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Comparison of Virus Watch COVID-19 Positivity, Incidence, and Hospitalization Rates With Other Surveillance Systems: Surveillance Study.
Get PDFBACKGROUND: Effective disease surveillance is essential for understanding pathogens' epidemiology, detecting outbreaks, and enabling timely public health responses. In the United Kingdom, large-scale studies, such as the Office for National Statistics COVID-19 Infection Survey (CIS), have monitored SARS-CoV-2 transmission but required significant resources, making them challenging to sustain when pandemic-specific funding ends and also in resource-limited settings. In contrast, the Virus Watch study, at lower cost, relied on self-reported and linked national testing data as well as symptomatic testing, while Severe Acute Respiratory Infections Watch (SARI) leveraged hospital data for cost-effective surveillance.
OBJECTIVE: This study aimed to evaluate the effectiveness of Virus Watch as a surveillance system in monitoring COVID-19 positivity, incidence, and hospitalization rates in England and Wales, using data from the CIS and SARI as benchmarks for comparison, while considering the key differences in the study designs, including recruitment strategies, incentives, and testing criteria.
METHODS: We used the Virus Watch prospective community cohort study to estimate COVID-19 positivity, incidence, and hospitalization rates in England and Wales from June 2020 to March 2023. Rate estimates were compared with CIS modeled positivity and incidence rates, and with SARI COVID-19 hospitalization rates. Global synchrony between datasets was measured using overall Spearman ⍴ and local synchrony using 9-week rolling Spearman ⍴. For England, comparisons with CIS estimates used Virus Watch rates calculated with and without linked national testing data. Positivity rates were also assessed overall and separately before and after the end of free national testing.
RESULTS: A total of 58,628 participants were recruited into the Virus Watch study, of whom 52,526 (89.6%) were resident in England and 1532 (2.6%) in Wales; region was missing for the remainder. Virus Watch-estimated COVID-19 positivity and incidence rates in England, calculated with and without linked testing data, showed strong global synchrony with CIS estimates (positivity ⍴: 0.91 and 0.90; both P<.001 and incidence ⍴: 0.92 and 0.90; both P<.001) and strong local synchrony (positivity ⍴: median 0.75, IQR 0.53-0.85 and median 0.67, IQR 0.47-0.83, and incidence ⍴: median 0.76, IQR 0.49-0.88 and median 0.66, IQR 0.45-0.82), despite having lower absolute values. Global and local synchrony of positivity rates were similar for periods before and after the end of free national testing, although the difference between Virus Watch and CIS estimates was greater post-free testing. COVID-19 hospitalization rates were also lower and less synchronized with SARI estimates. In Wales, Virus Watch estimates exhibited greater variability (positivity ρ: 0.75, P<.001; incidence rate ρ: 0.85, P<.001) and lower local synchrony (positivity ρ: median 0.61, IQR 0.34-0.74, and incidence ρ: median 0.52, IQR 0.38-0.71) compared to England.
CONCLUSIONS: Our results highlight the effectiveness of the Virus Watch approach in providing accurate estimates of COVID-19 positivity and incidence rates, even in the absence of national surveillance systems. This low-cost method can be adapted to various settings, particularly low-resource ones, to strengthen public health surveillance and inform timely interventions
Reconstructing Somalia's population: A district level analysis.
Get PDFSomalia has experienced more than 30 years of armed conflict exacerbated by drought and food insecurity, which has led to major migratory flows. Despite these large-scale movements, no census has been carried out since 1975. To support effective planning and service delivery, we reconstructed Somalia's population at district level by taking into account alternative sources of population data, natural growth and known internal and refugee displacement flows.A previous study, published in PLOS Global Public Health, attempted to reconstruct the population of Somalia by district (administrative level 2) on a monthly basis from 2013 to 2022. This initial method was based on the average of available estimates, on the assumption of a fixed rate of natural increase and on the allocation of displaced persons to the various districts. However, it assumed that internally displaced persons (IDPs) would remain in their destination districts indefinitely, leading to unrealistic population declines and inflated IDP numbers. The paper presents an improved reconstruction method using mechanistic and statistical models to overcome these limitations.The updated method incorporates dynamic modelling techniques, reflecting more realistic migration and displacement patterns. The new model indicates that previous estimates significantly underestimated populations in some districts. The revised estimates provide a more balanced distribution, reducing instances of implausibly high or negative population figures. For example, districts thought to be almost depopulated are revealed to have more viable population levels.Key advances include the use of probabilistic rates of return for displaced people and the integration of new data sources, allowing for a more accurate representation of population movements. These results provide a more reliable basis for planning and service delivery, accurately reflecting the impacts of conflict and climate-induced displacement between 2013 and 2024. The improved model presents a nuanced reconstruction of Somalia's population dynamics, essential for informed decision-making
Social equity in Ethiopian infants' breastfeeding and complementary feeding practices: a birth cohort study.
