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7-year trend of timely hepatitis B birth dose vaccination coverage in The Gambia: a retrospective, population-based analysis.
Get PDFBACKGROUND: According to WHO and UNICEF, Africa has the lowest coverage (18%) of timely (within the first 24 h) hepatitis B birth dose (HepB-BD) vaccination worldwide. To eliminate hepatitis B by 2030, 90% vaccination coverage is required. Experiences from The Gambia, the first African country to adopt HepB-BD vaccination in 1990, could guide HepB-BD implementation and scale-up in Africa. We aimed to assess the trend of, and barriers to, timely HepB-BD vaccination coverage over a 7-year period in The Gambia.
METHODS: In this retrospective analysis, 2015-21 data were extracted from population-based Health and Demographic Surveillance Systems in three rural areas (Basse, Bansang, and Farafenni) in The Gambia. Fluctuation tests and Bayesian analysis using Markov chain Monte Carlo methods assessed the rate of timely (within days 0-1 of birth) and delayed HepB-BD vaccination coverage, change points (abrupt variation between two stable periods) in the average coverage of timely HepB-BD vaccination, and the factors associated with delayed HepB-BD vaccination during the first 7 years following the WHO recommendations on hepatitis B elimination.
FINDINGS: Between Jan 1, 2015, and Dec 31, 2021, 4560 of 71 088 livebirths (6·4%, 95% CI 6·2-6·6) received a timely HepB-BD. Timely HepB-BD vaccination coverage increased from 1·7% (95% CI 1·3-2·0) in the first half of 2015 (ie, January to June) to 22·4% (21·3-23·6) in the second half of 2021 (ie, July to December; p<0·0001). Delayed HepB-BD administration was associated with being born on Friday (odds ratio [OR] 3·51 [95% CI 3·03-4·08]; p<0·0001) or Saturday (5·93 [4·96-7·13]; p<0·0001) compared with Tuesday; being born in Basse (2·03 [95% CI 1·83-2·25]; p<0·0001) or Farafenni (1·84 [1·63-2·08]; p<0·0001); and being born during the rainy season (1·16 [1·08-1·25]; p<0·0001). Average timely HepB-BD vaccination coverage significantly decreased from 10·1% (95% CI 9·5-10·6) pre-COVID-19 pandemic to 5·4% (4·5-6·3) during the first COVID-19 wave (p<0·0001). After adjusting for all other factors, being born during the first COVID-19 wave was associated with delayed HepB-BD vaccination (OR 1·41 [1·22-1·64]; p<0·0001).
INTERPRETATION: 30 years after the adoption of HepB-BD in The Gambia, the rate of vaccination coverage remains low and was significantly affected by the COVID-19 pandemic, highlighting the challenges for its implementation.
FUNDING: None
How effective are international deployments in strengthening low- and middle-income countries (LMICs) to respond to outbreaks in the long term?
Get PDFINTRODUCTION : International public health deployments are frequently used to support outbreak response, but there is limited evidence of their long-term impact on national response systems. This study assessed the extent to which deployments contribute to long-term, sustained impacts on the national outbreak response capacities of African Union Member States. METHODS : We used an exploratory sequential mixed-methods design for this study. We conducted 83 key informant interviews across ten countries, carried out two in-depth country case studies and administered an online survey among 304 stakeholders involved in international deployments from 28 African Union Member States. Qualitative data were analysed thematically. Adjusted ORs (aORs) and 95% CIs identified factors associated with perceived long-term, sustained impact of deployments using multivariable logistic regression. RESULTS: International deployments contributed to long-term impacts in national outbreak response across three domains: (1) strengthened systems and protocols; (2) continued use of infrastructure and equipment introduced during deployments and (3) enhanced confidence, knowledge and leadership among national stakeholders. Case studies further illustrated how adaptive, context-aware, collaborative deployments fostered national ownership and institutional memory. Deployments that were timely (aOR 4.4, CI 1.3 to 15.2), supported by deploying agencies (aOR 9.1, CI 2.1 to 39.9) and involved flexible and adaptive deployees (aOR 12.1, CI 1.9 to 77.1) were more likely to make substantial impact on national outbreak response. CONCLUSION : International deployments contribute to the sustained impact of outbreak response, particularly when they are country-led and align with local priorities. The findings suggest that international deployments should be viewed not only as emergency surge mechanisms, but also as strategic opportunities for contributing to longer-term impacts on national systems. Future deployment models should prioritise developing soft skills of deployees, ensure deployments are timely, context-appropriate and supported with additional resources to maximise their enduring value
High-Dimensional Propensity Scores for Mitigating Confounding: Implementation Using Primary and Secondary Care Data in Hong Kong.
