Wastewater-based epidemiology as a public health resource in low- and middle-income settings.

In the face of emerging and re-emerging diseases, novel and innovative approaches to population scale surveillance are necessary for the early detection and quantification of pathogens. The last decade has seen the rapid development of wastewater and environmental surveillance (WES) to address public health challenges, which has led to establishment of wastewater-based epidemiology (WBE) approaches being deployed to monitor a range of health hazards. WBE exploits the fact that excretions and secretions from urine, and from the gut are discharged in wastewater, particularly sewage, such that sampling sewage systems provides an early warning system for disease outbreaks by providing an early indication of pathogen circulation. While WBE has been mainly used in locations with networked wastewater systems, here we consider its value for less connected populations typical of lower-income settings, and in assess the opportunity afforded by pit latrines to sample communities and localities. We propose that where populations struggle to access health and diagnostic facilities, and despite several additional challenges, sampling unconnected wastewater systems remains an important means to monitor the health of large populations in a relatively cost-effective manner.

The impact of side effect framing on COVID-19 booster vaccine intentions in an Australian sample.

OBJECTIVE: To evaluate the effect of presenting positively attribute-framed side effect information on COVID-19 booster vaccine intention relative to standard negatively-framed wording and a no-intervention control. DESIGN AND PARTICIPANTS: A representative sample of Australian adults (N = 1204) were randomised to one of six conditions within a factorial design: Framing (Positive; Negative; Control) × Vaccine (Familiar (Pfizer); Unfamiliar (Moderna)). INTERVENTION: Negative Framing involved presenting the likelihood of experiencing side effects (e.g., heart inflammation is very rare, 1 in every 80,000 will be affected), whereas Positive Framing involved presenting the same information but as the likelihood of not experiencing side effects (e.g., 79,999 in every 80,000 will not be affected). PRIMARY OUTCOME: Booster vaccine intention measured pre- and post-intervention. RESULTS: Participants were more familiar with the Pfizer vaccine (t(1203) = 28.63, p <.001, Cohen's dz = 0.83). Positive Framing (M = 75.7, SE = 0.9, 95% CI = [73.9, 77.4]) increased vaccine intention relative to Negative Framing (M = 70.7, SE = 0.9, 95% CI = [68.9, 72.4]) overall (F(1, 1192) = 4.68, p =.031, ηp2 = 0.004). Framing interacted with Vaccine and Baseline Intention (F(2, 1192) = 6.18, p =.002, ηp2 = 0.01). Positive Framing was superior, or at least equal, to Negative Framing and Control at increasing Booster Intention, irrespective of participants' pre-intervention level of intent and vaccine type. Side effect worry and perceived severity mediated the effect of Positive vs. Negative Framing across vaccines. CONCLUSION: Positive framing of side effect information appears superior for increasing vaccine intent relative to the standard negative wording currently used. PRE-REGISTRATION: See: aspredicted.org/LDX_2ZL.

In depth analysis of patients with severe SARS-CoV-2 in sub-Saharan Africa demonstrates distinct clinical and immunological profiles.

Although the COVID-19 pandemic has left no country untouched there has been limited research to understand clinical and immunological responses in African populations. Here we comprehensively characterise patients hospitalised with suspected or confirmed COVID-19, and healthy community controls. PCR-confirmed COVID-19 participants were more likely to receive dexamethasone and a beta-lactam antibiotic, and survive to hospital discharge than PCR-/IgG+ and PCR-/IgG-participants. PCR-/IgG+ participants exhibited a nasal and systemic cytokine signature analogous to PCR-confirmed COVID-19 participants, but increased propensity for Staphylococcus aureus and Streptococcus pneumoniae colonisation. We did not find evidence that HIV co-infection in COVID-19 participants was associated with mortality or altered cytokine responses. The nasal immune signature in PCR-/IgG+ and PCR-confirmed COVID-19 participants was distinct and predominated by chemokines and neutrophils. In addition, PCR-/IgG+ individuals with high COVID-19 clinical suspicion had inflammatory profiles analogous to PCR-confirmed disease and potentially represent a target population for COVID-19 treatment strategies.

Pre-Exposure, But Not Overshadowing, Inhibits Nocebo Hyperalgesia.

