Handan Wand

Child malnutrition remains a major public health challenge in Sub-Saharan Africa, with persistent disparities in stunting and underweight among children under five. This study examined subnational spatial variation and structural determinants of child growth failure across the region using Demographic and Health Survey data from 24 Sub-Saharan African countries collected between 2015 and 2023 ( n = 198,443). Generalized additive models with spatial smoothing were used to assess geospatial patterns of stunting and underweight. Stunting prevalence ranged from 16% to 55%, and underweight from 5% to 29%, with substantial within-country heterogeneity. Children in the highest cumulative disadvantage quartile, characterized by poor maternal education, low household wealth, limited healthcare access, and reduced access to information, had substantially higher odds of stunting and underweight compared with those in the lowest quartile. Population-attributable risk estimates suggested that 45% to 89% of the burden was statistically associated with the included structural and socioeconomic risk factors under model assumptions. Spatial interpolation and smoothed intensity maps revealed localized hotspots of malnutrition that were often obscured by national averages. Despite variation in overall prevalence across countries, similar structural and socioeconomic factors were consistently associated with poor growth outcomes. These findings highlight the value of integrating high-resolution geospatial analysis with population-level impact measures to inform targeted, equity-focused nutrition policies and resource allocation strategies across Sub-Saharan Africa. Graphical Abstract Country-specific Observed vs. Theoretical Prevalence of Stunting and Underweight Among Children Under Five Across 24 African Countries (R-Script given in Appendix 2, Part C) ( a ) Stunting Prevalence ( b ) Underweight Prevalence. Observed Prevalence and Model-Based Estimates of Associated Burden. As presented in Fig. 1, only 4 out of 24 countries (17%) had stunting prevalence below the WHO-defined “low” threshold of 20%. The remaining 20 countries (83%) fell into the “medium” (20–29%) to “very high” (≥ 40%) categories, with nearly half (46%) classified as having “high” (30–39%) or “very high” (≥ 40%) stunting levels. When population-attributable risk percentages were applied, the model-based estimates suggested that the proportion of stunting burden statistically associated with the included structural and socioeconomic risk factors was substantial across countries. Under these theoretical assumptions, estimated stunting prevalence would fall below 20% in all 24 countries. Similarly, only 7 countries (29%) had underweight prevalence below the 10% threshold classified as “low,” while the majority (71%) were categorized as having “medium” (10–19%) to “high” (20–29%) prevalence, with 6 countries (25%) falling into the “high” category. Under the same model-based assumptions, the estimated proportion of underweight burden statistically associated with the included risk factors was also substantial, with theoretical underweight prevalence falling below 10% in all countries. These findings should be interpreted as theoretical, model-based estimates of associated burden rather than evidence of directly preventable reductions

Background: Sexually transmitted infections (STIs) are a major public health problem globally, particularly in low and middle-income countries. In the Western Pacific region, including Nauru, STIs are highly prevalent. Syndromic management misses a high proportion of infections and screen-and-treat strategies are not currently feasible at scale in these settings. Mass drug administration (MDA), widely used for control of neglected tropical diseases, may provide an alternative approach to the population control of STIs. Methods: We used a before-and-after study design to evaluate the impact of azithromycin MDA for trachoma control on STI prevalence in Nauru. The study enrolled 381 participants aged 18–29 years before MDA and 360 participants 6 months after MDA, with similar age distribution but a higher proportion of women post-MDA. Urine specimens were tested for Chlamydia trachomatis , Neisseria gonorrhoeae , Mycoplasma genitalium and Trichomonas vaginalis . Findings: At baseline, C. trachomatis infection was present in 21.7% of participants followed by T. vaginalis and M. genitalium (21.2% and 10.9%, respectively), while N. gonorrhoeae was detected in 2.7% of participants. At 6 months after azithromycin MDA, prevalence declined for all STIs except T. vaginalis . Relative reductions were 35% (95% CI 9.7 to 52.8) for C. trachomatis , 67% (−15.2 to 91.1) for N. gonorrhoeae and 47% (10.7 to 68.2) for M. genitalium . Reductions in prevalence following MDA were greater in men than women but CIs overlapped. Interpretation: This study provides the first evaluation among both men and women of changes in STI prevalence following azithromycin MDA in a high-prevalence general population. The potential role of this strategy in STI control needs further exploration.

