Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
School feeding aims to alleviate hunger and enhance child outcomes. Since the first Cochrane systematic review of school meals, there has been a marked increase in studies and reviews of school feeding programs. However, most systematic reviews are geographically limited and use qualitative analysis. We reviewed worldwide papers and performed several meta-analyses, providing a more comprehensive picture of the effectiveness of school feeding. 1. To assess effectiveness of school feeding programs for improving the physical and psychological health of children experiencing socioeconomic disadvantage worldwide. 2. To assess effectiveness of school feeding programs for improving the health of children experiencing socioeconomic disadvantage compared with children who are more advantaged. We searched 17 subject-specific and multidisciplinary databases and registries up to November 2023. In November 2024, two Information Specialists ran a top-up search for randomized controlled trials (RCTs). We handsearched references of included studies and relevant reviews. We included individually randomized, cluster-randomized, and cross-over trials, as well as longitudinal non-randomized studies of interventions (NRSIs). Studies had to compare the provision of free or reduced-price food in schools versus no school feeding, focusing on socioeconomically disadvantaged children. The food had to contain at least 3% of the daily energy requirement and at least 10% of the daily protein requirement for the specified age group(s). Eligible participants were primary or secondary school students aged five to 19 years. Our critical outcomes were change in: math achievement, reading achievement, attendance, enrollment, height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and overweight/obesity. Our important outcomes were change in: overall academic achievement, fluid intelligence, working memory, behavioral/emotional outcomes, height, weight, and anemia. We planned to study changes between baseline and final outcomes. In one study with extreme contamination, we used the first follow-up. We assessed the risk of bias for RCTs by outcome using the appropriate version of the Cochrane risk of bias tool (RoB 2): RoB 2 for individually randomized trials, for cluster-RCTs, and for cross-over trials. We evaluated the quality of NRSIs using the School-based Measurement & Assessment of Results Tool (SMART), which is adapted from the Newcastle Ottawa Scale. We used standardized mean differences (SMDs) with 95% confidence intervals (CIs) for educational and cognitive outcomes. We used mean differences (MDs), odds ratios (ORs), or incidence rate ratios (IRRs) for others. All meta-analyses used random-effects generic inverse variance. We conducted equity subgroup analyses by sex and socioeconomic status. We used GRADE to assess our confidence in the evidence for critical outcomes reported in RCTs. We included 40 studies with 83 reports. There were 13 RCTs (12 cluster-randomized trials and one individually randomized trial) and 27 NRSIs. Most studies (34) were from low- and middle-income countries (LMICs). In total, there were more than 91,885 students (four studies didn't report sample size). One study involved 59,613 students, while the others had between 60 and 6038 students. The studies included 48 outcomes; we meta-analyzed or reported 14. Low- and middle-income countries (LMICs) School feeding compared to no school feeding improves math achievement slightly (SMD 0.14, 95% CI 0.06 to 0.23; P = 0.001; I² = 68%; 6 cluster-RCTs, 5587 participants; high-certainty evidence), but may have little to no effect on reading achievement (SMD 0.02, 95% CI -0.06 to 0.11; P = 0.61; I2 = 54%; 3 cluster-RCTs, 3417 participants; low-certainty evidence). School feeding programs lead to a slight increase in enrollment rates (MD 3.44% increase, 95% CI 0.83 to 6.04; P = 0.01; I² = 0%; 2 cluster-RCTs, 5200 participants, high-certainty evidence) but may have little to no effect on attendance (MD 0.17%, 95% CI -2.64% to 2.97%; P = 0.91; I2 = 81%; 3 cluster-RCTs, 3566 participants; low-certainty evidence). School feeding programs likely lead to a slight increase in HAZ (MD 0.06, 95% CI 0.03 to 0.09; P < 0.001; I2 = 0%; 2 cluster-RCTs, 3678 participants; moderate-certainty evidence) and WAZ (MD 0.08, 95% CI 0.05 to 0.12; P < 0.001; I2 = 0%; 3 cluster-RCTs, 2132 participants; moderate-certainty evidence). Two cluster-RCTs assessed change in obesity/overweight. One 10-month study found that the odds of being overweight/obese were 53% lower among adolescents receiving school meals compared to control adolescents (OR 0.47, 95% CI 0.30 to 0.72). Another study found no cases of overweight/obesity before or after the intervention. These findings are of very low certainty. Some researchers encountered implementation problems beyond their control, including conflicts, delays, and bureaucratic decisions. Heterogeneity in contexts, outcomes, child populations, and statistics was a limitation of this review. High-income countries (HICs) One NRSI found very uncertain evidence that children assigned to a breakfast club increased their attendance by more than 1.6% on average compared to children in the control group. Equity analyses The equity (subgroup) analyses by sex and by socio-economic status were all non-significant. There were only two studies in each subgroup analysis; they were likely underpowered. In LMICs, school feeding programs lead to a slight improvement in math achievement, but may have little to no effect on reading achievement. School feeding programs lead to a slight increase in enrollment, but may have little to no impact on attendance. They likely lead to slight gains in HAZ and WAZ. There may be little to no association between school feeding and overweight/obesity, but the evidence is very uncertain. We recommend that researchers and policymakers view research as an integral part of the implementation process. To reduce heterogeneity in outcomes, we recommend even greater co-ordination of research, and that researchers and interest holders work together to identify a core set of outcomes. The authors would like to thank the following donors for their generous support in making this review possible: Dubai Cares, the World Food Programme's School Meals and Social Protection Service, and the Research Consortium for School Health and Nutrition. Protocol (2022): https://doi.org/10.1002/14651858.CD014794 Original review (2007): https://doi.org/10.1002/14651858.CD004676.pub2 Original Campbell protocol (2006): doi.org/10.1002/CL2.12.
