PLOS https://journals.plos.org/plosntds/ customercare@plos.org https://journals.plos.org/plosntds/feed/atom All PLOS articles are Open Access. https://journals.plos.org/plosntds/resource/img/favicon.ico https://journals.plos.org/plosntds/resource/img/favicon.ico 2026-10-02T17:39:45Z Eimear Griffin Thiago da Mata Barreto Zoe Ward Juliet Oliveira Santana Hussein Khalil Mike Begon Mitermayer Galvão G. Reis Cleber Cremonese Federico Costa Hernan D. Argibay Guy Howard 10.1371/journal.pntd.0014728 2026-10-01T14:00:00Z 2026-10-01T14:00:00Z <p>by Eimear Griffin, Thiago da Mata Barreto, Zoe Ward, Juliet Oliveira Santana, Hussein Khalil, Mike Begon, Mitermayer Galvão G. Reis, Cleber Cremonese, Federico Costa, Hernan D. Argibay, Guy Howard</p> Disadvantaged communities characterised by poor sanitation conditions, overcrowding, and limited vector control are highly susceptible to <i>Aedes aegypti</i> proliferation and arboviral disease transmission. Effective mosquito vector control requires a detailed understanding of <i>Ae. aegypti</i> oviposition preferences and spatial distribution within such urban environments. This study aimed to identify key environmental and behavioural drivers of <i>Ae. aegypti</i> proliferation in disadvantaged communities of Salvador, Brazil, combining household surveys, entomological assessments, and remote sensing to guide targeted public health interventions. Between March and December 2023, using a systematic sampling approach, an entomological survey was conducted in 174 households, alongside a socio-demographic and environmental visual inspection survey in 119 households within two disadvantaged communities of Salvador. Ovitraps were used to collect <i>Ae. aegypti</i> eggs and immatures, providing a detailed assessment of mosquito density. The visual inspection survey identified potential breeding sites (sources of standing water) for <i>Ae. aegypti</i> in the peri-domestic environment. Landcover classification was performed to provide insights into vegetation coverage and other landscape features in the study area. Multivariate modelling explored associations between environmental and household factors, and <i>Ae. aegypti</i> density. Of the 303 recovered ovitraps, 85 (55.6%) indoor and 123 (82.0%) outdoor were positive for eggs, with a total of 11,211 <i>Ae. aegypti</i> eggs recorded. Environmental factors strongly associated with egg abundance included ovitrap location, garbage deposited in front of the house, proximity (within 10 m) to an open sewer, and the presence of open plastic containers in the peri-domestic environment. No significant spatial clustering of mosquito egg density was observed. Breeding was most prolific in the peri-domestic environment, highlighting the importance of keeping these areas clean and well-managed. Improving waste disposal, water storage practices, and sanitation infrastructure could enhance the effectiveness of vector control. These findings provide evidence to inform integrated strategies for reducing arboviral disease risk in disadvantaged urban settings. Maximilian Augé Stock Dearie Glory Okwu Ayong More Anna Doralt Rodrigue Bikangui Ismaël Pierrick Mikelet Boussoukou Kirsten Alexandra Eberhardt Maren Sandkuhl Rella Zoleko Manego Ghyslain Mombo-Ngoma Matthew McCall Minka Breloer Meral Esen Marylyn Addo Bertrand Lell Luzia Veletzky Rafiou Adamou Maria Sophia Mackroth 10.1371/journal.pntd.0014104 2026-10-01T14:00:00Z 2026-10-01T14:00:00Z <p>by Maximilian Augé Stock, Dearie Glory Okwu, Ayong More, Anna Doralt, Rodrigue Bikangui, Ismaël Pierrick Mikelet Boussoukou, Kirsten Alexandra Eberhardt, Maren Sandkuhl, Rella Zoleko Manego, Ghyslain Mombo-Ngoma, Matthew McCall, Minka Breloer, Meral Esen, Marylyn Addo, Bertrand Lell, Luzia Veletzky, Rafiou Adamou, Maria Sophia Mackroth</p> Background <p>Loiasis is a chronic filarial infection endemic to Central and West Africa. Although long considered benign, increasing evidence links loiasis to substantial morbidity and mortality. The infection is associated with immune modulation, including Th2-skewed responses and elevated regulatory cytokines. Clinically, loiasis is classified as microfilaremic (presence of circulating microfilariae) or amicrofilaremic (“occult”) disease, the latter defined by a history of eyeworm migration without detectable microfilaremia. This study investigated how chronic <i>L. loa</i> infection influences antibody and T cell responses to SARS-CoV-2 following natural infection.</p> Methods <p>Between 2022 and 2024, this cross-sectional study was done in rural and periurban villages of the Ngounié and Moyen-Ogooué provinces of Gabon. Study procedures included diagnostics for loiasis and immunological assays. Microfilaremia was confirmed by stained blood smear microscopy, and occult disease was identified using the Rapid Assessment Procedure for Loiasis. SARS-CoV-2-specific IgG responses to spike and nucleocapsid proteins were measured by ELISA, and IFN-γ responses to spike antigen were assessed using an interferon-gamma release assay.</p> Results <p>Overall, 192 participants were categorized as microfilaremic (n = 43), occult loiasis (n = 59), or without evidence of active loiasis (n = 90). IFN-γ responses were reduced in microfilaremic individuals compared with other participants (<i>p</i> = 0.031), whereas IgG responses did not differ. Subsequent analysis across the three groups confirmed that IFN-γ responses were lower in microfilaremic compared with occult participants (<i>p</i> = 0.012).</p> Conclusion <p>These findings suggest that microfilaremic loiasis may impair proinflammatory T cell responses to viral antigens, highlighting the need for further research into the broader immunological effects of <i>Loa loa</i> infection in endemic populations.</p> Audra Bass Heloine Leite Lorena B. P. Oliveira Emma Nedell Pedro Marçal Julie A. Clennon Jeffrey M. Collins Thomas R. Ziegler Erica Magueta Silva Maisa P. Vieira Marcos D. S. Pinheiro Alexandre C. Branco José A. Ferreira Lance Waller Lucia A. O. Fraga Jessica K. Fairley 10.1371/journal.pntd.0013285 2026-10-01T14:00:00Z 2026-10-01T14:00:00Z <p>by Audra Bass, Heloine Leite, Lorena B. P. Oliveira, Emma Nedell, Pedro Marçal, Julie A. Clennon, Jeffrey M. Collins, Thomas R. Ziegler, Erica Magueta Silva, Maisa P. Vieira, Marcos D. S. Pinheiro, Alexandre C. Branco, José A. Ferreira, Lance Waller, Lucia A. O. Fraga, Jessica K. Fairley</p> Background <p>Neglected tropical diseases are often co-endemic in affected areas but how they interact is less clear, especially in the case of Hansen’s Disease (HD), commonly referred to as leprosy. Prior studies have demonstrated associations between helminths and HD and tuberculosis, but our understanding of the epidemiology of these infections is limited. Our goal was to assess the prevalence and potential associations of <i>Mycobacterium leprae</i> infection and parasitic infections in a sample of community members in a highly endemic area for HD in Minas Gerais, Brazil.</p> Methods <p>Adults and children ages 3 years and older were enrolled from communities in Governador Valadares, Minas Gerais, Brazil, and nearby municipalities. Questionnaires on demographics and infection history were administered. Serological reactivity against <i>M. leprae</i>, <i>Schistosoma mansoni,</i> and <i>Strongyloides stercoralis</i> was assessed by multiplexed bead assay (MBA). Descriptive, univariate, and multivariate statistics were performed to describe the outcomes and potential associations.