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In 2023, the World Health Organization (WHO) revised its guidelines for management of severe acute malnutrition (SAM). The revised guidelines include a focus on infants at risk of poor growth and development. The guideline identifies evaluation of routine antibiotics for these infants as a priority research area. We pooled data from two large randomized controlled trials evaluating azithromycin for prevention of infant mortality in Burkina Faso to assess whether azithromycin reduces mortality or wasting in this subgroup. Infants in the two trials were 1-12 weeks of age at enrollment. Infants were considered at risk of poor risk of growth and development per WHO: underweight (weight-for-age Z-score, WAZ < -2), wasted (weight-for-length Z-score, WLZ < -2), or MUAC < 11.0 cm among infants ≥6 weeks of age. Infants were randomized to a single oral (20 mg/kg) dose of azithromycin or matching placebo and were followed until 6 months of age. We evaluated vital status, underweight (WAZ < -2), wasting (WLZ < -2), and stunting (length-for-age Z-score, LAZ) at 6 months among infants at risk of poor growth and development based on WHO single measurement criteria. A total of 54,709 infants were enrolled in the two trials. Of these, 9,728 were at risk of poor growth and development based on baseline WAZ (N = 5,385), WLZ (N = 6,022), or MUAC (N = 1,541). We found no evidence of a difference in mortality (1.3% vs 1.1%, odds ratio, OR, 1.19, 95% confidence interval, CI, 0.82 to 1.72) or wasting (20.6% vs 20.2%, OR 1.03, 95% CI 0.92 to 1.14) at 6 months among infants receiving azithromycin versus placebo. In infants aged 1-12 weeks at risk of poor growth and development, we do not have evidence that single dose azithromycin reduces mortality or improves growth outcomes. ClinicalTrials.gov NCT03682654 and NCT03676764.

Screening for colorectal cancer (CRC) provides an effective strategy for early detection and prevention of the disease; however, global screening rates are still low. This study aims at assessing the awareness of CRC risk factors, warning signs, and attitudes towards CRC guidelines and screening modalities, in order to identify the barriers to and correlates of CRC screening in the Lebanese population. A self-administered questionnaire was distributed to 371 participants in the largest health care medical center in Lebanon. A validated 12- and 9-item Cancer Awareness Measurement questionnaire was used to assess participants' awareness of CRC risk factors and warning signs. 83% and 67% of participants were not aware of CRC risk factors and warning signs, respectively, 15% have previously undergone CRC screening, 56% were aware of the necessity for screening, and 43% were willing to undergo screening. Factors affecting awareness of the necessity for CRC screening, past screening and willingness to screen included awareness of risk factors and warning signs, undergoing regular physician check-ups, having a family physician as a primary source of knowledge of CRC, and knowing a family member or friend diagnosed with CRC. Barriers to screening were related to participants' evaluation of the screening technique and misconceptions about this disease. Serious active measures should be taken by health care sectors, authoritative groups, primary care physicians, and awareness campaigns to fill the gap in awareness of this disease and to alleviate the barriers and misconceptions around it.

