Gwenda Hughes

Forested Guinea has been the site of multiple high-consequence viral spillover events, including the index case of the 2013-16 West African Ebola epidemic. Deforestation and wildlife hunting rapidly expand the human-animal interface, increasing opportunities for transmission. Here we integrate serologic, spatial and questionnaire data to characterize zoonotic filovirus spillover events and risk factors amongst wildlife hunter communities in Forested Guinea. Hunters and close contacts from 43 villages in 2017 ( n = 511) and 2023 ( n = 648) were screened using a multiplex microsphere-based immunoassay panel of 9 filoviruses, identifying IgG binding against Ebola virus (EBOV) in 57/1159 individuals (4.9%), as well as species-specific binding against Bundibugyo (BDBV) (49/1159, 4.2%), Taï Forest (TAFV) (13/1159, 1.1%), Reston (4/1159, 0.3%), Měnglà (MLAV) (8/1159, 0.7%), Lloviu (LLOV) (8/1159, 0.7%) and Bombali (BOMV) (1/1159, 0.1%) viruses. Parallel pseudotyped virus neutralization assays identified species-specific neutralization of EBOV, BDBV and TAFV, as well as likely cross-neutralization of BOMV, LLOV and MLAV, suggesting multiple zoonotic virus spillover events. Mixed-effects regression analyses of satellite-derived land-cover data identified environmental risk factors (including forest fragmentation) reflecting potential pathways of exposure. Together, our data suggest multiple ongoing zoonotic filovirus spillover events in wildlife hunting communities and highlight the importance of landscape configuration in driving pathogen spillover.

Background: In the last 2 decades, there has been an increasing number of sexually transmissible enteric infection (STEI) outbreaks among gay, bisexual, or other men who have sex with men (GBMSM). There remain important gaps in our understanding of how STEI transmission is sustained that repeated collection of samples could help to address. Objective: This study aimed to assess the feasibility and acceptability of longitudinal samples and epidemiological data collection among GBMSM accessing sexual health services (SHS) through a prospective cohort study. Methods: GBMSM (≥16 years) accessing 2 SHS in Brighton and Sussex were recruited between May and October 2022. Participants provided an initial rectal swab and optional fecal sample and completed an online baseline questionnaire. Weekly follow-up questionnaires and rectal swabs were collected for a further 11 weeks. Sexually transmitted infection (STI) surveillance data were pseudonymously linked to provide additional clinical and demographic information. Selected participants were invited to take part in an optional one-to-one interview. We assessed the number completing study procedures, characteristics of those completing procedures and not, and representativeness of the study sample alongside facilitators and barriers from interviews. A chi-square test was used to compare groups. Results: Overall, 193 participants were recruited. Half (100/193, 51.8%) provided a baseline rectal swab, with a third (34/100, 34.0%) of them providing all 12 swabs. Alongside the baseline swab, 76.0% (76/100) provided the optional fecal sample. Just over a third (71/193, 36.8%) of participants completed a baseline questionnaire, with a fifth (15/71, 21.1%) providing all follow-up questionnaires. Interviews (n=21) found that participation was motivated by the feeling of giving something back for services received and a perceived indirect benefit to self. The study was generally accepted, with over half reflecting on the perceived ease of participation and relatively simple tasks that could be easily integrated into normal routine with an element of flexibility. Most participants were satisfied with the 12-week study length, and having a definitive end point aided the ability to assess if they would be able to participate. Barriers to completing the study procedures included not being aware of what was required, particularly for the follow-up questionnaires. Suggested improvements included concise and easier-to-read instructions, with a section to clearly list out the key procedures of the study. SMS text messaging reminders were sent, but these were seen with variable utility and interpreted in different ways (eg, personal or generic reminders or thank you messages). Conclusions: This study has provided evidence that longitudinal rectal swab sampling and data collection for research purposes are feasible and acceptable among GBMSM attending SHS. This provides an innovative way to address important knowledge gaps about STEI transmission, which will help inform public health measures for infection control. Tangible insights from this pilot can also inform the design of similar studies in other settings.

