January 2018-December 2024), we identified studies reporting both typhoid incidence and prevalence of community-onset bloodstream infections from sentinel sites. From authors, we requested data on blood culture isolates and analysed four metrics: (i) Salmonella Typhi prevalence among probable pathogens, (ii) Salmonella Typhi rank order, (iii) Salmonella Typhi to Escherichia coli ratio, and (iv) Salmonella Typhi to 'stably endemic' organisms ratio. Typhoid incidence was categorized as low (<10), medium (10-100) or high (>100) per 100,000 person-years. We used univariate ordinal regression to assess the association between each metric and typhoid incidence level. The model performance was evaluated by the c-statistic, sensitivity, and specificity. RESULTS:Analysis of 29 study sites (20 Africa, 9 Asia) yielded 4625 probable pathogens. The median (IQR) typhoid incidence was 140 (28-319) per 100,000 person-years. All metrics were associated with increased typhoid incidence level: for each 1% increase in Salmonella Typhi prevalence OR 1.07 (95%CI 1.02-1.15); for each unit increase in rank order OR 0.25 (95%CI 0.06-0.64); for each unit increase in the log Salmonella Typhi to E. coli ratio OR 2.88 (95%CI 1.48-7.39) for each unit increase in the log Salmonella Typhi to 'stably endemic' organisms ratio OR 3.74 (95%CI 1.80-10.7). A parsimonious model using Salmonella Typhi prevalence alone achieved c-statistics of 0.87 (0.58-0.97), 0.76 (0.51-0.91), and 0.88 (0.69-0.96) for low, medium, and high incidence, respectively. CONCLUSION:Sentinel prevalence metrics from bloodstream infections, particularly Salmonella Typhi prevalence among probable pathogens, could be useful for inferring local typhoid fever incidence where direct data are unavailable.

Prevalence and incidence are fundamental metrics with numerous applications in epidemiology. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline lacks specific items for reporting studies of disease prevalence or incidence. To address this gap, the STROBE Enhanced Prevalence and Incidence Criteria (STROBE EPIC) extension was developed in accordance with established methods for reporting guideline development. The authors generated an initial list of reporting items, conducted a modified Delphi process, and convened a face-to-face consensus meeting to confirm the need for a STROBE extension and to generate an early version of the checklist. They conducted 2 further Delphi surveys, first extending from typhoid and other invasive salmonelloses to all infectious diseases, and then to noncommunicable diseases and injuries. Finally, experts piloted the checklist on relevant manuscripts to critically assess if it was clear, concise, complete, and free of errors. An executive group curated the checklist after every survey round. The STROBE EPIC checklist comprises 47 items in the domains of title (1 item), abstract (2 items), introduction (1 item), methods (25 items), results (6 items), discussion (7 items), and other information (5 items). STROBE EPIC items address reporting of study design, adjustment factors for underreporting and underdiagnosis, denominator population estimation, case ascertainment methods, factors producing artefactual changes to observed disease prevalence or incidence, limitations of incomplete surveillance coverage, generalizability of short-duration studies, and data availability. The authors anticipate that the STROBE EPIC extension will be used by researchers, authors, modelers, burden-of-disease researchers, peer reviewers, and journal editors to optimize the presentation of epidemiologic evidence to support diverse health policy decisions.