</p> Results <p>Of 1,311 participants, 72 (5.5%) reported a prior history of HD, 94 (7.2%) tested positive for anti-LID-1, 836 (63.8%) reported having one or more parasitic diseases in the past, 153 (11.7%) tested positive for antibodies to schistosoma egg antigen (SEA), and 69 (5.3%) for antibodies to the <i>Strongyloides stercoralis</i> antigen, NIE. Rural residence and anti-LID-1 showed a positive association (aOR 1.79, CI: 1.07- 3.38) as did rural residence and history of HD (aOR, 1.97, CI: 1.14 – 3.38). While not statistically significant, there was a positive association between anti-LID-1 and NIE antibodies (aOR 1.57, CI: 0.69-3.57), and a negative association between anti-LID-1 and SEA antibodies (aOR 0.79, CI: 0.38 - 1.61).</p> Conclusion <p>We simultaneously measured seroreactivity among various pathogens. While we did not find that a history of HD and anti-LID-1 positivity were associated with seropositivity to NIE or SEA, our study found a high burden of several neglected tropical diseases (NTDs). There was also a strong association with rural residence and LID-1 positivity warranting investigation into the prevalence and epidemiology of <i>M. leprae</i> infection, as well as potential spatial and environmental risk factors.</p> Robert Machang’u Jacob N. Kagesyeko Majani Edward Wisdom Owoicho Ameh Lucy Chuwa Gabriel Upunda Jovin R. Tibenderana 10.1371/journal.pntd.0014761 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Robert Machang’u, Jacob N. Kagesyeko, Majani Edward, Wisdom Owoicho Ameh, Lucy Chuwa, Gabriel Upunda, Jovin R. Tibenderana</p> Introduction <p>Leprosy, also commonly known as Hansen’s Disease (HD) remains a neglected tropical disease and a public health concern in disease endemic regions of the world. However, significant progress in disease reduction has been achieved in recent years through multidrug therapy programs, implemented by the World Health Organization (WHO). This study assessed the trend and epidemiological profile of HD cases diagnosed at Nazareti Leprosy Center (NLC), Ifakara, Tanzania, over a 25-year period.</p> Methods <p>A retrospective cross-sectional study was conducted using routinely collected clinical records of newly diagnosed HD cases registered at NLC between 2000 and 2024. Data on demographic characteristics, clinical classification of HD, operational categories (paucibacillary and multibacillary), and disability grades of patients at presentation were collected. Poisson regression estimated annual incidence trends as incidence rate ratios (IRRs), while logistic regression assessed changes in leprosy characteristics as odds ratios (ORs), both reported with 95% confidence intervals (CIs).</p> Results <p>A total of 801 HD cases were recorded, of which males accounted for 67.4% of cases, with the highest proportion occurring among individuals aged 50 + years (33.2%). Multibacillary disease predominated (62.7%), while grade 1 disability (G1D), at diagnosis was more common (52.7%) than G2D. Overall, case notifications increased significantly over time, with an average annual rise of 4.0% (IRR = 1.04; 95% CI: 1.03–1.07; p < 0.001). Significant increases were observed among male individuals aged ≥50 years. Multibacillary HD cases and G1D disability also increased. In contrast, childhood cases (0–14 years) declined significantly during the study period.</p> Conclusions <p>Leprosy epidemiology in rural Tanzania shows evolving patterns characterized by increasing case detection, a rising burden of multibacillary disease, and disability at diagnosis, versus a decline in childhood cases over time. Intensifying early case detection, community awareness, treatment and surveillance are essential to eliminate HD as a public health concern.</p> Redeemer Joy Duboh Dickson Kweku Delali Emmanuel Manu 10.1371/journal.pntd.0014753 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Redeemer Joy Duboh, Dickson Kweku Delali, Emmanuel Manu</p> Background <p>Leprosy, a curable neglected tropical disease, continues to affect vulnerable populations in low-resource settings despite global control efforts. In Ghana, although leprosy has been eliminated as a public health problem, new cases continue to be detected, and persons cured of leprosy (PCLs) continue to face long-term stigma, disability, and barriers to healthcare in segregated communities. This qualitative descriptive study aimed to understand the knowledge of leprosy, sources of healthcare, and challenges shaping health-seeking behaviours among PCLs in Godokpe, Ho Municipality, Volta Region, Ghana.</p> Methodology <p>This qualitative descriptive study explored the knowledge, healthcare sources, and challenges shaping health-seeking behaviours among PCLs. Purposive sampling recruited 20 participants to reach saturation. Semi-structured, face-to-face, in-depth interviews lasting 20–30 minutes were conducted in Godokpe, audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis in Atlas.ti version 7.5.0, following COREQ guidelines.</p> Results <p>This study revealed four central themes. Knowledge of Leprosy showed predominant supernatural attributions, including bewitchment, ancestral curses, and contaminated food, alongside rare bacterial recognition, with signs such as skin lesions, ulcers, nodules, limb deformities, loss of sensation, and body pain. Social Treatment and Stigma reflected two distinct patterns: ongoing, unevenly resolved interpersonal avoidance by family and community, contrasted with a documented shift toward equal treatment of PCLs at health facilities over time. Health-Seeking Behaviour reflected a pluralistic pattern, drawing on biomedical facilities such as the Ho Polyclinic and Ho Teaching Hospital, herbal remedies, self-medication, and spiritual or church-based healing based on perceived severity. Challenges Influencing Health-Seeking encompassed logistical barriers such as distance, transport costs, drug unavailability, and informal charging for nominally free medication; physical limitations such as mobility impairment, painful or wounded legs, and visual loss; and socioeconomic constraints such as unemployment, financial hardship, low allowances, donor dependence, and the prioritisation of food over healthcare.</p> Conclusion <p>This study revealed persistent supernatural attributions of leprosy, an uneven trajectory of stigma reduction, pluralistic health-seeking, and layered barriers, including a documented gap between free-care entitlements and informal charging in practice, among PCLs in Godokpe. Addressing these gaps requires verification of fee-exemption entitlements at the facility level alongside sustained family- and community-level engagement, advancing Sustainable Development Goal (SDG) 1 on poverty reduction, SDG 3 on good health and well-being, and SDG 10 on reduced inequalities.</p> Ebrahim Babaee Arash Yousefzadeh Eshkoori Babak Eshrati Marzieh Nojomi Mohammad Reza Shirzadi Mehran Asadi-Aliabadi Amirhesam Moosazadeh 10.1371/journal.pntd.0014751 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Ebrahim Babaee, Arash Yousefzadeh Eshkoori, Babak Eshrati, Marzieh Nojomi, Mohammad Reza Shirzadi, Mehran Asadi-Aliabadi, Amirhesam Moosazadeh</p> Background <p>Animal bites remain an important public health issue in Iran. Understanding their epidemiological patterns and examining how registry-recorded cases are managed in relation to the Iranian rabies protocol and World Health Organization recommendations can provide insight into clinical practice and documentation quality within the national bite registry. Such analyses help identify strengths and gaps in protocol adherence and data completeness.