Get PDFINTRODUCTION: Monitoring social equity in infant feeding is essential to track countries’ progress towards global child nutrition and survival targets. We aimed to examine social equity in Ethiopian infants’ early initiation of breastfeeding, exclusive breastfeeding at five months, and quality of complementary foods at 12 months. METHODS: This study was a secondary analysis of the Ethiopia Performance Monitoring for Action panel data, prospectively collected from July 2020 to August 2021. A total of 1,850 infants were followed from birth to 12 months in five Ethiopian regions: Addis Ababa City Administration, Oromia, Amhara, Afar, and Southern Nations, Nationalities, and Peoples Regions. We analyzed social equity in infants’ early initiation of breastfeeding, exclusive breastfeeding at five months of age, and dietary diversity at 12 months of age, calculated slope and concentration indices and using mixed-effect regression models. RESULTS: Most infants started breastfeeding within one hour of birth (67%, 95% CI 63, 71) and were exclusively breastfed (69%, 95% CI 67, 71) at five months of age. Few (16%, 95% CI 13, 19) infants aged 12 months had complementary foods meeting the minimum quality criterion, i.e., from five or more food groups. Half (49%, 95% CI 44, 55) of infants aged 12 months consumed sugary foods or beverages. There was no inequity in early initiation and exclusive breastfeeding practices by mothers’ education and household wealth levels. There was social inequity in infants’ dietary diversity at 12 months of age, favoring educated (slope index: 0.368, p-value < 0.001) and better-off (concentration index: 0.350%, p-value < 0.001) families. CONCLUSIONS: The high coverage of early initiation of breastfeeding and exclusive breastfeeding at five months of age were equitably distributed by mothers’ education and household wealth. Few 12-month-old infants had a diverse diet, while half consumed sugary foods or beverages. The quality of complementary food was inequitable, favoring better-off and more educated families. Ensuring optimal access to infant feeding support for socially disadvantaged families is critical to improving the quality of complementary food and maintaining or further increasing appropriate breastfeeding
Global prioritised indicators for measuring WHO's quality-of-care standards for small and/or sick newborns in health facilities: development, global consultation and expert consensus.
Get PDFOBJECTIVES: The aim of this study was to prioritise a set of indicators to measure World Health Organization (WHO) quality-of-care standards for small and/or sick newborns (SSNB) in health facilities. The hypothesis is that monitoring prioritised indicators can support accountability mechanisms, assess and drive progress, and compare performance in quality-of-care (QoC) at subnational levels. DESIGN: Prospective, iterative, deductive, stepwise process to prioritise a list of QoC indicators organised around the WHO Standards for improving the QoC for small and sick newborns in health facilities. A technical working group (TWG) used an iterative four-step deductive process: (1) articulation of conceptual framework and method for indicator development; (2) comprehensive review of existing global SSNB-relevant indicators; (3) development of indicator selection criteria; and (4) selection of indicators through consultations with a wide range of stakeholders at country, regional and global levels. SETTING: The indicators are prioritised for inpatient newborn care (typically called level 2 and 3 care) in high mortality/morbidity settings, where most preventable poor neonatal outcomes occur. PARTICIPANTS: The TWG included 24 technical experts and leaders in SSNB QoC programming selected by WHO. Global perspectives were synthesised from an online survey of 172 respondents who represented different countries and levels of the health system, and a wide range of perspectives, including ministries of health, research institutions, technical and implementing partners, health workers and independent experts. RESULTS: The 30 prioritised SSNB QoC indicators include 27 with metadata and 3 requiring further development; together, they cover all eight standard domains of the WHO quality framework. Among the established indicators, 10 were adopted from existing indicators and 17 adapted. The list contains a balance of indicators measuring inputs (n=6), processes (n=12) and outcome/impact (n=9). CONCLUSIONS: The prioritised SSNB QoC indicators can be used at health facility, subnational and national levels, depending on the maturity of a country's health information system. Their use in implementation, research and evaluation across diverse contexts has the potential to help drive action to improve quality of SSNB care. WHO and others could use this list for further prioritisation of a core set
Effects of reductions in US foreign assistance on HIV, tuberculosis, family planning, and maternal and child health: a modelling study.
