A systematic review of environmental covariates and methods for spatial or temporal scrub typhus distribution prediction.

BACKGROUND: Scrub typhus is underdiagnosed and underreported but emerging as a global public health problem. To inform future burden and prediction studies we examined through a systematic review the potential effect of environmental covariates on scrub typhus occurrence and the methods which have been used for its prediction. METHODS: In this systematic review, we searched PubMed, Scopus, Web of Science, China National Knowledge Infrastructure and other databases, with no language and publication time restrictions, for studies that investigated environmental covariates or utilized methods to predict the spatial or temporal human. Data were manually extracted following a set of queries and systematic analysis was conducted. RESULTS: We included 68 articles published in 1978-2024 with relevant data from 7 countries/regions. Significant environmental risk factors for scrub typhus include temperature (showing positive or inverted-U relationships), precipitation (with positive or inverted-U patterns), humidity (exhibiting complex positive, inverted-U, or W-shaped associations), sunshine duration (with positive, inverted-U associations), elevation, the normalized difference vegetation index (NDVI), and the proportion of cropland. Socioeconomic and biological factors were rarely explored. Autoregressive Integrated Moving Average (ARIMA) (n = 8) and ecological niche modelling (ENM) approach (n = 11) were the most popular methods for predicting temporal trends and spatial distribution of scrub typhus, respectively. CONCLUSIONS: Our findings summarized the evidence on environmental covariates affecting scrub typhus occurrence and the methodologies used for predictive modelling. We review the existing knowledge gaps and outline recommendations for future studies modelling disease prediction and burden. TRIAL REGISTRATION: PROSPERO CRD42022315209.

Using priorities between human and livestock bacterial antimicrobial resistance (AMR) to identify data gaps in livestock AMR surveillance.

BACKGROUND: Bacterial antimicrobial resistance (AMR) is a global threat to both humans and livestock. Despite this, there is limited global consensus on data-informed, priority areas for intervention in both sectors. We compare current livestock AMR data collection efforts with other variables pertinent to human and livestock AMR to identify critical data gaps and mutual priorities. METHODS: We globally synthesized livestock AMR data from open-source surveillance reports and point prevalence surveys stratified for six pathogens (Escherichia coli, Staphylococcus aureus, non-typhoidal Salmonella, Campylobacter spp., Enterococcus faecalis, Enterococcus faecium) and eleven antimicrobial classes important in human and veterinary use, published between 2000 and 2020. We also included all livestock species represented in the data: cattle, chickens, pigs, sheep, turkeys, ducks, horses, buffaloes, and goats. We compared this data with intended priorities calculated from: disability-adjusted life years (DALYs), livestock antimicrobial usage (AMU), livestock biomass, and a global correlation exercise between livestock and human proportion of resistant isolates. RESULTS: Resistance to fluoroquinolones and macrolides in Staphylococcus aureus were identified as priorities in many countries but, less than 10% of these reported livestock AMR data. Resistance data for Escherichia coli specific to cattle, chickens, and pigs, which we prioritized, were also well collected. AMR data collection on non-typhoidal Salmonella and other livestock species were often not prioritized. Of 232 categories prioritized by at least one country, data were only collected for 48% (n = 112). CONCLUSIONS: The lack of livestock AMR data globally for broad resistance in Staphylococcus aureus could underplay their zoonotic threat. Countries can bolster livestock AMR data collection, reporting, and intervention setting for Staphylococcus aureus as done for Escherichia coli. This framework can provide guidance on areas to strengthen AMR surveillance and decision-making for humans and livestock, and if done routinely, can adapt to resistance trends and priorities.

Fatal journeys: causes of death in international travellers in South America.