Malaria is a major public health problem in the Central African Republic (CAR). Data on malaria epidemiology are often derived from confirmed cases of symptomatic malaria using passive detection approaches, with very limited knowledge of the extent of subclinical and submicroscopic infections. A community-based cross-sectional study was conducted in Bangui, the capital of the CAR, to assess the prevalence of subclinical malaria parasitaemia. Proportions of positive tests for malaria parasites were determined by combining the results of antigen-based malaria rapid diagnostic test (mRDT), thick blood smear microscopy, and polymerase chain reaction (PCR). A total of 638 participants (mean age, 26.44 years (range, [1-75] years) with a sex ratio (M/F) of 1.22) were tested for malaria using all three detection methods. Proportions of positives were 32.45% by PCR, 27.59% by mRDT, and 23.51% by Giemsa-based thick blood smear microscopy, representing the burden of subclinical malaria. In addition, a 9.56% prevalence of submicroscopic infections was observed. Subclinical malaria was more common in individuals aged 15-49 years, and microspatial heterogeneity in positivity was observed, with the majority of cases occurring in semi-urban areas by mRDT and microscopy, respectively. Approximately, 80% of microscopy-positive subjects had a low parasite density (<1000 parasites/µL whole blood). Although P. falciparum was the most common species (98.55%), the transmission of P. ovale appears to be well-established in the area, occurring either as mono-infection (1.45%) or co-infection (1.93%) with P. falciparum. This study of community malaria in Bangui highlights the high burden of subclinical malaria in the community and provides essential baseline data to guide future research on malaria parasites in the CAR, particularly regarding the circulating parasite species. The high prevalence of community malaria demonstrates its persistence as a major public health challenge in the country, highlighting the need to intensify its ongoing control using new tools such as the upcoming malaria vaccine. Malaria is widespread in the Central African Republic, with prevalence data based mainly on highly flawed medical records. Moreover, little is known about the extent of, and factors associated with subclinical Plasmodium infections, which are essential for guiding ongoing antimalarial interventions in the community. Subclinical infection is defined as an infection with no noticeable clinical symptoms. This study demonstrated that one out of three people living in Bangui is carrying malaria parasite without showing any symptoms. This high prevalence of low-density Plasmodium infections in the Bangui community, especially in 15–49 age group, raises concerns about the persistence of malaria in the community and the opportunity for its elimination in CAR. The current findings underscore the need to intensify community-based interventions, including vaccination, against malaria, particularly in CAR and Bangui.
The rate of moderate-to-severe hearing loss in Southeast Asia is 5.8%, among the world's most prevalent. However, it is difficult to measure for people whose healthcare access is limited by the ongoing civil war. Therefore, a cross-sectional study of the impacts of hearing loss was incorporated with ongoing vision/cataract clinics along the Thai-Burma border. In this cross-sectional observational study, culturally sensitive informed consent was obtained from patients presenting to a regionally promoted hearing clinic in Karen State, Burma (Myanmar) with a chief complaint of hearing loss. They were then administered a standardized survey derived from the Hearing Handicap Inventory for Adults/Elderly (HHI), then assessed based on history, otoscopy, Weber and Rinne testing, and portable audiometry. Twenty-two adults and children presented with a chief complaint of hearing loss, and 26 others came seeking vision care needing cataract surgery. HHI survey showed 41% had mild-to-moderate, and 34% had moderate-to-severe hearing impairment. On a 0-4 Likert scale, prominent complaints due to hearing loss were feeling upset (2.4 ± 1.8), limited social life (2.2 ± 1.6), using the phone less (2.1 ± 1.8) and needing to be warned of the danger by others (2.1 ± 1.9). Seventy-three percent had no prior hearing care. Access was limited due to financial (59%), limited travel (50%), and military conflict (41%). Pure-tone averages were 55.3 + 22.1 dB and 67.9 + 14.5 dB for the right and left ears, respectively. Pure tone averages are negatively correlated with HHI survey score (R = -0.53). Chicken feathers were a common mechanism of ear drum trauma. Twenty patients received Solar Ear hearing aids. Ongoing military conflict in the Karen State leaves the internally displaced people with high prevalence of hearing loss and fear of additional injury due to inability to hear danger. Surveys such as this appear more useful to assess the individual impact of hearing loss rather than severity. Efforts by regional medics to provide hearing care should be supported. Residents in a war zone in Karen State, Burma, had survey, ear exam and audiometry showing high prevalence of hearing loss including tympanic membrane perforation by chicken feathers.