Get PDFPURPOSE: Confounding is a key concern in observational studies using healthcare databases. The high-dimensional propensity score (HDPS) algorithm is an approach for generating and prioritising proxy variables, leveraging all available information in a database to mitigate residual confounding. This study aims to implement HDPS approaches in a novel setting using primary and secondary data available from Hong Kong (HK).
METHODS: Using data from HK, we implemented HDPS in a cohort study investigating the use of different antihypertensive drug classes and incident dementia risk. The top 250 HDPS covariates were included in inverse probability of treatment weighting in addition to investigator-specified variables. Diagnostics evaluated the performance of the HDPS. Sensitivity analyses included varying the number of HDPS covariates and removing potentially influential or inappropriate covariates.
RESULTS: 434 506 new-users of antihypertensives were included. With a traditional PS approach, no evidence for an association was observed for each antihypertensive comparison. After HDPS implementation, the estimate for beta-blockers shifted from no evidence (Hazard ratio (HR): 0.93, 95% confidence interval (CI): 0.86-1.02) to moderate evidence of a reduced hazard of incident dementia compared to angiotensin-converting enzyme inhibitors (HR: 0.90, 95% CI: 0.82-0.98). A greater overall covariate balance between comparison groups was achieved after the inclusion of HDPS covariates and potential frailty markers were identified as influential.
CONCLUSIONS: We successfully implemented the HDPS in HK data, observing improved covariate balance across a wider set of potential confounders. HDPS also identified possible database-specific frailty markers which could be considered more widely when specifying adjustment variables in this setting
Comorbidities associated with early chronickidney disease among young people living withHIV in Uganda. A nested case control study.
Get PDFINTRODUCTION: Chronic kidney disease (CKD) is often complicated by disorders in multiple body systems, associated with higher mortality and morbidity. Young people living with HIV (YPLHIV) have an increased risk of multisystem chronic comorbidities. However, there are few data describing comorbidities associated with CKD among YPLHIV.
METHODS: We conducted a case-control study in seven ART clinics in Kampala, Uganda. Cases were YPLHIV (aged 10–24 years) diagnosed with CKD and controls were those without CKD. We collected data on demographic and clinical factors: HIV viral load, CD4 T cell count, blood pressure, fasting glucose levels, anaemia, electrolytes, parathyroid hormone, and cognitive impairment. We summarized the demographic and clinical factors and used logistic regression to estimate odds ratios (OR) and 95% confidence intervals for associations between CKD comorbidities, adjusted for age, sex and viral suppression.
RESULTS: A total of 292 participants (96 cases and 196 controls) were recruited. Cases were mostly male (59.4% vs. 36.5%), and younger (88.5% vs. 46.4% aged < 17 years) compared to controls. CKD was associated with having a detectable HIV viral load (OR = 3.73; 95% CI 1.53–9.12) and proteinuria (aOR = 4.19; 95% CI 2.28–7.72). CKD was also associated with low haematocrit, hypochloraemia, hyperphosphatemia, and high mean corpuscular volume. There was no evidence of an association of CKD with hypertension, anaemia, or stunting.
CONCLUSION: The pattern of comorbidities among YPLHIV with CKD is uncertain and difficulties may relate to difficulty determining true kidney function and normal ranges in this population. Further studies are needed to discern the pattern of CKD complications to improve management efforts and clinical outcomes.
CLINICAL TRIAL NUMBER: Not applicable.
SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12882-025-04719-7
Sexual health interventions for treating sexual dysfunction in women with female genital mutilation: A systematic review.
Get PDFBACKGROUND: Female sexual dysfunction (FSD), characterized by persistent problems with desire, arousal, orgasm, or pain, can occur in women with any type of female genital mutilation (FGM) as a result of anatomical changes, pain, or psychological trauma.
OBJECTIVES: To systematically review the evidence on the effects of non-surgical interventions, including sexual counseling, mechanical devices, and lubricants, on the sexual function in women living with FGM.
SEARCH STRATEGY: A comprehensive search was conducted in CINAHL Plus, IRIS, MEDLINE (Ovid), PsycINFO (EBSCOhost), SCOPUS, and Web of Science from inception to November 2025. Reference lists were hand-searched and study authors contacted for additional data.
SELECTION CRITERIA: Studies were eligible if they involved women with any type of FGM who received non-surgical interventions for FSD.
DATA COLLECTION AND ANALYSIS: One controlled trial met the inclusion criteria. Data were extracted independently by two reviewers, and the certainty of the evidence was assessed using the GRADE approach. MAIN
RESULTS: In women with Type I FGM, use of the FDA-approved Eros-Clitoral Therapy Device (CTD) combined with psychotherapy led to statistically significant improvements across all domains of the Female Sexual Function Index compared with psychotherapy alone. In the control group, only orgasm scores improved.
