Healthy People 2030 aims to decrease low-risk cesarean delivery rates to 23.6% in the United States. In 2023, the national rate was 26.6%, though rates vary widely by state and hospital. This suggests a need for localized geographic estimates to identify places with higher burden. We modeled 2023 low-risk cesarean delivery rates by county of birth using birth certificate data and hierarchical Bayesian models that spatially smooth unstable estimates. We found considerable variation in rates, with county rates ranging from 5.8% to 53.4%. Counties in the West had lower rates than those in the Midwest, South, and Northeast. County rates increased with urbanicity. Only 47.7% (985) of counties had rates meeting the Healthy People 2030 target.

Monitoring the emergence and spread of drug-resistant parasites is essential for effective malaria control. Here, we describe the prevalence of genetic markers of Plasmodium falciparum antimalarial drug resistance and parasite population structure in Mozambique. Drug resistance loci and microhaplotypes were genotyped by multiplex targeted amplicon sequencing of 1146 P. falciparum samples collected in 2021 (n = 321) and 2022 (n = 825 rainy season, and n = 155 dry season). pfpm2 gene copy number (associated to piperaquine resistance) was assessed using real-time quantitative PCR. No pfk13 markers of partial artemisinin resistance nor pfpm2 duplications were observed. Prevalence of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine (SP) resistance was high across all regions (> 92.5% in 2021 and > 87.8% in 2022), but pfdhps-A581G mutation was rare (1.6% in 2021 and 0.8% 2022). Both prevalence of mutations in pfdhps-436 (p < 0.001) and genetic complexity of infections increased from South to North. These results support the continued use of artemisinin-based combination therapies in Mozambique, call for a close monitoring of chemopreventive efficacy based on SP, and confirm the spatial genetic distinction in P. falciparum population observed across the country.

Digital PCR (dPCR) systems offer high sensitivity and reproducibility without requiring external control standards. However, their performance against real-time reverse transcription-PCR (rRT-PCR) for detecting respiratory viruses remains unexplored in Ghana. We therefore evaluated the performance of a novel dPCR, Lab-On-An-Array (LOAA), for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), respiratory syncytial virus (RSV), and influenza viruses type A (Flu A) and B (Flu B). A cross-sectional hospital-based study was conducted between August 2022 and January 2023 in Ghana's Ashanti and Savannah Regions. Oropharyngeal swabs from 356 participants with a median age of 19 years, presenting with suspected respiratory illness, were tested using LOAA and rRT-PCR. Viral RNA was extracted using a Qiagen Viral Mini Kit (Qiagen Diagnostics GmbH, Germany). LOAA and rRT-PCR tests were performed using Genoplexor COVID-19/Flu/RSV Detection Kit (Optolane Technologies Inc, South Korea) and FluoroType SARS-CoV-2/Flu/RSV kits (Hain Lifescience GmbH, Germany), respectively. LOAA's performance metrics were assessed using rRT-PCR as the gold standard. Overall positivity rates were 29.78% and 30.90% for LOAA and rRT-PCR, respectively. Compared to rRT-PCR, LOAA's sensitivity was 87.76% for RSV, 91.30% for SARS-CoV-2, 86.21% for Flu B, and 88.89% for Flu A. Positive predictive value was the highest for RSV (97.73%) and lowest for Flu A (61.54%); negative predictive values were >/=98.00% for all respiratory viruses. LOAA recorded an "almost perfect" agreement (kappa >/=0.88) with rRT-PCR for RSV, SARS-CoV-2, and Flu B and good agreement for Flu A (kappa = 0.72). LOAA is sensitive in detecting SARS-CoV-2, RSV, and Flu B infections; however, minor improvements for Flu A are required. IMPORTANCE: This study presents the potential of a digital PCR as a highly sensitive and reproducible tool for detecting respiratory viruses in Ghana, where robust diagnostic methods are essential for managing public health challenges. By evaluating the novel Lab-On-An-Array (LOAA) system, we provide its critical operational performance against the gold-standard rRT-PCR for detecting severe acute respiratory syndrome coronavirus 2, respiratory syncytial virus, and influenza viruses. Our findings show that LOAA demonstrates excellent agreement with rRT-PCR for most viruses, offering a promising alternative for respiratory virus surveillance and diagnosis. This research is particularly significant for resource-limited settings, as it supports the adoption of advanced molecular diagnostics to improve early detection and response to respiratory infections. Minor refinements for specific viruses, such as influenza A, could further enhance its utility in clinical and epidemiological applications.

As part of Centers for Disease Control and Prevention's (CDC) Prevention Research Center (PRC) Vaccine Confidence Network (PRC VCN), 26 academic institutions were funded to increase COVID-19 vaccine confidence and uptake in their communities. Six sites (in communities located in Alabama, Illinois, Massachusetts, New York, South Carolina, and Texas) formed a workgroup to identify emergent themes, and share challenges and opportunities across projects. This essay describes their efforts to engage trusted messengers in vaccine activities, and discusses strategies to develop and sustain these types of partnerships in the future. All sites recruited trusted messengers with strong community relationships to engage in multiple activities to promote COVID-19 vaccine confidence and uptake. CDC and the PRCs provided data-driven, evidence-based training and support to enable trusted messengers to fully participate in the projects. We posit that trusted messengers are essential partners for informing public health campaigns, developing effective messages, and building trust with local communities. Flexible federal funding and local coordination are essential for creating and sustaining trusted messenger approaches that combine community needs and data-informed evidence to promote timely public health responses.