BACKGROUND: Understanding mortality among travellers is essential for mitigating risks and enhancing travel safety. However, limited evidence exists on severe illnesses and injuries leading to death among travellers, particularly in low- and middle-income countries and remote regions. METHODS: We conducted a retrospective census study using country-level observational data from death certificates of travellers of seven South American countries (Argentina, Brazil, Chile, Colombia, Ecuador, Peru, and Uruguay) from 2017 to 2021. Causes of death were evaluated using ICD-10 codes, categorised into non-communicable diseases (NCDs), communicable diseases, and injuries. We quantified causes of death by demographic characteristics (e.g. age, sex), and geographical variables. Chi-square tests were used to assess differences between categories. We calculated crude mortality rates and incidence rate ratios (IRRs) per country's subregions. RESULTS: A total of 17 245 deaths were reported. NCDs (55%) were the most common cause of death, followed by communicable diseases (23.4%) and injuries (18.1%). NCD-associated deaths increased after age 55 years and were highest among ≥85 years. Communicable diseases were more common at younger age (<20 years). Injury-associated deaths were more common in men (79.9%) and 25-29-year-olds (17.1%). Most deaths (68.2%) could have been avoided by prevention or treatment. Mortality risk was higher among travellers in bordering regions between countries. In Roraima [Brazil] and Norte de Santander [Colombia], locations bordering Venezuela, the death incidence rate ratio was 863 and 60, respectively. These countries' reference mortality rates in those regions were much lower. More than 80% of the deaths in these border regions of Brazil and Colombia involved Venezuelan citizens. Conclusion: The study identified risk factors and high-risk locations for deaths among travellers in seven countries of South America. Our findings underscore the need for specific health interventions tailored to traveller demographics and destination to optimise prevention of avoidable deaths in South America.

Global and regional seroprevalence, incidence, mortality of, and risk factors for scrub typhus: A systematic review and meta-analysis.

OBJECTIVES: Scrub typhus is underdiagnosed and underreported but emerging as a global public health problem. We aimed to provide the first comprehensive review on the seroprevalence, incidence, mortality of and risk factors for scrub typhus. METHODS: We searched PubMed, Scopus, Web of Science, China National Knowledge Infrastructure and other databases. Trended incidence and median mortality were calculated and pooled seroprevalence and risk factors for scrub typhus were evaluated using the random-effects meta-analysis. RESULTS: We included 663 articles from 29 countries/regions. The pooled seroprevalence was 10.73% (95%CI 9.47-12.13%) among healthy individuals and 22.58% (95%CI: 20.55%-24.76%) among febrile patients. Mainland China reported the highest number of cases and South Korea and Thailand had the highest incidence rates. Median mortalities were 5.00% (range: 0.00-56.00%) among hospital inpatients, 6.70% (range: 0.00-33.33%) among patients without specified admission status and 2.17% (range: 0.00-22.22%) among outpatients. The significant risk factors included agricultural work, specific vegetation exposure, other outdoor activities, risky personal health habits, and proximity to rodents, livestock, or poultry. CONCLUSIONS: Our comprehensive review elucidates the significant yet variable burden of scrub typhus across different regions, underscoring its emergence as a critical public health concern globally.

Ongoing transmission of lymphatic filariasis in Samoa 4.5 years after one round of triple-drug mass drug administration.

BACKGROUND: Lymphatic filariasis (LF) remains a significant global issue. To eliminate LF as a public health problem, the World Health Organization (WHO) recommends multiple rounds of mass drug administration (MDA). In certain scenarios, including when elimination targets have not been met with two-drug MDA, triple-drug MDA (using ivermectin, diethylcarbamazine and albendazole) is recommended. In this study, we report on antigen (Ag) and microfilaria (Mf) prevalence in eight primary sampling units (PSUs) in Samoa 4.5 years after one round of triple-drug MDA. METHODOLOGY: In 2023, community surveys were conducted in eight PSUs that had been surveyed previously in 2018 (between 1.5 and 3.5 months post triple-drug MDA) and 2019 (six to eight-months post triple-drug MDA). Fifteen houses were randomly selected in each PSU with household members aged ≥ 5 years invited to participate. Blood samples were tested for Ag and Mf. PRINCIPAL FINDINGS: Ag-positive participants were observed in six of the eight PSUs, and Ag prevalence was significantly above the 1% threshold in four PSUs. The presence of Mf-positive participants in five PSUs confirms the presence of residual active infections. CONCLUSIONS/SIGNIFICANCE: This study provides evidence of persistent LF transmission in Samoa 4.5 years after one round of triple-drug MDA, confirming that one round was insufficient for interruption of transmission in this setting. Our findings highlight the negative impact of delaying MDA rounds, for example, due to public health emergencies.

Evaluation of cancer screening services provided for people living with HIV in Botswana, 2022-2023.

