Tuberculosis (TB) among hospitalized patients is underdiagnosed. This study assessed systematic TB-screening, followed by an enhanced TB-diagnostic package for hospitalized patients implemented by trained lay health workers in KwaZulu-Natal, South Africa. In this before-and-after study we included patients ≥ 18 years. The intervention consisted of systematic clinical screening for TB, HIV and diabetes mellitus by lay health workers and provision of an enhanced TB-diagnostic package including sputum Xpert MTB/Rif Ultra, urine lateral-flow lipoarabinomannan assay (LF-LAM), chest x-ray, and sputum culture. We compared TB case findings with people hospitalized one year preceding the intervention. In the pre-intervention phase, 5217 people were hospitalized. Among 4913 (94.2%) people not on TB treatment, 367 (7.5%) were diagnosed with TB. In the intervention phase, 4015 eligible people were hospitalized. Among 3734 (93.0%) people not on TB treatment, 560 (15.0%) were diagnosed with TB. The proportion of patients diagnosed with TB was higher in the intervention phase (15.0% vs. 7.5%, p < 0.001). Overall in-hospital mortality was lower in the intervention phase [166/3734(4.5%) vs. 336/4913(6.8%), p < 0.001]. Lay health worker-led implementation of systematic TB-screening, coupled with provision of an enhanced TB-diagnostic package significantly improved TB case detection and mortality among hospitalized adults.

BACKGROUND

The global epidemic of Mycoplasma genitalium (MG) is marked by its widespread prevalence, varied resistance patterns, and significant impact on sexual health. This study aimed to understand the prevalence and interaction of MG infections with other sexually transmitted infections (STIs) in a low-resource setting, as well as the implications for routine STIs care.

METHODS

This nested cross-sectional study was conducted from July 2022 to April 2023 across six outpatient care sites in Shiselweni, Eswatini. Participants completed a self-questionnaire, underwent syndromic case management, and provided urine samples for parallel molecular-based testing using the Cepheid GeneXpert® platform for MG, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). The proportion of MG mono-infection and coinfections were calculated. Multivariable logistic regression models identified predictors of symptomatic MG mono-infections, which could be used to streamline at-risk patients for MG testing.

RESULTS

Among 735 participants, the median age was 27 (interquartile range 23—34) years, 65.9% were women, and 9.5% were HIV-positive. MG infection was detected in 10.5% (n = 77) of clients, with 45.5% (n = 35) coinfected with any of CT/NG/TV, and one case (0.1%) showing macrolide resistance. Among women with vaginal discharge syndrome (28.1%, n = 136), 0.7% (n = 1) had MG mono-infection, and 10.3% (n = 14) had MG and CT/NG/TV coinfections. Among men with male urethral syndrome (31.9%, n = 80), 3.8% (n = 3) had MG mono-infection, and 2.5% (n = 2) had MG and CT/NG/TV coinfections. Most MG-positive cases (66.2%, n = 51) did not receive antibiotic therapy, despite 68.6% (n = 35) reporting symptoms of STIs. Of treated cases, 26.0% (n = 20) received azithromycin monotherapy, 6.5% (n = 5) doxycycline monotherapy, and 1.3% (n = 1) both drugs. Of 305 individuals reporting STIs symptoms but tested negative for CT/NG/TV, 23 (7.5%) had symptomatic MG mono-infections. Unemployment and never having been tested for HIV were identified as risk factors. Streamlining 108/305 (35.4%) at-risk individuals for molecular-based MG testing would identify 14.8% (16/108) as positive, capturing 69.6% (16/23) of all symptomatic MG mono-infections.

CONCLUSIONS

MG was common among outpatients and frequently co-occurred with CT, NG, and TV infections. Syndromic case management often misclassified MG infections, leading to ineffective treatment. Expanding molecular-based MG testing could enhance antibiotic stewardship, crucial for preventing the spread of drug-resistant strains.

The recent expansion of mpox in Africa is characterized by a dramatic increase in zoonotic transmission (clade Ia) and the emergence of a new clade Ib that is transmitted from human to human by close contact. Clade Ia does not pose a threat in areas without zoonotic reservoirs. But clade Ib may spread widely, as did clade IIb which has spread globally since 2022 among men who have sex with men. It is not clear whether controlling clade Ib will be more difficult than clade IIb. The population at risk potentially counts 100 million but only a million vaccine doses are expected in the next year. Surveillance is needed with exhaustive case detection, polymerase chain reaction confirmation, clade determination, and about severe illness. Such data is needed to identify routes of transmission and core transmitters, such as sex workers. Health care workers are vaccinated to ensure their protection, but this will not curb mpox transmission. With the recent inequitable distribution of COVID-19 vaccines in mind, it is a global responsibility to ensure that low-income nations in the mpox epicenter have meaningful access to vaccines. Vaccination serves not only to reduce mortality in children but limit the risk of future mpox variants emerging that may spread in human populations globally.

The HPV-Automated Visual Evaluation (PAVE) Consortium is validating a cervical screening strategy enabling accurate cervical screening in resource-limited settings. A rapid, low-cost HPV assay permits sensitive HPV testing of self-collected vaginal specimens; HPV-negative women are reassured. Triage of positives combines HPV genotyping (four groups in order of cancer risk) and visual inspection assisted by automated cervical visual evaluation (AVE) that classifies cervical appearance as severe, indeterminate, or normal. Together, the combination predicts which women have precancer, permitting targeted management to those most needing treatment.

We analyzed CIN3+ yield for each PAVE risk level (HPV genotype crossed by AVE classification) from nine clinical sites (Brazil, Cambodia, Dominican Republic, El Salvador, Eswatini, Honduras, Malawi, Nigeria, and Tanzania). Data from 1832 HPV-positive participants confirmed that HPV genotype and AVE classification each strongly and independently predict risk of histologic CIN3+. The combination of these low-cost tests provided excellent risk stratification, warranting pre-implementation demonstration projects.