Background: Oral tenofovir and emtricitabine taken as pre-exposure prophylaxis (HIV-PrEP) is highly effective at reducing Human Immunodeficiency Virus (HIV) acquisition. Nucleotide analogues have also been shown to inhibit Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) polymerase activity in vitro, raising the question as to whether tenofovir-based HIV-PrEP could be useful for the prevention and treatment of COVID-19. We sought to examine the association between HIV-PrEP use and self-reported COVID-19 testing outcomes and respiratory symptoms among men and gender diverse people who have sex with men in the UK. Methods: Participants completed online surveys deployed at three time points during the COVID-19 pandemic (Survey 1 (S1) 23/06/20 − 14/07/20; S2 23/11/20 − 12/12/20; S3 23/03/21 − 14/04/21), including men (cis/transgender), transwomen or gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth. The outcome was self-reported COVID-19 testing and COVID-19 related respiratory symptoms including a new continuous cough, high temperature or loss of smell and/or taste during the most recent lookback period. All participants reporting taking HIV-PrEP in the past year were compared with those who did not. Analysis was performed using logistic regression, adjusting for sociodemographic and behavioural factors. Results: Among 4,544 participants living without HIV across three surveys (89.7% of all survey respondents), 21.4% ( n = 970) reported recently using HIV-PrEP, 564 (12.4%) participants reported respiratory symptoms and 160 (3.5%) reported a positive COVID-19 test. There was a slight, non-statistically significant positive association between HIV-PrEP use and a COVID-19 positive test in the first survey-period (P1) (adjusted Odds Ratio (aOR) = 1.11, CI = 0.51–3.98). This positive association significantly increased across survey periods (P2: aOR = 4.26, CI = 1.21–14.97, P3: aOR = 9.02, CI = 2.69–30.31). There was a positive association between HIV-PrEP use and respiratory symptoms in the first survey-period (aOR = 1.45, CI = 1.03–2.03). However, this positive association reversed in survey-period 2 and 3 (P2: aOR = 0.62, CI = 0.40–0.95, P3: aOR = 0.45, CI = 0.28–0.72). Conclusions: We found no evidence that HIV-PrEP use protected against COVID-19 among participants. Conversely, we identified a positive association between HIV-PrEP use and COVID-19 which may reflect uncaptured behaviours that increase COVID-19 exposure amongst those using HIV-PrEP. The decline in respiratory symptoms in HIV-PrEP users over time might reflect some immune protection following exposures to respiratory viruses through more social mixing or a direct impact of HIV-PrEP on symptom severity.

Objective: this scoping review examines evidence on strategies for mapping and recruiting community leaders in health surveillance programmes. Methods: searches followed the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines. The database search was performed in August 2024, covering literature published from 1986 to that date (1986–August 2024), in PubMed, the Virtual Health Library, and public health organization websites (WHO, CDC, PAHO, IFRC); records in English, Portuguese, and Spanish were included, and reference lists were hand-searched. Screening used Rayyan, and eligible documents underwent qualitative content analysis. Results: a total of 806 articles were identified after duplicates were removed; of : of these, 29 were read in full, plus 9 identified through reference lists, and 16 were included. Among 40 technical documents, 14 were eligible, resulting in nine selected, for a final total of 25 references. Few studies detailed mapping and recruitment strategies systematically. Key elements included: Community involvement in selection, collaboration with local institutions, and provision of training and supervision. A clear distinction between community leaders and volunteers was observed. Only some publications provide concrete evidence on strategies for mapping and recruiting leaders, yet it is possible to identify patterns and similarities across the stages described. Such processes are rarely grounded in reference models or presented in a structured manner. Understanding community profiles, aligning recruitment with local dynamics, and ensuring continuous support are essential to strengthening local health surveillance. Conclusion: despite identifying positive programme impacts, the way community representatives are recruited proved to be fundamental to implementation. The literature highlights that strengthening community participation in health requires long-term, process-oriented strategies rather than focusing solely on outcomes.