People living with human immunodeficiency virus (PLHIV) have an increased risk of cancers. Currently, Botswana has no screening guidelines for common cancers in PLHIV except cervical cancer. Also, the proportion of PLHIV who are screened for cancer is unknown. This study aimed to evaluate cancer screening services for PLHIV receiving care in the human immunodeficiency virus (HIV) clinics. Resources for cancer screening were assessed and medical records of adults initiating antiretroviral therapy (ART) from 2020 to 2021 in 20 high-volume HIV clinics in Gaborone and Francistown were reviewed. Questionnaires assessing knowledge and practices of cancer screening were administered to health workers. The majority of clinics had the required resources for cancer screening (specifically cervical cancer). Of the 62 health workers working at the HIV clinics, 57 (91.9%) completed the questionnaire: 35 (62.5%) nurses and 22 (37.5%) doctors. Only 26.3% of the health workers were trained in cervical cancer screening. Doctors were more likely to report practicing routine screening of other cancers (e.g. breast) (p = 0.003) while more nurses reported assessing patients for cancer history during follow-up visits (p = 0.036). Most health workers did not perform physical examinations to detect cancer at initial or follow-up visits. Of the 1000 records of PLHIV reviewed, 57.3% were females, and only 38% of these were screened for cervical cancer. Besides cervical cancer, almost all (97.8%) were not screened for any cancer at ART initiation and during follow-up. These findings highlight the need to improve cancer screening services of PLHIV in Botswana through the training of health workers, and the development and enhanced use of screening guidelines.

Frequency and mortality rate following antimicrobial-resistant bloodstream infections in tertiary-care hospitals compared with secondary-care hospitals.

There are few studies comparing proportion, frequency, mortality and mortality rate following antimicrobial-resistant (AMR) infections between tertiary-care hospitals (TCHs) and secondary-care hospitals (SCHs) in low and middle-income countries (LMICs) to inform intervention strategies. The aim of this study is to demonstrate the utility of an offline tool to generate AMR reports and data for a secondary data analysis. We conducted a secondary-data analysis on a retrospective, multicentre data of hospitalised patients in Thailand. Routinely collected microbiology and hospital admission data of 2012 to 2015, from 15 TCHs and 34 SCHs were analysed using the AMASS v2.0 (www.amass.website). We then compared the burden of AMR bloodstream infections (BSI) between those TCHs and SCHs. Of 19,665 patients with AMR BSI caused by pathogens under evaluation, 10,858 (55.2%) and 8,807 (44.8%) were classified as community-origin and hospital-origin BSI, respectively. The burden of AMR BSI was considerably different between TCHs and SCHs, particularly of hospital-origin AMR BSI. The frequencies of hospital-origin AMR BSI per 100,000 patient-days at risk in TCHs were about twice that in SCHs for most pathogens under evaluation (for carbapenem-resistant Acinetobacter baumannii [CRAB]: 18.6 vs. 7.0, incidence rate ratio 2.77; 95%CI 1.72-4.43, p<0.001; for carbapenem-resistant Pseudomonas aeruginosa [CRPA]: 3.8 vs. 2.0, p = 0.0073; third-generation cephalosporin resistant Escherichia coli [3GCREC]: 12.1 vs. 7.0, p<0.001; third-generation cephalosporin resistant Klebsiella pneumoniae [3GCRKP]: 12.2 vs. 5.4, p<0.001; carbapenem-resistant K. pneumoniae [CRKP]: 1.6 vs. 0.7, p = 0.045; and methicillin-resistant Staphylococcus aureus [MRSA]: 5.1 vs. 2.5, p = 0.0091). All-cause in-hospital mortality (%) following hospital-origin AMR BSI was not significantly different between TCHs and SCHs (all p>0.20). Due to the higher frequencies, all-cause in-hospital mortality rates following hospital-origin AMR BSI per 100,000 patient-days at risk were considerably higher in TCHs for most pathogens (for CRAB: 10.2 vs. 3.6,mortality rate ratio 2.77; 95%CI 1.71 to 4.48, p<0.001; CRPA: 1.6 vs. 0.8; p = 0.020; 3GCREC: 4.0 vs. 2.4, p = 0.009; 3GCRKP, 4.0 vs. 1.8, p<0.001; CRKP: 0.8 vs. 0.3, p = 0.042; and MRSA: 2.3 vs. 1.1, p = 0.023). In conclusion, the burden of AMR infections in some LMICs might differ by hospital type and size. In those countries, activities and resources for antimicrobial stewardship and infection control programs might need to be tailored based on hospital setting. The frequency and in-hospital mortality rate of hospital-origin AMR BSI are important indicators and should be routinely measured to monitor the burden of AMR in every hospital with microbiology laboratories in LMICs.