</p> Methodology/Principal findings <p>We conducted a secondary analysis of 507,404 animal bite cases recorded in the national rabies registry between March 2022 and September 2023. The unit of analysis was registry-recorded exposure visits. Data on demographics, exposure characteristics, and clinical management were examined to describe epidemiological patterns and assess documented adherence to recommended post-exposure prophylaxis (PEP) practices. Males accounted for 73.6% of cases. The largest age group among all patients was 31–40 years, comprising 19.8% of cases. Dogs were responsible for 76.2% of exposures and cats for 20.8%. Northern provinces such as North Khorasan (773 per 100,000) and Golestan (767 per 100,000) recorded the highest incidence. Wound irrigation was documented in 94.3% of patients, and 96.4% received the first vaccine dose within 48 hours. Overall, 68.1% received three vaccine doses and 24.2% four doses. Rabies immunoglobulin was administered to 95.6% of Category III exposures, though inappropriate use was also observed in Category I (6.1%) and II (4.7%). Deviations from vaccine regimens and misclassification of exposure categories were identified, and among bat-related exposures only 36.8% were classified as Category III, with 38.7% receiving immunoglobulin.</p> Conclusions/Significance <p>Among registry-recorded animal bite attendees, rapid initiation of PEP and frequent appropriate use of rabies immunoglobulin in severe exposures were documented. However, gaps in documentation, vaccine dosing accuracy, and exposure classification indicate areas for improvement. These findings reflect patterns within the national bite registry and should not be interpreted as a comprehensive evaluation of all surveillance system attributes. Strengthening provider training, reinforcing protocol adherence, and improving data quality within the registry could support national rabies control efforts and inform broader prevention strategies aligned with global elimination goals.</p> Barbara de Barros Farha Sultana Neeta Maximus Vivek V. Pai Anju Wakade Bhagyashree Bhame Bishwanath Acharya Abdulnaser Hamza Alemtsehay Getachew Medhi Denisa Alinda M. Yulianto Listiawan Shimelis N. Doni Deanna A. Hagge Indra Napit Mahesh Shah Joydeepa Darlong Peter Nicholls Bernd Genser Saba M. Lambert Diana N. J. Lockwood Stephen L. Walker on behalf of the Erythema Nodosum Leprosum International STudy (ENLIST) Group 10.1371/journal.pntd.0014739 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Barbara de Barros, Farha Sultana, Neeta Maximus, Vivek V. Pai, Anju Wakade, Bhagyashree Bhame, Bishwanath Acharya, Abdulnaser Hamza, Alemtsehay Getachew, Medhi Denisa Alinda, M. Yulianto Listiawan, Shimelis N. Doni, Deanna A. Hagge, Indra Napit, Mahesh Shah, Joydeepa Darlong, Peter Nicholls, Bernd Genser, Saba M. Lambert, Diana N. J. Lockwood, Stephen L. Walker, on behalf of the Erythema Nodosum Leprosum International STudy (ENLIST) Group </p> Background <p>Erythema nodosum leprosum (ENL) is a severe inflammatory complication of leprosy that often requires prolonged corticosteroid therapy which is associated with adverse effects. Methotrexate is an affordable immunomodulatory agent with limited evidence for its use in ENL treatment. We evaluated whether weekly oral methotrexate in addition to prednisolone reduces the need for additional prednisolone in adults with severe ENL.</p> Methods and findings <p>We performed an international, multicentre, double-blind, randomised, placebo-controlled trial conducted at five leprosy referral centres in Ethiopia, India, Indonesia, and Nepal. Adults aged 18–60 years with severe ENL were randomised to receive oral methotrexate (15mg, increased to 20mg in participants weighing ≥ 60 kg) for 48 weeks and prednisolone, or matching placebo and prednisolone. All participants received an identical 20-week prednisolone regimen, starting at 40mg daily, and were followed for 60 weeks. The primary outcome was time to first ENL flare requiring additional prednisolone, assessed over 24 and 48 weeks. Between January 2023 and June 2024, 231 individuals were screened and 137 were randomised (68 methotrexate and prednisolone; 69 placebo and prednisolone). By 24 weeks, 85/137 (62.0%) participants experienced an ENL flare requiring additional prednisolone; the adjusted hazard ratio (HR) for methotrexate versus placebo was 0.98 (95% CI 0.62–1.54). By 48 weeks, 102/137 (74.5%) experienced an ENL flare; adjusted HR 0.95 (95% CI 0.62–1.43). Secondary outcomes were similar: methotrexate did not reduce ENL severity at first flare, flare frequency, or severity of subsequent flares. Health-related quality of life improved substantially in both groups with no evidence of a differential treatment effect. Methotrexate was generally well tolerated. The trial was registered at ClinicalTrials.gov (NCT03775460).</p> Conclusions <p>Oral methotrexate added to prednisolone did not reduce the requirement for additional prednisolone or delay ENL flares compared to placebo and prednisolone, and our study does not support the use of methotrexate for severe ENL.</p> Trial Registration <p>ClinicalTrials.gov NCT03775460 registered on 29th November 2018.</p> Fadwa M. Arafa Mohamed Hagar Ahmed Zakaria Eman Sheta Nehal N. Hezema 10.1371/journal.pntd.0014734 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Fadwa M. Arafa, Mohamed Hagar, Ahmed Zakaria, Eman Sheta, Nehal N. Hezema</p> Given the grave risk posed by intestinal cryptosporidiosis to vulnerable populations, the current research focused on a new therapeutic avenue. Olibanum (OL) extract and probiotic <i>Bacillus clausii</i> (<i>B. clausii</i>) and their combination were evaluated against <i>Cryptosporidium in vivo</i> in immunosuppressed mice via parasitological, ultrastructural, biochemical, and histopathological analysis. Liquid chromatography-mass spectrometry (LC–MS) analysis of OL revealed the predominance of incensole isomers in its chemical composition. Regarding oocyst count in stool, the highest percentage of oocyst reduction was achieved after combined therapy (98.4%) on the 19^th day post-infection, followed by <i>B. clausii-</i>treated group (87.6%), then the OL-treated group (87%). Similar ultrastructural alterations were noticed by scanning electron microscopy (SEM) following treatment by both OL and <i>B. clausii</i>, ranging from shrunken oocysts to severely deformed ones with extensive pits or protrusions. Nonetheless, their combination resulted in complete distortion of the oocysts, leading to their rupture. Biochemically, both OL and <i>B. clausii</i> treatment, either alone or in combination, provoked a decrease in the serum MDA levels, together with a corresponding rise in the mean levels of GSH. Concerning the histopathological findings, the best results were achieved following the combined OL and <i>B. clausii</i> treatment, which has restored villus architecture and remarkably ameliorated detrimental intestinal inflammation and goblet cell count. Finally, immunohistochemical analysis of the lymphocytic population of the intestinal villi revealed a statistically significant rise in the CD4+ /CD8+ ratio after treatment with either OL, <i>B. clausii</i> or their combination, which signals their proficient use for this therapeutic endeavour. Yared Mulu Gelaw Gizachew Worku Dagnew Mulusew Alemneh Sinishaw Toyiba Hiyaru Getu Degu Alene Jean-Pierre Gangneux Florence Robert-Gangneux 10.1371/journal.pntd.0014616 2026-09-30T14:00:00Z 2026-09-30T14:00:00Z <p>by Yared Mulu Gelaw, Gizachew Worku Dagnew, Mulusew Alemneh Sinishaw, Toyiba Hiyaru, Getu Degu Alene, Jean-Pierre Gangneux, Florence Robert-Gangneux</p> Background <p><i>Toxoplasma gondii</i> primary infection during pregnancy can lead to congenital transmission and cause serious fetal and neonatal complications. Seroprevalence for toxoplasmosis is an indicator of the intensity of transmission and of the risk of infection during pregnancy, yet such data are limited in Ethiopia. This multi-center study utilizing the immunochromatographic test (Toxoplasma ICT IgG-IgM, LD Bio) aimed at determining the seroprevalence of toxoplasmosis among pregnant women and its associated risk factors in Bahir Dar, Ethiopia.