BACKGROUND: High and increasing syphilis rates among American Indian/Alaska Native (AI/AN) communities and particularly among AI/AN women and infants call for immediate interventions to reach and offer syphilis testing to sexually active populations paired with timely treatment. METHODS: The Great Plains Tribal Epidemiology Center within the Great Plains Tribal Leaders Health Board (GPTLHB) partnered with a local non-tribal healthcare facility to offer free community-based syphilis testing in Rapid City, South Dakota, starting in December 2022 through June 2024. Participants received cash incentive cards for undergoing testing for syphilis, human immunodeficiency virus (HIV) and hepatitis C (HCV). RESULTS: Fifteen community testing events were conducted. Laboratory-based syphilis testing was performed on 1434 unique individuals, average age 38.8 years. Seventy-six (76) people were diagnosed with syphilis that had previously not been identified (prevalence 5.3% (76/1434); 51 (67.1%) were female. Treatment was provided to 80.3% of people with syphilis (61/76) within an average of 36 days. In total, the 15 events cost $158,019 ($75,000 administrative staff time + $5,100 laboratory staff time + $24,009 lab tests + $ 53,910 incentives) or $88 per test performed ($158,019/1797). The cost to identify a previously unidentified case was $$2,079 ($158,019/76 newly identified infected persons). CONCLUSIONS: This community-based screening event revealed high prevalence of undiagnosed syphilis. Incentives supported community members to access screening services. Collaborations between clinical, tribal, and public health entities to bring diagnosis and treatment services to patients using a community-based approach have clear benefits but need ongoing supportive resources to be maintained.

INTRODUCTION AND METHODS: In a cohort study, enrolling new households annually during 2016-2018, we estimated the B. pertussis attack rate using serology and PCR, identified factors associated with seroconversion, and described antibody changes over time. Nasopharyngeal swabs were collected biweekly for 6-10 months annually, with cases defined as individuals testing PCR-positive at least once. Seroconversion was defined as a ≥4-fold increase in anti-pertussis toxin IgG concentration between consecutive blood draws. Logistic regression was used to identify factors associated with seroconversion among PCR-positive individuals. RESULTS: Among 1509 participants, the serology attack rate was 5.8% (87/1509), 6.2% (94/1509) by PCR, and 9.6% (145/1509) combining both methods. Among PCR-positive cases, 38.3% (36/94) seroconverted, with a mean time to seroconversion of 2.9 months (range: 3 weeks-5.9 months). Younger participants (5-18 years) (adjusted odds ratio (aOR) 6.8, 95% confidence interval (CI) 1.3-35.1) and those with episode durations of ≥7 days (aOR 13.3, 95% CI 3.4-51.1) were more likely to seroconvert. Among the seroconverted, 75.0% (27/36) maintained antibody concentrations >40 IU/ml for at least 12 months post-infection. DISCUSSION: Almost 10% of participants had B. pertussis infection during follow-up. Less than half of individuals with PCR-confirmed infection seroconverted but maintained elevated antibodies for at least one-year post-infection.

Background: Malaria is a mosquito borne disease caused by parasites of the genus Plasmodium. In 2023, the United States (US) experienced nine cases of autochthonous Plasmodium vivax malaria transmission; seven in Florida, one in Texas, and another in Arkansas. These were the first autochthonous cases since 2003 when a cluster was identified in Florida. The aim of this study was to genetically characterize the implicated P. vivax isolates in order to complement epidemiologic investigations of these cases. Methods: A custom Illumina AmpliSeq sequencing panel capturing 495 amplicons was designed. This panel was used to ascertain whether these 2023 cases were related, and assess if they were associated with a single or separate introduction events. Sequence data were hierarchically clustered and a Naïve Bayes classification approach was used to assign genotypes to a probable geographic origin based on 113 ‘geo-informative’ SNPs captured by the panel. Genotypes associated with the 2023 Arkansas, Texas, and Florida cases were clustered alongside those sequenced from archived blood samples from the 2003 Florida case-patients, a set of reference strains, and other travel-associated specimens. Microsatellite analysis was performed on a subset of samples from these autochthonous cases to complement the AmpliSeq analysis. Findings: The 2023 autochthonous Florida cases were genetically linked as were the 2003 Florida cases. The 2023 and 2003 Florida clusters were genetically distinct, and the two Florida clusters were distinct from the 2023 Texas and Arkansas cases, which were also distinct from each other. These genotypes classified to the Central or South American region using the Naïve Bayes classifier, including those from the 2003 cluster. Interpretation: These data support that at least three distinct P. vivax introduction events in the US in 2023, involving parasites possessing genetic signatures consistent with Central or South America. Funding: This work was supported by the National Center for Emerging and Zoonotic Infectious Diseases at the US Centers for Disease Control and Prevention. © 2025

Achieving the Sustainable Development Goal of reducing child mortality to <25 deaths per 1000 live births by 2030 requires strategies to prevent diarrheal disease-related morbidity and mortality. Accurate etiological diagnosis is essential. This study used postmortem diagnostics to investigate the contribution of diarrhea to under-5 mortality and examine co-morbidities and co-infections in Africa and South Asia. Child Health and Mortality Prevention Surveillance (CHAMPS) generates data on child deaths through minimally invasive tissue sampling, clinical record review, and verbal autopsies. Multidisciplinary panels assign cause(s) of death using WHO International Classification of Diseases. This analysis included deaths among children aged 1-59 months enrolled from 18 December 2016-31 December 2023 across six African sites (Ethiopia, Mali, Kenya, Sierra Leone, Mozambique, South Africa) and Bangladesh. Of 1517 deaths assessed, diarrhea was in the causal pathway in 240 (15.8%). The proportion of diarrhea-related deaths was highest in Ethiopia (41.0%, 34/83), followed by Bangladesh, (30.0%, 3/10), Mozambique (21.7%, 56/258), Mali (17.5%, 18/103), Kenya (13.9%, 51/366), Sierra Leone (12.8%, 46/358), and South Africa (9.4%, 32/339). Diarrhea was underlying cause in 44.2% (106/240) of cases and immediate/antecedent cause in 58.3% (140/240), with some deaths involving multiple roles in the causal chain. When diarrhea was underlying cause, sepsis (33.0%) and lower respiratory infections (25.5%) were common downstream conditions; when an antecedent/immediate cause, leading underlying causes were malnutrition (64.3%) and HIV (13.6%). No pathogen was identified in 49.6% (119/240) of diarrhea-related deaths; among these, diarrhea was underlying cause in 42.9%. Among the 121 pathogen-attributed deaths, the most frequent were EAEC (34.7%), typical EPEC (15.7%), Shigella/EIEC (14.0%), ST-ETEC (12.4%), rotavirus (26.4%), and adenovirus (non-40/41: 19.0%; 40/41: 5.0%). These pathogens were frequently identified as co-infections. Diarrheal disease accounted for a substantial share of child deaths across CHAMPS sites. Reducing mortality will require preventing diarrhea and addressing key contributors such as malnutrition and HIV.