Mastering geographically weighted regression: key considerations for building a robust model.

Geographically weighted regression (GWR) takes a prominent role in spatial regression analysis, providing a nuanced perspective on the intricate interplay of variables within geographical landscapes (Brunsdon et al., 1998). However, it is essential to have a strong rationale for employing GWR, either as an addition to, or a complementary analysis alongside, non-spatial (global) regression models (Kiani, Mamiya et al., 2023). Moreover, the proper selection of bandwidth, weighting function or kernel types, and variable choices constitute the most critical configurations in GWR analysis (Wheeler, 2021). [...].

The Trends and Risk Factors of AIDS-Defining Cancers and Non-AIDS-Defining Cancers in Adults Living with and without HIV: A Narrative Review.

Background: People living with HIV (PLHIV) are at a high-risk of developing AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs). This review is aimed at exploring available evidence regarding the trends of ADCs and NADCs and the associated risk factors among adult PLHIV. Methods: We conducted a comprehensive search of PubMed, Web of Science, and EBSCO host databases to identify articles published between 2010 and 2023 that reported incidence and mortality rates of cancer, including ADCs and NADCs among PLHIV. We compared trends and rates in PLHIV with HIV-negative adults and further assessed related risk factors. Results: A total of 1886 potentially eligible articles were screened, and of these, 36 were included in this study. More than 50% (n = 20) of these were based in high-income countries. Seventeen studies reported a higher prevalence of NADCs compared to ADCs, with twelve of these conducted in high-income countries. Conversely, eight out of twelve studies reporting a higher prevalence of ADCs versus NADCs were from low-and-middle and upper-middle-income countries. Ten studies indicated a higher incidence of ADCs (6 studies) and NADCs (4 studies) among PLHIV compared to HIV-negative individuals. In contrast, only two studies observed an increase in NADCs among the HIV-negative population. In comparing mortality, seven out of nine studies showed elevated NADC-related deaths compared to ADCs. The main risk factors identified for any cancer, NADCs, and related mortality were advancing age, and longer duration of HIV infection, while lower CD4 cell counts (<200 cells/µl), was associated with both ADC and NADC occurrences. Conclusion: Chronic HIV infection combined with advancing age in PLHIV taking antiretroviral therapy appears to have contributed to increasing cancer burden, particularly the incidence of NADCs and associated mortality. These findings stress the importance of screening for high-risk cancers among PLHIV for early detection and treatment to ensure improved outcomes.

Serum microRNA Profiles and Pathways in Hepatitis B-Associated Hepatocellular Carcinoma: A South African Study.

The incidence and mortality of hepatocellular carcinoma (HCC) in Sub-Saharan Africa is projected to increase sharply by 2040 against a backdrop of limited diagnostic and therapeutic options. Two large South African-based case control studies have developed a serum-based miRNome for Hepatitis B-associated hepatocellular carcinoma (HBV-HCC), as well as identifying their gene targets and pathways. Using a combination of RNA sequencing, differential analysis and filters including a unique molecular index count (UMI) ≥ 10 and log fold change (LFC) range > 2: <-0.5 (p < 0.05), 91 dysregulated miRNAs were characterized including 30 that were upregulated and 61 were downregulated. KEGG analysis, a literature review and other bioinformatic tools identified the targeted genes and HBV-HCC pathways of the top 10 most dysregulated miRNAs. The results, which are based on differentiating miRNA expression of cases versus controls, also develop a serum-based miRNA diagnostic panel that indicates 95.9% sensitivity, 91.0% specificity and a Youden Index of 0.869. In conclusion, the results develop a comprehensive African HBV-HCC miRNome that potentially can contribute to RNA-based diagnostic and therapeutic options.

Improved household flooring is associated with lower odds of enteric and parasitic infections in low- and middle-income countries: A systematic review and meta-analysis.

