Risky sexual behavior and associated factors among reproductive age women in eastern African countries: a multilevel analysis of the recent demographic and health survey.

INTRODUCTION: Risky sexual behavior exposes an individual to the risk of contracting sexually transmitted infections including human immunodeficiency virus (HIV). Even though risky sexual behavior is a devastating problem in low- and middle-income countries, studies on risky sexual behavior and associated factors among reproductive-age women in Eastern African countries are limited. Therefore, this study aimed to assess the magnitude of risky sexual behavior and associated factors among reproductive-age women in Eastern African countries that help to target high-risk groups and set appropriate intervention. METHOD: The appended and recent Demographic and Health Survey dataset of 10 Eastern African countries from 2012 to 2022 was used for data analysis. A total of 111,895 participants were included in this study as a weighted sample. Associated factors were determined using a multilevel mixed-effects logistic regression model. Significant factors in the multilevel mixed-effect logistic regression model were declared significant at p-values < 0.05. The adjusted odds ratio (AOR) and confidence interval (CI) were used to interpret the results. RESULT: The overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was 28.16% (95% CI 27.90%, 28.43%), which ranged from 3.80% in Ethiopia to 67.13% in Kenya. In the multivariable analysis, being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, drinking alcohol, and being an urban dweller were factors that were significantly associated with higher odds of risky sexual behavior. CONCLUSION: The overall magnitude of risky sexual behavior among reproductive-age women in Eastern African countries was high. Individual-level (being a younger woman, being an educated woman, being tested for human immunodeficiency virus, having work, and drinking alcohol) and community-level (being an urban dweller) variables were associated with higher odds of risky sexual behavior. Therefore, policymakers and other stakeholders should give special consideration to urban dwellers, educated, worker and younger women. Better to improve the healthy behavior of women by minimizing alcohol consumption and strengthening HIV testing and counseling services to reduce the magnitude of risky sexual behavior.

Violence Against Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review.

Women who sell sex (WSS) are vulnerable to violence. We present a scoping review of the last decade of research on the prevalence and incidence of, factors associated with, and services regarding violence against WSS in Eastern and Southern African (ESA). A systematic search of various databases resulted in 20 papers being reviewed. Inclusion criteria, applied by the first two authors, were as follows: empirical papers, key research problem is violence against WSS, and conducted in ESA countries. The lifetime prevalence of violence revealed in the studies ranged from 21% to 82%. A pattern of generalized violence against WSS from paying clients, male partners, strangers, family members, friends/acquaintances, and the authorities emerged. Factors associated with violence included the context within which the sex work occurs, alcohol use, type of sex exchange interactions, and personal factors (low education, low income, marriage, youth, high client volume, time in sex work, forced sexual debut, and internalized sex work stigma). WSS seldom access services after violence. Evaluations of two programs, a woman-focused HIV intervention, and the Diagonal Interventions to Fast-Forward Reproductive Health project, showed improvements in gender-based violence services. Findings suggest that targeted programmes should be paired with improving general health services and focus on promoting collective agency among WSS.

Public health priorities for Sino-Africa cooperation in Eastern Africa in context of flooding and malaria burden in Children: a tridecadal retrospective analysis.

BACKGROUND: Malaria remains a major public health burden to children under five, especially in Eastern Africa (E.A), -a region that is also witnessing the increasing occurrence of floods and extreme climate change. The present study, therefore, explored the trends in floods, as well as the association of their occurrence and duration with the malaria incidence in children < 5 years in five E.A partner countries of Forum for China-Africa Cooperation (FOCAC), including Ethiopia, Kenya, Somalia, Sudan, and Tanzania between 1990 and 2019. METHODS: A retrospective analysis of data retrieved from two global sources was performed: the Emergency Events Database (EM-DAT) and the Global Burden of Diseases Study (GBD) between 1990 and 2019. Using SPSS 20.0, a correlation was determined based on ρ= -1 to + 1, as well as the statistical significance of P = < 0.05. Time plots of trends in flooding and malaria incidence were generated in 3 different decades using R version 4.0. RESULTS: Between 1990 and 2019, the occurrence and duration of floods among the five E.A partner countries of FOCAC increased and showed an upward trend. On the contrary, however, this had an inverse and negative, as well as a weak correlation on the malaria incidence in children under five years. Only Kenya, among the five countries, showed a perfect negative correction of malaria incidence in children under five with flood occurrence (ρ = -0.586**, P-value = 0.001) and duration (ρ = -0.657**, P-value = < 0.0001). CONCLUSIONS: This study highlights the need for further research to comprehensively explore how different climate extreme events, which oftentimes complement floods, might be influencing the risk of malaria in children under five in five E.A malaria-endemic partner countries of FOCAC. Similarly, it ought to consider investigating the influence of other attributes apart from flood occurrence and duration, which also compound floods like displacement, malnutrition, and water, sanitation and hygiene on the risk and distribution of malaria and other climate-sensitive diseases.