Objective: to describe the training experience of community leaders recruited to participate in Event-Based Surveillance (EBS) in Brazil and Cabo Verde, to characterize their profile, and to describe the use of a mobile application for recording EBS signs. Methods: this descriptive study details the training of community leaders to use a mobile data collection tool for EBS. Leaders were recruited through participatory mapping and snowball sampling in bothcountries. Training workshops included theoretical and practical sessions, focusing on health surveillance concepts, leadership roles, and the use of a digital application to report potential hazards to health known as “signals”. Data were collected via questionnaires and monitored through a digital dashboard. Results: training activities began in July 2024, and 89 leaders were trained, 39 in Brazil and 50 in Cabo Verde. Most participants had lived in their communities for over five years and had completed at least upper secondary education. Approximately 73% reported familiarity with health surveillance, and 63% with event-based surveillance. Following the training, 77% of Brazilian and 72% of Cabo Verdean leaders actively reported signals weekly. Reports began to occur in epidemiological week 34 of 2024. From epidemiological weeks 34 to 52 of 2024, 626 reports were submitted, with 71 classified as signals and 16 as potential public health risks. Conclusion: the pilot demonstrates that community leaders can be effectively trained to participate in Event-based surveillance, thereby contributing to the early detection of health threats. Participatory approaches and tailored training materials were fundamental to overcoming recruitment and technological challenges by involving community leaders in the evaluation of training content, using locally adapted language and examples, and providing hands-on training and continuous technical support. Continuous engagement and integration into local health systems are essential for long-term success through regular feedback mechanisms, supervision, and alignment with routine surveillance workflows.

Neisseria gonorrhoeae (NG) has become an increasing global health threat due to drug resistance and potentially invasive disease. In this study, we assessed the genotypic profile in both invasive and non-invasive NG strains from patients at University of Sao Paulo Faculty of Medicine Clinics Hospital, Brazil. We analyzed the NG genotypic profiles and clinical data from 25 patients hospitalized at Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP) from January 2017 to March 2020. A total of 25 isolates underwent whole genome sequencing, of which 10 (40%) were collected from sterile sites like blood and classified as invasive. Invasive and noninvasive specimens were clustered in 5 STs and 11 STs, respectively, sharing 3 STs in common. We identified resistance markers for macrolides (mtrR) in 40% of isolates and 92% exhibited at least one resistance marker for beta-lactams (penA, blaTEM-1B, or blaTEM-135), predominantly PBP1 and PBP2 alterations. Resistance genes blaTEM-1B (7%vs.50%, p=0.023) and tetM (13%vs.80%, p=0.002) were more frequently found in invasive disease isolates, always accompanied by the mobile genetic elements pJD4 and pEP5289, respectively. Associated with these elements were two toxin encoding genes (vapD and zeta1/2) previously described as possible virulence factors and resistance genes for beta-lactams and tetracyclines. Results revealed that invasive strains of NG are genotypically clustered and frequently harbor two plasmids which may be associated with invasive disease. Resistance markers for beta-lactam as PBP1 and PBP2 alterations warn against a future potential resistance to this class.