Objectives: Neisseria gonorrhoeae and Chlamydia trachomatis can be transmitted from an infected woman to her baby during vaginal birth to cause neonatal conjunctivitis (ophthalmia neonatorum). Little is known about how often these pathogens cause infection in babies without conjunctivitis. The objectives of this study were to investigate the frequency of C. trachomatis and N. gonorrhoeae in newborn babies with and without conjunctivitis and to estimate the prevalence of these infections and the proportion that was asymptomatic. Methods: We conducted a cross-sectional study, nested in a randomised controlled trial in Papua New Guinea. At a visit scheduled 1–2-weeks after birth (visit 1), we took conjunctival swabs from babies with clinical signs of conjunctivitis and from a sample of those with no clinical signs. Babies with conjunctivitis received antibiotic treatment. Swabs were tested for N. gonorrhoeae and C. trachomatis by PCR after the end of the study. We estimated the weighted percentage (with 95% confidence intervals, CI) of babies with either organism detected and the asymptomatic proportion. Results: From 21 ^st October, 2017 to 2 ^nd February, 2022, 1699 of 2055 newborn babies attended visit 1. Among 310 babies with clinical data and a result from any swab, 97 had signs of conjunctivitis and 213 did not. Where results were available, C. trachomatis was detected in 12/97 (12.4%) of babies with conjunctivitis and 7/211 (3.3%) without. N. gonorrhoeae was detected in 1/97 (1.0%) of babies with conjunctivitis and 6/210 (2.9%) without. The weighted estimate of C. trachomatis or N. gonorrhoeae prevalence was 6.6% (3.8-9.9%), of which an estimated 87.0% (74.8%-93.8%) was asymptomatic. Conclusions: C. trachomatis and N. gonorrhoeae were detected in the absence of clinical signs of conjunctivitis in about 1 in 15 babies. This finding has implications for estimation of mother-to-child transmission and evaluation of prophylaxis and treatment interventions. Key messages: What is already known on this topic: ▪ Neisseria gonorrhoeae and Chlamydia trachomatis cause neonatal conjunctivitis (ophthalmia neonatorum), which can lead to permanent vision loss if untreated; ▪ Little is known about the occurrence and frequency of N. gonorrhoeae and C. trachomatis in newborn babies without conjunctivitis. What this study adds: ▪ This study included babies with clinical conjunctivitis and a sample of babies without clinical signs of conjunctivitis and tested swabs using PCR at a visit scheduled 1-2 weeks after birth; ▪ The overall prevalence of C. trachomatis or N. gonorrhoeae was estimated to be 6.6% (95% CI 3.8-9.9%), of which an estimated 87.0% (74.8%-93.8%) occurred in babies without clinical signs of conjunctivitis. How this study might affect research, practice or policy: ▪ The clinical relevance of asymptomatic C. trachomatis or N. gonorrhoeae detection remains unclear; all samples from babies with asymptomatic detection tested negative at a visit scheduled 4-6 weeks after birth; ▪ The results are important for research about mother-to-child transmission of C. trachomatis and N. gonorrhoeae and evaluation of prophylaxis and treatment interventions conducted using molecular diagnostics.