Sustainable access of quality seeds of genetically engineered crops in Eastern Africa - Case study of Bt Cotton.

The genetically engineered bollworm-resistant Bt cotton hybrid varieties offer opportunities for reducing crop losses and enhancing productivity. In Eastern Africa region, Sudan, Ethiopia, and Kenya have approved and released Bt cotton in 2012, in 2018, and in 2019, respectively. The region has potential to grow cotton in over 5 million hectares. For commercial plantings in Ethiopia, Sudan and Kenya, hybrid Bt cotton seeds have been imported from India. Due to the COVID-19 pandemic-induced supply chain disruptions, high shipment costs, bureaucratic procedures for importing seeds, and foreign exchange shortages, farmers have not been able to access Bt cotton seeds. Stakeholders are seeking local production of seeds to provide sustainable access by farmers at affordable cost. Country case studies reveal the importance of enhancing capacity for local seed production and extension advisory services. Revival of the cotton sector needs enhanced public-private partnerships to pave the way for sustainable seeds access in the region.

Molecular epidemiology of Bartonella quintana endocarditis in patients from Israel and Eastern Africa.

BACKGROUND: Bartonella quintana is an important cause of culture-negative endocarditis. Although humans have been considered as its only reservoir, recent studies showed that macaque species are also reservoirs of B. quintana. Based on multi-locus sequence typing (MLST) B. quintana strains have been classified into 22 sequence types (STs), with 7 STs exclusively found in humans. Data regarding the molecular epidemiology of B. quintana endocarditis is limited to only 3 STs identified in 4 patients from Europe and Australia. We studied B. quintana endocarditis acquired in Eastern Africa or Israel to investigate the genetic diversity and clinical relatedness of B. quintana from distinct geographic regions. METHODS: Eleven patients with B. quintana endocarditis, 6 from Eastern Africa and 5 from Israel, were studied. DNA was extracted from cardiac tissue or blood specimens and analyzed by MLST based on 9 genetic loci. An evolutionary relationship between STs was visualized by a minimum spanning tree. A phylogenetic tree was constructed with the concatenated sequences (4271 bp) of the 9 loci using the maximum-likelihood method. RESULTS: Six strains were classified into previously described STs while 5 strains were identified for the first time and classified into new STs 23-27 which clustered with the previously reported STs 1-7 from human strains found in Australia, France, Germany, the USA, Russia, and the former Yugoslavia, without indication of geographical structuring. ST2 was the most prevalent ST, found in 5 of 15 patients with endocarditis (33.3%). ST26 appears to be a primary founder of the human lineage. CONCLUSIONS: The new and previously reported human STs form a single human lineage, clearly separated from the other 3 B. quintana lineages of cynomolgus, rhesus, and Japanese macaques. From evolutionary perspectives, these findings support the assumption that B. quintana has co-evolved with host species to form a host-speciation pattern. ST26 is suggested herein as a primary founder of the human lineage and may be key to explore where B. quintana had first originated; ST2 is a dominant genetic type associated with B. quintana endocarditis. To confirm these findings, additional worldwide molecular epidemiological studies are required.

Cystic echinococcosis in donkeys in eastern Africa.