Get PDFBACKGROUND: The USA has traditionally been the largest donor to health programmes in low-income and middle-income countries (LMICs). In January 2025, almost all such funding was stopped and prospects for its resumption are uncertain. The suddenness of the funding cuts makes it difficult for national health programmes in LMICs to adapt. We aimed to estimate the impact of these cuts on deaths and other outcomes (new infections, number of family planning users, and unplanned pregnancies) for four health areas that have been a focus of a substantial amount of US foreign assistance: HIV, tuberculosis, family planning, and maternal and child health. METHODS: We applied established mathematical models to the countries receiving US foreign assistance in each domain to estimate health impacts over the period 2025 to 2030. We used six models of HIV, three different approaches to estimate family planning impact, and one model each for tuberculosis and maternal and child health, applying these models to as many as 80 countries. We compared model projections assuming constant funding (status quo) with projections assuming complete elimination of US funding in each country. Some models also considered partial cuts or restoration of funding over time. FINDINGS: A complete cessation of US funding without replacement by other sources would lead to drastic increases in deaths from 2025 to 2030: 4·1 million (range 1·6-6·6) additional AIDS-related deaths across 55 countries, 606 900 (95% uncertainty interval [UI] 466 000-768 800) additional tuberculosis deaths across 79 countries, 40-55 million additional unplanned pregnancies and 12-16 million unsafe abortions across 51 countries, and 2·5 million (1·3-4·5) additional child deaths from causes other than HIV and tuberculosis across 24 countries. Restoration of funding for HIV treatment but not prevention would avoid most of the increase in deaths but still result in nearly 1 million more new HIV infections from 2025 to 2030. INTERPRETATION: Substantial progress has been made in improving global health in the past few decades. This progress has strengthened hope in reaching global development goals. However, the recent funding cuts threaten to change these trajectories and could lead to sharp increases in avoidable mortality for the poorest countries. Even a partial restoration of US funding would combat the most severe effects and provide time for countries that have received substantial US foreign assistance to adjust to the new funding landscape. FUNDING: Economic and Social Research Council; Engineering and Physical Sciences Research Council; European and Developing Countries Clinical Trials Partnership; Gates Foundation; Global Fund to Fight AIDS, Tuberculosis, and Malaria; Open Philanthropy; UK Foreign, Commonwealth & Development Office; UK Medical Research Council; UN Population Fund; UNAIDS; US National Institute of Allergy and Infectious Diseases; University of Edinburgh; US National Institutes of Health; US President's Emergency Plan for AIDS Relief; Wellcome Trust; World Bank; WHO
Secondary Distribution of Dual HIV/Syphilis Self-Testing Among Men Who Have Sex With Men: Pragmatic Randomized Controlled Trial in China.
Get PDFBACKGROUND: The World Health Organization recommends dual HIV/syphilis testing, but this approach has not been examined in many low- and middle-income countries. Dual HIV/syphilis self-testing may accelerate secondary distribution of self-test kits. Preliminary studies in Guangdong, China, have demonstrated the feasibility and cost-effectiveness of dual HIV/syphilis self-testing distribution via social media, but evidence comparing dual HIV/syphilis self-testing to single HIV self-testing for secondary distribution within social networks remains limited in resource-limited settings.
OBJECTIVE: We aimed to evaluate the effectiveness of secondary distribution of dual HIV/syphilis self-testing kits in promoting HIV testing uptake among men who have sex with men (MSM) in China.
METHODS: We conducted a pragmatic 3-arm randomized controlled study in the Guangxi Zhuang Autonomous Region, China. MSM aged 18 years or older who were HIV-negative were enrolled and randomly assigned (1:1:1) to either the site-based HIV testing (SBT) group (110/330, 33.3%), single HIV self-testing (SST) group (110/330, 33.3%), or dual HIV/syphilis self-testing (DST) group (110/330, 33.3%). Participants in the SST and DST groups received free finger-prick-based HIV self-testing or HIV/syphilis self-testing kits at enrollment and during the 12-month follow-up. The primary outcome was the mean number of social network members motivated by the participant and the mean frequency of HIV tests per participant within a 3-month period. The data were analyzed using an intention-to-treat analysis.