INTRODUCTION: Increasing walking for transportation is a strategy to integrate physical activity into daily life. We examined reported environmental, access, and individual reasons for not walking to places near home among US adults, by sociodemographic characteristics and geographic location. METHODS: We used data from the 2022 SummerStyles survey on 3,967 US adults aged 18 years or older. We calculated prevalence of reporting 11 selected reasons for not walking to places within 10 minutes of home, overall and by sex, race or ethnicity, age, education, income, US census region, and metropolitan residence (an area with at least 1 urban area of ≥50,000 inhabitants) versus nonmetropolitan residence. We used Bonferroni-corrected pairwise comparisons and orthogonal polynomial contrasts (ordered groups) to compare prevalence by subgroup. RESULTS: Overall, 79.0% of respondents identified at least 1 reason for not walking to places near home (within 10 minutes). Commonly reported reasons were hot and humid conditions (36.0%), no places to walk within 10 minutes (24.9%), a preference for driving (22.1%), and inconvenience (21.5%). The reasons varied significantly across sociodemographic and geographic subgroups. The prevalence of reporting none of the listed reasons was higher among males than females, higher among non-Hispanic Black and non-Hispanic Asian adults than non-Hispanic White adults, and higher among adults from the Northeast versus the South. CONCLUSION: Eight of 10 US adults reported at least 1 environmental, access, or individual reason for not walking to places near home. Designing communities to make walking for transportation more accessible, convenient, and desirable may help address the leading reasons reported, which may support adults in adding more physical activity to their daily lives.

INTRODUCTION: Municipalities can improve access to food through transit planning. The primary objective of this study was to describe the prevalence of public transit supports for food access among a sample of US municipalities and their association with the municipalities' sociodemographic characteristics. METHODS: This study used a nationally representative sample (N = 1,956) of US municipalities with a population of at least 1,000 that responded to the 2021 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. We assessed 4 outcomes: public transit availability and planning, presence of demand responsive transportation (DRT), DRT services to food retail destinations (farmers markets and supermarkets), and consideration of these locations in transit planning. We used χ(2) tests to compare the prevalence of outcomes by municipal characteristics and multivariable logistic regression to calculate odds ratios to assess the relationship between municipal characteristics and having DRT. RESULTS: Approximately half (weighted 53.2%) of municipalities reported having or planning for public transit, of which 27.1% and 52.6% reported considering service to farmers markets or supermarkets, respectively. Approximately one-third (35.5%) of municipalities reported having DRT, of which 52.0% and 84.4% reported services to farmers markets or supermarkets, respectively. All outcomes significantly differed by municipal characteristics. We found higher odds of having DRT in municipalities with 2,500 to 50,000 people or more (vs <2,500 people); those with 50% or less of the population being non-Hispanic White (vs >50% non-Hispanic White); and municipalities containing low-income/low-access tracts. The odds of having DRT were lower in rural (vs urban) municipalities and in those in Northeast and South (vs the Midwest). CONCLUSION: Results suggest opportunities for municipalities to use transit planning to improve food access, especially in northeastern, southern, smaller, or rural communities.

Nipah virus (NiV) is a zoonotic paramyxovirus belonging to the genus Henipavirus, which infects Pteropus bat species in Southeast and South Asia. Since its discovery in the late 1990s in Malaysia, NiV has caused outbreaks in humans in Singapore, Bangladesh, India and the Philippines. The spillover pathway for the most recent NiV outbreak in 2023 in Kerala, India, remains speculative. NiV causes serious disease in infected humans, with a mean case-fatality rate of 70%, and no approved treatment or vaccines exist. Humans have been infected directly from bats through shared food or through infected bridging hosts, including pigs and horses, although other spillover pathways may exist. Here, we review the pathways of NiV spillover and transmission, highlighting areas needing further research. We emphasize the importance of collaborative and multidisciplinary efforts both in the laboratory and in the field, and the implementation of a One Health strategy to prevent future epidemics.

OBJECTIVES: To evaluate the potential contributions of routine opt-out testing (ROOT) in clinical settings and preexposure prophylaxis (PrEP) on achieving Ending the HIV Epidemic in the U.S. (EHE) incidence reduction goals in the South. DESIGN: Simulation Study. METHODS: An agent-based epidemic projection model simulated adherence to the CDC's ROOT guidelines. Simulations were informed by literature reviews, the National Survey of Family Growth and ARTnet. Interventions included ROOT in Community Health Center (CHC) and Emergency Departments (ED) alone and in combination. PrEP was modeled as either persistent at 2019 levels or expanding consistent with historical trends. RESULTS: ROOT in CHCs and EDs averted 13.9% (95%SI: -15.5, 42.4) of infections and increased the proportion of persons with HIV (PWH) who were aware of their status from 84.8% to 94.4% (95%SI: 92.8, 95.4). In conjunction with the ongoing expansion of PrEP the proportion diagnosed increased from 84.8% at baseline to 95.1% (95% SI: 93.9, 96.4) and 23.3% (95% SI: -7.9, 50.6) of infections were averted, reducing the annual incidence rate by 42.4% compared to the baseline scenario. CONCLUSIONS: In our analysis, ROOT coupled with the ongoing expansion of PrEP averted almost a quarter of new infections over the 8 years from 2022 to 2030. While short of the overall EHE goal of 90%, it represents substantial potential progress for a low-cost and low-barrier intervention. ROOT also provides a method for identifying PWH who are undiagnosed both in and out of priority populations, those out of care, and individuals reluctant to seek screening.

