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Aims/hypothesis 6q24 transient neonatal diabetes mellitus (TNDM) is a rare form of diabetes presenting in the neonatal period that remits during infancy but, in a proportion of cases, recurs in later life. We aim to describe the clinical presentation of 6q24 TNDM in the largest worldwide cohort of patients with defined molecular aetiology, in particular seeking differences in presentation or clinical history between aetiological groups. Methods One-hundred and sixty-three patients with positively diagnosed 6q24 TNDM were ascertained from Europe, the Americas, Asia and Australia. Clinical data from referrals were recorded and stratified by the molecular aetiology of patients. Results 6q24 TNDM patients presented at a modal age of one day, with growth retardation and hyperglycaemia, irrespective of molecular aetiology. There was a positive correlation between age of presentation and gestational age, and a negative correlation between adjusted birthweight SD and age of remission. Congenital anomalies were significantly more frequent in patients with paternal uniparental disomy of chromosome 6 or hypomethylation of multiple imprinted loci defects than in those with 6q24 duplication or isolated hypomethylation defects. Patients with hypomethylation had an excess representation of assisted conception at 15%. Conclusions/interpretation This, the largest case series of 6q24 TNDM published, refines and extends the clinical phenotype of the disorder and confirms its clinical divergence from other monogenic TNDM in addition to identifying previously unreported clinical differences between 6q24 subgroups.

This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation [Grant Number: OPP1144]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. Funding was also provided by the Dudley Stamp Memorial Award from the Royal Geographical Society. The Alborada Trust provides support for James Wood.

Introduction Pregnant women in sub-Saharan Africa represent a high-risk group for HIV infection, but most endemic countries including Uganda do not engage specific HIV prevention measures in pregnancy. This longitudinal study aimed to assess outcomes of a comprehensive, ANC-embedded strategy to prevent seroconversions during pregnancy in Western Uganda. Methods HIV-negative ANC clients were administered an HIV risk assessment tool, followed by individual risk counselling. They received a fixed appointment for repeat HIV testing after three months. Those attending ANC without partners obtained formal partner invitation letters. At follow-up after three months, women not attending repeat testing were reminded via text message. Post-intervention risk behavior engagement was captured. We analyzed uptake of the intervention, HIV incidence rate, and associations with risk behavior. Results Of 1081 participants, 116 (10.7%) reported risk behavior engagement at first ANC visit, 148/1081 (13.7%) were accompanied by partners. The repeat test visit was attended by 848/1081 (78.5%) women, 42 (5.0%, p < 0.001) reported post-intervention risk behavior engagement, and 248 (29.4%, p < 0.001) were accompanied by partners. Seroconversion occurred in two women. In multivariable logistic regression, rural facility clients compared to urban ones (aOR 3.96; 95%CI 1.53-10.26), and women with positive or unknown partner HIV-status (aOR 2.86; 1.18-6.91) and partner alcohol abuse (aOR 2.68; 1.15-6.26) had increased odds for engagement in risk behavior despite the intervention. Conclusions After our intervention, risk behavior in pregnancy was reduced by half, and partner attendance had doubled compared to baseline. Our cohort showed a 0.76/100 women-years HIV incidence rate compared to 2.85 in pre-intervention data from the same setting. Clients from rural settings and women experiencing precarious partner situations require special attention to reduce risk behavior engagement during pregnancy. Key messages • HIV incidence in pregnancy in Western Uganda can be significantly reduced through a comprehensive, ANC-based counselling intervention. • Pregnant women from rural settings and those experiencing precarious partner situations require special attention regarding sexual risk behavior.

Introduction: The COVID-19 pandemic overwhelmed health systems globally and affected the delivery of health services. We conducted a study in Uganda to describe the interventions adopted to maintain the delivery of other health services. Methods: We reviewed documents and interviewed 21 key informants. Thematic analysis was conducted to identify themes using the World Health Organization health system building blocks as a guiding framework. Results: Governance strategies included the establishment of coordination committees and the development and dissemination of guidelines. Infrastructure and commodity strategies included the review of drug supply plans and allowing emergency orders. Workforce strategies included the provision of infection prevention and control equipment, recruitment and provision of incentives. Service delivery modifications included the designation of facilities for COVID-19 management, patient self-management, dispensing drugs for longer periods and the leveraging community patient networks to distribute medicines. However, multi-month drug dispensing led to drug stock-outs while community drug distribution was associated with stigma. Conclusions: Health service maintenance during emergencies requires coordination to harness existing health system investments. The essential services continuity committee coordinated efforts to maintain services and should remain a critical element of emergency response. Self-management and leveraging patient networks should address stigma to support service continuity in similar settings and strengthen service delivery beyond the pandemic.