</p> Methods <p>A cross-sectional study was conducted at two tertiary hospitals. Pregnant women below 20 weeks of gestation were included during the first antenatal care consultation. Participants were selected using systematic random sampling. A blood sample was collected for <i>Toxoplasma</i> serology, and socio-demographic and clinical data were collected through a questionnaire. Serology was performed using a rapid immunochromatographic test (ICT Toxo IgG/IgM, LD Bio). The test detects any Toxoplasma antibody (recent or chronic infection), but not separately reported. Data were analysed using SPSS version 23. Individual data were compared between <i>Toxoplasma</i>-seropositive and seronegative women to determine risk factors for infection. Bivariable and multivariable binary logistic regression were performed to identify factors associated with seropositivity.</p> Results <p>Overall, 1010 women were included in the study at their first antenatal care visit (13.89 ± 4.26 weeks of gestation). Their mean age was 26.8 ± 4.67 years, 85.2% resided in urban areas, and the median monthly income was 5000 Ethiopian Birr. The seroprevalence was 75.8%. Seroprevalence increased with age and parity (p < 0.001), but did not differ according to socio-economic parameters, including educational level, monthly income, occupation, residence, or any hygienic factors. Multivariable analysis showed that age (AOR = 1.09), Parity (AOR = 1.33), eating undercooked meat (AOR = 1.29), and consumption of raw milk (AOR = 1.82) were significantly associated with the seropositivity of T. plasma gondii among pregnant women.</p> Conclusion <p>The burden of toxoplasmosis among pregnant women was high in Bahir Dar. Therefore, efforts should be made to increase women’s awareness of risk factors, particularly the habit of consuming raw meat and raw milk. The ease of use of the Toxoplasma ICT test allows serologic screening of pregnant women at antenatal care facilities.</p> Abigail Agbanyo Yaw Ampem Amoako Charles Opondo Michael Ntiamoah Oppong Adwoa Asante-Poku Jacob Novignon Joseph Tuffour Ishaque Saim Mintah Ruth Dede Tuwor Dzifa Kofi Ahiatrogah Richard Adjei Akuffo Miriam Gborglah Iris Mosweu Catherine Pitt Elizabeth Allen Stephen L. Walker Dorothy Yeboah-Manu Michael Marks Richard Odame Phillips SHARP Collaboration 10.1371/journal.pntd.0014783 2026-09-29T14:00:00Z 2026-09-29T14:00:00Z <p>by Abigail Agbanyo, Yaw Ampem Amoako, Charles Opondo, Michael Ntiamoah Oppong, Adwoa Asante-Poku, Jacob Novignon, Joseph Tuffour, Ishaque Saim Mintah, Ruth Dede Tuwor, Dzifa Kofi Ahiatrogah, Richard Adjei Akuffo, Miriam Gborglah, Iris Mosweu, Catherine Pitt, Elizabeth Allen, Stephen L. Walker, Dorothy Yeboah-Manu, Michael Marks, Richard Odame Phillips, SHARP Collaboration </p> Background <p>The current 8-week regimen of rifampicin and clarithromycin for Buruli ulcer (BU) is suboptimal. High-dose rifampicin could shorten treatment and improve outcomes. We evaluated whether a 4-week high-dose regimen could improve time to clearance of viable <i>Mycobacterium ulcerans</i>.</p> Methodology <p>In this open-label, individually randomised trial conducted in Ghana, participants with PCR-confirmed BU were assigned (1:1) to either high-dose oral rifampicin (20mg/kg) with clarithromycin (15mg/kg) for 4 weeks (HR) or standard-dose rifampicin (10mg/kg) with clarithromycin (15mg/kg) for 8 weeks (SR). All wounds were dressed with DACC-coated dressings. The primary outcome was time to clearance of viable <i>M. ulcerans</i> assessed by 16S rRNA qPCR up to week 20.</p> Findings <p>Between 26^th November 2021 and 31^st July 2024, 42 participants were randomised (HR:23, SR:19), which was short of the target (n = 112). The mean time to clearance was 4.9 weeks (SE 1.4) in the HR arm versus 7.0 weeks (SE 1.9) in the SR arm, with an adjusted mean difference of -0.5 weeks (95%CI -5.0 to 4.1, p = 0.835). No recurrences occurred in either arm. Paradoxical reactions were observed in 0/21 participants in the HR arm vs. 5/15 in the SR arm (adjusted OR 0.19, 95%CI 0.00-1.35, p = 0.102). Secondary infection rates were similar between groups.</p> Conclusion <p>High‑dose rifampicin combination for 4 weeks was well tolerated in this population. A nominally lower proportion of paradoxical reactions was observed in the high-dose rifampicin arm compared with standard therapy. The trial did not find evidence of significantly shorter time to microbiological clearance or healing compared with standard therapy. Larger trials are needed to determine efficacy and safety.</p> Trial Registration <p>Pan African Clinical Trials Repository, trial registration number: PACTR202011867644311 (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=14534).</p> The PLOS Neglected Tropical Diseases Editors 10.1371/journal.pntd.0014748 2026-09-28T14:00:00Z 2026-09-28T14:00:00Z <p>by The PLOS Neglected Tropical Diseases Editors </p> Muluneh Assefa Mitkie Tigabie Abebaw Setegn Yenesew Mihret Wondmagegn Azanaw Amare Getu Girmay Sirak Biset Wesam Taher Almagharbeh 10.1371/journal.pntd.0014744 2026-09-28T14:00:00Z 2026-09-28T14:00:00Z <p>by Muluneh Assefa, Mitkie Tigabie, Abebaw Setegn, Yenesew Mihret Wondmagegn, Azanaw Amare, Getu Girmay, Sirak Biset, Wesam Taher Almagharbeh</p> Background <p>The burden of pre-extensively drug-resistant tuberculosis (Pre-XDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) cases in Ethiopia has become one of the most challenging problems for monitoring the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). This study aimed to provide a valuable evidence synthesis on the pooled prevalence of Pre-XDR and XDR-TB among MDR-TB patients in Ethiopia.</p> Methodology <p>This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from relevant articles were analyzed using STATA version 17.0. The pooled estimate of the effect size was computed using a restricted maximum likelihood random-effects model, considering a 95% confidence interval, and a forest plot was used to visualize the proportion of Pre-XDR and XDR-TB. Because the Pre-XDR and XDR-TB cases are rare, the Freeman-Tukey double arcsine transformation was applied to estimate the pooled proportions. The I2 statistic and Galbraith plot confirmed heterogeneity. A univariate meta-regression, sensitivity, and subgroup analyses were conducted to identify the source of heterogeneity. Egger’s test and funnel plot were used to check publication bias.</p> Results <p>Eight studies comprising 1,518 MDR-TB patients, with 656 new and 862 previously treated cases, were included. Among those, 52 Pre-XDR and 13 XDR-TB cases were identified. According to the Freeman-Tukey transformation, the overall pooled prevalence of Pre-XDR-TB was 3% (95% CI: 2%-5%, I2 = 43.69%) and XDR-TB was 1% (95% CI: 0%-4%, I2 = 54.07%). In the subgroup analysis, the prevalence of Pre-XDR-TB across studies from multiple regions of Ethiopia was 7% (95% CI: 3%-13%), and in Addis Ababa, it was 3% (95% CI: 2%-4%). Single studies in the Amhara, Tigray, and Oromia regions reported Pre-XDR-TB prevalence of 6%, 5%, and 3%, respectively. The pooled prevalence of XDR-TB in Addis Ababa was 1% (95% CI: 0%-2%). A single study conducted in Oromia reported a relatively higher prevalence of XDR-TB; 10% (95% CI: 3%-26%). Regarding the study year, the XDR-TB prevalence was 3% (95% CI: 0%-11%) in 2005–2018 and 1% (95% CI: 0%-2%) in 2019–2024. A statistically significant publication bias was observed in XDR-TB prevalence (p = 0.024).