CONCLUSIONS: Evidence on non-surgical interventions for FSD in women with FGM is extremely limited and based solely on a small single trial in women with Type I FGM. Although Eros-CTD shows promise, findings cannot be generalized to other FGM types, and data on safety and contraindications are lacking. Further research is needed across diverse populations and FGM types to inform practice and policy
Racism and racial health inequity: four theories for public health.
Get PDFVirtually all public health practitioners acknowledge the need to combat racism. Yet very few public health initiatives in the United Kingdom (UK) are rooted in social scientific ideas offering testable, adaptable frameworks for understanding and dismantling racial inequality. This reluctance does not stem from a lack of awareness of the causes of racial disparities—such as European colonialism, slavery, and their ongoing reverberations—but from the field’s focus on immediate, practical responses to urgent public health issues. As a result, social scientific theories—especially those exploring how ‘race’ is constructed and racial inequality perpetuated—are unevenly integrated into practice. But the social sciences offer precisely the concepts that are needed for understanding how racial categories are constructed and how they come to normalize racial health inequities, including those generated by public health.
This article identifies four key social theories essential to combatting racism and racial health inequity. These theories emerged when the London Association of Directors of Public Health (ADPHL) engaged two anthropologists, Dr Parker and Professor Parker, to help develop their anti-racism strategy. Over the past year, we collaborated through discussions and critically examined literature in critical race theory, Black studies, race and ethnicity studies, and the anthropology of white supremacy. Together, these sources form a body of conceptual tools to help public health dismantle racism and disparities
Building equitable and sustainable vaccine ecosystems in Africa to achieve health sovereignty and universal immunization by 2040
Get PDFThis review presents a comprehensive systems-based assessment of Africa’s vaccine ecosystem. It highlights persistent inequities in vaccine access, manufacturing, and distribution, while proposing a strategic and evidence-informed roadmap toward achieving regional vaccine sovereignty and universal immunization coverage by 2040. Despite decades of implementation under the Expanded Programme on Immunization, Africa continues to depend on imports for over 99% of its vaccine supply while consuming approximately one-quarter of the global demand. The COVID-19 pandemic further magnified these systemic weaknesses, revealing gaps in supply chain efficiency, regulatory harmonization and sustainable domestic financing mechanisms. The analysis identifies four strategic pillars essential for transformation: strengthening local research and development (R&D) and innovation ecosystems; expanding regional manufacturing hubs and fill-and-finish facilities; harmonizing regulatory and quality-assurance systems through the African Medicines Agency and regional authorities; and developing diversified, long-term financing models, including public–private partnerships and health investment funds. The proposed roadmap aligns with continental and global frameworks, notably the Africa CDC’s Partnership for African Vaccine Manufacturing, the African Union’s Agenda 2063, and the WHO’sImmunization Agenda 2030. It follows a 3-phased approach: foundation building by 2027, scaling regional production and supply systems by 2035, and achieving full health sovereignty by 2040. Lessons from COVID-19 underscore the importance of community engagement, equitable access strategies, transparent governance, and robust data and surveillance systems. This study contributes a novel framework grounded in expert-informed, policy-aligned scenarios rather than empirical modeling, clarifying that the proposed milestones represent aspirational yet achievable targets. This calls for enhanced South–South and North–South cooperation, multi-stakeholder partnerships, and evidence-driven monitoring mechanisms to build resilient and self-reliant vaccine ecosystems capable of responding swiftly to future public health emergencies. Ultimately, achieving an equitable and sustainable vaccine ecosystem will position Africa not only as a beneficiary but also as a global contributor to its health security
Towards universal social protection for people affected by tuberculosis in the Western Pacific Region: a social protection baseline assessment and policy entry points
Get PDFBackground: Achieving universal social protection (SP) coverage for people affected by tuberculosis (TB) is increasingly recognised as an essential component of its response, as well as other diseases of poverty. Realising this goal requires to clearly understand the SP needs of people affected by TB and to identify means to maximise their access to existing or new SP benefits in an efficient, effective, and sustainable manner.