IMPORTANCE: Most of the 2.3 million annual neonatal deaths occur in sub-Saharan Africa and South Asia, with perinatal asphyxia and neonatal sepsis being the leading causes of neonatal mortality. Most neonatal deaths are considered preventable through high-quality clinical care, which includes adherence to clinical care guidelines. OBJECTIVE: To assess adherence to World Health Organization clinical care guidelines for management of perinatal asphyxia and neonatal sepsis and to identify patient-level factors in adherence among neonates who died from these conditions. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data from December 2015 through October 2023 from the Child Health and Mortality Prevention Surveillance (CHAMPS) catchment areas in 7 low- and middle-income countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and South Asia (Bangladesh). Participants were neonates who were born alive and were aged 0 to 28 days at the time of death and had either perinatal asphyxia or neonatal sepsis. EXPOSURE: Medical records of neonates who died from perinatal asphyxia or neonatal sepsis determined by postmortem diagnostics. MAIN OUTCOMES AND MEASURES: The main outcome was the proportion of deceased neonates who received guideline-adherent treatments before they died. Mixed-effect multivariable logistic regression analyses were performed to identify factors associated with administration of at least bag-valve-mask (BVM) ventilation for perinatal asphyxia. RESULTS: Of the 1194 neonates (median [IQR] age at the time of death, 2 [1-6] days; 692 males [58.0%]) who died and were enrolled in CHAMPS with available clinical data, 476 (39.9%) died from perinatal asphyxia, 562 (47.0%) died from neonatal sepsis, and 156 (13.1%) from both conditions. These neonates had a median (IQR) birth weight of 2130 (1266-2988) g. For cases with perinatal asphyxia, guideline adherence ranged from 12.2% (n = 77) for adrenaline administration to 85.4% (540) for supplemental oxygen administration. Only 4.4% of neonates (28) with perinatal asphyxia received all recommended treatments. Among cases with neonatal sepsis, antibiotics were administered to 86.8% (623), although the recommended treatment was administered to only 61.0% (438). In multivariable analyses, neonates in whom clinicians accurately identified perinatal asphyxia were more likely to receive BVM ventilation than those who had received discordant antemortem and postmortem diagnoses (adjusted odds ratio, 2.00; 95% CI, 1.29-3.12). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, clinical care guideline adherence was suboptimal among neonates who died from perinatal asphyxia or neonatal sepsis. This finding underscores the critical need to increase adherence in regions with high rates of neonatal mortality and may inform strategies for strengthening health systems to support compliance with clinical care guidelines.

Dermatophytosis (also called ringworm or tinea infection) is a common, contagious superficial infection of the skin, hair, or nails caused by dermatophyte molds. Historically, clinicians have considered dermatophytosis as a mild, easy-to-treat condition; however, the epidemiology of dermatophytosis has changed dramatically in the past decade because of the emergence of dermatophyte strains causing increasingly severe and difficult-to-treat infections. We review three recently emerged dermatophytes of public health concern: Trichophyton indotineae, which is causing outbreaks of frequently terbinafine-resistant and difficult-to-treat tinea in South Asia, with cases also reported across six continents; Trichophyton mentagrophytes genotype VII (TMVII), associated with oral and anogenital tinea infections particularly among men who have sex with men in France and the United States; and terbinafine-resistant Trichophyton rubrum, noted as a cause of difficult-to-treat tinea infections, although data are limited. We discuss practical considerations for identifying these pathogens, which relies on DNA sequencing or MALDI-ToF rather than on morphological characteristics. Additionally, we highlight the importance of antifungal susceptibility testing and practical laboratory considerations. Finally, we emphasize the importance of increased adoption of diagnostic testing for suspected dermatophyte infections, as well as the development of rapid, accurate, and affordable dermatophyte testing methods to help improve diagnostic accuracy and judicious antifungal use. Overall, the emergence of severe and antifungal-resistant dermatophyte infections poses a global public health concern. Clinical microbiologists can play a crucial role in addressing this threat by familiarizing themselves with techniques for identifying emerging dermatophyte species and performing antifungal susceptibility testing to guide patient management, monitor trends, and inform future public health interventions. Copyright © 2025

BACKGROUND: Despite the growing adoption of the Family Mid-Upper Arm Circumference (MUAC) approach to empower caregivers in detecting child malnutrition, limited evidence exists on whether caregivers act on identified cases by seeking care and factors influencing their decisions. Most research has focused on the accuracy of caregiver MUAC measurements, leaving a gap in understanding behavioral, social, emotional, and contextual barriers to care-seeking. Addressing this gap is critical for informing interventions to ensure early detection translates into timely treatment. This study aimed to explore the barriers and facilitators influencing care-seeking practices within a Family MUAC program in South Sudan. METHODS: We conducted a mixed-methods, prospective, non-randomized study in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. We enrolled 2,893 children aged 5-53 months and trained their caregivers on using MUAC tapes. Caregivers were followed for 8 months, including three monitoring visits and baseline/endline surveys, capturing self-reported care-seeking practices. Qualitative data were obtained through 20 focus group discussions (FGDs) with caregivers, using the Health Belief Model as a theoretical framework to explore perceptions, barriers, and enablers of care-seeking. A combined deductive and inductive coding approach was used for thematic analysis. RESULTS: Among children identified with wasting using MUAC tapes, 86.5% of caregivers sought care, with significantly higher rates in Warrap (97.6%) than Central Equatoria (79.4%) (p < 0.008). Barriers to care-seeking included distance to health facilities (18.9%), transportation costs (11.3%), and treatment costs (9.4%). Qualitative findings revealed additional challenges such as social stigma, lack of knowledge about where to seek care, and negative experiences with health workers. Despite some caregivers reporting a lack of encouragement, most valued the MUAC tapes, used them weekly, and were confident in their ability to take accurate measurements. CONCLUSIONS: Policies and programmatic interventions should consider integrating Family MUAC programs with community-based financial initiatives like savings groups to address financial barriers. Tailoring interventions to rural and urban contexts through formative research can enhance program effectiveness, while training health workers in compassionate care may improve caregiver trust and increase care-seeking rates. Strengthening these areas can maximize the impact of Family MUAC and improve child health outcomes. TRIAL REGISTRATION: N/A.

