Challenges and opportunities in achieving sustainable development goal 3 in KwaZulu-Natal: reflections from a research institute, South Africa.

BACKGROUND: South Africa is committed to achieving Sustainable Development Goal 3 (SDG 3), which aims to ensure health and well-being for all. However, in rural provinces like KwaZulu-Natal, structural inequalities, socio-cultural challenges, and environmental stressors hinder progress. This study synthesises findings from qualitative research conducted at the Africa Health Research Institute (AHRI) to explore the challenges and opportunities in meeting SDG 3 targets.  METHODS: An integrative literature review was conducted, analysing studies from 2015 to 2024 that focused on SDG 3related topics, including HIV/AIDS, tuberculosis, maternal and child health, sexual and reproductive health, and the impact of climate change. A framework analysis approach was applied to identify common themes, opportunities and challenges to achieving SDG 3 in rural KwaZulu-Natal. RESULTS AND DISCUSSION: Key challenges to achieving SDG 3 include limited access to healthcare, socio-cultural norms that influence health-seeking behaviours, climate-related stressors, and gender disparities. Studies highlighted poor maternal immunisation uptake due to traditional beliefs, stigma-related challenges in HIV prevention, and climate-induced economic hardships affecting treatment adherence. Gendered challenges were prominent, with men’s healthcare engagement being hindered by masculinity norms and adolescent girls facing restricted access to sexual health services. The COVID-19 pandemic further disrupted access to healthcare, particularly for older adults. Despite these challenges, opportunities exist for progress. Community-driven interventions such as DREAMS and MTV-Shuga improved adolescent engagement with sexual health education. Male-focused interventions like Stepping Stones and Creating Futures increased men’s involvement in HIV care. Additionally, integration of climate adaptation strategies into health systems could mitigate environmental health risks.  CONCLUSION: This study provides critical insights for policymakers to enhance the progress towards achieving SDG 3. To do so policymakers should focus on addressing systemic healthcare challenges, integrating gender-responsive interventions, and strengthening community-based health initiatives. Climate-resilient healthcare infrastructure and policies are crucial to ensuring sustained progress. Future efforts should focus on expanding youth-friendly services, enhancing male engagement in healthcare, and leveraging local partnerships to improve health outcomes in rural communities

Rift Valley fever seroprevalence and risk factors among human populations in Uganda's cattle corridor: a cross-sectional study.

INTRODUCTION: Rift Valley fever (RVF) is an epidemic-prone zoonotic disease whose distribution of exposure is poorly described in endemic communities. We investigated the seroprevalence and risk factors for RVF among humans in Uganda's cattle corridor. METHODS: This cross-sectional study used data and stored plasma specimens collected by the Uganda population-based HIV impact assessment (UPHIA) survey 2016/2017. Participants were sampled from 35 districts of the cattle corridor. Ethical and regulatory approvals were obtained to use the UPHIA data and to test the specimens for the presence of RVF anti-Gn glycoprotein immunoglobulin G (anti-Gn IgG) antibodies using an enzyme linked immunosorbent Assay (ELISA). RVF seroprevalence was calculated in Stata with household as the random intercept, and associations between potential determinants and RVF seropositivity were assessed using mixed effects logistic regression analysis. RESULTS: Overall, 267 households comprising 1319 individuals were included in the analysis. Over half (56.3%) of the participants were female, median age 22 (IQR 11-34) years. Most (84.2%) were rural and owned cattle (41.2%), sheep/goats (51.7%) and poultry (65%). The overall RVF seroprevalence was 10.24%, 95% CI 8.63% to 12.10%. RVF seropositivity was associated with advanced age (25-44 years adjusted OR 2.79 (95% CI 1.81 to 4.32); and 45-64 years (3.0 (95% CI 1.76 to 5.14)); ethnicity (Iteso 2.54 (95% CI 1.15 to 5.62), Langi 2.61 (95% CI 1.20 to 5.66) and Karamojong 3.70 (95% CI 1.61 to 8.47)); owning cattle (1.59 (95% CI 1.03 to 2.45)) and owning poultry (1.73 (95% CI 1.05 to 2.87)). CONCLUSIONS: RVF seropositivity is common among humans in Uganda's cattle corridor and the risk of exposure is mostly determined by increasing age, ethnicity, owning cattle and poultry. Future RVF seroprevalence and risk evaluation studies should include poultry as potential determinants of infection

Description of four cases of male genital schistosomiasis (MGS) in children and adolescents, with a scoping review.