The coverage of access to basic drinking water and sanitation facilities in India was estimated to be 93% and 60%, respectively, in 2017. The monitoring of the burden of diarrhoeal illnesses, especially in children, remains important to assess the impact of the expansion of water and sanitation (WaSH) in the Indian setting. This study aimed to estimate the burden of diarrhoea in an established longitudinal pediatric cohort in an urban settlement of Vellore in South India. The ‘Surveillance for Enteric Fever in India (SEFI)’ cohort established in an urban settlement of Vellore, south India, enrolled 6760 children aged between 6 months and 15 years. The cohort was followed up for typhoid and paratyphoid fever between 2017 and 2019. Field research assistants contacted caregivers of these children weekly to elicit any diarrhoeal illness in the child in the preceding week. As a part of SEFI environmental surveillance, drinking water samples from the study households were tested for coliforms. Sociodemographic characteristics, including source of drinking water, sanitation and hygiene practices, were collected. Incidence of diarrhoea was estimated and expressed as the number of diarrhoeal episodes over child-years of observation (CYO). Poisson regression analysis was performed to identify predictors of diarrhoeal episodes. The estimated incidence of diarrhoea in the 6501 children followed up between November 1, 2017, and October 31, 2019, was 31.1 episodes per 100 CYO, with children in the age group of 6 months and <5 years having a higher incidence of diarrhoea than those aged between 5 and 15 years (58.6 versus 22 episodes per 100 CYO). Of the 6467 children with information on WaSH available, 5812 (89.9%) used the public distribution system for drinking water. Of the 1804 drinking water samples tested, 1346 (74.6%) had coliform counts >10,000/100 mL. Only about one-third of the cohort (n=2293, 35.5%) lived in households with access to improved sanitation. Multivariable analysis showed that children aged <2 years, residing in crowded settlements, using the public distribution system for drinking water and from households with poor hygiene practices related to excreta disposal of under-five children had a higher risk for diarrhoea. Approximately 8 in 10 children in urban Vellore lack access to safely managed drinking water, and thereby, are at a high risk for diarrheal illnesses, especially in the under-5 children. With rapidly expanding urbanisation in the Indian setting, it is pertinent that emphasis be laid on robust planning and provision of safely managed water and sanitation.

BACKGROUND:Wastewater surveillance can be used to monitor Salmonella enterica serovar Typhi (S Typhi) transmission in the community, allowing early outbreak detection and vaccine effect evaluation. This study aims to establish the baseline detection rate of S Typhi in wastewater and to evaluate its relationship with the clinical burden of typhoid before typhoid conjugate vaccine (TCV) introduction in an endemic urban context. METHODS:We conducted wastewater surveillance for S Typhi in Vellore, Tamil Nadu, India, from Dec 12, 2022, to June 30, 2023, before implementing a cluster-randomised trial of a TCV. 723 grab and 723 Moore swabs were collected from 50 sampling locations and concentrated using Nanotrap A beads for grab samples and Moore swabs as a passive sampler. S Typhi was detected using multiplex quantitative PCR targeting ttr, staG, and tviB genes. Blood culture-confirmed cases of typhoid fever were recorded through hospital-based surveillance established as a part of an independent ongoing VeVact study, an observer-blinded, cluster-randomised trial of a TCV (TyphiBEV). We calculated proportions of typhoid positivity in wastewater sampling sites and the incidence rates of blood culture-confirmed typhoid cases. Spatial analysis was performed to detect statistically significant hotspots for typhoid fever cases in the study area. Bayesian inference using the integrated nested Laplace approximation and mixed-effects spatiotemporal regression quantified associations between wastewater S Typhi detection and typhoid incidence. FINDINGS:S Typhi was detected in 80 (5·5%) of 1446 wastewater samples, higher in grab samples (60 [8·3%] of 723) than in Moore swabs (20 [2·8%] of 723). 207 typhoid cases were recorded, with cases peaking between March and May, 2023. Spatial clustering of typhoid cases corresponded with higher wastewater S Typhi detection. The proportion of wastewater samples that were positive over the study period correlated with typhoid incidence when analysed across the 60 vaccine trial clusters (Spearman's ρ=0·32; p=0·014) or the non-overlapping wastewater site catchment areas (ρ=0·57; p<0·0001). Mixed-effects logistic regression adjusting for spatiotemporal random effects, levels of human faecal contamination, rainfall, and laboratory processing method, gave a 2·43 (95% CI 1·38-4·27) times higher odds of detecting S Typhi in wastewater samples for each 10-fold increase in typhoid fever incidence. INTERPRETATION:Wastewater surveillance data correlate with clinical disease incidence in an endemic setting and could be used to monitor targeted interventions, including TCV introduction. FUNDING:The Gates Foundation.