RESULTS: A total of 330 MSM were recruited, among whom 319 (319/330, 96.7%) completed at least 1 follow-up survey and were subsequently included in the analysis. Among the participants, 245/319 (77%) had a college education or above. Compared to social network members in the SBT group, those in the intervention SST and DST groups were more likely to motivate others for HIV testing over a 3-month average duration. The mean number of motivated individuals was 0.42 in the SST group versus 0.20 in the SBT group, a mean difference (MD) of 0.22 (95% CI 0.12-0.33; P<.001). The mean was 0.51 in the DST group versus 0.20 in the SBT group, with an MD of 0.32 (95% CI 0.20-0.43; P<.001). The mean frequency of total HIV tests per participant in the SST group (1.33) was higher than that in the SBT group (0.87), with an MD of 0.46 (95% CI 0.31-0.62; P<.001) over 3 months. Over a 3-month period, the mean number of HIV tests per participant was higher in the DST group (1.43) than in the SBT group (0.87), with an MD of 0.57 (95% CI 0.41-0.73; P<.001). A total of 4 (1.3%) individuals had a new HIV positive result, while 11 (3.4%) had a new syphilis positive result. All individuals who had positive self-test results underwent laboratory-based confirmation tests. There were no adverse events reported.
CONCLUSIONS: Our data demonstrate that the secondary distribution strategy of HIV/syphilis self-testing proves to be an effective means of expanding HIV testing coverage by encouraging the distribution of testing kits within the social networks of MSM.
TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100050898; https://www.chictr.org.cn/hvshowproject.html?id=158876
Seasonal mass vaccination with R21/Matrix-M for malaria elimination (SERVAL): protocol of the cluster randomised trial.
Get PDFINTRODUCTION: Progress in malaria control has stalled since 2015, highlighting the need for new control tools. The R21/Matrix-M (R21) malaria vaccine, a pre-erythrocytic vaccine recently approved by WHO for small children, may be one of these tools. This trial aims to assess whether seasonal mass vaccination with R21 reduces malaria transmission in The Gambia and Burkina Faso, two countries at the extreme of the transmission spectrum.
METHODS: This is a multi-centre open cluster-randomised controlled trial to assess the impact of mass vaccination with R21 on malaria transmission and morbidity. The trial will be implemented in eastern Gambia (low to moderate transmission) and Central Burkina Faso (intense transmission). Thirty medium-sized villages in The Gambia and 24 in Burkina Faso will be randomised (1:1) to either intervention or control arm. All eligible residents in intervention villages will receive R21 vaccinations in three-monthly rounds, from May to July 2024, prior to the malaria transmission season. A booster vaccine dose will be administered the following year, in June 2025. The primary outcome is malaria prevalence at peak transmission (November 2024). Secondary outcomes include safety and tolerability, incidence of clinical malaria, vaccination coverage and community acceptability, cost and cost-effectiveness of the intervention.
DISCUSSION: This is the first trial on seasonal mass vaccination aiming at reducing malaria transmission. Strengths of the study include its design as an adequately powered cluster-randomised trial and the inclusion of study sites with differing transmission intensity which will also provide safety and efficacy data for different age groups. Key challenges remain vaccine hesitancy and vaccination coverage. If successful, R21 seasonal mass vaccination will be an innovative intervention to accelerate malaria elimination efforts and reach the goal set in the Global Technical Strategy for malaria 2016-2030.
TRIAL REGISTRATION: Clinical trials.gov, NCT06578572. Registered on 27 March 2024
Behavioural factors influencing hand hygiene practices across domestic, institutional and public community settings: a systematic review and qualitative meta-synthesis.
Get PDFINTRODUCTION: This systematic review sought to understand barriers and enablers to hand hygiene in community settings.
METHODS: Eligible studies addressed hand hygiene in a community setting, included a qualitative component, and were published in English between 1 January 1980 and 29 March 2023. Studies were excluded if in healthcare settings or were animal research. We searched PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, Public Affairs Information Service Index, WHO Institutional Repository for Information Sharing, UN Digital Library and World Bank eLibrary, manually searched relevant systematic reviews' reference lists, and consulted experts. We used MaxQDA software to code papers, using the COM-B (Capability, Opportunity, Motivation and Behaviour) framework to classify barriers and enablers. We used thematic analysis to describe each COM-B subtheme identified, GRADE-CERQual to assess confidence in evidence for thematic findings and the Mixed Method Appraisal Tool (MMAT) to assess risk of study bias.