Cystic echinococcosis (CE) is endemic in humans and domestic animals in eastern Africa. All the species of the Echinococcus granulosus sensu lato complex have been reported in this region except for E. equinus, possibly due to the small number of studies involving equids. This study reports the frequency of different Echinococcus species in donkeys from eastern Africa. A total of 5961 donkeys were examined during meat inspection in 3 slaughterhouses in Kenya. Identification of Echinococcus spp. was achieved through polymerase chain reaction-restriction fragment-length polymorphism and sequencing of the mitochondrial nicotinamide adenine dinucleotide (NADH) dehydrogenase subunit 1 gene. The prevalence of CE was 5.7% (337/5961). The 263 genotyped cysts belonged to E. equinus (n = 163), E. granulosus sensu stricto (n = 70), E. canadensis (G6/7) (n = 26) and E. ortleppi (n = 4). One donkey harboured a metacestode of Spirometra theileri. All E. equinus cases, except 2, originated from southern Ethiopia, whereas the other species were more evenly distributed across the study area. Most of the cysts belonging to E. equinus were fertile (111/163), while those of the other species were non-fertile. This is the first report of Echinococcus spp. in donkeys from sub-Saharan Africa and the first confirmation of E. equinus in East Africa. The frequent fertility of E. equinus cysts in donkeys affirms their suitability as intermediate hosts of this species, while low frequency and cyst fertility suggest a marginal role of donkeys in the transmission of E. granulosus s. s., E. canadensis (G6/7) and E. ortleppi.

Stigma of infidelity associated with condom use explains low rates of condom uptake: qualitative data from Uganda and Tanzania.

Despite widespread messaging supporting male (external) condom use to prevent HIV in endemic settings, utilization of condoms is low across sub-Saharan Africa. A thorough understanding of barriers to condom use as a form of HIV prevention is necessary to reduce HIV transmission. Here, we present qualitative data from rural eastern Africa to explain low utilization of condoms among heterosexual adults. Focus groups and interviews were conducted in Tanzania and Uganda between 2016 and 2019. A content analysis approach was used to identify attitudes about condoms and factors related to use/non-use. We found that strategies such as abstinence and being faithful to one's partner are perceived as ideal but rarely achievable methods of HIV prevention. Condoms are used in the setting of "failure" to abstain or be faithful and are therefore stigmatized as markers of infidelity. As such, use within cohabiting and long-term relationships is low. Our data suggest that negative perceptions of condoms may stem from persistent effects of the formerly applied "ABC" HIV prevention approach, a public health messaging strategy that described A-abstinence, B-be faithful, and C-use a condom as tiered prevention tools. Condom uptake could increase if HIV prevention messaging acknowledges existing stigma and reframes condom use for proactive health prevention. These studies were approved by Weill Cornell Medicine (Protocols 1803019105 and 1604017171), Mbarara University of Science and Technology (Protocol 16/0117), Uganda National Council of Science and Technology (Protocol SS-4338), and the Tanzania National Institute for Medical Research (Protocol NIMR/HQ/R.8c/Vol.I/1330).

Condoms are used to prevent HIV infection. Even though public health organizations have encouraged people to use condoms, many people in sub-Saharan Africa do not, especially in sexual encounters with someone that they are living with or married to. In this study, we wanted to understand the reasons that people were not using condoms. Between 2016 and 2019, we spoke with individuals in Uganda in one-on-one interviews about HIV prevention and testing and with focus groups in Tanzania about family planning. We analyzed transcripts of these conversations to find common themes about people's impressions of condom use. We learned that many of our participants believed that abstaining from sex and being faithful were the best ways to prevent HIV infection, but that they were not realistic strategies in the long term. Condoms were thought of as a useful tool for prevention when you "fail" at abstinence and monogamy. They were linked with being unfaithful, so people did not feel comfortable suggesting their use in committed relationships. These findings show that the "ABC" strategy for HIV prevention education may be continuing to make people think negatively about condom use. This strategy presented a tiered approach to HIV prevention, telling people it was best to (A) abstain, (B) be faithful to one's partners, and (C) use a condom. In order to increase engagement with HIV prevention, public health messages need to acknowledge the negative associations between condoms and infidelity.

Paromomycin and Miltefosine Combination as an Alternative to Treat Patients With Visceral Leishmaniasis in Eastern Africa: A Randomized, Controlled, Multicountry Trial.