Objectives: In remote Australian First Nations communities, the burden of curable sexually transmitted infections (STIs) is highest for young women and men aged 16–29 years and for women is associated with two-fold higher rates of hospitalisations for pelvic inflammatory disease (PID) than for non-First Nations women. Following a randomised trial, decentralised community-led molecular point-of-care (POC) testing for STIs has operated in remote primary care across Australia for more than 7 years, improving uptake and timeliness of treatment for chlamydia, gonorrhoea and trichomonas infections. However, cost-effectiveness remains unknown. Methods: A decision analytic model was devised to compare costs and outcomes associated with a POC testing programme for chlamydia, gonorrhoea and trichomonas infections in women and men aged 16–29 years seeking care, compared with standard care (laboratory-based testing). The analysis used a government payer perspective and 10-year time horizon. The primary outcome was the cost ($A) per quality-adjusted life year (QALY) gained. Sensitivity analyses examined uncertainty around the results. Results: Based on a combined testing positivity rate of 36% and 29% for chlamydia, gonorrhoea and trichomonas for women and men, respectively, the POC testing programme, compared with laboratory testing, produced an estimated incremental cost per QALY ratio (ICER) of $A19 714 (95% CIs $A19 608 to $A19 821) over 10 years. Among those with an STI, the POC testing programme was predicted to reduce diagnosed PID by 30% and preterm/low birth weight babies by 17%. Sensitivity analyses indicated that the ICER was most sensitive to the probability of infection and receiving treatment within 2 days, based on a willingness-to-pay threshold of $A50 000. Conclusion: This health economic evaluation indicates that a scaled molecular POC testing programme for the management of STIs in remote primary care settings is cost-effective compared with standard care. Sustained POC testing in this setting is likely to improve reproductive health outcomes.

Objective: In remote Australia, where there is a substantial burden of sexually transmitted infections (STIs) among First Nations peoples, testing and timely treatment are key to reducing prevalence. We evaluated the impact of introducing molecular point-of-care (POC) testing for chlamydia/gonorrhoea and later trichomonas on STI testing (including syphilis) and positive tests. Methods: We conducted a retrospective interrupted time-series analysis of routinely collected data from First Nations peoples aged 15–54 years attending 20 remote/regional clinics participating in the Test, Treat and GO programme (2016–2019). We used segmented regression models to estimate the immediate level change (first month of POC) and after-period trends in monthly tests, positive tests and proportion of concurrent syphilis tests to assess sustainability. Before and after comparisons were estimated using linear regression models. Results: There were 17 437 chlamydia/gonorrhoea and 14 173 trichomonas tests performed, mostly among women (69% and 64%) and individuals aged 15–34 years (72% and 68%). Following the introduction of molecular POC testing, there were immediate level increases in monthly tests: chlamydia/gonorrhoea by 26% (+154, p<0.001) and trichomonas by 21% (+116, p=0.004) and level increases of positive tests: gonorrhoea by 30% (+13, p=0.017) and trichomonas by 29% (+14, p=0.034); chlamydia was unchanged. The proportion of chlamydia/gonorrhoea tests with concurrent syphilis tests remained unchanged (−1.7%; −0.9%; p=0.531), while the proportion increased among positive chlamydia/gonorrhoea tests by 25% (+13%; p=0.013). Increased levels of testing were sustained for gonorrhoea/chlamydia (+2.7, p=0.118) and trichomonas (−3.5, p=0.400) and syphilis among those with positive chlamydia/gonorrhoea tests (−0.2%, p=0.593). Conclusion: Molecular POC testing led to immediate and sustained increases in STI testing and an immediate increase in positive tests in remote primary care. The use of POC testing is likely to result in earlier diagnosis and treatment and reduced onward transmission and sequelae, supporting a broader integration of POC testing in high-burden settings.

Vaccination is among the most effective public health interventions, preventing an estimated 4–5 million deaths annually and serving as a foundation of child survival strategies (World Health Organ...

Background: Biopsychosocial comorbidities are common in chronic illnesses like HIV, often resulting in complex clinical presentations. The Clinical Complexity Rating Scale for HIV (CCRS-HIV) was developed to identify these factors. This study examined whether complexity, as measured by the CCRS-HIV, could change over time. Methods: Patients at The Albion Centre in Sydney were assessed at two time points (T ₁ and T ₂ ) using the CCRS-HIV. Changes in total and subscale scores were analysed, along with the odds of scoring in the complex range (40+ or 45+). The impact of age and time between assessments was also evaluated. Results: Results showed a significant decrease in total complexity scores from T ₁ to T ₂ , with improvements across four subscales—two psychological/behavioural, one social, and one biomedical. The proportion of complex cases declined, and participants were nearly twice as likely to be complex at T ₁ compared to T ₂ . Longer intervals between assessments were linked to greater improvements, while age and sex had no effect. Conclusions: These findings suggest that complexity in people living with HIV (PLHIV) is modifiable and support the CCRS-HIV as a valuable tool for screening and tracking changes in clinical complexity.