</p> Conclusion <p>There is a significant prevalence of Pre-XDR and XDR-TB cases among MDR-TB patients in Ethiopia. It highlights the need for strengthened surveillance in all regions and expanded drug susceptibility testing of local strains for better management of MDR-TB patients.</p> Ana Paula Menezes Camila Gachet-Castro Suzanne McGill Richard Burchmore Ariel Silber Maria Carolina Elias Júlia P. C. da Cunha 10.1371/journal.pntd.0013299 2026-09-28T14:00:00Z 2026-09-28T14:00:00Z <p>by Ana Paula Menezes, Camila Gachet-Castro, Suzanne McGill, Richard Burchmore, Ariel Silber, Maria Carolina Elias, Júlia P. C. da Cunha</p> <i>Trypanosoma cruzi</i>, the etiological agent of Chagas Disease (CD), represents a significant public health concern and serves as a valuable model for investigating the cell cycle in early-diverging eukaryotes. Its unique cellular features,including the absence of chromosome condensation and the coordination of nuclear division with specialized organelles, provide insights into non-canonical regulatory mechanisms, and underscore the pivotal role of the nucleus in maintaining genomic integrity and regulating fundamental processes such as DNA replication and gene expression. To investigate nuclear dynamics throughout the cell cycle, we synchronized <i>T. cruzi</i> epimastigotes at the G1/S transition using hydroxyurea (HU), followed their progression through S and G2/M phases, and quantitatively analyzed isolated nuclear proteins by LC-MS/MS. We identified 2,937 nuclear-enriched proteins, revealing distinct, phase-specific expression patterns. The G1/S phase was marked by increased levels of metabolic enzymes including those related to energy and nucleotide/nucleoside metabolisms. The S phase showed elevated abundance of canonical and variant histones, consistent with chromatin remodeling and DNA replication. The G2/M phase was enriched in proteins involved in protein synthesis and microtubule dynamics, essential for mitosis. Notably, metabolic enzymes represented approximately 6% of the proteins identified in the purified nuclear fraction, consistent with previously published proteomic analyses of <i>T. cruzi</i> nuclear-enriched fractions. Hexokinase, citrate synthase, and pyruvate kinase activities were detected in extracts from this fraction, while immunofluorescence supported the association of hexokinase and citrate synthase with the nuclear region. These results suggest that metabolic enzymes and/or their metabolites may modulate nuclear processes in <i>T. cruzi</i>, potentially influencing the epigenome and gene expression regulation, as proposed in other eukaryotic models. Altogether, our findings reveal dynamic remodeling of the nuclear proteome during the <i>T. cruzi</i> cell cycle and point to a previously underappreciated role for metabolic enzymes likely regulating nuclear functions in a cell cycle-dependent manner. Amy C. Dupper Charles D. Mackenzie Timothy G. Geary Deborah L. Elder Wided Najahi-Missaoui Christopher A. Cleveland Ellen K. Haynes Michael J. Yabsley Guilherme Gomes Verocai Macon Overcast John A. Bryan II Fernando Torres-Velez Métinou Koumétio Sidouin Bongo Nare Richard Ngandolo Philip Tchindebet Oaukou Adam J. Weiss Rebecca Garabed 10.1371/journal.pntd.0014763 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Amy C. Dupper, Charles D. Mackenzie, Timothy G. Geary, Deborah L. Elder, Wided Najahi-Missaoui, Christopher A. Cleveland, Ellen K. Haynes, Michael J. Yabsley, Guilherme Gomes Verocai, Macon Overcast, John A. Bryan II, Fernando Torres-Velez, Métinou Koumétio Sidouin, Bongo Nare Richard Ngandolo, Philip Tchindebet Oaukou, Adam J. Weiss, Rebecca Garabed</p> Since being targeted for eradication in the 1980s, global human cases of dracunculiasis (Guinea worm disease; GWD) have been reduced by over 99.9% through interventions aimed at interrupting the life cycle of the causative parasite, <i>Dracunculus medinensis</i>. However, the burden of GWD in dogs is higher than in humans and other monitored mammalian host species, threatening eradication of GWD. Expanding on a previous clinical trial of flubendazole (FLBZ) in dogs in Chad, we conducted a cluster-randomized controlled trial in which half of enrolled villages (N = 29) were assigned to receive FLBZ and the other half (N = 27) to receive no treatment. An annual difference-in-differences analysis revealed that treated villages had 59.3% fewer predicted emerging <i>D. medinensis</i> adult females (95% CI: 53.8% fewer to 69.2% fewer) per village per year during the second year of the study compared to control villages. Analyses examining effects of FLBZ monthly, at the individual dog level, and through histopathology of <i>D. medinensis</i> female reproductive morphology, all support the conclusion that FLBZ inhibits embryogenesis and larval development within the uterus of gravid female worms. Together these data are consistent with a hypothesis that although <i>D. medinensis</i> emerged from individually treated dogs, the L1s released from dogs treated with FLBZ exhibited reduced viability, thus reducing the risk of infection in the next mammalian host. This trial builds the body of knowledge about FLBZ’s impacts on <i>D. medinensis</i> in the canine host and provides compelling evidence on the effectiveness of FLBZ in reducing the number of emerging <i>D. medinensis</i> in dogs, which can contribute to the eradication of this parasite. However, additional questions remain regarding the formulation, which need to be addressed in future studies before being deployed at scale. Danhong Cheng Lei Zhang Le Sun Min Yin Yu Wang Shuwen Yang Xing Yan Xiaoyan Zhu Cuiying Li Weixun Chunyu 10.1371/journal.pntd.0014760 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Danhong Cheng, Lei Zhang, Le Sun, Min Yin, Yu Wang, Shuwen Yang, Xing Yan, Xiaoyan Zhu, Cuiying Li, Weixun Chunyu</p> Paragonimiasis, a food-borne zoonosis caused by <i>Paragonimus</i> spp., can cause severe pulmonary inflammation and fibrosis. However, relationships among the host, parasite and lung microbiome at defined infection stages remain poorly understood. We compared independent groups of rats sampled at 14, 28 and 42 days post-infection (dpi), together with a separate group sampled after triclabendazole (TCBZ) treatment. Histopathological and molecular analyses were combined with multi-region (5R) 16S rRNA gene sequencing and fluorescence <i>in situ</i> hybridization (FISH). Groups sampled at later post-infection time points showed greater pulmonary inflammation and collagen deposition, with the highest values in Pp-42d; both outcomes were lower in Pp-TCBZ than in Pp-42d. Th1-, eosinophil-, Th2- and Treg- associated markers differed among experimental groups. TLR4/NF-κB -related protein expression and pulmonary microbial profiles also differed among groups including enrichment of taxa such as <i>Lactobacillus</i> in infected animals. FISH detected bacterial signals within inflammatory lesions and <i>Lactobacillus</i>-associated signals spatially associated with parasite eggs. These repeated cross-sectional findings identify stage-associated differences in pulmonary pathology, immune markers and microbiota during <i>P. proliferus</i> infection, together with lower pathological measures in the Pp-TCBZ group than in the untreated Pp-42d group. The egg-associated bacterial signals warrant further investigation but do not establish a functional host-parasite-microbiome mechanism. Kien Quoc Do Ha Thu Nguyen Thi Thanh Thao Nguyen Cong Tuan Pham Nguyen T. T. K Dang Khanh Linh Vien Dung Phung 10.1371/journal.pntd.0014754 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Kien Quoc Do, Ha Thu Nguyen, Thi Thanh Thao Nguyen, Cong Tuan Pham, Nguyen T. T. K, Dang Khanh Linh Vien, Dung Phung</p> Background <p>Dengue is a major vector-borne disease, with rising incidence driven by climate change, rapid urbanization, and increased international travel. Although early warning systems (EWSs) have shown promising predictive performance in endemic settings, limited evidence on implementation barriers from local end users hinders their integration into routine proactive vector control.