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response. This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery. Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork. In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

In Uganda, 22% of all women of reproductive age have an unmet need for family planning services. Access to contraceptive services, especially long-term reversible contraceptives such as implants, remains a challenge. The number of trained health providers is also not sufficient to address the needs for contraception. The Uganda Ministry of Health implemented a community-based implant provision pilot project where community health extension workers (CHEWs) were trained and accredited to insert implants at community level. This study aims to evaluate the implementation and acceptability of stakeholders toward task shifting the provision of family planning implants to CHEWs in Uganda. The evaluation will use a cross-sectional design using both quantitative and qualitative methods. The quantitative component will use a noninferiority design, whereas the qualitative component will use a descriptive approach. The noninferiority design involves a comparison of the competence of the currently authorized cadre to offer the service to the proposed cadre (CHEWs). Compared with a randomized controlled trial, the noninferiority design is more appropriate for this evaluation because the CHEWs and the authorized cadre are not comparable in terms of level of training and competencies. The authorized cadre has gone through formal training, which is not comparable with the training the CHEWs have received, and so the comparison is such that the competencies of the CHEWs are noninferior or at most equal to the competencies of the authorized cadre. Quantitative data will be collected among 92 CHEWs and 92 qualified health workers using performance assessment checklists and practice-based questionnaires that were developed based on the training manuals. Competency will be measured on a continuous scale and summarized as mean (SD) scores. Qualitative data will be collected through key informant interviews (n=23), in-depth interviews (n=24), and focus group discussions (n=18). Qualitative data will be analyzed using thematic analysis following the framework method for the analysis of qualitative data using ATLAS.ti (version 9). Preliminary findings indicate improved confidence and capacity of community health workers to provide implants despite challenges such as poor waste disposal, record keeping, and data management. By August 2025, training of research assistants had been concluded, and data collection had started. We anticipate that the data collection will be completed by the end of October 2025, the data analysis will be completed by November 2025, and the final results will be published by December 2026. This pilot will generate contextual information that can be used to improve access to family planning services at the community level.

Background Private entities play a major role in health globally. However, their contribution has not been fully optimized to strengthen delivery of public health services. The COVID-19 pandemic has overwhelmed health systems and precipitated coalitions between public and private sectors to address critical gaps in the response. We conducted a study to document the public and private sector partnerships and engagements to inform current and future responses to public health emergencies. Methods This was a multi-country cross-sectional study conducted in the Democratic Republic of Congo, Nigeria, Senegal and Uganda between November 2020 and March 2021 to assess responses to the COVID-19 pandemic. We conducted a scoping literature review and key informant interviews (KIIs) with private and public health sector stakeholders. The literature reviewed included COVID-19 country guidelines and response plans, program reports and peer-reviewed and non-peer-reviewed publications. KIIs elicited information on country approaches and response strategies specifically the engagement of the private sector in any of the strategic response operations. Results Across the 4 countries, private sector strengthened laboratory systems, COVID-19 case management, risk communication and health service continuity. In the DRC and Nigeria, private entities supported contact tracing and surveillance activities. Across the 4 countries, the private sector supported expansion of access to COVID-19 testing services through establishing partnerships with the public health sector albeit at unregulated fees. In Senegal and Uganda, governments established partnerships with private sector to manufacture COVID-19 rapid diagnostic tests. The private sector also contributed to treatment and management of COVID-19 cases. In addition, private entities provided personal protective equipment, conducted risk communication to promote adherence to safety procedures and health promotion for health service continuity. However, there were concerns related to reporting, quality and cost of services, calling for quality and price regulation in the provision of services. Conclusions The private sector contributed to the COVID-19 response through engagement in COVID-19 surveillance and testing, management of COVID-19 cases, and health promotion to maintain health access. There is a need to develop regulatory frameworks for sustainable public–private engagements including regulation of pricing, quality assurance and alignment with national plans and priorities during response to epidemics.