Antibiotic use during early infancy has been linked to childhood obesity in high-income countries. We evaluated whether a single oral dose of azithromycin administered during infant-well visits led to changes in infant growth outcomes at 6 months of age in a setting with a high prevalence of undernutrition in rural Burkina Faso. Infants were enrolled from September 25, 2019, until October 22, 2022, in a randomized controlled trial designed to evaluate the efficacy of a single oral dose of azithromycin (20 mg/kg) compared to placebo when administered during well-child visits for prevention of infant mortality. The trial found no evidence of a difference in the primary endpoint. This paper presents prespecified secondary anthropometric endpoints including weight gain (g/day), height change (mm/day), weight-for-age Z-score (WAZ), weight-for-length Z-score (WLZ), length-for-age Z-score (LAZ), and mid-upper arm circumference (MUAC). Infants were eligible for the trial if they were between 5 and 12 weeks of age, able to orally feed, and their families were planning to remain in the study area for the duration of the study. Anthropometric measurements were collected at enrollment (5 to 12 weeks of age) and 6 months of age. Among 32,877 infants enrolled in the trial, 27,298 (83%) were followed and had valid anthropometric measurements at 6 months of age. We found no evidence of a difference in weight gain (mean difference 0.03 g/day, 95% confidence interval (CI) -0.12 to 0.18), height change (mean difference 0.004 mm/day, 95% CI -0.05 to 0.06), WAZ (mean difference -0.004 SD, 95% CI -0.03 to 0.02), WLZ (mean difference 0.001 SD, 95% CI -0.03 to 0.03), LAZ (mean difference -0.005 SD, 95% CI -0.03 to 0.02), or MUAC (mean difference 0.01 cm, 95% CI -0.01 to 0.04). The primary limitation of the trial was that measurements were only collected at enrollment and 6 months of age, precluding assessment of shorter-term or long-term changes in growth. Single-dose azithromycin does not appear to affect weight and height outcomes when administered during early infancy. ClinicalTrials.gov NCT03676764.

Background Delays in care-seeking for childhood illness may lead to more severe outcomes. We evaluated whether community distance from a primary healthcare facility was associated with decreased healthcare utilization in a rural district of northwestern Burkina Faso. Methods We conducted passive surveillance of all government-run primary healthcare facilities in Nouna District, Burkina Faso from March 1 through May 31, 2020. All healthcare visits for children under 5 years of age were recorded on a standardized form for sick children. We recorded the age, sex, and community of residence of the child as well as any diagnoses and treatments administered. We calculated healthcare utilization per 100 child-months by linking the aggregate number of visits at the community level to the community’s population of children under 5 months per a census that was conducted from August 2019 through February 2020. We calculated the distance between each community and its corresponding healthcare facility and assessed the relationship between distance and the rate of healthcare utilization. Results In 226 study communities, 12,676 primary healthcare visits were recorded over the three-month period. The median distance between the community and primary healthcare facility was 5.0 km (IQR 2.6 to 6.9 km), and median number of healthcare visits per 100 child-months at the community level was 6.7 (IQR 3.7 to 12.3). The rate of primary healthcare visits declined with increasing distance from clinic (Spearman’s rho − 0.42, 95% CI − 0.54 to − 0.31, P  < 0.0001). This relationship was similar for cause-specific clinic visits (including pneumonia, malaria, and diarrhea) and for antibiotic prescriptions. Conclusions We documented a distance decay effect between community distance from a primary healthcare facility and the rate of healthcare visits for children under 5. Decreasing distance-related barriers, for example by increasing the number of facilities or targeting outreach to more distant communities, may improve healthcare utilization for young children in similar settings.

Background While Seasonal Malaria Chemoprevention (SMC) has been adopted as a malaria control strategy in regions with seasonal transmission, continued monitoring and evaluation of its effectiveness across diverse ecological, epidemiological, and healthcare settings remain critical for optimizing the intervention. This study aims to assess the ongoing population-level impact of SMC under routine programme conditions by evaluating rates of uncomplicated and severe malaria following four rounds of administration. Methods A pre-post analysis was conducted using real-world surveillance data from clinic visits in 285 villages in Nouna District, Burkina Faso, along with National Malaria Control Programme data on SMC administration. Estimates of the population used for person-time calculations were derived from a census conducted as part of a randomized controlled trial. Malaria rates for children under 5 were analyzed for each epidemiological week in 2021, for each health post in the study area. Negative binomial regression models were used, with person-time at risk used as an offset and standard errors clustered by health post, to obtain incidence rate ratios (IRRs) and rate differences. Changes in diagnoses were estimated from the administration weeks to each of the three weeks post- administration within the same population. Injury rates were used as a negative control outcome to assess potential unmeasured confounding. Results Although SMC was administered during peak malaria transmission weeks within each cycle, both uncomplicated and severe malaria rates remained high through December, following the fourth and final round of SMC. There was a substantial reduction in infection rates in the 3 weeks post SMC, with gradual increases in rates across the three weeks. The rates of uncomplicated and severe malaria per 1000 person-weeks in the administration weeks were 8.5 (95% CI 7.0 to 10.1) and 0.31 (95% CI 0.22 to 0.40), respectively. Uncomplicated malaria rates were lower by 41%, 95%CI (31–50%), 34% (23–43%) and 22% (12–31%) in the first, second and third weeks after administration, respectively. Severe malaria rates declined by 47% (21–64%), 47% (31–59%) and 34% (17–47%) in the three weeks post-administration. Injury rates, the negative control outcome, did not change significantly across the three weeks. Conclusion In programme settings, at the population level, SMC administration was associated with a substantial reduction in uncomplicated and severe malaria, though this effect was limited to the immediate weeks following administration. The gradual increase in malaria rates by the third week suggests a shorter duration of protection than previously observed. Extending the areas where 5 rounds of distribution occur may be necessary to effectively prevent malaria infections in regions with a longer transmission season. Regular evaluation of local malaria trends and impact of SMC can help further tailor and optimize SMC programmes for specific regional contexts.