BACKGROUND: Adolescents living with HIV(ALHIV) often experience lower retention in care and reduced viral suppression after transitioning to adult care. Differentiated care can enhance the uptake and utilisation of evidence-based transition interventions among populations with the greatest need. We aim to investigate the effectiveness, acceptability, feasibility, implementation, and costs of in-person and mHealth-based adolescent-friendly transition interventions. METHODS: We are conducting a type 1 hybrid implementation-effectiveness design, with a cluster-randomised, stepped-wedge trial (SWT) to assess the effectiveness of in-person and mHealth-based adolescent-friendly transition interventions on retention in care and viral suppression among adolescents aged 15–19 years with perinatally-acquired HIV and low transition readiness. The SWT will be conducted in 16 clinics in urban (eThekwini) and rural (uMkhanyakude) KwaZulu-Natal over 24 months. Clinics will be randomly allocated to receive the intervention in period 1 (early) or period 2 (delayed). ALHIV, in the standard of care clinics, will be able to access the HIV prevention and treatment services delivered through the primary health clinics. We will use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to guide our implementation outcomes. The primary outcomes for effectiveness are: (1) retention in care and (2) viral suppression measured in three cross-sectional surveys. We will measure retention in care as 80% of ART pharmacy refills on time, and 80% of scheduled clinic appointments attended, and we define viral suppression as < 200 copies/ml. We will compare the effectiveness and implementation outcomes of the in-person intervention with the mHealth intervention and compare outcomes between urban and rural clinics. DISCUSSION: The findings of this trial will inform the expansion of differentiated care models for ALHIV to improve the transition process from paediatric to adult HIV care, optimised to support retention in care and viral suppression. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT06035445.
Leishmaniasis is among the most neglected tropical diseases in Yemen, where both cutaneous and visceral clinical forms represent a public health challenge. Leishmania tropica is the main cause of cutaneous leishmaniasis, whereas L. donovani and L. infantum cause visceral leishmaniasis in the country. Although leishmaniasis has been recognized for decades, its actual burden in Yemen remains poorly defined, largely due to weak surveillance, constraints in diagnostic services, and the lack of a national control program. Conflict-related disruptions in healthcare, poverty, poor housing, and malnutrition further contribute to continued transmission. Surveillance of potential vectors and reservoirs is extremely limited, and access to effective diagnosis and treatment remains inadequate, particularly in rural areas. In the absence of integrated vector management and intersectoral coordination, disease control primarily relies on case management. This paper reviews the historical, epidemiological, clinical, and ecological aspects of leishmaniasis in Yemen, with attention to the diversity of Leishmania species, as well as their vectors and potential animal reservoirs that sustain transmission. Because there are no reliable baseline estimates on the national or subnational incidence of leishmaniasis, its elimination as a public health problem has been defined operationally in line with World Health Organization guidance as achieving a reduction in reported cases exceeding 90%, along with no mortality from visceral leishmaniasis, following implementation of strengthened active surveillance and systematic risk mapping. To advance such elimination, this paper also proposes a "One Health" approach integrating human, animal, and environmental health sectors through coordinating surveillance, mapping national risks, engaging communities, and strengthening diagnostic and treatment strategies. This collaborative framework is essential for informing targeted interventions, mobilizing resources, and ultimately eliminating the disease as a public health problem.