Although existing disease preparedness and response frameworks provide guidance about strengthening emergency response capacity, little attention is paid to health service continuity during emergency responses. During the 2014 Ebola outbreak, there were 11,325 reported deaths due to the Ebola virus and yet disruption in access to care caused more than 10,000 additional deaths due to measles, HIV/AIDS, tuberculosis, and malaria. Low- and middle-income countries account for the largest disease burden due to HIV, tuberculosis, and malaria and yet previous responses to health emergencies showed that HIV, tuberculosis, and malaria service delivery can be significantly disrupted. To date, there has not been a systematic synthesis of interventions implemented to maintain the delivery of these services during emergencies. This study aimed to synthesize the interventions implemented to maintain HIV/AIDS, tuberculosis, and malaria services during public health emergencies in low- and middle-income countries. The systematic review was registered in the international register for prospective systematic reviews. It will include activities undertaken to improve human health either through preventing the occurrence of HIV, tuberculosis, or malaria, reducing the severity among patients, or promoting the restoration of functioning lost as a result of experiencing HIV, tuberculosis, or malaria during health emergencies. These will include policy-level (eg, development of guidelines), health facility-level (eg, service rescheduling), and community-level interventions (eg, community drug distribution). Service delivery will be in terms of improving access, availability, use, and coverage. We will report on any interventions to maintain services along the care cascade for HIV, tuberculosis, or malaria. Peer-reviewed study databases including MEDLINE, Web of Science, Embase, Cochrane, and Global Index Medicus will be searched. Reference lists from global reports on HIV/AIDS, tuberculosis, or malaria will also be searched. We will use the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation-Confidence in Evidence from Reviews of Qualitative Research) approach to report on the quality of evidence in each paper. The information from the studies will be synthesized at the disease or condition level (HIV/AIDS, tuberculosis, and malaria), implementation level (policy, health facility, and community), and outcomes (improving access, availability, use, or coverage). We will use the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist to report findings and discuss implications for strengthening preparedness and response, as well as strengthening health systems in low- and middle-income countries. The initial search for published literature was conducted between January 2023 and March 2023 and yielded 8119 studies. At the time of publication, synthesis and interpretation of results were being concluded. Final results will be published in 2025. The findings will inform the development of national and global guidance to minimize disruption of services for patients with HIV/AIDS, tuberculosis, and malaria during public health emergencies. PROSPERO CRD42023408967; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=408967. PRR1-10.2196/64316.

Mortality data are critical for planning and prioritization of public health interventions and are generated through civil registration and vital statistics systems like mortality surveillance systems. However, frameworks for strengthening mortality surveillance systems do not acknowledge the cultural relativism surrounding death and how it influences strategies to improve mortality surveillance systems. This paper aims to describe the experiences and perceptions about death reporting and notification among rural dwellers on the islands of Lake Victoria in Central Uganda. The study was conducted in Buvuma and Kalangala Districts on Lake Victoria using a phenomenological qualitative research design. We conducted 12 in-depth interviews with community members who were purposively identified by village leaders and had experienced the death of a next of kin and reported and notified, and 8 in-depth interviews with those who had experienced the loss of a next of kin but did not notify and report the death. Key informant interviews were also conducted with 2 police officers and 2 cultural leaders. A total of 4 focus group discussions were conducted among village leaders. Interviews were abductively analyzed to generate grand narratives. The findings revealed 6 grand narratives of the perceptions and experiences of the process of death reporting and notification among the rural dwellers. These include (1) death reporting and notification are preceded by a tragic event that affects how, when, and if it is conducted; (2) a long and cumbersome process; (3) a process that involves multiple stakeholders with official and unofficial roles and responsibilities; (4) a process with little perceived individual or societal value; (5) a process with several mandatory but unofficial costs; and (6) a process preceded by events with deep cultural undertones. Death reporting and notification are perceived to be tedious and cumbersome, which discourages community members from conducting them. There is a need to evaluate the process to remove any perceived or actual barriers through strategies such as decentralization of the process to lower levels of political administration. Death reporting and notification are also part of a broader social context that includes cultural beliefs, norms, and traditions. Efforts to strengthen mortality surveillance systems would profit from acknowledging the broader sociocultural issues around death and grieving and the role that cultural and religious institutions can contribute to addressing misconceptions and articulating the benefit of the process to society.

Background The Coronavirus disease (COVID-19) pandemic caused significant morbidity and mortality in Africa, in addition to other socio-economic consequences. Across the continent, Schools of Public Health (SPHs) played several roles in supporting national, regional, and global response to the pandemic. Following a published and grey literature search, this paper reviews and analyses the contribution of SPHs in Africa during the COVID-19 pandemic. Contribution of the Schools of Public Health SPH faculty in most countries contributed their expertise through COVID-19 task forces and advisory committees where they guided and supported decision-making. Faculty also supported the identification, review, and synthesis of rapidly evolving global and local evidence, adapting it to the local context to guide policy decisions. Through research, SPHs contributed to a better understanding of the disease epidemiology, response interventions, as well as prevention and control measures. SPHs engaged in training field epidemiologists, frontline health workers, and district response teams. SPH staff, students and field epidemiology trainees also supported field activities including surveillance, contact tracing, as well as managing quarantine facilities and points of entry. SPHs engaged in public education and awareness-raising initiatives to share information and dispel misinformation. In partnership with other stakeholders, SPHs also developed important innovations and technologies. Conclusion SPHs are a critical pillar for pandemic prevention, preparedness, and response, that support health systems with important functions. To further enhance their capacity, efforts to improve coordination of SPHs, strengthen collaboration among schools, harmonize training and curricula, and enhance capacity for advanced research are needed. There is also a need to bridge the inequities in capacity and resources that exist among SPHs across regions and countries.