Pregnant women have a high HIV incidence in South Africa (SA), increasing the risk of mother-to-child transmission (MTCT) of HIV. Strengthening coverage of HIV prevention strategies such as pre-exposure prophylaxis (PrEP) is essential to ending the epidemic in SA. We estimated awareness and coverage of PrEP among pregnant women attending antenatal clinics. Using the national cross-sectional antenatal HIV sentinel survey SA, that was conducted from February to April 2022, we performed descriptive and survey logistic regression analyses. Women were deemed as aware about PrEP if they reported ever having heard of PrEP. Women were eligible for PrEP if they were HIV-negative and had either: (1) an HIV-positive/status-unknown partner; (2) multiple sexual partners in the past twelve months; (3) a sexually transmitted infection in the preceding six months; or (4) sex under the influence of alcohol/drugs in the past six months. 31.18% (n = 7 271) of HIV-negative women were eligible for PrEP. Among eligible women, 33.65% (n = 2 403) were aware about PrEP, 3.58% (n = 271) took PrEP before pregnancy, and 6.50% (n = 507) were currently on PrEP. Compared to follow-up visit attendees, first ANC visit attendees were less likely to be: (1) aware about PrEP (adjusted odds ratio (aOR) = 0.65; 95% confidence interval (CI): 0.59-0.72), and (2) to currently be on PrEP (aOR = 0.69; 95% CI: 0.57-0.84). Women who had never tested for HIV before pregnancy were less likely to: (1) be aware about PrEP (aOR = 0.51; 95% CI: 0.45-0.59), and (2) currently be on PrEP (aOR = 0.56; 95% CI: 0.43-0.74) compared to those who had tested for HIV before pregnancy. Women who reported having an HIV-positive partner compared to those with an HIV-negative partner had higher: (1) PrEP awareness (aOR = 2.21; 95% CI: 1.80-2.71), and (2) PrEP coverage during pregnancy (aOR = 8.51; 95% CI: 6.43-11.25). Overall PrEP awareness and coverage were low. PrEP is being integrated into safe conception programs as an HIV prevention strategy. Entry into ANC presents an important opportunity to prevent new HIV infections among new mothers, accelerating the elimination of MTCT of HIV in the country.

OBJECTIVE: The objective of this study was to generate updated estimates for the incidence rate, cost burden, and case fatality rate (CFR) of neonatal herpes simplex virus (nHSV) infections in the US in 2019. METHODS: A nationally representative sample of US pediatric discharges was assessed using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database to estimate the incidence, costs, and fatality of nHSV in 2019. Cases were estimated using herpes simplex virus International Classification of Diseases, Tenth Revision, Clinical Modification codes (B00.xx, A60.xx, or P35.2) among infants aged 28 days or younger admitted to the hospital and with hospital stays more than 5 days or resulting in death. A matching algorithm was developed to deduplicate records of readmissions or transfers from another hospital. Estimates were generated overall and by sociodemographic factors including race, US region, primary payer, and median household income. RESULTS: In total, 561 nHSV cases were estimated in the US in 2019, resulting in an incidence rate of 15.7 per 100 000 hospital births. The highest incidence rate was in the South (21.3; 95% confidence interval [CI], 19.0-23.9) and in infants born to Black birth parents (27.3; 95% CI, 22.8-32.4). The total cost to the US health care system was estimated at $28.9 million. The CFR among infants with nHSV was estimated to be 4.6%. CONCLUSION: This study updates the incidence rate, cost burden, and CFR of nHSV in 2019, an increase compared with past estimates, and highlights the racial and geographic disparities across the US. Public health interventions for early detection and prevention are critical to mitigate these disparities.

BACKGROUND: We estimate annual viral influenza-associated mild-to-moderate illness, hospitalizations, and deaths in 6 South American countries (Argentina, Brazil, Chile, Ecuador, Paraguay, and Uruguay) during the 2015-2019 influenza seasons as a first step in evaluating the full value of influenza vaccination in the subregion. METHODS: We applied a multiplier method using monthly hospital discharge and vital statistics death records, influenza surveillance data, and population projections to estimate mild-to-moderate influenza-associated illness, hospitalizations, and deaths. We estimated the uncertainty bounds based on the 2.5th and 97.5th percentiles of the Monte Carlo simulated distributions for the number of cases and obtained the ranges from the minimum value of the 2.5th and the maximum value of the 97.5th percentile. RESULTS: In selected countries with a total population of 307 million people, the yearly influenza-associated burden of disease ranged between 51 and 78 million mild-to-moderate influenza illnesses, between 323 379 and 490 049 hospitalizations, and between 22 662 and 46 971 deaths during the 2015-2019 influenza seasons. CONCLUSIONS: Each year, influenza is associated with millions of illnesses, hundreds of thousands of hospitalizations, and tens of thousands of deaths in 6 South American countries, affecting a significant portion of the population. Such findings can be used to estimate the number of illnesses averted through vaccination programs and the cost-benefit of influenza vaccines.