This study aimed to determine the seroprevalence of toxoplasmosis in people living with HIV (PWH) in Maputo, Mozambique, exploring the interactions between HIV/acquired immunodeficiency syndrome (AIDS) and toxoplasmosis, including HIV-related factors such as the World Health Organization (WHO) HIV/AIDS clinical stage, degree of immunosuppression based on CD4+ T-cell count, and associated risk factors. Additionally, it aimed to assess the prevalence of neurological and psychiatric disorders (NPD) among study participants and its possible association with toxoplasmosis seropositivity. We conducted a descriptive, cross-sectional study of 200 patients aged >18 years who were admitted to Maputo Central Hospital, Maputo, Mozambique, between March 2020 and October 2021. The participants were recruited by convenience, regardless of the reason for their admission. Sociodemographic and clinical data, such as age, sex, WHO HIV/AIDS stage, and CD4+ T-cell count, were collected. NPD disorders were assessed using the International Classification of Diseases criteria. Venous blood (5 mL) was obtained from each participant to determine anti-Toxoplasma gondii IgM and IgG antibodies using commercial enzyme-linked immunosorbent assay. Participants were aged 18-72 years, with the majority being female (64%) and unemployed (57%). Overall, 54.5% of patients tested positive for at least one anti-Toxoplasma gondii IgG (52%) or IgM (6.5%). Risk factors for Toxoplasma gondii infection (p < 0.05) were associated with age group 18-28 years, being male and unemployed. Moreover, 68.5% of the participants had NPD and of those, 65.1% exhibited anti-Toxoplasma antibodies. We found a significant association between anxiety and IgM seropositivity for p = 0.016. Though three out of four participants with positive anti-Toxoplasma gondii IgG had mood disorders, no significant association was found between Toxoplasma gondii infection with mood disorders, nor with other NPD assessed (56% depression, 33% motor disorder, 25.5% psychosis, 17% cognitive impairment, 7.5% mental retardation). Toxoplasmosis may contribute to NPD in PWH patients. Further studies are recommended to better understand the complex interactions between Toxoplasma gondii, NPD disorders, and HIV. Toxoplasmosis is a disease caused by the zoonotic and food-borne parasite, Toxoplasma gondii. It predominantly manifests in immunocompromised individuals, such as those living with human immunodeficiency virus (PWH), causing neurological and psychiatric impairments due to brain infections. The few existing studies in Mozambique on the burden of neurological and psychiatric disorders have not yet assessed the profile of neurological and psychiatric disorders in patients with HIV or the possible role that this parasite might play as a causative agent. The present study revealed that at least 54.5% of PWH were seropositive for Toxoplasma gondii antibodies and 68.5% had neurological and psychiatric disorders. Additionally, the majority (65.1%) of the patients with neurological and psychiatric disorders were seropositive for Toxoplasma gondii antibodies. Our findings highlight the need to screen for this parasite to clarify its role in the etiology of neurological and psychiatric disorders in both PWH and people without HIV for better healthcare delivery and management.
Invasive pneumococcal disease (IPD) is associated with increased long-term mortality, but it is unclear if this is explained by pre-existing comorbidities. We aimed to estimate the long-term survival following IPD in comparison with the general population, adjusting for potential confounders such as underlying comorbidities. We conducted a matched cohort study comparing long-term survival (>120 days after infection) in individuals with IPD and comparators without IPD. Cases were individuals aged 65 years or older with laboratory-confirmed IPD (2012-19) identified through enhanced national surveillance. Comparators matched on age, sex, and calendar date of laboratory-confirmed diagnosis were drawn from primary care electronic health records in Clinical Practice Research Datalink GOLD. We used Cox regression, stratified by matched set, to compare mortality in people with and without IPD, adjusting for relevant comorbidities, socioeconomic deprivation, and ethnicity. We included 13 401 IPD cases and 67 005 comparators without IPD. There were 5038 (53·5%) female and 4380 (46·5%) male IPD cases and 19 927 (53·5%) female and 17 351 (46·5%) male comparators without IPD. After adjusting for comorbidities, socioeconomic deprivation, and ethnicity, we found increased all-cause mortality in IPD cases compared with comparators without IPD (hazard ratio 3·74 [95% CI 3·50-3·99]). The predicted median survival was 4·7 years (IQR 2·9-7·4) for IPD cases and more than 11·9 years (IQR 8·7 to >11·9) for comparators without IPD. This increased mortality was consistent across subgroups defined by age, vaccination history, and comorbidity status (including diabetes, chronic respiratory disease, and chronic heart disease). IPD was associated with increased mortality at least 5 years after infection. These findings emphasise the value of IPD prevention and the need for more research into the clinical management of people who have had IPD. Long-term mortality should be incorporated in cost-effectiveness analyses for pneumococcal vaccines. National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Vaccines and Immunisation (NIHR200929).