</p> Methods <p>A qualitative study with in-depth interviews was conducted with local end users, including local authorities, health practitioners, and health volunteers. A deductive approach utilizing a predefined conceptual framework was employed to code the verbatim transcripts. Inductive coding was subsequently incorporated to capture emerging concepts that were not represented in the initial framework. Thematic analysis was performed to analyse the collected data. To enhance the methodological rigor, interviews and coding were performed by multiple and diverse researchers from various academic and practice institutions, and the transcripts were validated through member checking with selected participants.</p> Results <p>The lack of supportive policies, limited engagement from relevant stakeholders due to low familiarity with EWS concepts, and operational challenges were identified as critical barriers to implementing EWS-informed proactive source reduction. The perception that dengue risks were only during the rainy season, together with socio-economic constraints, water scarcity exacerbated by extreme weather events, and the application of inappropriate source reduction measures, further constrained household participation. The multi-level barriers collectively disrupted the translation of EWS alerts into proactive dengue prevention.</p> Conclusions <p>Early warning information alone is insufficient to translate into effective and sustained proactive vector control for dengue prevention. Strengthening enabling policies, local stakeholder and community engagement, and awareness of EWS-informed risk management across multiple levels are essential to translate EWS alerts into timely and sustained vector control actions in dengue-endemic settings similar to Vietnam. Further studies across diverse settings are needed to assess the broader applicability of EWS-informed approaches.</p> Liliana Marcela Montilla Rodríguez Cesar García-Balaguera Sandra Campo Palacio David Bonilla Montes Yuri Daniela Cadena Díaz Paula Alejandra Mosquera Tocora Norma Cristina Pavas Escobar Camilo Andrade Carreño Elsa Victoria Andrade Miranda Marina Sthella Gonzalez Robayo 10.1371/journal.pntd.0014733 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Liliana Marcela Montilla Rodríguez, Cesar García-Balaguera, Sandra Campo Palacio, David Bonilla Montes, Yuri Daniela Cadena Díaz, Paula Alejandra Mosquera Tocora, Norma Cristina Pavas Escobar, Camilo Andrade Carreño, Elsa Victoria Andrade Miranda, Marina Sthella Gonzalez Robayo</p> Background <p>Dengue remains a major public health challenge in hyperendemic regions, where shifts in serotype circulation, spatial transmission patterns, and clinical presentation can significantly influence outbreak dynamics. Colombia has experienced intense dengue activity in recent years; however, integrated analyses combining virological, spatial, and clinical data remain limited.</p> Methods <p>A retrospective longitudinal observational study was conducted using routinely collected dengue surveillance data from the Department of Meta, Colombia, covering the period from January 2023 to September 2025. Confirmed dengue cases with viral isolation and serotype identification were included. Temporal trends, serotype replacement dynamics, municipal-level spatial redistribution patterns, and clinical characteristics were analyzed using laboratory-confirmed dengue cases. Multivariable logistic regression models were used to identify factors associated with dengue positivity overall and by serotype, while interannual variation was assessed to evaluate changes in transmission intensity and the spatial redistribution of dengue transmission risk.</p> Results <p>Marked serotype replacement was observed during the study period. DENV-2 predominated during the 2023 peak, followed by a decline and a sustained increase in DENV-3 and DENV-4 by 2025, while DENV-1 disappeared from recent records. Spatial analysis showed declining diagnostic positivity in historically hyperendemic municipalities and significant interannual increases in intermediate municipalities, indicating an epidemiological rebound outside major urban centers. Classical dengue symptoms, including headache, myalgia, and rash, were inversely associated with virological confirmation, whereas nonspecific neurological manifestations, such as somnolence and irritability, emerged as independent predictors. Severe thrombocytopenia remained strongly associated with infection, particularly in DENV-2 cases.</p> Conclusions <p>The dengue outbreak in Meta (2023–2025) was characterized by dynamic serotype replacement, spatial redistribution of transmission risk, and changing clinical presentations. The rapid emergence of DENV-4 in 2025 serves as an early warning of serotype replacement and underscores the need to update clinical screening protocols to include nonspecific neurological manifestations. Strengthening decentralized laboratory networks and closing surveillance gaps in low-endemicity areas are strategic priorities to improve early detection and outbreak control in hyperendemic regions.</p> Felix Lankester Ahmed Lugelo Joel Changalucha Danni Anderson Christian Tetteh Duamor Anna Czupryna Kennedy Lushasi Elaine Ferguson Emmanuel S. Swai Maganga Sambo Jonathan Yoder Sarah Cleaveland Sally Wyke Benezeth Lutege Malinda Paul C. D. Johnson Katie Hampson 10.1371/journal.pntd.0014704 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Felix Lankester, Ahmed Lugelo, Joel Changalucha, Danni Anderson, Christian Tetteh Duamor, Anna Czupryna, Kennedy Lushasi, Elaine Ferguson, Emmanuel S. Swai, Maganga Sambo, Jonathan Yoder, Sarah Cleaveland, Sally Wyke, Benezeth Lutege Malinda, Paul C. D. Johnson, Katie Hampson</p> Background <p>Approximately 60,000 people die from rabies annually, mostly in Africa and Asia. Mass dog vaccination is critical for elimination. Herd immunity has been calculated to be attained when >40% (critical threshold) of dogs are vaccinated. A common delivery method implemented in Tanzania and other countries typically involves non-local teams travelling to villages implementing dog vaccination annually through static-point clinics using cold chain stored vaccines (Team-based delivery). Determination that a canine rabies vaccine is thermotolerant enables novel Community-based dog vaccination strategies whereby community vaccinators use vaccines stored locally throughout the year (Community-based delivery).</p> Methods <p>Two dog vaccination strategies were compared using a three-year cluster randomized controlled trial in Tanzania (Clinical Trials Registration Number ISRCTN14813279). The strategies were designed to represent implementation using resources typical of government-led initiatives. Wards (<i>n</i> = 112) were randomly assigned to either Team-based delivery or Community-based delivery. Coverage was estimated using household surveys implemented biannually.