Mycetoma, chromoblastomycosis, and sporotrichosis are fungal neglected tropical diseases (NTDs) recognized by the World Health Organization. These implantation diseases cause substantial morbidity, disability, decreased quality of life, and can lead to long-term complications including tissue fibrosis, skin cancer, and amputation. The 2024–2030 South-East Asia Regional NTD Strategic Framework includes mycetoma but neglects the full extent of mycetoma endemicity in the region. Furthermore, the framework excludes chromoblastomycosis and sporotrichosis. We describe the data demonstrating fungal NTDs being of public health concern in this region and more widely distributed than acknowledged in the framework. Additionally, we propose modifications to public health interventions and services for fungal NTDs including an active case search approach through community health workers. Severe disease from fungal NTDs in South-East Asia can be eliminated by improving burden data quality, early diagnosis, accessible treatment, and integration with other common and neglected skin diseases. © 2025

BACKGROUND: Coronavirus disease 2019 (COVID-19) burden is difficult to quantify with cases missed by surveillance systems. During COVID-19 Delta and Omicron BA.1-5 periods, we assessed the COVID-19 burden in New South Wales (NSW), Australia, from May 2021-July 2022 using a participatory surveillance system of self-reported respiratory disease and a database of people seeking healthcare. METHODS: To estimate community illness burden, we adjusted the NSW age-stratified non-case population by reported severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) percent positive and acute respiratory illness (ARI) rates. Hospitalization and death burden were estimated by adjusting reported rates to the NSW population and by the proportion of COVID-19 admissions attributable to COVID-19 illness. Burden estimates were compared to reported case counts. RESULTS: From May 2021-July 2022, an estimated 3,450,516 (95%CI: 2,847,355-4,119,472) symptomatic community ARI illnesses, 24,684 (95%CI: 20,714-29,144) hospitalizations, and 4,638 (95% CI: 3,263-6,049) deaths were attributable to COVID-19 in NSW. Reported cases (3,039,239) were 14% lower than the estimated symptomatic community illness burden but within the estimate's 95% confidence interval. Overall, 0.7% of symptomatic community illnesses resulted in hospitalization and 0.1% resulted in death. CONCLUSIONS: Estimated symptomatic case hospitalization and fatality risk could be used for COVID-19 modelling and forecasting.

BACKGROUND: Evaluation of optimal dosing has generally been inadequate during TB drug development. Fluoroquinolones are central to TB treatment. We aimed to determine the dose of levofloxacin needed to achieve maximal efficacy and acceptable safety and tolerability as part of a multidrug TB regimen. METHODS: Opti-Q was an international, multi-center, randomized, placebo-controlled, phase II trial. Eligible participants with TB resistant to isoniazid and rifampicin but susceptible to fluoroquinolones (MDR-TB) were randomized to receive one of four weight-adjusted once-daily doses of levofloxacin given for 24 weeks(168 doses): 11mg/kg(750mg), 14mg/kg(750mg/1000mg), 17 mg/kg(1000mg/1250mg) or 20mg/kg(1250mg/1500mg) alongside a multidrug regimen. The primary efficacy outcome was time to sputum culture conversion and the primary safety outcome was grade 3 or higher adverse events. FINDINGS: 111 participants were randomized from three sites in South Africa and Peru. 83(75%) had cavities on chest x-ray, 55(50%) had a smear grading of 3+, median BMI was 20.4 kg/m(2). Median levofloxacin AUC/MIC was 573, 633, 918 and 1343 across the four treatment arms. There was no difference in time to culture conversion on solid or liquid media by treatment arm (stratified log-rank p=0.282), by tertile of AUC/MIC (p=0.350), or by dose received (p=0.723); 69.3%, 74.8%, 70.6% and 78.3% achieved culture conversion after 8 weeks on solid media respectively across the treatment arms; 64.6%, 69.5%, 52.6% and 69.6% in liquid culture. More participants experienced a grade 3-5 adverse event by dose (37.0% and 16.0% in the highest and lowest dose groups respectively, p=0.042, Cochran-Armitage test for trend) and by tertile of AUC (p=0.011). INTERPRETATION: As part of a multidrug regimen, doses of levofloxacin above 1000mg resulted in greater exposures and increased frequency of adverse events but did not result in faster time to sputum culture conversion. A dose of 1000mg daily can achieve the target exposure in nearly all adults and was well tolerated. Clinical trial registration available at www. CLINICALTRIALS: gov, ID: NCT01918397.

BACKGROUND: Clusters of rapid HIV transmission indicate larger underlying networks that are not effectively reached by HIV prevention, testing, and care services. Starting in 2018, the Centers for Disease Control and Prevention (CDC) funded 59 U.S. health departments (HDs) to detect and respond to HIV clusters; HDs began reporting clusters to CDC in January 2020. METHODS: For clusters reported to CDC, we described cluster characteristics at detection, including detection method; size; HIV transmission category, defined as that of >50% of cluster members; and HD investigation and response activities. RESULTS: During 2020-2022, 45 HDs reported 322 HIV clusters, with most detected by molecular analysis of HIV sequences (75%). Most were detected in the South (46%) and three-quarters were predominant sexual transmission. Median cluster size at detection for molecular clusters was 10 persons (interquartile range 7-18). Among 205 clusters with follow-up data, investigation and response activities were conducted for 95%, including direct outreach to persons in clusters for partner services (64%), medical chart reviews (42%), and focused testing events (13%). Limited data on named partners tested showed that 11% received new HIV diagnoses. CONCLUSIONS: HD HIV cluster detection activities detected many clusters. Response activities were tailored for different clusters and intervened in networks with rapid transmission and high undiagnosed infection, as indicated by high positivity among partners. Cluster detection and response is an important tool to identify and address gaps in HIV prevention, testing, and care that facilitate rapid transmission.