This paper presents (a) the progress made towards achieving the 2023 Lymphatic Filariasis (LF) Mass Drug Administration (MDA) campaign goals, (b) the estimated financial savings resulting from integrating LF MDA into Polio immunization campaigns, and (c) the best practices, challenges, and recommendations. In 2023, 21,336,057 people in 83 districts were affected by LF and required Preventive Chemotherapy (PC). The National NTD Control Programme (NTDCP) conducted three phases of LF MDA campaigns in those districts. In the first phase, 24 districts received triple therapy of Ivermectin, Diethylcarbamazine, and Albendazole (IDA), while the remaining 59 districts continued to receive dual therapy of Diethylcarbamazine and Albendazole (DA) as before. The first phase (15 districts) was not integrated, while the second phase (61 districts) was conducted simultaneously with the Polio Supplementary Immunization Activities (SIA) fourth round. The third phase (7 districts) was combined with periodic intensification of routine immunization (PIRI) and vitamin A supplementation. In Phases 2 and 3, the campaign covered 99.97% of the targeted 12,208 villages, meaning only three villages remained untreated. In contrast, Phase 1 covered all the targeted 2,847 villages, attaining 100% geographic coverage. The 68 districts (Phase 2 and 3) that implemented an integrated approach attained an average therapeutic coverage of 76.6% (STDEV=8.3) compared to 73.2% (STDEV=6.7) among the 15 districts (Phase 1) that conducted MDA for LF without integration. The p-values for geographical and therapeutic coverage were below the significance level of 0.05, leading to the conclusion that the average geographic and therapeutic coverages for districts implementing LF MDA with and without integration into Polio immunization campaigns differed significantly. Integrating the LF MDA campaign into the Polio SIA and PIRI campaigns saved US$1,431,203. Incorporating LF MDA into polio immunization campaigns can improve financial efficiency and effectiveness in meeting the objectives of LF programs.
Intestinal tuberculosis (iTB) represents a potentially underrecognized clinical entity with limited clinical and radiological differentiating features. This study aims to assess the patterns of iTB clinical and radiological findings, along with the treatment approaches and the overall outcome. This retrospective cross-sectional study included patients with histopathologically confirmed iTB who presented with acute abdomen and were surgically managed between September 2005 and October 2023. Clinical and sociodemographic variables, imaging features, surgical treatments, and overall outcomes were retrospectively analyzed. 96 patients with iTB were included, with a mean age of 36.1 ± 11.5 years and a relatively proportionate gender distribution. Abdominal pain was the most common presenting symptom (45.8%). The radiological features varied by the modality. Plain imaging showed non-specific findings, while ultrasonography showed loculated ascites (25%), and lymphadenopathy (22%). In computed tomography scans, multi-segmental symmetric intestinal thickening (53.1%) was the most prevalent finding. The most commonly performed surgical procedure was adhesiolysis (29.2%), with the ileocecal junction being the most commonly involved structure (39.6%). Histopathological examination of all the tissue biopsies revealed epithelioid granulomas. Postoperative complications occurred in 19 patients (19.8%), with surgical site infection being the most common complication (10.4%). Intestinal obstruction is an underrecognized manifestation of tuberculosis, particularly in endemic regions. The non-specific clinical presentation, coupled with the limited utility of laboratory and radiological tests, often leads to delayed recognition and treatment. Maintaining a high index of suspicion is essential, especially in younger patients, inhabitants of endemic areas, or those with laboratory findings indicative of chronic inflammation. Prompt recognition is crucial to ensure the timely initiation of anti-tuberculosis therapy and to optimize patient outcomes through appropriate follow-up.
Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.
Chagas disease (CD) is caused by the parasite Trypanosoma cruzi, and it is endemic in Central, South America, Mexico and the South of the United States. It is an important cause of early mortality and morbidity, and it is associated with poverty and stigma. A third of the cases evolve into chronic cardiomyopathy and gastrointestinal disease. The infection is transmitted vertically and by blood/organ donation and can reactivate with immunosuppression. Case identification requires awareness and screening programmes targeting the population at risk (women in reproductive age, donors, immunocompromised patients). Treatment with benznidazole or nifurtimox is most effective in the acute phase and prevents progression to chronic phase when given to children. Treating women antenatally reduces but does not eliminate vertical transmission. Treatment is poorly tolerated, contraindicated during pregnancy, and has little effect modifying the disease in the chronic phase. Screening is easily performed with serology. Migration has brought the disease outside of the endemic countries, where the transmission continues vertically and via blood and tissue/organ donations. There are more than 32 million migrants from Latin America living in non-endemic countries. However, the infection is massively underdiagnosed in this setting due to the lack of awareness by patients, health authorities and professionals. Blood and tissue donation screening policies have significantly reduced transmission in endemic countries but are not universally established in the non-endemic setting. Antenatal screening is not commonly done. Other challenges include difficulties accessing and retaining patients in the healthcare system and lack of specific funding for the interventions. Any strategy must be accompanied by education and awareness campaigns directed to patients, professionals and policy makers. The involvement of patients and their communities is central and key for success and must be sought early and actively. This review proposes strategies to address challenges faced by non-endemic countries.