Background Sexual health service (SHS) delivery in England has shifted substantially following a rapid expansion of online services during the COVID-19 pandemic. While digital provision may improve reach, there are limited data on the extent of unmet need for in-person SHS in England. We sought to address this among men and gender-diverse individuals who have sex with men in England, a group disproportionately affected by sexual health inequalities. Methods We analysed data from “Reducing inequalities in Sexual Health” (RiiSH) 2024 (Nov/Dec 2024), an online cross-sectional survey of men and gender-diverse individuals who have sex with men residing in England. We assessed in-person SHS access and among those who tried to access a SHS in the last year - unmet need (i.e. participants who tried but were unable to access a SHS in-person) alongside reasons for inaccessibility. Using multivariable logistic regression, we examined sociodemographic and behavioural associations with unmet SHS need. Results Among 2,404 participants living in England (median age 45 years [interquartile range: 36-55], 88% White, 95% cisgender), 86% reported accessing in-person SHS ever, and 59% in the past year. Of those who tried to access in-person care in the past year, 12% (95% CI: 11%-14%) experienced unmet need, especially Outside London (15% vs. 8% in London). Common barriers included unavailable (50%) or inconvenient (41%) appointment times. In adjusted multivariable analysis, unmet need continued to be lower among participants living in London (aOR: 0.64 [95% CI: 0.44-0.92]), those financially comfortable (aOR: 0.69 [0.49-0.97]), and those reporting ≥1 marker(s) of sexual risk (e.g. HIV-PrEP use in the last year and/or in the last 3-4 months, the report of a bacterial STI diagnosis, engaging in chemsex, having had ≥10 male physical sex partners; aOR: 0.14 [0.10-0.20]). Unmet need was higher among participants with limiting long-term physical health conditions (aOR: 1.61 [1.12-2.30]) and those who reported ever using online postal self-sampling services for STI testing (OPSS) (aOR: 1.50 [1.07-2.09]). Conclusions Despite high SHS engagement, one in ten participants in this national community-based sample reported recent unmet need for in-person SHS. Equity-focused strategies are needed to meet evolving SHS demand. Local service delivery guided by joint strategic needs assessments could help address unmet need for SHS. Ethical considerations Ethical approval of this study was provided by the UKHSA Research and Ethics Governance Group (REGG; ref: R&D 524). Consent to participate Online informed consent was received from all participants and all methods were performed in accordance with guidelines and regulations set by the UKHSA REGG. Declaration of conflicting interest Authors have no conflicting interests to declare. Funding statement The RiiSH 2024 study and authors HM, JS, DR, CHM received partial funding support as part of The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London in partnership with the UK Health Security Agency (https://bbsti.hpru.nihr.ac.uk). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors received no specific funding for this work. Data availability The data that support the findings of this study are not publicly available to protect participant privacy. However, some aggregate data are available upon reasonable request from the UK Health Security Agency (UKHSA). Requests can be directed to DataAccess{at}ukhsa.gov.uk .

Background The Kenyan coast frequently experiences infectious disease outbreaks, but the response is often hindered by limited diagnostic capacity, diagnostic delays, and logistic barriers related to sample transportation and storage. Portable genomic sequencing technology offers the potential to accelerate outbreak investigations and inform timely public health interventions. However, a critical gap remains in understanding stakeholders' needs and level of engagement in integrating this technology within resource-limited settings. Methods We conducted a framework analysis on the stakeholder discussions from a consultative engagement meeting held in Nairobi, Kenya, in July 2024. Twenty-one stakeholders participated in discussions focusing on exploring outbreak response strategies within the respective counties and the potential integration of portable genomic sequencing technologies. The meeting sessions were recorded, and verbatim transcripts were analyzed using qualitative methods with NVivo software. Results Three key aspects of outbreak response were reported to be influenced by the resources available in each county: a) outbreak notification and reporting, b) outbreak management, and c) the sample journey. Participants strongly supported integrating portable sequencing technologies, identifying several key facilitators such as outbreak notification mechanisms, establishing public-private partnerships, and good security within the counties. However, logistical challenges were highlighted, including geographical inaccessibility, poor internet connectivity, power outages, and cultural or religious barriers to sample collection and sequencing. Conclusion Portable genomic sequencing was viewed as a high-value innovation with great potential to transform outbreak management in coastal Kenya. However, its successful integration during outbreaks will require addressing logistical challenges and leveraging existing partnerships and notification systems.