Antimicrobial resistance (AMR) is an urgent threat to public health, but gaps in surveillance limit the detection of emergent novel threats and knowledge about the global distribution of AMR genes. International travelers frequently acquire AMR organisms, and thus may provide a window into AMR dynamics in otherwise poorly monitored regions and environments. To assess the utility of travelers as global AMR sentinels, we collected pre- and post-travel stool samples from 608 travelers, which were screened for the presence of extended-spectrum beta-lactamase producing Enterobacterales, carbapenem-resistant Enterobacterales, and mcr-mediated colistin-resistant Enterobacterales. A total of 307 distinct AMR organisms were sequenced in order to determine genotypic patterns and their association with travel region and behavior. Travel-associated AMR organisms were overwhelmingly E. coli, which exhibited considerable phylogenetic diversity regardless of travel region. However, the prevalence of resistance genes varied by region, with bla (CTX-M-55) and bla (CTX-M-27) significantly more common in travelers returning from South America and South-Eastern Asia, respectively. Hybrid assembly and plasmid reconstruction revealed the genomic neighborhood of bla (CTX-M-55) frequently matched a motif previously linked to animal populations. Contact with animals was also associated with virulence factors in acquired AMR organisms, including carriage of the ColV plasmid, a driver of avian pathogenic E. coli. We identified novel variants of the mcr-1 gene in strains acquired from Western Africa, highlighting the potential for traveler surveillance to detect emerging clinical threats. Ongoing efforts to track travel-acquired organisms could complement existing global AMR surveillance frameworks.

BACKGROUND: Approaches for determining whether influenza vaccination prevents infection, attenuates illness, or both are important for developing improved vaccines. We estimated influenza infection incidence and evaluated symptom ascertainment methodologies in children to inform future vaccine trial design. METHODS: We conducted a prospective cohort study among children aged 6 to 23 months from May to October 2022. Study nurses collected symptom and temperature data and midturbinate nasal swabs twice weekly irrespective of symptoms; caregivers entered symptom data daily and collected nasal swabs weekly. Samples were tested for influenza with polymerase chain reaction. RESULTS: Of 230 healthy screened children, 93 were enrolled, of whom 87 (94%) completed 6-month follow-up. In total, 95% (4245/4476) of scheduled nurses, 90% (2045/2276) of caregiver swabs, 99% (92/93) of baseline blood collections, and 67% (9245/13 768) of scheduled symptom diaries were completed. Polymerase chain reaction-confirmed influenza incidence was 65% (60/93) for ≥1 infection; 11 (18%) individuals had 2 episodes and 1 (2%) had 3. Of 73 episodes, 55 (75%) had ≥1 symptom and 37 (51%) had fever (measured and/or reported). Median infection duration was 7 days (IQR, 4-9). Human RNase P gene was detected in 99% (2032/2045) of caregiver-collected swabs, through which 5 additional episodes were identified. Per episode, caregivers' diaries of reported and measured fever were 19% (25/73, 34%) and 11% (15/73, 21%) higher than nurse-reported (11/73, 15%) and nurse-measured (7/73, 10%) fever, respectively. CONCLUSIONS: The incidence of influenza infection was high and mainly symptomatic, suggesting that this platform could be suitable for future trials of vaccine efficacy and correlates of protection against infection and illness in children.

OBJECTIVES: To evaluate how postmortem anthropometric malnutrition (PAM) measures align with expert panel attribution of malnutrition as a causal or significant condition in under-5 mortality (U5M). DESIGN: Cohort study using data from the Child Health and Mortality Prevention Surveillance network, incorporating clinical records, postmortem anthropometrics, minimally invasive tissue sampling, clinical abstraction and verbal autopsy to determine multiple causes of death. SETTING/PARTICIPANTS: 1405 deaths of children aged 1-59 months from six African countries between 2016 and 2023. PRIMARY AND SECONDARY OUTCOME MEASURES: PAM was determined using z-scores from the WHO Child Growth Standards: underweight (weight-for-age<(-2)), wasting (arm circumference-for-age or weight-for-length<(-2)) and stunting (length-for-age <(-2)). Performance metrics (sensitivity (SE), specificity (SP) and positive predictive values (PPV)) were calculated to determine the alignment between PAM and expert panel attribution of malnutrition as a causal or significant condition to death. RESULTS: Nearly 75% of cases demonstrated moderate-to-severe malnutrition by PAM, while expert panels attributed malnutrition in 41% of cases. Performance metrics varied across anthropometric indices: underweight exhibited the highest SE (89.7%), while wasting based on arm circumference had the highest SP (81.9%) and PPV (76.8%). Discrepancies between PAM classification and expert panel attribution differed significantly by site, age, location of death and preventability of death (p<0.05). Adjusted multivariate regression showed that expert panel attribution was more likely with increasing severity of PAM. CONCLUSIONS: The proportion of U5M attributable to malnutrition ranged between 41% (expert panel attribution) and 74% (PAM). Variability in classification underscores the need for monitoring and quality improvement measures to address discrepancies. Improved alignment between PAM and panel assessments is essential for accurately identifying malnutrition-related deaths and designing effective interventions to reduce U5M.

Anemia is an important cause of child morbidity and mortality. Postmortem point-of-care hemoglobin testing is a potential method for assessing anemia at death, but its reliability has not been extensively studied. We aimed to assess the feasibility and validity of postmortem point-of-care hemoglobin assessment using HemoCue in the setting of a child mortality surveillance program in South Africa.In a pilot cohort study, 44 children under five years of age who died in an academic hospital in South Africa were enrolled. Hemoglobin levels were measured from venous blood antemortem using standard hematology analyzers and postmortem using the HemoCue 201 from blood collected within 72 hours of death (either by needle aspiration or from whole blood collected in an EDTA tube). Updated World Health Organization hemoglobin cutoffs to define anemia were used. Wilcoxon signed-rank tests, equivalence tests, and regression models assessed the concordance between antemortem and postmortem hemoglobin concentrations. Postmortem testing showed a significant decrease in hemoglobin concentrations compared to antemortem levels. However, no significant differences were found between hemoglobin measurements from needle aspiration and those from EDTA tubes postmortem. The prevalence of anemia increased from 52% antemortem to 73-77% postmortem, with the most notable rises in moderate and severe anemia. Bland-Altman analysis confirmed a systematic, not random, decrease in postmortem hemoglobin measurements. Upon applying a fixed adjustment of 2.5 g/dL, the sensitivity and specificity of postmortem hemoglobin testing to diagnose anemia were 69.6% and 61.9%, respectively. Postmortem point-of-care hemoglobin testing using HemoCue is feasible and offers a potentially valid reflection of antemortem anemia status in deceased children, despite consistently lower measured values postmortem. These findings support the utility of postmortem hemoglobin assessments in determining the presence and severity of anemia at the time of death.