Nocebo hyperalgesia is a pervasive problem that significantly adds to the burden of pain. Conditioning is a key mechanism of nocebo hyperalgesia and recent evidence indicates that, once established, nocebo hyperalgesia is resistant to extinction. This means that preventive strategies are critical. We therefore tested whether two novel strategies - overshadowing (Experiment 1) and pre-exposure (Experiment 2) - could inhibit conditioned nocebo hyperalgesia. Overshadowing involves introducing additional cues during conditioning that should compete with and overshadow learning about the target nocebo cue. Pre-exposure involves pre-exposing the target nocebo cue in the absence of pain, which should diminish its ability to become associated with pain later. In both studies, healthy volunteers (N = 141) received exposure to a series of electrocutaneous pain stimuli with and without a sham electrode 'activated', which they were led to believe was a genuine hyperalgesic treatment. Nocebo conditioning was achieved by pairing sham activation with high pain prior to testing at equivalent pain intensity. In both studies, standard nocebo conditioning led to clear nocebo hyperalgesia relative to natural history controls. In Experiment 1, there was no evidence that overshadowing attenuated nocebo hyperalgesia. Importantly, however, Experiment 2 found that pre-exposure successfully attenuated nocebo hyperalgesia with post hoc analysis suggesting that this effect was dose-dependent. These findings provide novel evidence that pre-exposure, but not overshadowing, could be a cheap and effective way for mitigating the substantial harm caused by conditioned nocebo hyperalgesia in clinical settings. PERSPECTIVE: Nocebo hyperalgesia causes substantial patient burden with few preventive options available. Our study found novel evidence that pre-exposing treatment cues without pain, but not overshadowing them with other cues, has the capacity to inhibit conditioned nocebo hyperalgesia. Pre-exposure may therefore be an effective preventive strategy to combat nocebo hyperalgesia.

Prevalence and Treatment of Postpartum Stress Urinary Incontinence: A Systematic Review.

OBJECTIVES: Many women present for treatment of stress urinary incontinence (SUI) after childbirth. This systematic review describes the efficacy of treatment options for SUI initiated during the 12 months after delivery. METHODS: We conducted a systematic review to identify studies comparing treatment options for SUI initiated in the 12 months after parturition. We searched MEDLINE from inception to February 2019, using Medical Subject Heading terms related to pregnancy and urinary incontinence. Preintervention and postintervention populations were compared using analysis of variance with Fisher least significant difference method used to determine efficacy between groups. Grades for Recommendation, Assessment, Development and Evaluation system was used to categorize quality of evidence as high, moderate, low, or very low. RESULTS: We double screened 4548 abstracts, identifying 98 articles for full-text review. Seven studies met the eligibility criteria and were included. Compared with a control group, the 4 interventions identified outperformed the control group (P < 0.001) using Fisher (with effect sizes noted): (1) supervised pelvic floor physical therapy (0.76), (2) electrical stimulation (0.77), (3) home physical therapy (PT) (0.44), and (4) surgery (not applicable). Based on Grades for Recommendation, Assessment, Development and Evaluation assessment, there was moderate evidence to support PT and electrical stimulation, with insufficient evidence for surgery. There were no significant differences in parity, age, or body mass index via analysis of variance. The overall strength of evidence is poor for the treatment of postpartum SUI; more data are needed to fully evaluate other treatment options. CONCLUSIONS: All identified interventions demonstrated greater improvement for postpartum SUI over no treatment. Supervised PT ± electrostimulation was the most effective nonsurgical intervention.

Behind the Mask: An Exploratory Assessment of Female Surgeons' Experiences of Gender Bias.

Though overt sexism is decreasing, women now experience subtle, often unconscious, gender bias as microaggressions. The authors sought to explore the prevalence and impact of the sexist microaggressions female surgeons experience, using a sequential exploratory mixed methods approach (January 2018-April 2018), to identify opportunities for education and prevention. First, all resident, fellow, and attending female surgeons at the University of New Mexico Health Sciences Center (UNM HSC) were invited to participate in focus groups conducted by experienced moderators using a semistructured interview guide based on the 7 Sexist Microaggressions Experiences and Stress Scale (Sexist MESS) domains. Qualitative analysis was performed using line-by-line manual coding to identify themes aligned with the Sexist MESS domains as well as other gender bias experiences of female surgeons. Next, a survey was sent to all resident, fellow, and attending female surgeons at the UNM HSC, which included the Sexist MESS questionnaire and questions related to surgeon-specific experiences of gender bias that the authors developed based on major thematic categories from the focus groups.Four focus groups of 23 female surgeons were conducted, revealing 4 themes: exclusion, increased effort, adaptation, and resilience to workplace slights. The survey response rate was 64% (65/101 surgeons). Across Sexist MESS domains, the frequency and severity of microaggressions was higher for trainees than attendings. The variables of non-White race/ethnicity, having children under 18, and fellowship training generally did not demonstrate statistical significance. This exploratory study adds to the growing body of evidence that gender bias in surgery continues and frequently manifests as microaggressions. Trainees reported the highest rates and severity of microaggressions and bias experiences. Further research should investigate how to address microaggressions, the experiences of male surgeons, the perspectives of medical students and groups who were reported as often perpetuating gender bias, and the efficacy of possible interventions.