The COVID-19 pandemic accelerated the development of AI-driven tools to improve public health surveillance and outbreak management. While AI programs have shown promise in disease surveillance, they also present issues such as data privacy, prejudice, and human-AI interactions. This sixth session of the of the WHO Pandemic and Epidemic Intelligence Innovation Forum examines the use of Artificial Intelligence (AI) in public health by collecting the experience of key global health organizations, such the Boston Children's Hospital, the Global South AI for Pandemic & Epidemic Preparedness & Response (AI4PEP) network, Medicines Sans Frontières (MSF), and the University of Sydney. AI's utility in clinical care, particularly in diagnostics, medication discovery, and data processing, has resulted in improvements that may also benefit public health surveillance. However, the use of AI in global health necessitates careful consideration of ethical issues, particularly those involving data use and algorithmic bias. As AI advances, particularly with large language models, public health officials must develop governance frameworks that stress openness, accountability, and fairness. These systems should address worldwide differences in data access and ensure that AI technologies are tailored to specific local needs. Ultimately, AI's ability to improve healthcare efficiency and equity is dependent on multidisciplinary collaboration, community involvement, and inclusive AI designs in ensuring equitable healthcare outcomes to fit the unique demands of global communities.

BACKGROUND

In settings with low pneumococcal conjugate vaccine (PCV) coverage, multi-age cohort mass campaigns could increase population immunity, and fractional dosing could increase affordability. We aimed to evaluate the effect of mass campaigns on nasopharyngeal pneumococcal carriage of Pneumosil (PCV10) in children aged 1-9 years in Niger.

METHODS

In this three-arm, open-label, cluster-randomised trial, 63 clusters of one to four villages in Niger were randomly assigned (3:3:1) using block randomisation to receive campaigns consisting of a single full dose of a 10-valent PCV (Pneumosil), a single one-fifth dose of Pneumosil, or no campaign. Independently sampled carriage surveys were done among 2268 households 6 months before and after vaccination, collecting nasopharyngeal swabs from healthy children for culture and serotyping; those with contraindication to nasopharyngeal swabbing were excluded. The primary outcome was nasopharyngeal carriage of vaccine-serotype pneumococcus. We tested whether vaccine-type carriage was reduced in full-dose versus control clusters; and whether fractional doses were non-inferior to full-doses (lower bound 95% CI more than -7·5%), using generalised estimating equations to analyse cluster summaries at baseline and follow-up, controlling for covariates to estimate risk differences and their 95% CIs. The study is registered with ClinicalTrials.gov (NCT05175014) and the Pan-African Clinical Trials Registry (PACTR20211257448484).

FINDINGS

Surveys were done between Dec 22, 2021, and March 18, 2022, and between Dec 12, 2022, and March 9, 2023. The vaccination campaign ran from June 15 to Aug 2, 2022. Participants' characteristics were consistent across surveys and groups. Pre-vaccination, vaccine-type carriage was 15·6% (149 of 955 participants) in the full-dose group, 17·9% (170 of 948) in the fractional-dose group, and 18·8% (60 of 320) in the control group. Post-vaccination, vaccine-type carriage was 4·6% (44 of 967) in the full-dose group, 8·0% (77 of 962) in the fractional-dose group, and 16·5% (53 of 321) in the control group. The primary analysis showed a risk difference of -16·2% (95% CI -28·6 to -3·0) between the full-dose group and control group (p=0·002 for superiority), and -3·8% (-6·1 to -1·6) between the full-dose group and fractional-dose group, meeting the non-inferiority criteria. No adverse events were judged to be related to vaccination.

INTERPRETATION

Multi-age cohort campaigns had a marked effect on vaccine-type carriage and fractional-dose campaigns met non-inferiority criteria. Such campaigns should be considered in low-coverage settings, including humanitarian emergencies, to accelerate population protection.

In sub-Saharan Africa, reported COVID-19 numbers have been lower than anticipated, even when considering populations’ younger age. The extent to which risk factors, established in industrialised countries, impact the risk of infection and of disease in populations in sub-Saharan Africa, remains unclear. We estimated the incidence of mild and moderate COVID-19 in urban Mozambique and analysed factors associated with infection and disease in a population-based surveillance study. During December 2020-March 2022, 1,561 households (6,049 participants, median 21 years, 54.8% female, 7.3% disclosed HIV positive) of Polana Caniço, Maputo, Mozambique, were visited biweekly to report respiratory symptoms, anosmia, or ageusia, and self-administer a nasal swab for SARS-CoV-2 testing. Every three months, dried blood spots of a subset of participants (1,412) were collected for detection of antibodies against SARS-CoV-2 spike glycoprotein and nucleocapsid protein. Per 1000 person-years, 364.5 (95%CI 352.8–376.1) respiratory illness episodes were reported, of which 72.2 (95%CI 60.6–83.9) were COVID-19. SARS-CoV-2 seroprevalence rose from 4.8% (95%CI 1.1–8.6%) in December 2020 to 34.7% (95%CI 20.2–49.3%) in June 2021, when 3.0% were vaccinated. Increasing age, chronic lung disease, hypertension, and overweight increased risk of COVID-19. Older age increased the risk of SARS-CoV-2 seroconversion. We observed no association between socio-economic status, behaviour and COVID-19 or SARS-CoV-2 seroconversion. Active surveillance in an urban population confirmed frequent COVID-19 underreporting, yet indicated that the large majority of cases were mild and non-febrile. In contrast to reports from industrialised countries, social deprivation did not increase the risk of infection nor disease.