Background In many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria. Methods A cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed. Results Across the three countries, fewer primary health facilities (ranging from 6.3–12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26–43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services. Conclusions Our findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities.

Strongyloidiasis is an underappreciated helminth infection that belongs to a group of neglected tropical diseases. The aim of this systematic review and meta-analysis was to determine the pooled prevalence of Strongyloides stercoralis infection in humans in 16 West African countries. We searched African Journals Online, Embase, Horizon, Google Scholar, ProQuest, PubMed, Scopus, and Web of Science to identify articles assessing S. stercoralis prevalence data. The search was restricted to articles published between 1 January 1975 and 31 December 2024 without language restriction. We followed the PRISMA guidelines. A total of 21,250 articles were identified, 336 of which met the inclusion criteria. The most frequently used diagnostic tools were Kato-Katz (35.1%) and formol-ether coprological methods (23.4%). Strongyloidiasis was reported in 15 of the 16 West African countries; Mali was the only country where it was absent. The S. stercoralis regional prevalence was 4.4%, ranging from 0.2% in Burkina Faso to 18.9% in The Gambia. S. stercoralis infection prevalence decreased from 14.0% (1975–1984) to 4.1% (2015–2024). S. stercoralis prevalence showed strong heterogeneity with the highest prevalence mainly observed in countries in the Gulf of Guinea. Most of the employed diagnostic techniques were inappropriate; the reported S. stercoralis prevalence is, thus, likely an underestimation of the true situation. Our observations call for more sensitive S. stercoralis diagnostic tools and strategies for strongyloidiasis control that are tailored to the different social-ecological settings of West Africa.

Background Biannual, mass azithromycin distribution has previously been shown to reduce all-cause child mortality in sub-Saharan Africa. Subgroup analysis suggested that the strongest effects were in the youngest children, leading to the hypothesis that targeting younger age groups might be an effective strategy to prevent mortality. We present the methods of two randomized controlled trials designed to evaluate mass and targeted azithromycin distribution for the prevention of child mortality in Burkina Faso, West Africa. Methods/design The Child Health with Azithromycin Treatment (CHAT) study consists of two nested, randomized controlled trials. In the first, communities are randomized in a 1:1 fashion to biannual, mass azithromycin distribution or placebo. The primary outcome is under-5 all-cause mortality measured at the community level. In the second, children attending primary healthcare facilities during the first 5–12 weeks of life for a healthy child visit (e.g., for vaccination) are randomized in a 1:1 fashion to a single orally administered dose of azithromycin or placebo. The primary outcome is all-cause mortality measured at 6 months of age. The trial commenced enrollment in August 2019. Discussion This study is expected to provide evidence on two health systems delivery approaches (mass and targeted treatment) for azithromycin to prevent all-cause child mortality. The results will inform global and national policies related to azithromycin for the prevention of child mortality. Trial registration ClinicalTrials.gov, ID: NCT03676764 . Registered on 19 September 2018; prospectively registered pre results.