The Stress Urinary Incontinence in CrossFit (SUCCeSS) Study.

OBJECTIVE: To evaluate the prevalence and severity of urinary incontinence (UI) in women who participate in CrossFit classes compared with women who participate in non-CrossFit group fitness classes. METHODS: The authors conducted a cross-sectional study of women who participate in either CrossFit or non-CrossFit group fitness classes using an online survey. Participants provided demographic information and completed the Incontinence Severity Index and Urinary Distress Inventory. Participants were recruited from local CrossFit and non-CrossFit gyms, online via social media, and an electronic CrossFit Newsletter. Associated comorbidities, exercises associated with UI, and coping mechanisms for urinary leakage were also assessed. RESULTS: Four hundred twenty-three women meeting inclusion criteria completed the survey, including 322 CrossFit participants and 101 non-CrossFit participants. We found that CrossFit participants were older than non-CrossFit participants and more likely to self-identify as non-Hispanic white. CrossFit participants more commonly reported UI (84% vs 48%, P = <0.001), higher severity of UI (Urinary Distress Inventory score: 20.8 vs 12.5, P < 0.001), and specifically more stress UI (73% vs 47%, P < 0.001). Weightlifting and jumping movements were the most common exercises associated with UI in CrossFit participants. Age and participation in CrossFit are significant and independent predictors of UI. CONCLUSIONS: More than 80% of CrossFit participants reported UI and half of these reported moderate-severe UI, as compared with women who participate in non-CrossFit classes, less than half of whom reported UI with a small minority reporting moderate-severe UI. Exercises most associated with UI were jumping and weightlifting.

Implementing malaria control in South Africa, Eswatini and southern Mozambique during the COVID-19 pandemic.

The COVID-19 pandemic has strained healthcare delivery systems in a number of southern African countries. Despite this, it is imperative that malaria control and elimination activities continue, especially to reduce as far as possible the number and rate of hospitalisations caused by malaria. The implementation of enhanced malaria control/elimination activities in the context of COVID-19 requires measures to protect healthcare workers and the communities they serve. The aim of this review is therefore to present innovative ideas for the timely implementation of malaria control without increasing the risk of COVID-19 to healthcare workers and communities. Specific recommendations for parasite and vector surveillance, diagnosis, case management, mosquito vector control and community outreach and sensitisation are given.

Maintaining focus on administering effective malaria treatment during the COVID-19 pandemic.

As September marks the start of the malaria season in South Africa (SA), it is essential that healthcare professionals consider both COVID- 19 and malaria when a patient who lives in or has recently travelled to a malaria area presents with acute febrile illness. Early diagnosis of malaria by either a rapid diagnostic test or microscopy enables prompt treatment with the effective antimalarial, artemether-lumefantrine, preventing progression to severe disease and death. Intravenous artesunate is the preferred treatment for severe malaria in both children and adults. Adding single low-dose primaquine to standard treatment is recommended in endemic areas to block onward transmission. Use of the highly effective artemisinin-based therapies should be limited to the treatment of confirmed malaria infections, as there is no clinical evidence that these antimalarials can prevent or treat COVID-19. Routine malaria case management services must be sustained, in spite of COVID-19, to treat malaria effectively and support SA's malaria elimination efforts.