</p> Findings <p>Mean coverage achieved by Community-based delivery (55%; 95% Confidence Interval (CI): 45–65%) was higher than Team-based delivery (37%; 95% CI: 28–46%). Moreover, because coverage was lower and declined over each year only in Team-based delivery, the probability of coverage being below the critical threshold was higher for Team-based delivery (60%) compared to Community-based delivery (18%). To ensure coverage does not dip below the critical threshold by the year end, coverage at the start of the year in Team-based delivery needed to be higher (61%) than in Community-based (42%).</p> Interpretation <p>Community-based delivery achieved higher and more consistent vaccination coverage across a range of settings typical of many sub-Saharan African countries. Generalisation to different sociocultural/ agroecological settings requires further evidence. Although direct evidence on impact on rabies elimination was not measured, this approach could play a role in national elimination strategies, developed for the global ‘Zero by 30’ strategy to end dog-mediated rabies deaths by 2030, and in response to investment by Gavi, the vaccine alliance.</p> Carlos Acosta Diana Cubas-Montecino Joaquin Gomez Marlon Saavedra Mitchel Guzman-Guzman Sara A. Bickersmith Jan E. Conn Dionicia Gamboa Joseph M. Vinetz 10.1371/journal.pntd.0014261 2026-09-25T14:00:00Z 2026-09-25T14:00:00Z <p>by Carlos Acosta, Diana Cubas-Montecino, Joaquin Gomez, Marlon Saavedra, Mitchel Guzman-Guzman, Sara A. Bickersmith, Jan E. Conn, Dionicia Gamboa, Joseph M. Vinetz</p> Background <p>Malaria persists as a leading cause of morbidity in the Amazon Basin, where the Loreto region of Peru contributes over 90% of the national burden. Despite widespread deployment of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) under Peru's Malaria Elimination Plan 2022–2030, residual transmission continues in rural riverine communities. This transmission is driven by the interplay between vector ecology and human behavior. This study quantified residual human exposure to <i>Nyssorhynchus darlingi</i> by integrating hourly entomological indices with real-time human behavioral data across two seasons in three communities in Mazán, Loreto.</p> Methodology/principal findings <p>Entomological (HLC) and epidemiological (HBS) data were collected during the wet and dry seasons of 2022. <i>Plasmodium</i> infections were detected in 619 participants by microscopy and qPCR. Molecular surveillance revealed a 13% infection prevalence over seven times higher than routine microscopy (2%) indicating a substantial submicroscopic reservoir. Infection burden was heterogeneous, with Gamitanacocha showing the highest prevalence (33%). LLIN usage was high (>97%), yet nets prevented only 63.3%–80.3% of potential mosquito bites. Residual exposure occurred mainly indoors during early evening (18:00–21:00) while individuals were awake and unprotected, particularly in the dry season when domestic routines coincided with peak vector biting. Outdoor exposure increased during the wet season due to evening recreational activities. Multivariate analysis identified age as the only significant predictor of infection (<i>p < 0.05</i>), with individuals over five years showing consistently higher odds of infection than children under five (OR range: 3.62–5.46).</p> Conclusions/significance <p>A critical protection gap exists during early evening and dawn, when human activity overlaps with peak vectors biting outside the protection of bed nets. The high submicroscopic burden and persistent indoor exposure while awake demonstrate that current interventions are insufficient for elimination. These findings highlight that Loreto's elimination strategies must complement intradomiciliary tools with peri-domestic and behavioral interventions—such as full house screening and spatial repellents—specifically targeting the exposure windows identified here.</p> Emily A. Dickie Stefan K. Weidt Jennifer Haggarty Gavin Blackburn Mary K. Doherty Ryan Ritchie Edith Paxton Simon Young Phillip D. Whitfield Terry K. Smith Liam J. Morrison Michael P. Barrett Pieter C. Steketee 10.1371/journal.pntd.0014771 2026-09-24T14:00:00Z 2026-09-24T14:00:00Z <p>by Emily A. Dickie, Stefan K. Weidt, Jennifer Haggarty, Gavin Blackburn, Mary K. Doherty, Ryan Ritchie, Edith Paxton, Simon Young, Phillip D. Whitfield, Terry K. Smith, Liam J. Morrison, Michael P. Barrett, Pieter C. Steketee</p> African trypanosomes are a group of pathogens that cause disease in humans (human African trypanosomiasis; HAT) and animals (African animal trypanosomosis; AAT) across sub-Saharan Africa, leading to profound impacts on human health as well as economic instability. Achieving sustainable disease control requires a One Health approach, yet the development of urgently required pan-species chemotherapeutics is severely hindered by a lack of unified biological understanding of the causative species. A major bottleneck in drug discovery is the distinct <i>in vitro</i> requirements of the clinically relevant species. Whilst <i>Trypanosoma brucei</i> is typically cultured in FBS-supplemented culture, <i>T. congolense</i>, the primary cause of AAT, requires the use of goat serum. The differing serum supplementation requirements of these two trypanosome species point to metabolic distinctions, which may be important considerations in developing experimental systems to enable the identification and design of novel, pan-species therapies. In this study, untargeted LC-MS lipidomics analyses were conducted to determine the relative lipidomic profiles of <i>T. brucei</i> and <i>T. congolense</i> bloodstream form parasites. The use of a novel medium formulation that permits effective <i>in vitro</i> culture of both species revealed that their lipidomic profiles are distinct. Notably, ether phospholipids, key molecules in <i>T. brucei</i> lipid biology, are relatively absent in <i>T. congolense</i>. Furthermore, the <i>T. brucei</i> lipidome is enriched with shorter chain saturated lipids, whilst <i>T. congolense</i> exhibits a preference for longer-chain polyunsaturated fatty acids (PUFAs). These observations indicate that there are significant differences in the ways these parasites synthesise and remodel their lipid complement, highlighting an evolutionary divergence between the species that likely carries implications for host-pathogen interactions as well as trypanosome membrane biology. Crucially, defining the species-specific lipid dependencies provides the foundation for pan-species culture systems, thereby removing a critical barrier to the discovery and design of novel therapeutics effective against all African trypanosome species. Malena Grados Vásquez Juan Carlos Guerra Blas Anthony Salcedo-Prudencio Thayane Santos Siqueira Wuelton Monteiro John Alexanders Amaya Parra Flor Ernestina Martinez-Espinosa 10.1371/journal.pntd.0014747 2026-09-24T14:00:00Z 2026-09-24T14:00:00Z <p>by Malena Grados Vásquez, Juan Carlos Guerra Blas, Anthony Salcedo-Prudencio, Thayane Santos Siqueira, Wuelton Monteiro, John Alexanders Amaya Parra, Flor Ernestina Martinez-Espinosa</p> Background <p>Snakebite envenoming remains a major neglected tropical disease worldwide, disproportionately affecting rural and socioeconomically vulnerable populations in tropical and subtropical regions. In Peru, snakebite burden is strongly concentrated in Amazonian territories, yet nationwide evidence on its long-term spatial dynamics and socioeconomic determinants remains limited.