We present four cases of male genital schistosomiasis (MGS) within children and adolescents opportunistically encountered as part of a wider screening programme for imported schistosomiasis in Germany and community outreach screening in Mali. Such genital manifestations in young children and adolescents are often overlooked but can include hydrocele, hypogonadism, varicocele, cutaneous granulomata on the penis and scrotum, echogenic spots in the prostate and the epididymis, alongside testicular masses. Though these cases appear sporadic, from our scoping literature review, they draw fresh attention on MGS in young children and highlight wider confusion with other congenital, neoplastic and infectious disease. These might include an insufficient closure of the tunica vaginalis, malignancies or lymphatic filariasis. Frequently haematuria is not present. One typical sign indicating MGS in adults, i.e. haematospermia is not present before puberty. Another reason of missing MGS cases may be that screening with scrotal or transabdominal ultrasonography are not easily accepted unless the reason for it is not extensively explained beforehand and that transabdominal ultrasonography is less sensitive for revealing prostatic lesions than transrectal ultrasonography

Conceptualizing the implementation of post-discharge malaria chemoprevention in Malawi using a co-design approach.

BACKGROUND: Severe malaria poses a significant challenge to under-five children in Malawi, leading to high rates of hospitalization and mortality. The World Health Organization has recently recommended post-discharge malaria chemoprevention (PDMC) as a preventive strategy for under-five children with severe anaemia in malaria-endemic regions. In response to this recommendation, Malawi's Ministry of Health (MoH) plans to implement PDMC nationwide. To facilitate effective implementation, the MoH has partnered with the Training and Research Unit of Excellence (TRUE) to conduct PDMC delivery trials to gather evidence for practical implementation in Malawi and similar settings. A key component of this initiative involved the MoH leading the co-design workshops with key stakeholders to foster collaboration, spur innovation, and develop user-centred strategies. This collaborative effort aimed to investigate optimal PDMC implementation strategies to guide the scale-up in Malawi and contribute to policy-making processes that enhance transparency, accountability, and ownership. METHODS: This participatory action research occurred in the Salima district, Malawi, from 11 to 12 May 2023. Two co-design workshops were utilized, involving policymakers (n = 15), healthcare providers (n = 8), and prospective users (n = 2). The approach consisted of two stages. First, separate information-gathering sessions were held with policymakers, healthcare providers, and prospective users. Second, a structured discussion was facilitated, allowing collaboration between policymakers, healthcare providers, and prospective users to develop strategies for delivering and integrating the intervention. Discussions were audio recorded, transcribed verbatim, and manually analyzed using a thematic approach. RESULTS: The inductive analysis yielded four overarching themes from the data. These key themes are PDMC adaptability, trialability, implementability, and sustainability. Stakeholders recommended adopting PDMC in Malawi, with health facilities as the optimal delivery option, ensuring that discharged children receive dihydroartemisinin-piperaquine doses for three months. PDMC aligns with existing systems, offering integration opportunities for managing childhood illnesses. However, gaps in policy development, approval, and health system strengthening-including supply chain, monitoring, evaluation, and follow-up-must be addressed to ensure PDMC's sustainability. CONCLUSIONS: The co-design results indicate stakeholders' willingness to adopt and implement PDMC in Malawi. However, there is an awareness of the challenges that must be addressed to facilitate PDMC's successful implementation and sustainability

Impacts of discretionary universal free school meal schemes on primary school children’s education attainment and school absence: A natural experiment study in England

Discretionary Universal Free School Meal (UFSM) schemes for 4-11-year-olds were implemented in four local authorities with high child poverty levels in London, UK. The schemes were initiated between 2009/10 and 2014/15. The first scheme was evaluated as part of a national 2-year pilot. The present study concerns the first six years of all four schemes. In addition, we report on the longer-term effects (7+ years) for two of the schemes while the others were interrupted by COVID-19. The intention-to-treat impacts on z-score standardised attainment scores (reading, mathematics) and school absence in 10-11-year-olds were studied in a natural experiment design. We used a dynamic difference-in-differences approach with matched controls in sociodemographically similar neighbourhoods elsewhere in London. UFSM provision was on average not significantly associated with attainment nor absence during the initial six years of the schemes. However, scheme effects differed by local authority with the two longest running schemes showing positive results for reading and mathematics as secondary outcomes. Further studies are needed to better understand the mechanisms, how the schemes impact on the school environments, and how they may be improved

Geographical Differences in SARS-CoV-2 Antibody Response Dynamics and Neutralisation Profiles to Mild COVID-19: Lessons from a UK-Uganda Comparison.