This review focusses on the interactions between the etiologic agent of Chagas disease, Trypanosoma cruzi, and its triatomine vector. The flagellate mainly colonizes the intestinal tract of the insect. The effect of triatomines on trypanosomes is indicated by susceptibility and refractoriness phenomena that vary according to the combination of the strains. Other effects are apparent in the different regions of the gut. In the stomach, the majority of ingested blood trypomastigotes are killed while the remaining transform to round stages. In the small intestine, these develop into epimastigotes, the main replicative stage. In the rectum, the population density is the highest and is where the infectious stage develops, the metacyclic trypomastigote. In all regions of the gut, starvation and feeding of the triatomine affect T. cruzi. In the small intestine and rectum, starvation reduces the population density and more spheromastigotes develop. In the rectum, feeding after short-term starvation induces metacyclogenesis and after long-term starvation the development of specific cells, containing several nuclei, kinetoplasts and flagella. When considering the effects of T. cruzi on triatomines, the flagellate seems to be of low pathogenicity. However, during stressful periods, which are normal in natural populations, effects occur often on the behaviour, eg, in readiness to approach the host, the period of time before defecation, dispersal and aggregation. In nymphs, the duration of the different instars and the mortality rates increase, but this seems to be induced by repeated infections or blood quality by the feeding on infected hosts. Starvation resistance is often reduced by infection. Longevity and reproduction of adults is reduced, but only after infection with some strains of T. cruzi. Only components of the surface coat of blood trypomastigotes induce an immune reaction. However, this seems to act against gut bacteria and favours the development of T. cruzi.
Helicobacter pylori (H. pylori) is believed to have spread from East Africa, but its burden is still unknown in less privileged regions of Ethiopia. Indigestion is an upset stomach, upper abdomen discomfort, heartburn, and bloating. This study evaluated the burden and risk factors for H. pylori infection among government employees who clinically complained of indigestion but allergic diseases in five public health institutions in Southeastern Ethiopia. A health facilities-based cross-sectional survey study was conducted in Southeastern Ethiopia from March to November 2022, employing cluster sampling. Blood specimens, clinical data, and semi-structured questionnaires about risk factors were collected. Data analysis was conducted using descriptive, bivariate, and multivariable logistic regression in STATA software, Windows version 16.1. The overall prevalence of infection was found to be 77.6%. The sampled health institution (ρ-value < 0.05), engagement in sideline business (ρ-value < 0.05), sharing local spoon on meal [AOR = 39.30; CI:19.52 -78.31; ρ-value < 0.001], admitting "Gursha" during meal [AOR = 71.48; CI:3.99 -1279.77; ρ-value < 0.05], the toilet type [AOR = 1410.98; CI:121.16 -16,431.19; ρ-value < 0.001], alcohol drinking [AOR = 15.15; CI:1.90 -120.62; ρ-value < 0.05], sleeping hours length [AOR = 15.01; CI:13.48-55.96; ρ-value < 0.001], chewing Khat [AOR = 76.73; CI:8.57-687.07; ρ-value < 0.001], and regular hand washing before eating [AOR = 0.15; CI:0.12-0.19; ρ-value < 0.05] were the independent predictors of H. pylori infection. The prevalence rate of H. pylori infection in Southeastern Ethiopia is agonizingly high, exceeding the world average by 27.6%, the first report, and seems to be one of the neglected infectious diseases. Hence, the Oromia Region Health Bureau should reinvigorate the basic infectious disease control methods, establish routine laboratory diagnostic platforms, and intervene in selected societal practices spreading infections.
Visceral leishmaniasis (VL) is a neglected tropical disease (NTD) that affects millions of people globally, particularly in low- and middle-income countries. It is caused by the Leishmania parasite, transmitted through sandfly bites, leading to severe illness and high mortality if untreated. Globally, VL is prevalent in East Africa, South Asia, and parts of South America, with East Africa accounting for a significant proportion of cases. Somalia, a country with a fragile healthcare system, faces a growing burden of the disease, particularly in rural and conflict-affected areas. Despite efforts to control the disease, it remains a public health challenge due to a lack of comprehensive data on its exact burden. In Somalia, VL service delivery is hindered by several barriers, including an under-resourced health system, shortages of skilled healthcare providers, inadequate diagnostic equipment, medication shortages, and weak infrastructure. The ongoing conflict and insecurity have exacerbated these challenges, particularly in areas most affected by VL. Stigma, cultural misconceptions, economic constraints, and limited access to healthcare further impede effective VL management. Current programs, supported by international organizations, provide some relief but are insufficient to address the widespread challenges comprehensively. To improve VL service delivery in Somalia, several strategies are recommended. Integration of VL services into primary healthcare, expanding training for healthcare workers, and increasing domestic funding are critical steps to reduce dependency on international aid. Strengthening community engagement, increasing awareness about VL, and leveraging technological innovations like telemedicine and DHIS2 for surveillance and care are vital. Public-private partnerships should be enhanced to ensure the availability of affordable treatments. Through a multifaceted approach that addresses systemic barriers and builds local capacities, sustainable improvements in VL control and service delivery in Somalia can be achieved.