Background Preventive chemotherapy with praziquantel is the cornerstone of schistosomiasis control. However, in some social-ecological settings, the prevalence and/or intensity of Schistosoma infection does not lower meaningfully despite multiple rounds of preventive chemotherapy, a phenomenon termed persistent hotspot (PHS). We assessed the characteristics of PHS in a Schistosoma mansoni -endemic area of Côte d’Ivoire. Methods In October 2016, a cross-sectional survey was conducted in 14 schools in the western part of Côte d’Ivoire, one year after multiple rounds of preventive chemotherapy. In each school, 50 children aged 9–12 years provided two stool samples and one urine sample. Stool samples were subjected to triplicate Kato-Katz thick smears for S. mansoni diagnosis. Urine samples were examined by a filtration method for S. haematobium eggs. PHS was defined as failure to achieve a reduction in the prevalence of S. mansoni infection of at least 35% and/or a reduction of infection intensity of at least 50%. Six schools underwent more detailed investigations, including a questionnaire survey for demographic characteristics and a malacological survey. Results In the six schools subjected to detailed investigations, the overall prevalence of S. mansoni and S. haematobium was 9.5% and 2.6%, respectively. Four schools were classified as PHS. The S. mansoni prevalence in the four PHS was 10.9% compared to 6.6% in the remaining two schools. The S. mansoni infection intensity, expressed as arithmetic mean eggs per gram of stool (EPG) among infected children, was 123.8 EPG in PHS and 18.7 EPG in the other two schools. Children bathing in open freshwater bodies were at higher odds of S. mansoni infection (odds ratio: 4.5, 95% confidence interval: 1.6–12.6). A total of 76 human-water contact sites (53 in PHS and 23 in the other schools) were examined and 688 snails were collected, including potential intermediate host snails of Schistosoma ( Biomphalaria pfeifferi , Bulinus forskalii , Bu. globosus and Bu. truncatus ). Conclusion Children in PHS schools bathed more frequently in open freshwater bodies, and hence, they are more exposed to Schistosoma transmission. Our findings call for an integrated control approach, complementing preventive chemotherapy with other interventions, particularly in PHS settings.

More than 1 billion people are currently infected with soil-transmitted helminths and schistosomes. The global strategy to control helminthiases is the regular administration of anthelmintic drugs to at-risk populations. However, rapid re-infection occurs in areas where hygiene, access to clean water, and sanitation are inadequate. In July 2011, inhabitants from two villages and seven hamlets of the Taabo health demographic surveillance system in south-central Côte d'Ivoire provided stool and urine samples. Kato-Katz and ether-concentration methods were used for the diagnosis of Schistosoma mansoni, soil-transmitted helminths (Ascaris lumbricoides, Trichuris trichiura, and hookworm), and intestinal protozoa. Urine samples were subjected to a filtration method for the diagnosis of Schistosoma haematobium. A questionnaire was administered to households to obtain information on knowledge, attitude, practice, and beliefs in relation to hygiene, sanitation, and defecation behavior. Logistic regression models were employed to assess for associations between questionnaire data and parasitic infections. A total of 1,894 participants had complete data records. Parasitological examinations revealed prevalences of hookworm, S. haematobium, T. trichiura, S. mansoni, and A. lumbricoides of 33.5%, 7.0%, 1.6%, 1.3% and 0.8%, respectively. Giardia intestinalis and Entamoeba histolytica/E. dispar were detected in 15.0% and 14.4% of the participants, respectively. Only one out of five households reported the presence of a latrine, and hence, open defecation was common. Logistic regression analysis revealed that age, sex, socioeconomic status, hygiene, and defecation behavior are determinants for helminths and intestinal protozoa infections. We found that inadequate sanitation and hygiene behavior are associated with soil-transmitted helminths and intestinal protozoa infections in the Taabo area of south-central Côte d'Ivoire. Our data will serve as a benchmark to monitor the effect of community-led total sanitation and hygiene education to reduce the transmission of helminthiases and intestinal protozoa infections.