BACKGROUND: This study aimed to determine whether paromomycin plus miltefosine (PM/MF) is noninferior to sodium stibogluconate plus paromomycin (SSG/PM) for treatment of primary visceral leishmaniasis in eastern Africa. METHODS: An open-label, phase 3, randomized, controlled trial was conducted in adult and pediatric patients at 7 sites in eastern Africa. Patients were randomly assigned to either 20 mg/kg paromomycin plus allometric dose of miltefosine (14 days), or 20 mg/kg sodium stibogluconate plus 15 mg/kg paromomycin (17 days). The primary endpoint was definitive cure after 6 months. RESULTS: Of 439 randomized patients, 424 completed the trial. Definitive cure at 6 months was 91.2% (155 of 170) and 91.8% (156 of 170) in the PM/MF and SSG/PM arms in primary efficacy modified intention-to-treat analysis (difference, 0.6%; 97.5% confidence interval [CI], -6.2 to 7.4), narrowly missing the noninferiority margin of 7%. In the per-protocol analysis, efficacy was 92% (149 of 162) and 91.7% (155 of 169) in the PM/MF and SSG/PM arms (difference, -0.3%; 97.5% CI, -7.0 to 6.5), demonstrating noninferiority. Treatments were well tolerated. Four of 18 serious adverse events were study drug-related, and 1 death was SSG-related. Allometric dosing ensured similar MF exposure in children (<12 years) and adults. CONCLUSIONS: PM/MF and SSG/PM efficacies were similar, and adverse drug reactions were as expected given the drugs safety profiles. With 1 less injection each day, reduced treatment duration, and no risk of SSG-associated life-threatening cardiotoxicity, PM/MF is a more patient-friendly alternative for children and adults with primary visceral leishmaniasis in eastern Africa. CLINICAL TRIALS REGISTRATION: NCT03129646.

The associations between women's empowerment measures, child growth and dietary diversity: Findings from an analysis of demographic and health surveys of seven countries in Eastern Africa.

Evidence on the efficacy of women's empowerment to improve child growth and minimum dietary diversity (MDD) in the Eastern Africa (EA) region is limited. This cross-sectional study used recent Demographic and Health Survey data of mother-child dyads from seven countries in EA to examine the associations between women's empowerment measures, child growth and MDD. Length-for-age z-scores, weight-for-length z-scores and weight-for-age z-scores were used to categorize growth indicators of 6-23 months old children. Multivariable logistic regression was used to identify significant associations. Among all countries, 32%-59% of children experienced growth failure. Children meeting MDD were 18%-45%. Women having self-esteem were associated with lower odds of stunting (adjusted odds ratio [AOR] = 0.62 in Rwanda), wasting (AOR = 0.38 in Uganda), underweight (AORs = 0.60 and 0.57 in Tanzania and Uganda, respectively) and growth failure (AOR = 0.64 in Rwanda). Having health decision control in Burundi was associated with lower odds of stunting (AOR = 0.49) and child growth failure (AOR = 0.52) and higher odds of meeting MDD (AOR = 2.50). Having Legal empowerment among women increased the odds of stunting (AOR = 1.79 in Burundi), underweight (AOR = 1.77 in Uganda) and growth failure (AOR = 1.87 in Burundi). Economic empowerment showed mixed associations with child growth and MDD among some countries. Women's self-esteem and health decision control were associated with better child growth and MDD for some countries in EA. Nutrition-sensitive interventions aimed at improving child growth and MDD should consider local contexts when addressing women's empowerment.

Genetic diversity of Diaphorina citri (Hemiptera: Liviidae) unravels phylogeographic structure and invasion history of eastern African populations.