OBJECTIVE: This pilot study explores the feasibility and acceptability of using telephonic verbal autopsies (teleVAs) in South Africa to collect information on causes of death. DESIGN: Quantitative and qualitative data collection methods were used to evaluate the feasibility and acceptability of these telephonic interviews. SETTING: The teleVA pilot was conducted in South Africa's Western Cape province. The qualitative component also included two rural South African Population Research Infrastructure Network nodes (Africa Health Research Institute in KwaZulu-Natal and Agincourt in Mpumalanga), which had transitioned to teleVAs during COVID-19, allowing exploration of teleVA's feasibility in both urban and rural settings. PARTICIPANTS: We recruited 229 respondents to participate in a pilot teleVA. After each VA, VA interviewers filled in a survey to assess their perceptions and discern if they experienced any technical challenges. We also conducted 18 in-depth interviews with both interviewers (n=6) and respondents (n=12) to explore their views on the acceptability of the teleVA. We conducted a thematic analysis of these interviews. INTERVENTIONS: VA was piloted over the phone, instead of face-to-face. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes focused on the feasibility and acceptability of phone VAs among both interviewers and respondents. Secondary outcomes evaluated the quality of teleVAs. RESULTS: Participants expressed willingness to participate in teleVAs, considering them valuable for public health planning and decision-making. The feasibility of collecting next-of-kin information proved challenging, with incomplete or incorrect contact details posing future logistic issues. Only one question out of 76, showed a statistically significant difference in the proportions of non-informative teleVA compared with face-to-face VA. CONCLUSIONS: The study offers valuable insights into using teleVAs to gather cause of death information in resource-limited settings. It highlights the feasibility and acceptability of teleVAs while emphasising the need for comprehensive planning, integration with the civil registration and vital statistics system and community participation enhancement.

Transgender youth are disproportionately affected by HIV, particularly minoritized youth in the US south. To understand HIV service use among transgender youth, we interviewed 25 young racial and ethnic minority clients of four southern community-based HIV service organizations (CBOs), and CBO staff (n = 12), about service access and use. Participants were assigned male at birth and identified as female (n = 8), transgender (n = 11) or gender-fluid or nonbinary (n = 6). The majority were Black/African American or mixed race; four were Hispanic or Latino/a. Most were unemployed; nearly half were unstably housed or homeless during the prior year. Four service types were each used by approximately two-thirds of participants: counseling/support, HIV/STD testing/education, pre-exposure prophylaxis education/prescriptions, and transgender-related medical services (primarily hormone provision). Just over a quarter used social services (e.g., housing, employment). Key facilitators to service use included a non-stigmatizing CBO atmosphere, and easy and convenient access. Poor access (e.g., inconvenient hours, location), lack of transportation or parking, social service needs, and lack of money were barriers. Qualitative reports highlighted unmet social service needs, particularly housing, especially for those without HIV. To reduce disparities, HIV prevention for racial and ethnic minoritized transgender youth should simultaneously address hormone provision, HIV risk reduction and social service needs.

BACKGROUND: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre. METHODS: Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics. RESULTS: The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg point-of-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported. CONCLUSION: There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

Background: The World Health Organization (WHO) has developed guidance for community health workers (CHWs) in identifying sick young infants based on clinical signs. We conducted a prospective, observational cohort study to characterise mortality risk of young infants based on their clinical signs. Methods: We conducted a population-based, prospective observational cohort study at five sites in Bangladesh (Sylhet, November 01, 2011–December 31, 2013), India (Vellore and Odisha, September 01, 2013–February 28, 2015), and Pakistan (Karachi, January 01, 2012–December 31, 2013; Matiari, March 01, 2012–December 31, 2013) to identify newborn infants who were followed-up by CHWs through 10 scheduled home visits over the first 60 completed days after birth to identify signs of possible serious bacterial infection (PSBI). We determined the frequency of signs and conducted Cox regression to investigate the association of signs with mortality risk within 7 days of identification of the signs. Findings: CHWs made 522,309 visits to assess 63,017 young infants and found ≥1 sign(s) of PSBI at 14,245 visits (2.7%), including 5.8% (5568 of 96,390) and 1.8% (6635 of 365,769) of visits of infants 0–<3 and 7–<60 days of age, respectively. Each of the seven signs of PSBI when found alone was associated with significantly (p < 0.0001) increased risk for mortality, which increased further if any other additional sign of PSBI was found concurrently. Over the young infant period (days 0–<60) CHW identification of no movement or movement only on stimulation was associated with the highest risk for mortality [adjusted hazard ratio (aHR) 73.0, 95% confidence interval (CI) 44.4–119.9] followed by poor feeding (aHR 31.9, 95% CI 24.1–42.3) and hypothermia (<35.5 °C) (aHR 31.4, 95% CI 23.5–41.9). Hypothermia had particularly high risk for mortality during days 7–<60 (HR 45.1, 95% CI 27.6–73.4). Interpretation: WHO reconsideration of hypothermia as a sign of critical illness is warranted. Implementation research is urgently needed to reduce infant mortality by ensuring immediate referrals and interventions for children identified early by CHWs with no movement or movement only on stimulation, hypothermia, or poor feeding, especially in resource-poor settings. Funding: Bill and Melinda Gates Foundation, New Venture Fund for Global Policy and Advocacy. © 2025 The Author(s)