Allergic conditions, including asthma, allergic rhinitis, and atopic dermatitis, are increasingly recognized as critical global health concerns in tropical regions. The unique environmental characteristics of the tropics, such as high humidity, diverse vegetation, persistent pollen exposure, and elevated levels of mold and insect allergens, increase the prevalence and severity of allergic diseases. Addressing these challenges requires tailored strategies that are both practical and evidence-based. This review introduces a comprehensive seven-day and seven-step framework for managing allergies in tropical climates. This is designed to empower individuals with actionable steps and scientifically supported interventions. Databases such as PubMed, Scopus, Web of Science, and EMBASE were used. The search strategy includes specific keywords and Medical Subject Headings (MeSH) terms related to allergies or offering insights into preventive measures. The plan encompasses a structured approach, beginning with identifying triggers and creating an allergen-friendly environment. Symptoms management, prevention of cross-contamination, dietary optimization, and long-term evaluation. Emphasis is placed on the adaptability of these measures to resource-constrained settings in tropical regions by integrating modern scientific insights with practical, step-by-step guidance. This framework addresses the distinct challenges of managing allergies in tropical environments but also highlights the importance of education, environmental control, and community-level engagement. This review underscores the need for sustainable and locally relevant solutions to improve health outcomes and enhance the quality of life for individuals living in tropical climates.
Emerging evidence suggests presence of novel or unclassified taxa within the Anopheles gambiae s.l. species complex, the principal vector of malaria in sub-Saharan Africa. The response of these new lineages to standard vector control tools and/or adaptation to selection pressure is currently unknown, underscoring the need for further characterization. We performed a genome-wide selective scan (GWSS) analysis to gain genomic insights into the local adaptation of An. gambiae Bissau molecular form (hereafter "Bissau"), a recently described taxon from The Gambia. Genomic regions under selection in Bissau primarily code for clusters of gene families associated with metabolic resistance mechanisms against insecticides, specifically Cyp6aa/Cyp6p, Cyp9K, and Gste. Notably, a distinct signal of selection for the Choline acetyltransferase gene (ChAT) was detected in the chromosome arm 2R of Bissau. In the sibling taxa An. coluzzii, two distinctive signals of selection overlapping E-ubiquitin protein and N-acetyltransferase genes were evident. These unique genes warrant further functional validation and monitoring to confirm their potential role as molecular markers for target site resistance. A selective sweep spanning clusters of odorant receptor (OR) genes, usually associated with chemosensory, was also unique to Bissau. Diplotype clustering of OR regions revealed six groups with low heterozygosity and non-synonymous mutations, suggesting local adaptation to fundamental biological traits such as host seeking and habitat selection. Haplotype clustering analysis ruled out adaptive sharing of OR alleles, depicting ongoing independent evolution of chemosensory perception in Bissau population. Contrastingly, the sharing of adaptive alleles was evident between An. gambiae s.s and Bissau in regions coding metabolic resistance genes, potentially facilitating the spread of insecticide resistance across taxa. Common and taxon-specific signatures of selection are evolving in An. gambiae s.l. needing further studies and monitoring to guide targeted vector control efforts.