The Asian citrus psyllid (Diaphorina citri Kuwayama) is a key pest of Citrus sp. worldwide, as it acts as a vector for Candidatus Liberibacter asiaticus, the bacterial pathogen that causes citrus Huanglongbing. Diaphorina citri has been reported in Kenya, Tanzania, and more recently in Ethiopia. This study assessed the genetic diversity and phylogeographic structure of the pest to gain insights into the potential sources of its introduction into Africa. Population structure and differentiation of D. citri populations from China, Ethiopia, Kenya, Tanzania, and the USA were assessed using 10 microsatellite loci. Additionally, five new complete mitogenomes of D. citri collected in China, Ethiopia, Kenya, Tanzania, and the USA were analyzed in the context of publicly available sequences. Genotype data grouped the D. citri populations from Kenya and Tanzania in one cluster, and those from Ethiopia formed a separate cluster. The two genetic clusters inferred from genotype data were congruent with mitochondrial sequence data. The mitogenomes from Kenya/Tanzania/China had 99.0% similarity, and the Ethiopia/USA had 99.9% similarity. In conclusion, D. citri populations in eastern Africa have different sources, as the Kenyan and Tanzanian populations probably originated from southeastern Asia, while the Ethiopian population most probably originated from the Americas.

"I was still very young": agency, stigma and HIV care strategies at school, baseline results of a qualitative study among youth in rural Kenya and Uganda.

INTRODUCTION: Adolescents and young adults living with HIV (AYAH) have the lowest rates of retention in HIV care and antiretroviral therapy (ART) adherence, partly due to the demands of school associated with this life stage, to HIV-related stigma and to fears of serostatus disclosure. We explore the implications of school-based stigma and disclosure on the development of agency during a critical life stage in rural Kenya and Uganda. METHODS: We conducted a qualitative study in the baseline year of the SEARCH Youth study, a combination intervention using a life-stage approach among youth (15-24 years old) living with HIV in western Kenya and southwestern Uganda to improve viral load suppression and health outcomes. We conducted in-depth, semi-structured interviews in 2019 with three cohorts of purposively selected study participants (youth [n = 83], balanced for sex, life stage and HIV care status; recommended family members of youth [n = 33]; and providers [n = 20]). Inductive analysis exploring contextual factors affecting HIV care engagement revealed the high salience of schooling environments. RESULTS: Stigma within school settings, elicited by non-consensual serostatus disclosure, medication schedules and clinic appointments, exerts a constraining factor around which AYAH must navigate to identify and pursue opportunities available to them as young people. HIV status can affect cross-generational support and cohort formation, as AYAH differ from non-AYAH peers because of care-related demands affecting schooling, exams and graduation. However, adolescents demonstrate a capacity to overcome anticipated stigma and protect themselves by selectively disclosing HIV status to trusted peers and caregivers, as they develop a sense of agency concomitant with this life stage. Older adolescents showed greater ability to seek out supportive relationships than younger ones who relied on adult caregivers to facilitate this support. CONCLUSIONS: School is a potential site of HIV stigma and also a setting for learning how to resist such stigma. School-going adolescents should be supported to identify helpful peers and selectively disclose serostatus as they master decision making about when and where to take medications, and who should know. Stigma is avoided by fewer visits to the clinic; providers should consider longer refills, discreet packaging and long-acting, injectable ART for students.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion.

Objectives: There is a need to hone reproductive health (RH) services for women who sell sex (WSS). The aim of this review was to collate findings on non-barrier contraception, pregnancies, and abortion amongst WSS in Eastern and Southern African (ESA). Methods: A scoping review methodology was employed. Inclusion criteria were: 1) empirical papers from 2) ESA, 3) published since 2010, and 4) addressing WSS in relation to 5) the identified RH issues. Results: Reports of rates of non-barrier contraceptive usage varied from 15% to 76%, of unintended pregnancy from 24% to 91%, and of abortion from 11% to 48%. Cross-cutting factors were alcohol use, violence, health systems problems, and socio-economic issues. Pregnancy desire was associated with having a non-paying partner. Barriers to accessing, and delaying, antenatal care were reported as common. Targeted programmes were reported as promoting RH amongst WSS. Conclusion: Programmes should be contextually relevant, based on local patterns, individual, interpersonal and systemic barriers. Targeted approaches should be implemented in conjunction with improvement of public health services. Linked HIV and RH services, and community empowerment approaches are recommended.

Birth prevalence of neural tube defects in eastern Africa: a systematic review and meta-analysis.