Background Recent increases in syphilis diagnoses among heterosexual individuals are a growing public health concern. We aimed to qualitatively assess the risk factors, lifestyles, and contexts facilitating syphilis transmission among heterosexually-identifying individuals in England through the NEXUS study. Methods and Findings NEXUS was a qualitative study based on semi-structured one-to-one interviews conducted between December 2023 and September 2024. Heterosexually-identifying individuals diagnosed with primary, secondary, or early latent syphilis in the previous year at a sexual health service in one of three regions in England were recruited. Interviews were also conducted with healthcare professionals involved in syphilis management. An analytical framework approach identified salient themes from interview transcripts. The service-user data were triangulated using healthcare professional data. Interviews were conducted with 19 service-users and seven healthcare professionals. Syphilis acquisition was primarily associated with condomless vaginal or oral sex. Half (10/19) reported multiple partners around the time of diagnosis; other known risk factors, like swinging (multiple concurrent partners) (1/19), sex work (3/19), or transmission among heterosexually-identifying men who have sex with men (1/19), were linked to a minority of infections. Of those reporting a single partner (9/19), four were in a believed exclusive relationship. Many had low perceptions of STI risk but intended to alter sexual behaviours post-diagnosis. Syphilis knowledge was limited among heterosexual individuals and initially seeking medical advice for symptoms from non-sexual health specialists sometimes led to diagnosis delays. Service-users suggested information on syphilis epidemiology, symptoms, and prevention, conveyed through National Health Service sources and mass media, would have been beneficial. Conclusions We identified a range of contexts associated with syphilis transmission. While multiple partners were common, infections also occurred through infrequent or novel practices or among those with few sexual encounters. Increasing awareness of syphilis among heterosexually-identifying individuals and healthcare professionals working in specialties other than sexual health is important to improve detection, facilitate treatment, and reduce transmission.

OBJECTIVES: We aimed to describe the epidemiology, antimicrobial resistance pattern, and treatment outcomes of symptomatic and asymptomatic Mycoplasma genitalium (MG) infections in patients from a public HIV/STI clinic in São Paulo, Brazil. METHODS: This cross-sectional study ran from July 2023 to September 2024. Patients tested for bacterial STIs were invited to participate by consenting to sample storage for resistance analysis. Clinical management followed standard care at the clinician’s discretion, and data were retrospectively analyzed. MG positive samples were analyzed for macrolide and quinolone resistance associated mutations, respectively in the region V of the 23s rRNA and the ParC genes, using Allplex Azi-R and Moxi-R assays (Seegene, Inc., Seoul, Korea). RESULTS: MG prevalence was 12.5% (47/376) in the study population and 66.0% (31/47) were asymptomatic infections. Mutations associated with macrolide (MDRM) and quinolone resistance were detected in 78.8% (26/33) and 21.1% (8/38) of the MG-positive samples, respectively. MDRM were significantly more common among symptomatic than asymptomatic patients (100.0% (13/13) vs 65.0% (13/20); p=0.016). Among untreated asymptomatic patients, 50.0% (3/6) cleared the infection without antibiotics. Treatment for 39.5% (15/38) included single-dose azithromycin, according to current national guidelines. Treatment failures were more common in the symptomatic group (91.7% (11/12) vs 40.0% (6/15); p=0.005). CONCLUSION: Macrolide and quinolone resistance were common in Mycoplasma genitalium samples from an STI clinic in São Paulo, Brazil, with frequent treatment failures among symptomatic patients. Current Brazilian guidelines should be urgently revised. Screening and treating asymptomatic MG cases may promote antimicrobial overuse without clear benefits, as spontaneous clearance may be common. Larger studies are needed to guide management and clarify the clinical relevance of asymptomatic MG infections. KEY POINTS: What is already known on this topic: Mycoplasma genitalium is common in vulnerable populations and poses a risk to antimicrobial resistance worldwide. What this study adds: Detection of high rates of macrolide and fluoroquinolone resistance in Mycoplasma genitalium in Brazil, along with frequent spontaneous clearance in asymptomatic cases. How this study might affect research, practice or policy: Findings support an update of Brazilian treatment guidelines and highlight the need for further investigation into the clinical relevance and management of asymptomatic infections.