Background: The global SARS-CoV-2 pandemic revealed stark variability in clinical outcomes across populations, underscoring the need for region-tailored vaccination strategies. To inform standardised global immunisation efforts, this study compared longitudinal binding antibody responses and neutralisation capacities in mild COVID-19 cases from Uganda and the United Kingdom (UK). Methods: IgG responses to spike (S) and nucleocapsid (N) proteins, along with IgM responses to S and receptor-binding domain (RBD) proteins, were assessed in 29 Ugandan and 14 UK participants over 84 and 82 days, respectively. Antibody levels were quantified using a validated enzyme-linked immunosorbent assay (ELISA), alongside pseudovirus neutralisation assays targeting the D614G variant. Results: Ugandan participants exhibited higher early IgG and IgM levels, particularly against spike and RBD, with a rapid onset of responses that waned quickly. UK participants showed a slower but sustained increase in IgG and IgM levels. Neutralisation titres revealed elevated responses in 16.4% of Ugandan participants (>2000) compared to 4.5% of UK participants, suggesting a greater sensitivity to viral neutralisation. Conversely, 31.8% of UK participants exhibited low titres (<25) compared to 14.8% of Ugandan participants, indicating differences in resistance mechanisms. Neutralisation correlated strongly with spike and receptor-binding domain IgG in the UK cohort but showed weaker correlations in Ugandan participants. Conclusions: These findings highlight distinct population-level immune responses, suggesting that geographic factors shaped the quality and durability of SARS-CoV-2 immunity. Tailored vaccination strategies are essential to optimise immunity across diverse populations and improve global epidemic preparedness

Foetal growth in pregnant women with HIV.

OBJECTIVE: Pregnant women with HIV (PWHIV) are at increased risk of delivering babies that are small for gestational age (SGA). We aimed to determine the foetal growth trajectories of PWHIV, compared to HIV-negative women. DESIGN: Prospective pregnancy cohort study in Soweto, South Africa, in 2013-2016. METHODS: Serial ultrasound measurements (every 5 ± 1 weeks) of foetal head circumference, biparietal diameter (BPD), abdominal circumference and femur length were obtained from less than 14 weeks' gestation to term. Multivariable linear mixed effects models were used to estimate differences in mean foetal growth measures [head circumference, BPD, abdominal circumference and femur length, and estimated foetal weight (EFW)] and mean foetal growth velocity increments (head circumference, BPD, abdominal circumference, and femur length) according to maternal HIV status. Z -scores and centiles were calculated according to the INTERGROWTH-21 st standards for foetal growth. Multivariable mixed effects logistic regression was used to examine the association of maternal HIV infection with in-utero SGA (EFW <10 th centile) and very SGA (VSGA, EFW <3 rd centile). RESULTS: Ultrasound measurements of 228 PWHIV and 384 HIV-negative pregnant women, with a median of five antenatal ultrasound scans per women, were analysed. There were no significant differences in mean foetal growth measures of head circumference [-0.37 mm, 95% confidence interval (CI) -1.46 to 0.72], BPD (0.07 mm, 95% CI -0.45 to 0.30), abdominal circumference (0.15 mm, 95% CI -1.47 to 1.17), femur length (0.04 mm, 95% CI -0.27 to 0.34) and EFW (1 g, 95% CI 0.98-1.02), and growth velocity increments for head circumference (-0.07 mm/week, 95% CI -0.24 to 0.10), BPD (-0.01 mm/week, 95% CI -0.06 to 0.04), abdominal circumference (0.19 mm/week, 95% CI -0.06 to 0.44) and femur length (0.00 mm/week, 95% CI -0.04 to 0.04) between foetuses of PWHIV and HIV-negative women. The prevalence of SGA ranged between 14.2% and 26.4% for PWHIV and between 18.5% and 24.1% for HIV-negative pregnant women during different gestation windows. There was no significant association between maternal HIV infection and in-utero SGA [adjusted odds ratio (aOR) 0.90, 95% CI 0.54-1.52] or VSGA (aOR 1.16, 95% CI 0.55-1.54). A sensitivity analysis restricted to PWHIV who received efavirenz-based antiretroviral therapy (ART) yielded results consistent with the overall analysis. CONCLUSION: Maternal HIV infection treated with ART does not appear to be associated with altered foetal growth, foetal growth velocity, or in-utero SGA, compared to HIV-negative women. Our findings support current international clinical guidelines recommending ART for PWHIV to improve maternal health and reduce vertical HIV transmission

A global living systematic review and meta-analysis hub of emerging vaccines in pregnancy and childhood.