BACKGROUND: Neural tube defects (NTDs) are associated with high rates of neonatal mortality and morbidity worldwide. The promotion of folic acid fortification and supplementation in pregnant women by the Food and Drug Administration significantly decreased the incidence of NTDs in the United States. This practice is not widely adopted in Eastern Africa countries. We hypothesized that these countries experience a higher burden of NTDs than countries that promote the use of folic acid. We aimed to estimate the birth prevalence of NTDs in the United Nations (UN) Eastern African region. METHODS: PubMed (Medline), Embase, and Cochrane Library databases were systematically searched from inception to December 17, 2021. We included randomized controlled trials or observational studies that reported the prevalence estimates of NTDs in Eastern Africa. Random effects model was used to pool the effect estimates. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess the certainty of the evidence. Outcome measures were overall and specific (spina bifida, anencephaly, encephalocele) rates of NTDs per 10,000 births, including live and stillborn cases. RESULTS: The meta-analysis included 20 studies consisting of 752,936 individuals. The pooled prevalence of all NTDs per 10,000 births in Eastern Africa was 33.30 (95% CI: 21.58 to 51.34). Between-study heterogeneity was high (I2 = 97%, p < 0.0001), The rate was highest in Ethiopia (60 per 10,000). Birth prevalence of spina bifida (20 per 10,000) was higher than anencephaly (9 per 10,000) and encephalocele (2.33 per 10,000). No studies on NTDs were identified in 70% of the UN Eastern Africa region. Birth prevalence increased by 4% per year from 1983 to 2018. The level of evidence as qualified with GRADE was moderate. CONCLUSION: The birth prevalence of NTDs in the United Nations region of Eastern Africa is 5 times as high as observed in Western countries with mandatory folic acid supplementation in place. Therefore, mandatory folic acid supplementation of stable foods may decrease the risk of NTDs in Eastern Africa.

Prevalence and factors associated with caesarean section in Rwanda: a trend analysis of Rwanda demographic and health survey 2000 to 2019-20.

BACKGROUND: Caesarean section (CS) is an important medical intervention for reducing the risk of poor perinatal outcomes. However, CS trends in sub-Saharan Africa (SSA) continue to increase yet maternal and neonatal mortality and morbidity remain high. Rwanda, like many other countries in SSA, has shown an increasing trend in the use of CS. This study assessed the trends and factors associated with CS delivery in Rwanda over the past two decades. METHODS: We used nationally representative child datasets from the Rwanda Demographic and Health Survey 2000 to 2019-20. All births in the preceding 3 years to the survey were assessed for the mode of delivery. The participants' characteristics, trends and the prevalence of CS were analysed using frequencies and percentages. Unadjusted and adjusted logistic regression analyses were used to assess the factors associated with population and hospital-based CS in Rwanda for each of the surveys. RESULTS: The population-based rate of CS in Rwanda significantly increased from 2.2% (95% CI 1.8-2.6) in 2000 to 15.6% (95% CI 13.9-16.5) in 2019-20. Despite increasing in all health facilities over time, the rate of CS was about four times higher in private (60.6%) compared to public health facilities (15.4%) in 2019-20. The rates and odds of CS were disproportionately high among women of high socioeconomic groups, those who resided in Kigali city, had multiple pregnancies, and attended at least four antenatal care visits while the odds of CS were significantly lower among multiparous women and those who had female babies. CONCLUSION: Over the past two decades, the rate of CS use in Rwanda increased significantly at health facility and population level with high regional and socio-economic disparities. There is a need to examine the disparities in CS trends and developing tailored policy guidelines to ensure proper use of CS in Rwanda.

A nonanalog Pliocene ungulate community at Laetoli with implications for the paleoecology of Australopithecus afarensis.