Enteric and parasitic infections such as soil-transmitted helminths cause considerable mortality and morbidity in low- and middle-income settings. Earthen household floors are common in many of these settings and could serve as a reservoir for enteric and parasitic pathogens, which can easily be transmitted to new hosts through direct or indirect contact. We conducted a systematic review and meta-analysis to establish whether and to what extent improved household floors decrease the odds of enteric and parasitic infections among occupants compared with occupants living in households with unimproved floors. Following the PRISMA guidelines, we comprehensively searched four electronic databases for studies in low- and middle-income settings measuring household flooring as an exposure and self-reported diarrhoea or any type of enteric or intestinal-parasitic infection as an outcome. Metadata from eligible studies were extracted and transposed on to a study database before being imported into the R software platform for analysis. Study quality was assessed using an adapted version of the Newcastle-Ottawa Quality Assessment Scale. In total 110 studies were eligible for inclusion in the systematic review, of which 65 were eligible for inclusion in the meta-analysis after applying study quality cut-offs. Random-effects meta-analysis suggested that households with improved floors had 0.75 times (95CI: 0.67-0.83) the odds of infection with any type of enteric or parasitic infection compared with household with unimproved floors. Improved floors gave a pooled protective OR of 0.68 (95CI: 0.58-0.8) for helminthic infections and 0.82 OR (95CI: 0.75-0.9) for bacterial or protozoan infections. Overall study quality was poor and there is an urgent need for high-quality experimental studies investigating this relationship. Nevertheless, this study indicates that household flooring may meaningfully contribute towards a substantial portion of the burden of disease for enteric and parasitic infections in low- and middle-income settings.

Using Regional Sero-Epidemiology SARS-CoV-2 Anti-S Antibodies in the Dominican Republic to Inform Targeted Public Health Response.

Incidence of COVID-19 has been associated with sociodemographic factors. We investigated variations in SARS-CoV-2 seroprevalence at sub-national levels in the Dominican Republic and assessed potential factors influencing variation in regional-level seroprevalence. Data were collected in a three-stage cross-sectional national serosurvey from June to October 2021. Seroprevalence of antibodies against the SARS-CoV-2 spike protein (anti-S) was estimated and adjusted for selection probability, age, and sex. Multilevel logistic regression was used to estimate the effect of covariates on seropositivity for anti-S and correlates of 80% protection (PT80) against symptomatic infection for the ancestral and Delta strains. A total of 6683 participants from 134 clusters in all 10 regions were enrolled. Anti-S, PT80 for the ancestral and Delta strains odds ratio varied across regions, Enriquillo presented significant higher odds for all outcomes compared with Yuma. Compared to being unvaccinated, receiving ≥2 doses of COVID-19 vaccine was associated with a significantly higher odds of anti-S positivity (OR 85.94, [10.95-674.33]) and PT80 for the ancestral (OR 4.78, [2.15-10.62]) and Delta strains (OR 3.08, [1.57-9.65]) nationally and also for each region. Our results can help inform regional-level public health response, such as strategies to increase vaccination coverage in areas with low population immunity against currently circulating strains.

The uncertain role of substandard and falsified medicines in the emergence and spread of antimicrobial resistance.

Approximately 10% of antimicrobials used by humans in low- and middle-income countries are estimated to be substandard or falsified. In addition to their negative impact on morbidity and mortality, they may also be important drivers of antimicrobial resistance. Despite such concerns, our understanding of this relationship remains rudimentary. Substandard and falsified medicines have the potential to either increase or decrease levels of resistance, and here we discuss a range of mechanisms that could drive these changes. Understanding these effects and their relative importance will require an improved understanding of how different drug exposures affect the emergence and spread of resistance and of how the percentage of active pharmaceutical ingredients in substandard and falsified medicines is temporally and spatially distributed.

Stakeholder's perspectives on acceptable interventions for promoting hypertension medication adherence in Namibia: nominal group technique.