Implementing malaria control in South Africa, Eswatini and southern Mozambique during the COVID-19 pandemic

The COVID-19 global pandemic reached South Africa (SA), Mozambique and Eswatini in March 2020.[1] Since then an exponential increase in SARS-CoV-2 infections has severely stretched SA's healthcare system, especially in terms of in-hospital treatment of severe cases. The impact of COVID-19 in Mozambique and Eswatini at the time of writing has been comparatively mild, but is increasing. It is therefore imperative to reduce as far as possible the number and rate of hospitalisations caused by trauma and other diseases, including malaria. Malaria incidence in SA is seasonal and peaks in the wetter summer months, especially during January to April.[2] Although malaria incidence in SA is currently low, the risk of outbreaks is always present, with the most recent having occurred in 2017 and, at a more localised level in Limpopo Province, in 2019. The reasons for these latest outbreaks are varied and include unusually high rainfall and cross-border movement of migrant populations, fuelling local transmission. These issues are particularly pertinent to COVID-19 in SA's malaria-affected districts. They highlight the importance of mitigating factors contributing to high malaria incidence and consequent hospitalisations, which may be further exacerbated by COVID-19/malaria coinfections and the re-opening of SA's borders with those neighbouring countries with higher malaria transmission intensities.

Retrospective evaluation of prazosin and diazepam after thoracolumbar hemilaminectomy in dogs.

Management of urinary retention after spinal cord injury in dogs is often needed and can include use of medications to relax the urethral sphincter. This was a retrospective study evaluating two such medications, prazosin and diazepam, and whether dogs treated with these medications had different lengths of hospitalization, urinary continence levels, or development of bacteriuria compared to dogs not receiving these medications after thoracolumbar hemilaminectomy for intervertebral disc herniation (IVDH). Electronic medical records were searched for dogs that underwent CT or MRI followed by a hemilaminectomy between the 3rd thoracic and 3rd lumbar vertebra for treatment of IVDH. Dogs were grouped based on whether or not they received a medication to aid in urethral sphincter relaxation (either prazosin, diazepam, or both medications). The total length of hospitalization, urinary continence at the time of discharge, and presence of bacteriuria were recorded from the medical file. Medical records from 71 dogs were included in the analysis. There were no significant associations between administration of prazosin and/or diazepam and length of hospitalization or urinary continence scores at the time of discharge from the hospital (P > 0.05).

Gender Bias Experiences of Female Surgical Trainees.

OBJECTIVE: Medical schools now average approximately 50% female students, yet a disproportionate number of women continue to choose nonsurgical over surgical specialties. Once in training, studies indicate that pervasive gender stereotypes, sexism and harassment negatively affect female surgeons. The aim of this study is to describe female surgeons' experiences with gender bias and microaggressions in the workplace during residency and fellowship training, and understand if differences exist in the experiences of trainees in male-dominant vs female-dominant surgical specialties. DESIGN: A mixed methods approach was used to explore the experiences of female surgical trainees. Participants were recruited from all surgical disciplines at an academic center. Initially, focus groups were used to explore themes that trainees face related to gender bias. A trained moderator conducted all focus groups, which were audio recorded and transcribed. Qualitative analysis of de-identified transcripts was performed to identify emerging themes. We then created an online survey using the validated 44-question Sexist Microaggression Experiences and Stress Scale to assess frequency and psychologic impact of these events with additional questions developed from the focus groups. The survey was sent to all female residents and fellows at one academic institution. SETTING: University of New Mexico Hospital, a tertiary care academic medical center. PARTICIPANTS: Fifteen female surgical trainees participated in focus groups. Thirty-three female surgical trainees participated in the online survey. RESULTS: Two focus groups including 15 female trainees were conducted, revealing 4 themes: Exclusion, Adaptation, Increased effort, and Development of Resilience Strategies. All participants had experienced gender bias or discrimination during medical school or surgical training. The quantitative survey had a 66% response rate (33/50 female trainees). Significant differences were found in the experience of female trainees in male-dominant vs female-dominant specialties, with those in male-dominant fields often reporting more frequent, severe, and stressful microaggression experiences. When describing how gender bias would affect their future in medicine, trainees in male-dominant specialties were more likely to report that due to gender bias, they "may leave medicine/retire early" (33% vs 6%, p = 0.040) and that they "would not recommend my profession to trainees or family members" (40% vs 6%, p = 0.015)." CONCLUSIONS: Female surgical trainees continue to experience gender bias. A culture of sexism leads to physical and social adaptations to fit into the role of surgeon. Participants expressed significant effort to sustain this level of adaptation, leading to fatigue and creation of resilience mechanisms. The environment in which a trainee operates (male-dominant vs female-dominant) significantly impacts their experience. Those experiencing more bias were less likely to recommend their specialty and reported plans to leave medicine earlier. Culture change across institutions and system-level interventions are necessary to create meaningful and sustainable change that improves the experience of female surgical trainees.