The dietary guild structure of ungulate communities is a useful paleoecological tool for understanding the context of hominin paleobiology and evolution. Ungulates are well represented in the fossil record, and their dietary preferences reflect those of major habitat types. However, paleoecology relies on modern ecological patterns as analogs for recreating ecologies of the past. It has previously been suggested that for much of the Pliocene, no such modern analogs exist for the herbivore communities associated with hominins in eastern Africa. This study aims to determine whether the ungulate community associated with A. afarensis at the Pliocene site of Laetoli, Tanzania, shares similarities with extant communities or whether it lacks a modern analog. Our multiproxy approach using mesowear, hypsodonty, and stable carbon isotopes of tooth enamel to infer the diets of ungulates in the Upper Laetolil Beds shows that this community is dominated by browsers and mixed feeders and has a very low prevalence of grazers and frugivores. This dietary guild composition distinguishes the Upper Laetolil Beds from modern African communities and suggests either that the Upper Laetolil Beds had a unique vegetation structure which was able to support a higher diversity of browsing ungulates than that exists in African ecosystems today or that it retained an ungulate community that was resilient to environmental change. The Upper Laetolil Beds ungulate community is also unique relative to other mid-Pliocene communities in eastern Africa, some of which are similar to extant communities, while others, such as Laetoli, lack modern counterparts. This suggests that A. afarensis was a eurytopic species that inhabited a variety of ecosystems, including those with and without modern analogs. The co-occurrence of both analog and nonanalog communities in the Pliocene suggests that the transformation toward ungulate communities of modern aspect occurred asynchronously in eastern Africa.

Early Pleistocene large mammals from Maka'amitalu, Hadar, lower Awash Valley, Ethiopia.

The Early Pleistocene was a critical time period in the evolution of eastern African mammal faunas, but fossil assemblages sampling this interval are poorly known from Ethiopia's Afar Depression. Field work by the Hadar Research Project in the Busidima Formation exposures (~2.7-0.8 Ma) of Hadar in the lower Awash Valley, resulted in the recovery of an early Homo maxilla (A.L. 666-1) with associated stone tools and fauna from the Maka'amitalu basin in the 1990s. These assemblages are dated to ~2.35 Ma by the Bouroukie Tuff 3 (BKT-3). Continued work by the Hadar Research Project over the last two decades has greatly expanded the faunal collection. Here, we provide a comprehensive account of the Maka'amitalu large mammals (Artiodactyla, Carnivora, Perissodactyla, Primates, and Proboscidea) and discuss their paleoecological and biochronological significance. The size of the Maka'amitalu assemblage is small compared to those from the Hadar Formation (3.45-2.95 Ma) and Ledi-Geraru (2.8-2.6 Ma) but includes at least 20 taxa. Bovids, suids, and Theropithecus are common in terms of both species richness and abundance, whereas carnivorans, equids, and megaherbivores are rare. While the taxonomic composition of the Maka'amitalu fauna indicates significant species turnover from the Hadar Formation and Ledi-Geraru deposits, turnover seems to have occurred at a constant rate through time as taxonomic dissimilarity between adjacent fossil assemblages is strongly predicted by their age difference. A similar pattern characterizes functional ecological turnover, with only subtle changes in dietary proportions, body size proportions, and bovid abundances across the composite lower Awash sequence. Biochronological comparisons with other sites in eastern Africa suggest that the taxa recovered from the Maka'amitalu are broadly consistent with the reported age of the BKT-3 tuff. Considering the age of BKT-3 and biochronology, a range of 2.4-1.9 Ma is most likely for the faunal assemblage.

Hunter-gatherer genomes reveal diverse demographic trajectories during the rise of farming in Eastern Africa.

The fate of hunting and gathering populations following the rise of agriculture and pastoralism remains a topic of debate in the study of human prehistory. Studies of ancient and modern genomes have found that autochthonous groups were largely replaced by expanding farmer populations with varying levels of gene flow, a characterization that is influenced by the almost universal focus on the European Neolithic.1-5 We sought to understand the demographic impact of an ongoing cultural transition to farming in Southwest Ethiopia, one of the last regions in Africa to experience such shifts.6 Importantly, Southwest Ethiopia is home to several of the world's remaining hunter-gatherer groups, including the Chabu people, who are currently transitioning away from their traditional mode of subsistence.7 We generated genome-wide data from the Chabu and four neighboring populations, the Majang, Shekkacho, Bench, and Sheko, to characterize their genetic ancestry and estimate their effective population sizes over the last 60 generations. We show that the Chabu are a distinct population closely related to ancient people who occupied Southwest Ethiopia >4,500 years ago. Furthermore, the Chabu are undergoing a severe population bottleneck, which began approximately 1,400 years ago. By analyzing eleven Eastern African populations, we find evidence for divergent demographic trajectories among hunter-gatherer-descendant groups. Our results illustrate that although foragers respond to encroaching agriculture and pastoralism with multiple strategies, including cultural adoption of agropastoralism, gene flow, and economic specialization, they often face population decline.