The COVID-19 pandemic accelerated vaccine development and generated a rapidly evolving body of evidence before and after the vaccine rollout. We developed a robust online platform to efficiently synthesize this emerging information for current and future challenges. Expanding upon our interactive living systematic review-initially focused on COVID-19- we now include chikungunya and Lassa fever (with protocols presented in this issue), Mpox, and Disease X ( https://www.safeinpregnancy.org ). We aim to continuously monitor and periodically update and disseminate high-quality data on vaccine safety, efficacy, effectiveness, and immunogenicity in pregnancy and childhood. This platform computes real-time meta-analyses and features a visualization tool to present findings in a clear and accessible manner, supporting decision-making, vaccine development pipelines, and implementation strategies worldwide. It is also designed to integrate data on a hub of emerging vaccines in pregnancy and childhood and reflects a collaborative effort among multiple organizations

How social norms influence processes of change related to an economic intervention in Bangladesh

Intimate partner violence (IPV) occurs due to multiple factors at the individual, relational, community and societal levels. Previous research has shown that a cash, food and behaviour change communication programme called the Transfer Modality Research Initiative (TMRI) implemented from 2012 to 2014 in Bangladesh had sustained effects on IPV. We collected qualitative data among former TMRI participants in 2023 that allows exploring how social norms may have played a role in shaping the changes related to IPV along four pathways through which TMRI influenced IPV: 1) economic security, 2) family relationships, 3) women's empowerment, and 4) social support and community relationships. We conducted nine focus group discussions (FGDs) with 49 women TMRI participants, nine FGDs with 52 husbands of women TMRI participants, 54 in-depth interviews (IDIs) with women TMRI participants, and 10 IDIs with women who did not participate in TMRI. We find: along 1) women's economic contributions may facilitate weakening of IPV norms, however norms on gender roles and seclusion constrain change; along 2) norms related to family reputation could influence IPV condemnation, however norms on female submission and obedience to in-laws constrain change; along 3) norms on female submission constrain female empowerment but could be weakened if women display knowledge aligning with gender roles; and, along 4) linkages to reduced IPV were less clear, with female seclusion norms constraining change, highlighting the importance of group activities. Our findings draw attention to the potential for economic interventions layered with context-specific norms interventions to achieve longer-term changes in IPV and gender inequalities

Parathyroidectomy and Risk of Incident Diabetes in Patients With Primary Hyperparathyroidism.

IMPORTANCE: Primary hyperparathyroidism (PHPT) is linked to insulin resistance, glucose intolerance, and diabetes. Whether parathyroidectomy is associated with lower risk of diabetes has not been evaluated in a large cohort. OBJECTIVE: To examine the independent association between parathyroidectomy and the risk of incident diabetes in patients with PHPT. DESIGN, SETTING, AND PARTICIPANTS: Patients diagnosed with PHPT between January 2006 and December 2023 were identified from a territorywide electronic health database in Hong Kong and classified into surgical and nonsurgical groups based on presence of subsequent parathyroidectomy. They were followed up with from the index date (first diagnosis of PHPT), until the outcome of interest (incident diabetes), death, or end of the study period (December 2023), whichever came first. EXPOSURE: Parathyroidectomy vs nonsurgical management. MAIN OUTCOMES AND MEASURES: The primary outcome of this study was incident diabetes. Inverse probability of treatment weighting was used to balance all baseline characteristics. Cox proportional hazards regression was used to evaluate the hazard of incident diabetes associated with parathyroidectomy. RESULTS: A total of 3135 patients with PHPT were included (596 [19.0%] surgical and 2539 [81.0%] nonsurgical). The mean (SD) age was 67.5 (14.2) years, and 2211 (70.5%) individuals were female. A total of 518 patients in the nonsurgical group developed incident diabetes during a median (IQR) follow-up of 2.2 (0.9-4.3) years, compared to 156 patients in the surgical group during a median (IQR) follow-up of 5.5 (3.3-8.0) years. Parathyroidectomy was associated with lower risk of incident diabetes (hazard ratio [HR], 0.68 [95% CI, 0.65-0.71]; P 65 years: HR, 0.64 [95% CI, 0.60-0.68] vs HR, 0.68 [95% CI, 0.63-0.72]; interaction P  twice the upper limit of normal vs PTH ≤ twice the upper limit of normal: HR, 0.58 [95% CI, 0.53-0.63] vs HR, 0.73 [95% CI, 0.69-0.77]; calcium > 2.8 vs calcium ≤ 2.8 mmol/L : HR, 0.58 [95%CI, 0.54-0.63] vs HR, 0.69 [95%CI, 0.66-0.73]; interaction P < .001). CONCLUSIONS AND RELEVANCE: In this cohort of patients with PHPT, parathyroidectomy was associated with a lower risk of incident diabetes. The association was more prominent in younger patients and those with more severe PHPT. These results may suggest potential additional metabolic benefits of parathyroidectomy in PHPT