Deceptive but not open label placebos attenuate motion-induced nausea.

OBJECTIVE: Nausea is a common complaint, known to respond to the placebo effect. Existing research has employed deception when administering placebos for nausea, limiting therapeutic translation on ethical grounds. We therefore examined the potential of non-deceptive open-label placebos (OLPs) to reduce nausea. METHODS: Galvanic Vestibular Stimulation (GVS) and Virtual Reality (VR) were employed to model nausea in healthy volunteers across two experiments. In both experiments nausea was elicited with and without sham treatment (peppermint vapor and brain stimulation, respectively). In Exp. 1, participants (n = 61) were randomized to deceptive placebo, semi-open placebo, fully-open placebo, or control. In Exp. 2, participants (n = 93) were randomized to deceptive placebo, semi-open placebo, or control. RESULTS: Exp. 1 found limited evidence for a placebo effect (F(1, 56) = 1.15, p = .29, ηp2 =0.02), even following deceptive treatment (F(1, 56) = 1.92, p = .17, ηp2=0.03). In Exp. 2, deceptive placebo reduced nausea relative to control (F(1, 89) = 6.91, p = .010, ηp2=0.07) and OLP (F(1, 89) = 5.47, p = .022, ηp2=0.06). Pooled Bayesian analysis across experiments provided strong evidence that deceptive placebos reduce nausea relative to control (BF10 = 30.91) and anecdotal evidence for the benefit of deceptive treatment over non-deceptive (BF10 = 2.46) and no benefit of OLP over control (BF10 = 0.63). CONCLUSIONS: No positive evidence for OLP effects in nausea were observed. However, a deceptive effect in VR was observed. These findings raise questions regarding the efficacy of open-label intervention in nausea.

Use of cancellous bone grafting to promote granulation tissue in a distal limb wound in a dog.

A 5-year-old female spayed Shetland sheepdog presented for evaluation of bandage sores on the left pelvic limb after a splint was placed to stabilise a digit fracture incurred approximately 2 weeks previously. Multiple areas of necrosis were identified upon bandage removal. After debridement of devitalised tissue, a 4 cm wound on the plantar surface of the metatarsal bones (with exposed bone and tendons) remained. The Papineau technique (which involves removal of infected or necrotic tissue, placement of autogenous cancellous bone graft within a wound, and delayed skin closure) was used to treat this wound. Use of bone graft in this manner aims to promote early granulation tissue formation and reduce the time until wound reconstruction can be performed. Autogenous cancellous bone graft was harvested from the proximal humerus and placed within the metatarsal wound. Once a healthy granulation tissue bed was noted to cover the bone graft, a meshed full thickness skin graft was placed. To our knowledge, this is the first report of the Papineau technique being used for this purpose in a dog.

Complex interactions between malaria and malnutrition: a systematic literature review.

BACKGROUND: Despite substantial improvement in the control of malaria and decreased prevalence of malnutrition over the past two decades, both conditions remain heavy burdens that cause hundreds of thousands of deaths in children in resource-poor countries every year. Better understanding of the complex interactions between malaria and malnutrition is crucial for optimally targeting interventions where both conditions co-exist. This systematic review aimed to assess the evidence of the interplay between malaria and malnutrition. METHODS: Database searches were conducted in PubMed, Global Health and Cochrane Libraries and articles published in English, French or Spanish between Jan 1980 and Feb 2018 were accessed and screened. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias across studies was assessed using the GRADE approach. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline were followed. RESULTS: Of 2945 articles screened from databases, a total of 33 articles were identified looking at the association between malnutrition and risk of malaria and/or the impact of malnutrition in antimalarial treatment efficacy. Large methodological heterogeneity of studies precluded conducting meaningful aggregated data meta-analysis. Divergent results were reported on the effect of malnutrition on malaria risk. While no consistent association between risk of malaria and acute malnutrition was found, chronic malnutrition was relatively consistently associated with severity of malaria such as high-density parasitemia and anaemia. Furthermore, there is little information on the effect of malnutrition on therapeutic responses to artemisinin combination therapies (ACTs) and their pharmacokinetic properties in malnourished children in published literature. CONCLUSIONS: The evidence on the effect of malnutrition on malaria risk remains inconclusive. Further analyses using individual patient data could provide an important opportunity to better understand the variability observed in publications by standardising both malaria and nutritional metrics. Our findings highlight the need to improve our understanding of the pharmacodynamics and pharmacokinetics of ACTs in malnourished children. Further clarification on malaria-malnutrition interactions would also serve as a basis for designing future trials and provide an opportunity to optimise antimalarial treatment for this large, vulnerable and neglected population. TRIAL REGISTRATION: PROSPERO CRD42017056934 .