OBJECTIVE: To determine the most acceptable hypertension intervention package to promote hypertension adherence based on stakeholders' perspectives. DESIGN: We employed the nominal group technique method and purposively sampled and invited key stakeholders offering hypertension services and patients with hypertension. Phase 1 was focused on determining barriers to hypertension adherence, phase 2 on enablers and phase 3 on the strategies. We employed the ranking method based on a maximum of 60 scores to establish consensus regarding hypertension adherence barriers, enablers and proposed strategies. SETTING AND PARTICIPANTS: 12 key stakeholders were identified and invited to participate in the workshop in Khomas region. Key stakeholders included subject matter experts in non-communicable diseases, family medicine and representatives of our target population (hypertensive patients). RESULTS: The stakeholders reported 14 factors as barriers and enablers to hypertension adherence. The most important barriers were: lack of knowledge on hypertension (57 scores), unavailability of drugs (55 scores) and lack of social support (49 scores). Patient education emerged as the most important enabler (57 scores), availability of drugs emerged second (53 scores) and third having a support system (47 scores). Strategies were 17 and ranked as follows: continuous patient education as the most desirable (54 scores) strategy to help promote hypertension adherence, followed by developing a national dashboard to primarily monitor stock (52 scores) and community support groups for peer counselling (49 scores). CONCLUSIONS: Multifaceted educational intervention package targeting patient and healthcare system factors may be considered in implementing Namibia's most acceptable hypertension package. These findings will offer an opportunity to promote adherence to hypertension therapy and reduce cardiovascular outcomes. We recommend a follow-up study to evaluate the proposed adherence package's feasibility.

Spatial variations in STIs among women enrolled in HIV prevention clinical trials in Durban, KwaZulu-Natal, South Africa.

South Africa is faced with a high HIV and STI prevalence and incidence, respectively, with pockets of high burden areas driving these diseases. Localised monitoring of the HIV epidemic and STI endemic would enable more effective targeted prevention strategies. We assessed spatial variations in curable STI incidence among a cohort of women enrolled in HIV prevention clinical trials between 2002 and 2012. STI incidence rates from 7557 South African women enrolled in five HIV prevention trials were geo-mapped using participant household GPS coordinates. Age and period standardised incidence rates were calculated for 43 recruitment areas and Bayesian conditional autoregressive areal spatial regression (CAR) was used to identify significant patterns and spatial patterns of STI infections in recruitment communities. Overall age and period standardised STI incidence rate were estimated as 15 per 100 PY and ranged from 6 to 24 per 100 PY. We identified five significant STI high risk areas with higher-than-expected incidence of STIs located centrally (three-locations) and southern neighbouring areas of Durban (two-locations). Younger age (<25), not married/cohabitating, parity <3 and poor education were all significant correlates of high STI communities. Findings demonstrate sustained STI incidence rates across the greater Durban area. The role of STI incidence in HIV acquisition in high HIV endemic areas need to be revisited as current highly effective PrEP interventions do not protect from STI acquisition. In these settings there is an urgent need for integrative HIV and STI prevention and treatment services.

Pre- and post-intervention survey on lung cancer awareness among adults in selected communities in KwaZulu-Natal, South Africa: A quasi-experimental study.

Background: Lung cancer remains the number one cause of cancer mortality estimated at 1.8 million deaths. There are limited studies in resource poor countries regarding knowledge, attitudes and practices towards lung cancer. Objective: This study aimed to assess the effects of a lung cancer awareness intervention in selected communities in KwaZulu- Natal, South Africa. Materials and Methods: A quasi-experimental study design was conducted in the selected communities in KwaZulu-Natal. A community intervention was administered in the communities after a baseline survey. The intervention effects were assessed a month after implementation. Results: There were statistical differences in the mean age (p<0.001) and proportion of males and females (p<0.001) at baseline and post-intervention. There were no differences in terms of smoking status (p=0.958), however, there was a reduction in the number of cigarettes smoked per day (p<0.001) and the number of packs smoked per week (p=0.026). The mean knowledge score increased from 41.8% (95% CI 35.7 - 47.9) at baseline to 59.9 (95% CI 53.8 - 66.0) post-intervention (p<0.001). The proportion of participants who were aware that lung cancer can be detected early increased from 46.5% (95% CI 39.1 - 53.9) at baseline to 81.1% (95% CI 71.7 - 87.9) post-intervention (p<0.001). The intervention had a statistically significant effect (aOR 4.370, 95% CI 1.477-12.928) on the level of lung cancer knowledge in the selected communities (p<0.001). Conclusions: Interventions increasing the recognition of signs and symptoms, focusing on the importance of early detection and health seeking behaviour (including screening), smoking cessation, and addressing the perceived health system barriers are required.

Drug-resistant bacterial infections: We need urgent action and investment that focus on the weakest link.

Despite high mortality and morbidity, drug-resistant bacterial infections remain the forgotten pandemic. We argue for strengthening of diagnostics, WASH (water, sanitation, and hygiene) and infection prevention and control to reduce drug-resistant infections, as an integral part of sustainable high-quality health services, particularly in low- and middle-income countries.