BACKGROUND:Green dentistry promotes sustainable practices in oral healthcare. As environmental challenges intensify, integrating eco-friendly principles into dental education and practice becomes increasingly important. To advance sustainability in oral health settings, it is crucial to comprehend the knowledge, attitudes, and practices (KAP) of dental professionals and students. Despite growing interest, there is scarcity of research on green dentistry and a lack of standardized, validated tools to measure KAP makes it more difficult to compare studies. The rationale for this study was to conduct a psychometric analysis of a KAP questionnaire designed to assess eco-friendly clinical dental practices among dental school personnel and students in a dental school of Karachi. METHOD:A 43-item questionnaire on green dentistry, adapted from existing green models and literature, and further validated through expert consultation and psychometric analysis, covers knowledge, attitudes, and practices. This cross-sectional pilot study involved 150 dental school personnel and students from the clinical side of an institution, using a self-administered, web-based questionnaire based on the Green Dental Model (GDM). The construct validity of 'knowledge' and 'practice' sections of the questionnaire was assessed using Partial Least Squares- Structural Equation Modeling (PLS-SEM) whereas Exploratory Factor Analysis (EFA) to uncover the latent factor structure of the 'attitude' section. RESULTS:Findings indicate that the model was identified as formative, with VIF values (< 5) indicating no multicollinearity. Through careful decision-making, almost all formative indicators were retained based on outer loads > 0.5. In EFA, factor loadings for the three extracted factors exceeded the reliability threshold. Factor 1 dealt with digital radiography and energy and water conservation; factor 2 involved waste management, recycling, and sterilization; and factor 3 represented green practices as a financial burden. CONCLUSION:The instrument's construct validity and feasibility makes it a valuable resource for sustainability focused researchers and dental professionals. This study uses advanced statistical techniques intended to address the questionnaire's formative and reflective elements, improving the validity of assessment, a factor that was frequently overlooked in other studies on green dentistry. The distinctive contribution of this novel approach to the existing body of literature could facilitate potential research on the tool's responsiveness to interventions on KAP change.

The following protocol is for use on environmental samples that have been collected by Moore swab or grab sampling methods and processed up to the stage of DNA extraction. The protocol includes DNA extraction and qPCR analysis of the samples to detect three gene targets for identifying Salmonella Typhi, a human faecal indicator (HF183), and a commercial spike-in control. The qPCR uses fluorescence of Taqman probes for measuring the product. Care must be taken to ensure that the fluorescent dyes chosen for the probes are suitable for the machine being used or can be calibrated for use on the machine. If the dyes selected are different from those described in the protocol, make sure that their excitation/emission spectra do not overlap to avoid crossover between targets. Generation of standard curves is mentioned in this protocol but is described in more detail in a separate protocol in the Typhoid ES workspace.

Malnutrition is a critical health concern for the elderly. It frequently results from impaired oral function due to tooth loss, obstructing eating and swallowing. Dysphagia and malnutrition can diminish the quality of life. Screening instruments, such as the modified water swallow test (MWST) and Eating Assessment Tool (EAT-10-ID), facilitate the early detection of dysphagia. These instruments are precise and assist in identifying dysphagia, facilitating prompt intervention. Timely identification and intervention for dysphagia and malnutrition can reduce morbidity, length of hospital stays, and health care expenditures in geriatric patients. This article examines the relationship between the dysphagia and nutritional status, as well as its association with tooth loss in the elderly in Indonesia. This study used a cross-sectional design. The participants in this study were individuals 60 years and above --a total of 130 participants who fulfilled the inclusion criteria engaged in the study. Patients were measured for the number of remaining teeth and the condition of denture use, followed by an evaluation of their nutritional health by filling out the Mini Nutritional Assessment form, and swallowing assessment was performed using two methods, objectively and subjectively. The objective method is by the MWST. Subsequently, the participant's subjective dysphagia was evaluated using the EAT-10-ID questionnaire, which is a 10-item screening instrument for assessing dysphagia risk. Multivariate analysis indicated a strong association between dysphagia, education, and malnutrition. Individuals with objective dysphagia possess a four times greater risk of malnutrition relative to those without dysphagia. Individuals with dysphagia exhibited a fourfold increased risk of malnutrition compared with those without dysphagia. Besides dysphagia, educational attainment was also related with nutritional health. Individuals with an education level of elementary school or higher exhibited a lower risk of malnutrition than those with a primary school education or less. This study indicated that patients with < 20 teeth who wore dentures exhibited a decreased percentage of dysphagia compared with those with < 20. Consequently, the diagnosis of dysphagia may be conducted with the EAT-10-ID or by subjective assessment.