Resident and Program Director's Perceptions of Milestone-Based Feedback in Obstetrics and Gynecology.

INTRODUCTION: In July 2014, US residency programs fully implemented the Next Accreditation System including the use of milestone evaluation and reporting. Currently, there has been little investigation into the result of implementation of this new system. Therefore, this study sought to evaluate perceptions of Obstetrics and Gynecology residents and program directors regarding the use of milestone-based feedback and identify areas of deficiency. METHODS: A Web-based survey was sent to US-based Obstetrics and Gynecology residents and program directors regarding milestone-based assessment implementation. RESULTS: Out of 245 program directors, 84 responded to our survey (34.3% response rate). Of responding program directors, most reported that milestone-based feedback was useful (74.7%), fair (83.0%), and accurate (76.5%); however, they found it administratively burdensome (78.1%). Residents felt that milestone-based feedback was useful (62.7%) and fair (70.0%). About 64.3% of residents and 74.7% of program directors stated that milestone-based feedback is an effective tool to track resident progression; however, a sizable minority of both groups believe that it does not capture surgical aptitude. Qualitative analysis of free response comments was largely negative and highlighted the administrative burden and lack of accuracy of milestone-based feedback. CONCLUTION: Overall, both Obstetrics and Gynecology program directors and residents report that milestone-based feedback is useful and fair. Issues of administrative burden, timeliness, evaluation of surgical aptitude, and ability to act on assigned milestone levels were identified. Although this study is limited to one specialty, such issues are likely important to all residents, faculty, and program directors who have implemented the Next Accreditation System requirements.

Quality of development and reporting of dietetic intervention studies in primary care: a systematic review of randomised controlled trials.

BACKGROUND: High-quality research methodologies and clear reporting of studies are essential to facilitate confidence in research findings. The aim of the present study was to conduct an in-depth examination of the methodological quality and reporting of studies included in a recent systematic review of dietitians' effectiveness at providing individualised nutrition care to adult patients. METHODS: The methodological quality and reporting of 27 Randomised Controlled Trials (RCTs) were appraised using the UK Medical Research Council (MRC) Guidelines for complex interventions and the CONSORT checklist for reporting RCTs. A quality appraisal checklist was developed for each guideline/assessment tool aiming to evaluate the extent to which each study met the designated criteria. Excerpts from studies that best addressed criteria were collated to provide exemplary accounts of how criteria may be achieved in future studies. RESULTS: None of the reviewed studies met more than half of the MRC Guidance criteria, indicating that there is clear room for improvement in reporting the methodological underpinnings of these studies. Similarly, no studies met all criteria of the CONSORT checklist, suggesting that there is also room for improvement in the design and reporting of studies in this field. CONCLUSIONS: Dietitians, researchers and journal editors are encouraged to use the results and exemplary accounts from this review to identify key aspects of studies that could be improved in future research. Improving future research will enhance the quality of the evidence-base that investigates the outcomes of dietary interventions involving dietitians.

Pharmacokinetics of Sulfadoxine and Pyrimethamine for Intermittent Preventive Treatment of Malaria During Pregnancy and After Delivery.

Sulfadoxine/pyrimethamine is recommended for intermittent preventative treatment of malaria during pregnancy. Data from 98 women during pregnancy and 77 after delivery in four African countries were analyzed using nonlinear mixed-effects modeling to characterize the effects of pregnancy, postpartum duration, and other covariates such as body weight and hematocrit on sulfadoxine/pyrimethamine pharmacokinetic properties. During pregnancy, clearance increased 3-fold for sulfadoxine but decreased by 18% for pyrimethamine. Postpartum sulfadoxine clearance decreased gradually over 13 weeks. This finding, together with hematocrit-based scaling of plasma to whole-blood concentrations and allometric scaling of pharmacokinetics parameters with body weight, enabled site-specific differences in the pharmacokinetic profiles to be reduced significantly but not eliminated. Further research is necessary to explain residual site-specific differences and elucidate whether dose-optimization, to address the 3-fold increase in clearance of sulfadoxine in pregnant women, is necessary, viable, and safe with the current fixed dose combination of sulfadoxine/pyrimethamine.