Excess Mortality Attributable to Hospital-Acquired Antimicrobial-Resistant Infections: A 2-Year Prospective Surveillance Study in Northeast Thailand.

Background: Quantifying the excess mortality attributable to antimicrobial-resistant (AMR) bacterial infections is important for assessing the potential benefit of preventive interventions and for prioritization of resources. However, there are few data from low- and middle-income countries. Methods: We conducted a 2-year prospective surveillance study to estimate the excess mortality attributable to AMR infections for all types of hospital-acquired infection (HAI), and included bacterial species that were both locally relevant and included in the World Health Organization priority list. Twenty-eight-day mortality was measured. Excess mortality and population attributable fraction (PAF) of mortality caused by AMR infections compared to antimicrobial-susceptible (AMS) infections, adjusted for predefined confounders, were calculated. Results: We enrolled 2043 patients with HAIs. The crude 28-day mortality of patients with AMR and AMS infections was 35.5% (491/1385) and 23.1% (152/658), respectively. After adjusting for prespecified confounders, the estimated excess mortality attributable to AMR infections was 7.7 (95% confidence interval [CI], 2.2-13.2) percentage points. This suggests that 106 (95% CI, 30-182) deaths among 1385 patients with AMR infections might have been prevented if all of the AMR infections in this study were AMS infections. The overall PAF was 16.3% (95% CI, 1.2%-29.1%). Among the bacteria under evaluation, carbapenem-resistant Acinetobacter baumannii was responsible for the largest number of excess deaths. Among all types of infection, urinary tract infections were associated with the highest number of excess deaths, followed by lower respiratory tract infections and bloodstream infections. Conclusions: Estimating and monitoring excess mortality attributable to AMR infections should be included in national action plans to prioritize targets of preventive interventions. Clinical Trials Registration: NCT03411538.

Prevalence and distribution pattern of malaria and soil-transmitted helminth co-endemicity in sub-Saharan Africa, 2000-2018: A geospatial analysis.

BACKGROUND: Limited understanding exists about the interactions between malaria and soil-transmitted helminths (STH), their potential geographical overlap and the factors driving it. This study characterised the geographical and co-clustered distribution patterns of malaria and STH infections among vulnerable populations in sub-Saharan Africa (SSA). METHODOLOGY/PRINCIPAL FINDINGS: We obtained continuous estimates of malaria prevalence from the Malaria Atlas Project (MAP) and STH prevalence surveys from the WHO-driven Expanded Special Project for the Elimination of NTDs (ESPEN) from Jan 1, 2000, to Dec 31, 2018. Although, MAP provides datasets on the estimated prevalence of Plasmodium falciparum at 5km x 5km fine-scale resolution, we calculated the population-weighted prevalence of malaria for each implementation unit to ensure that both malaria and STH datasets were on the same spatial resolution. We incorporated survey data from 5,935 implementation units for STH prevalence and conducted the prevalence point estimates before and after 2003. We used the bivariate local indicator of spatial association (LISA analysis) to explore potential co-clustering of both diseases at the implementation unit levels among children aged 2-10 years for P. falciparum and 5-14 years for STH, living in SSA. Our analysis shows that prior to 2003, a greater number of SSA countries had a high prevalence of co-endemicity with P.falciparium and any STH species than during the period from 2003-2018. Similar prevalence and distribution patterns were observed for the co-endemicity involving P.falciparum-hookworm, P.falciparum-Ascaris lumbricoides and P.falciparum-Trichuris trichiura, before and after 2003. We also observed spatial variations in the estimates of the prevalence of P. falciparum-STH co-endemicity and identified hotspots across many countries in SSA with inter-and intra-country variations. High P. falciparum and high hookworm co-endemicity was more prevalent in West and Central Africa, whereas high P. falciparum with high A. lumbricoides and high P. falciparum with high T. trichiura co-endemicity were more predominant in Central Africa, compared to other sub-regions in SSA. CONCLUSIONS/SIGNIFICANCE: Wide spatial heterogeneity exists in the prevalence of malaria and STH co-endemicity within the regions and within countries in SSA. The geographical overlap and spatial co-existence of malaria and STH could be exploited to achieve effective control and elimination agendas through the integration of the vertical control programmes designed for malaria and STH into a more comprehensive and sustainable community-based paradigm.