Prevalence and associated factors of home delivery in Eastern Africa: Further analysis of data from the recent Demographic and Health Survey data.

Objectives: The current study aimed to determine the magnitude of home delivery and its associated factors in East Africa using data from the Demographic and Health Survey. Methods: We pooled data from the Demographic and Health Survey of the 11 East African countries and included a total weighted sample of 126,107 women in the study. The generalized linear mixed model was fitted to identify factors associated with home delivery. Variables with adjusted odds ratio with a 95% confidence interval, and p value < 0.05 in the final generalized linear mixed model were reported to declare significantly associated factors with home delivery. Result: The weighted prevalence of home delivery was 23.68% (95% confidence interval: [23.45, 23.92]) among women in East African countries. Home delivery was highest in Ethiopia (72.5%) whereas, it was lowest in Mozambique (2.8%). In generalized linear mixed model, respondent's age group, marital status, educational status, place of residence, living country, wealth index, media exposure, and number of children ever born were shown significant association with the home delivery in the East African countries. Conclusion: Home delivery varied between countries in the East African zone. Home delivery was significantly increased among women aged 20-34 years, higher number of ever born children, rural residence, never married, or formerly married participants. On the contrary, home delivery decreased with higher educational level, media exposure, and higher wealth index. Wide-range interventions to reduce home delivery should focus on addressing inequities associated with maternal education, family wealth, increased access to the media, and narrowing the gap between rural and urban areas, poor and rich families, and married and unmarried mothers.

Malaria prevalence and performance of diagnostic tests among patients hospitalized with acute undifferentiated fever in Zanzibar.

BACKGROUND: Control efforts in Zanzibar reduced the burden of malaria substantially from 2000 to 2015, but re-emergence of falciparum malaria has been observed lately. This study evaluated the prevalence of malaria and performance of routine diagnostic tests among hospitalized fever patients in a 1.5 years period in 2015 and 2016. METHODS: From March 2015 to October 2016, paediatric and adult patients hospitalized with acute undifferentiated fever at Mnazi Mmoja Hospital, Zanzibar were included. The malaria prevalence, and performance of rapid diagnostic test (RDT) and microscopy, were assessed using polymerase chain reaction (PCR) as gold standard. RESULTS: The malaria prevalence was 9% (63/731). Children under 5 years old had lower malaria prevalence (5%, 14/260) than older children (15%, 20/131, p = 0.001) and persons aged 16 to 30 years (13%, 15/119, p = 0.02), but not different from persons over 30 years old (6%, 14/217, p = 0.7). All cases had Plasmodium falciparum infection, except for one case of Plasmodium ovale. Ten malaria patients had no history of visiting mainland Tanzania. The RDT had a sensitivity of 64% (36/56) and a specificity of 98% (561/575), and microscopy had a sensitivity of 50% (18/36) and  a specificity of 99% (251/254), compared to PCR. The malaria parasitaemia was lower in patients with false negative results on RDT (median 7 × 103 copies/µL, interquartile range [IQR] 2 × 103 - 8 × 104, p = 0.002) and microscopy (median 9 × 103 copies/µL, IQR 8 × 102 - 7 × 104, p = 0.006) compared to those with true positive RDT (median 2 × 105 copies/µL, IQR 3 × 104 - 5 × 105) and microscopy (median 2 × 105 copies/µL, IQR 6 × 104 - 5 × 105). CONCLUSIONS: The study emphasizes that malaria was a frequent cause of febrile illness in hospitalized patients in Zanzibar in the years 2015-2016, particularly among school age children and young adults. We found evidence of autochthonous malaria transmission in Zanzibar. Compared to PCR, both RDT and microscopy had low sensitivity, and false negative results were associated with low parasitaemia. While low parasitaemia identified only by PCR in a semi-immune individual could be coincidental and without clinical relevance, clinicians should be aware of the risk of false negative results on routine tests.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. METHODS: This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. DISCUSSION: This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. TRIAL REGISTRATION: This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393 .