Main body: To address these questions, between 2022 and 2023, the WHO Western Pacific Regional office conducted the first SP baseline assessment for people affected by TB in Mongolia, Lao People’s Democratic Republic, the Philippines, Cambodia, and Viet Nam. This exercise encompassed a desk review of SP programmes operating in these countries, followed by an expert consultation to discuss barriers and entry points to expand SP coverage among people affected by TB. Overall evidence gathered from publicly available reports and publications suggests that existing SP programmes in these countries are insufficiently accessible and inadequate to meet the needs of people affected by TB. Most countries provide TB-specific benefits only to people with multidrug-resistant TB, leaving most people with TB unserved. The most reported barriers to access to SP included lack of awareness, stigma, poverty, as well as programmes’ fragmentation, and administrative and financial constraints. Identified solutions included raising awareness about SP, extending TB-specific SP benefits to all people with TB in need, advocating for a better inclusion of people with TB into existing governmental programmes, and strengthening the referral system across the health and SP sectors.
Conclusions: By identifying concrete policy entry points and actionable solutions, this SP baseline assessment provided a foundation for these five countries to embed social protection more systematically into their national TB responses. Ideally, this effort should now be replicated in all high TB-burden countries willing to achieve universal SP coverage among people affected by TB. The lessons that emerged from this baseline assessment are consistent with the recommended actions and principles underlying the Western Pacific Regional Framework for Reaching the Unreached and are thus transferrable to other diseases of poverty
Delivering an effective violence prevention intervention at scale: testing an alternative delivery model for the Good School Toolkit in Uganda
Get PDFAlmost no evidence exists on effectively delivering school violence prevention interventions at scale. The Good School Toolkit (GST), developed by Uganda-based non-governmental organisation (NGO) Raising Voices, is an effective whole-school violence prevention intervention when delivered by NGO staff. This study aimed to determine whether GST, delivered via a scalable delivery model using Regional Resource Persons (RRPs), is effective in changing teachers’ attitudes towards violence and improving perceptions of school operational culture.
A pre–post study was conducted in 95 schools across Uganda, randomly selected from 1000 schools implementing GST via RRPs. All schools had the opportunity to implement GST. Teachers participated in cross-sectional baseline (February–April 2022) and endline (September–October 2023) surveys. Primary outcomes were acceptance of physical discipline and markers of school operational culture. We fitted mixed-effects linear regression models to examine changes in outcomes over time and influence of GST exposure.
Analyses showed that each unit increase in GST exposure was associated with an increase of 0.59 (95% CI 0.49 to 0.69, p<0.001) in teachers’ perception of school operational culture, and 0.12 (95% CI 0.09 to 0.14, p<0.001) in perceptions of staff and student involvement in school operations. Although mean acceptance of physical discipline increased over time (β=0.51, 95% CI 0.27 to 0.76, p<0.001)—likely attributable to changes in schools post-COVID-19—each unit increase in GST exposure corresponded to an attenuation in acceptance by 0.06 (95% CI −0.12 to 0.00, p=0.046). Teachers reporting higher exposure to GST were also less likely to report using past year physical violence (OR=0.92, 95% CI 0.89 to 0.96, p<0.001).
This study is the first in the Global South to evaluate a new delivery model for implementing an evidence-based violence prevention intervention at scale. GST delivered via RRPs mitigated an increased acceptance of physical discipline and was associated with improvements in school operational culture and reduced teacher physical violence, highlighting the promise of the RRP delivery model for implementing GST
Public health impact of heatwave in Africa: an urgent call for action
Get PDFIntroduction: Heatwaves are a global phenomenon that disproportionately affects low- and lower-middle-income countries. Africa contributes little to global emissions yet faces rising heatwave risk, with direct impacts such as heat exhaustion, heatstroke, and dehydration, and indirect effects on air quality, infectious disease transmission, and mental health. Limited adaptive measures in many African settings highlight the public health gap.
Theory: This review is based on public health and climate adaptation frameworks. It draws on environmental epidemiology, disaster risk reduction, and health system resilience to examine how heatwaves affect vulnerable populations and guide context-specific adaptation strategies.
Method: We conducted a narrative review of studies from 2000, identified through PubMed, Google Scholar, and reports from global health organizations. Titles, abstracts, and reference lists were screened, and key articles and reports were included.
Results: This review identified the direct health effects of heatwaves, including heatstroke, cardiovascular events, and renal dysfunction, and indirect impacts such as worsened respiratory disease, increased vector-borne transmission, and mental health stress. These outcomes fall most heavily on older adults, children, outdoor workers, and people with pre-existing conditions. Projections indicate an increasing frequency and intensity of heatwaves across Africa.
Discussion: Our findings highlight the urgent need for integrated, African-specific adaptations. Priorities include heat health early warning systems, climate-resilient urban planning, targeted public health messaging, and health services. Future research should refine heatwave definitions, apply longitudinal designs, and evaluate adaptation measures to reduce the growing burden on health systems and vulnerable communities