This study aims to determine the baseline seroprevalence of leptospirosis, a zoonotic and neglected disease, in people living with HIV (PWH) in Maputo, Mozambique, and to evaluate the relationship between selected HIV-related factors that might influence risk of coinfection with leptospirosis, such as degree of immunosuppression, as assessed by CD4 cell count, World Health Organization (WHO) HIV/AIDS clinical stage and antiretroviral therapy (ART) intake. This was a descriptive cross-sectional analysis of 157 PWH, aged over 18 years old, admitted to the Maputo Central Hospital, in Maputo, Mozambique, between March 2020 and October 2021. The study participants were recruited as a convenience sample regardless of the reasons for their admission. We collected sociodemographic and clinical data, including ART and WHO HIV/AIDS clinical stage, and blood for CD4 cell count and detection of Leptospira IgG antibodies using a commercial Kit ab247199 Leptospira IgG ELISA (www.abcam.com/ab247199) with sensitivity and specificity of 100% and 97.3%, respectively. Laboratory testing was performed at the Faculty of Medicine, Eduardo Mondlane University and Laboratory of Clinical Analysis, in Maputo. Participants were aged 18 to 72 years (median age 39 years; SD ± 10.5), the majority were female 100 (63.7%), from urban areas 138 (87.9%), with secondary-level education 80 (51%). The overall seroprevalence of Leptospira IgG antibodies was 40.1%. The median CD4 cell count was 385 cells/µl (02 to 2297; SD ± 378.47). Higher seroprevalence of Leptospira antibodies was found among participants with CD4 cell counts <250 cells/µl (54.8%), WHO HIV/AIDS stage IV (70.2%) and those on ART (92%), though there were no statistically significant differences between groups with and without Leptospira antibodies. Our study confirmed that Leptospira antibodies are highly prevalent in PWH in Maputo; however, Leptospira infection was not associated with the degree of immunosuppression, WHO HIV/AIDS clinical stage, or the use of ART. Our data support the need for routine screening for leptospirosis in PWH in Mozambique. Future studies are warranted to characterize the incidence and outcomes of symptomatic leptospirosis in this patient population and to identify circulating serovars and species in the country and region, as well as the implicated reservoirs.
Border regions such as the US-Mexico border may be particularly vulnerable to dengue emergence and re-emergence due to high human mobility, cross-border movement, and favorable conditions for Aedes mosquitoes. We investigated dengue and other arboviruses in mosquito vectors, and dengue seroprevalence among migrants residing in camps in Reynosa, Mexico, between October 2019 and November 2022. Entomological surveillance was conducted in two phases using BG-Sentinel traps, CDC backpack aspirators, Autocidal Gravid Ovitraps, and resting boxes. Mosquito trapping was done twice a week with an interval of 3 days between each trapping. Mosquito samples were tested by RT-PCR for dengue, chikungunya, and Zika viruses, while migrant blood samples were screened for anti-dengue IgM antibodies using ELISA. In the first phase, 2263 mosquitoes were collected, including 456 females Aedes aegypti grouped into 42 pools; three pools were positive for DENV-2 while none were positive for DENV-1, DENV-3, DENV-4, chikungunya virus, or Zika virus. During the second phase, 1713 mosquitoes were collected, including 179 female A. aegypti grouped into 14 pools, with one pool positive for dengue virus and none positive for chikungunya or Zika viruses. Among the 95 migrant serum samples analyzed, four were positive for anti-DENV IgM, yielding a seroprevalence of 4.2% (95% CI: 1.2-10.4%). Participants reported frequent mosquito exposure and general awareness of mosquitoes, although knowledge of mosquito-borne arboviruses and preventive practices remained limited. IgM-seropositive participants were less likely to report mosquito contact in their country of origin than seronegative individuals (0% vs. 67.8%; p = 0.013), which may suggest local exposure, though IgM serology cannot determine the timing or location of infection. These findings highlight the need for strengthened vector control and arboviral surveillance in Reynosa, both to reduce local transmission and to mitigate the risk of cross-border spread.
Scorpion envenomation is a global health problem that results in life-threatening medical emergencies in the tropical and subtropical regions. Pediatric victims are at a higher risk of severe envenomation than are adults. This study aimed to determine the clinical features and outcomes of patient's hospitalized for scorpion stings at Tesseney Community Hospital. A prospective, descriptive, cross-sectional study was conducted from 1st June 2019 to 31st May 2020 in patients hospitalized due to scorpion stings at the Tesseney Community Hospital. About 165 scorpion-sting patients were admitted during the study period. The majority of cases were older than 15 years (61.8%) with an approximately equal male-to-female sex ratio (0.94:1), and the scorpion sting cases largely occurred in urban areas (57%) compared to rural areas. The black scorpion (38.8%) was the predominant scorpion; however, in some cases, the scorpion color was undetermined (31.5%). The foot was the predominant sting site (64.8%), followed by the hand (31.5%). Single stings (91.5%) were more frequent than multiple stings (8.5%). The majority (94.8%) of scorpion sting cases occurred during summer, with the highest scorpion sting cases occurring in September and October. The main clinical manifestations upon presentation were localized pain (70.3%) and sweating (56.4%), with more severe symptoms exhibited among age groups less than 15 years. The fatality rate (4.8%) was largely associated with age groups less than 15 years and class three scorpion stings. Our study found that children experienced more severe envenoming symptoms and related mortality than adults did. This study may be a tool to identify at-risk population groups and build measures to prevent scorpion stings within the western lowlands of Eritrea.