The mumps vaccine remains excluded from India's National Immunization Schedule (NIS) because of insufficient data on the community-level disease burden, despite mumps being a vaccine-preventable disease. In the present study, biobanked serum samples from an urban population in Vellore, stratified by age (in age groups of 1-5, 6-15, and 16-40 years) and sex, were tested for anti-mumps IgG antibodies using ELISA. The seroprevalence rates of mumps were 26%, 71%, and 84% in the 1- to 5-year, 6- to 15-year, and 16- to 40-year age groups, respectively, indicating a high burden in the community. Women in the 16- to 40-year age group exhibited a higher seroprevalence compared with males, with antibody levels consistently lower in males across both the 6- to 15-year and 16- to 40-year age groups (P <0.05). The present study highlights increasing mumps exposure with age and underscores the urgent need to include the mumps vaccine in the NIS to address the high disease burden and prevent complications.

Abstract Background The rising antimicrobial resistance in Salmonella Typhi presents a critical public health challenge by limiting effective treatment options. This highlights the importance of sustained genomic surveillance of the high-risk lineages and antimicrobial resistance determinants of S . Typhi to inform and support the implementation of typhoid vaccination programs, especially in endemic regions. In this context, we investigated a recent outbreak of carbapenem-resistant Salmonella Typhi in India, to elucidate the genomic epidemiology, resistance mechanisms, and evolution of drug resistance. Methods A total of 21 carbapenem-resistant S . Typhi isolates collected from multiple healthcare facilities were subjected to phenotypic and genotypic characterization. Short-read whole-genome sequencing (WGS) was performed to analyze the population structure, identify single nucleotide polymorphisms (SNP), and investigate the evolution of antimicrobial resistance. A maximum likelihood phylogenetic was constructed in the context of global isolates to infer the emergence and dissemination of carbapenem-resistant S . Typhi. Additionally, two isolates were subjected to long-read nanopore sequencing to characterize the plasmids and assess their circulation among other Enterobacterales. Results Antimicrobial susceptibility testing of isolates revealed resistance to ampicillin, ciprofloxacin, ceftriaxone, and carbapenem, while the isolates remained susceptible to chloramphenicol, cotrimoxazole, and azithromycin. The genomic analysis identified the presence of two plasmids: IncFIB(K) harboring bla CTX-M-15 , qnrS1 , tetA , tetR, and IncX3, carrying the bla NDM-5 gene. Phylogenetic analysis classified the isolates within a novel genotype, 4.3.1.1.1 belonging to genotype 4.3.1.1(H58 lineage I). The independent acquisition of resistance plasmids from other Enterobacterales in multiple S . Typhi genotypes highlights a significant public health concern. Conclusion Our findings emphasize the need for robust genomic surveillance to monitor antimicrobial resistance, trace the dissemination of high-risk S . Typhi lineages, and guide evidence-based antibiotic policies for the treatment of drug-resistant strains. Strengthening surveillance addresses travel-associated transmission and prevents the global spread of drug-resistant strains.