RESULTS: 80 studies were included; most took place in Africa (31; 39%), South-East Asia (31; 39%) and domestic settings (54; 68%). The mean MMAT score was 4.86 (good quality). Barriers and/or enablers were reported across all COM-B constructs and subconstructs. The most reported barriers aligned with Physical Opportunity (eg, soap availability), Reflective Motivation (eg, hand hygiene not prioritised) and Automatic Motivation (eg, no habit). In contrast, the most reported enablers aligned with Automatic Motivation (ie, habit) and Reflective Motivation (ie, perception of health risk).
CONCLUSION: Findings confirm that a lack of necessary resources for hand hygiene hinders practice, even when people are motivated. Results may explain why hand hygiene increases when there are acute health risks (eg, COVID-19), but decreases when risks are perceived to fade. The qualitative methodology used among the studies may have revealed a broader array of barriers and enablers than what might have been found by quantitative, researcher-driven studies, but representativeness may be limited. Evidence was also limited on alcohol-based hand rubs. Findings can inform the design of future hand hygiene initiatives.
PROSPERO REGISTRATION NUMBER: CRD42023429145
Preference for Face-to-Face Contraceptive Service Delivery Post-COVID-19 Pandemic: A Cross-Sectional Study.
Get PDFOBJECTIVE: To measure the prevalence of, and social positions associated with, preference for solely face-to-face contraceptive service delivery among women and people assigned female at birth in post-COVID-19 pandemic England.
DESIGN: Cross-sectional online study. SETTING: England.
SAMPLE: The Reproductive Health Survey for England (RHSE) recruited women and people assigned female at birth aged 16-55 living in England using an online non-probability convenience sampling strategy from September-October 2023. The study population was limited to contraception users who answered the question of interest.
METHODS: Multivariable logistic regression identified variables independently associated with preference for face-to-face services.
MAIN OUTCOME MEASURES: Preference for face-to-face services, derived from response to the question 'How would you prefer to access contraceptive services?' (face-to-face vs. telephone/video/website/combination/no preference).
RESULTS: The study population included 28 328 participants: median age was 30 (IQR:24-38), 92.5% (n = 26 193) reported White ethnicity, and 96% (n = 27 296) identified as a woman/girl. Preference for solely face-to-face services services was reported by 24.7% (n = 6992/28 328). In adjusted analysis, preference for face-to-face was associated with younger and older age; not having degree-level qualifications, self-reporting financial hardship, living with a disability, identifying as a woman/girl, and not being in a (cohabiting) relationship. Whilst there was a significant independent association between paid employment and preference for face-to-face services, effect direction was dependent on ethnicity.
CONCLUSIONS: Although a minority of participants reported a preference for solely face-to-face services, they may represent those with the highest unmet need for contraceptive services. Maintaining choice within contraceptive service delivery in an increasingly digitised healthcare landscape is crucial to advance equitable, person-centred reproductive healthcare
Integrative mapping of preexisting influenza immune landscapes predicts vaccine response.
Get PDFBACKGROUND: Predicting individual vaccine responses is a substantial public health challenge. We developed Immunaut, an open-source, data-driven framework for systems vaccinologists to analyze and predict immunological outcomes across diverse vaccination settings, beyond traditional assessments.
METHODS: Using a comprehensive live attenuated influenza vaccine (LAIV) dataset from 244 Gambian children, Immunaut integrated prevaccination and postvaccination humoral, mucosal, cellular, and transcriptomic data. Through advanced modeling, our framework provided a holistic, systems-level view of LAIV-induced immunity.
RESULTS: The analysis identified 3 distinct immunophenotypic profiles driven by baseline immunity: (a) CD8+ T cell responders with strong preexisting immunity boosting memory T cell responses; (b) mucosal responders with prior influenza A virus immunity developing robust mucosal IgA and subsequent influenza B virus seroconversion; and (c) systemic, broad influenza A virus responders starting from immune naivety who mounted broad systemic antibody responses. Pathway analysis revealed how preexisting immune landscapes and baseline features, such as mucosal preparedness and cellular support, quantitatively dictate vaccine outcomes.
CONCLUSION: Our findings emphasize the power of integrative, predictive frameworks for advancing precision vaccinology. The Immunaut framework is a valuable resource for deciphering vaccine response heterogeneity and can be applied to optimize immunization strategies across diverse populations and vaccine platforms.
FUNDING: Wellcome Trust (110058/Z/15/Z); Bill & Melinda Gates Foundation (INV-004222); HIC-Vac Consortium; NIAID (R21 AI151917); NIAID CEIRR Network (75N93021C00045)