</p> Methodology <p>This study provides the first multiscale spatiotemporal assessment of snakebite envenoming incidence in Peru between 2010 and 2025. National surveillance data were analyzed at departmental and district levels to evaluate temporal trends, spatial clustering, hotspot persistence, ecological suitability, and socioeconomic associations. Spatial autocorrelation was assessed using Global Moran’s I and Local Indicators of Spatial Association (LISA), while associations between Human Development Index (HDI) and snakebite envenoming incidence were evaluated across Peruvian macroregions.</p> Findings <p>A total of 32,942 snakebite envenoming cases were reported during the study period, with more than 60% concentrated in Amazonian departments, particularly Loreto, San Martín, and Ucayali. Snakebite incidence exhibited significant spatial autocorrelation throughout the study period (Moran’s I = 0.53–0.61; <i>p</i> < 0.05), revealing a non-random and spatially structured distribution of risk. LISA analyses identified persistent hotspot districts concentrated mainly in the northern and central Peruvian Amazon, forming a stable corridor of elevated incidence over time. Persistent hotspots spatially overlapped with areas of high environmental suitability for medically important venomous snakes, particularly <i>Bothrops atrox</i>, and elevated potential species richness. Socioeconomic analyses revealed marked regional heterogeneity, with a significant moderate negative correlation between HDI and snakebite incidence in the Northern Amazon (Spearman’s ρ = −0.42; <i>p</i> < 0.001), indicating higher burden in socioeconomically vulnerable districts.</p> Conclusions <p>These findings demonstrate that snakebite envenoming in Peru is spatially persistent, ecologically structured, and closely associated with socioeconomic inequalities in Amazonian regions. Identifying persistent high-risk areas may support geographically targeted surveillance, optimized antivenom allocation, and territorially adapted public health interventions.</p> Hasyanee Binmaeil Thanakon Bunsong Janjira Thaipadungpanit Wipawee Saenwongsa Montira Ngoenpramual Sutthinan Chawsorngkorn Soawarat Deekae Sunee Chayangsu Wang Nguitragool Narisara Chantratita 10.1371/journal.pntd.0014730 2026-09-24T14:00:00Z 2026-09-24T14:00:00Z <p>by Hasyanee Binmaeil, Thanakon Bunsong, Janjira Thaipadungpanit, Wipawee Saenwongsa, Montira Ngoenpramual, Sutthinan Chawsorngkorn, Soawarat Deekae, Sunee Chayangsu, Wang Nguitragool, Narisara Chantratita</p> Effective control of tuberculosis, nontuberculous mycobacterial (NTM) disease, and melioidosis depends on rapid and accurate laboratory diagnosis. <i>Mycobacterium tuberculosis</i> complex (MTBC) remains a health priority, whereas NTM infections, particularly <i>Mycobacterium avium</i> complex (MAC), are increasingly recognized and may be misdiagnosed as tuberculosis. Melioidosis, caused by <i>Burkholderia pseudomallei</i>, is underdiagnosed in endemic regions. These infections have overlapping clinical presentations, and conventional diagnostics methods may not accurately differentiate among these diseases. We developed and evaluated a quadruplex real-time PCR assay (TAM-mPCR) for simultaneous detection of MTBC, MAC, and <i>B. pseudomallei</i>, targeting <i>IS6110</i>, <i>rrs</i>, and <i>BPSS1187</i>. A total of 607 pulmonary and extrapulmonary specimens from patients with suspected tuberculosis were collected at two sites in Thailand between 2024 and 2025. The limits of detection were 2 pg/reaction for MTBC, 0.1 ng/reaction for MAC, and 50 fg/reaction for <i>B. pseudomallei</i>, with 100% analytical specificity. For MTBC detection, TAM-mPCR demonstrated 100% sensitivity (330/330) and 99% (189/191) specificity. All three culture-confirmed MAC specimens were detected. For <i>B. pseudomallei</i>, the assay demonstrated 73.2% sensitivity (30/41) and 100% specificity (79/79). For MTBC, TAM-mPCR showed high concordance with NAAT and culture results, but differed significantly from AFB microscopy (<i>P</i> < 0.001). The assay also detected additional MTBC, MAC, and <i>B. pseudomallei</i> infections that were missed by routine diagnostics. TAM-mPCR enables rapid simultaneous pathogen detection and differentiation and may improve case detection and patient management in setting where tuberculosis and melioidosis co-endemic. Alejandro Mejía Muñoz Ana María Mejía-Jaramillo Carl Lowenberger Karla Saavedra-Rodríguez Omar Triana-Chávez 10.1371/journal.pntd.0014144 2026-09-24T14:00:00Z 2026-09-24T14:00:00Z <p>by Alejandro Mejía Muñoz, Ana María Mejía-Jaramillo, Carl Lowenberger, Karla Saavedra-Rodríguez, Omar Triana-Chávez</p> Insecticide spraying is a common strategy for controlling dengue outbreaks, but its effectiveness is compromised by the development of resistance in mosquito populations. In this study, we subjected a strain of <i>Aedes aegypti</i> known for its exceptional ability to develop resistance to controlled permethrin and lambda-cyhalothrin insecticides pressure using two different concentrations. We analyzed resistance mechanisms that are enhanced at each concentration and used RNA sequencing to identify transcripts specifically associated with these exposure levels. Our objective was to uncover the molecular mechanisms triggered by different insecticide concentrations and to distinguish responses between type I and type II pyrethroids, which differ in chemical structure. Our results showed that <i>kdr</i> mutations confer only moderate levels of resistance, as do detoxifying enzymes. For lambda-cyhalothrin, we identified genes involved in the electron transport chain, mitochondrial function, and overall responses to oxidative stress. tRNA transcripts were also upregulated, along with mitochondrial and stress-response transcripts, suggesting a metabolic shift, particularly toward maintaining homeostasis under oxidative stress. These changes point to mechanisms that sustain resistance to this type II insecticide beyond direct detoxification in this population. On the contrary, permethrin induced marked overexpression of cuticle genes, CYP450 genes (especially CYP4), and Odorant Binding Proteins. These expression patterns, together with metabolic enzymes, point to detoxification, reduced penetration, or even sequestration of insecticide, all of which intensify with increasing concentrations. This overregulation of genes suggests an integrated response complemented by classical metabolic detoxification and accompanied by overregulation of mitochondrial complexes. We showed that despite the shared mode of action of the insecticides permethrin and lambda-cyhalothrin, they elicit distinct responses in this <i>Ae. aegypti</i> population. We also showed that the transcriptomic response depends on insecticide concentration and may modulate insecticide tolerance. This article advances understanding of the complexity of pyrethroid resistance in <i>Aedes aegypti</i> and underscores the importance of considering both the insecticide type and the concentration used in vector control programs. Guanghui Xia Rui Gao Huanhong Pan Jun Zong Zhili Zeng Zifen Li Chenwei Li Shiyu Liao Tong Luo Guai Tang Zijing Peng Xiaoqing Liu Shiwen Liu Jianxiong Li Tianchen Zhang 10.1371/journal.pntd.0014746 2026-09-23T14:00:00Z 2026-09-23T14:00:00Z <p>by Guanghui Xia, Rui Gao, Huanhong Pan, Jun Zong, Zhili Zeng, Zifen Li, Chenwei Li, Shiyu Liao, Tong Luo, Guai Tang, Zijing Peng, Xiaoqing Liu, Shiwen Liu, Jianxiong Li, Tianchen Zhang</p> Background <p>Hemorrhagic fever with renal syndrome (HFRS) is a significant public health concern in Jiangxi Province, China, where both Hantaan (HTNV) and Seoul (SEOV) co-circulate. Previous studies have identified three distinct clusters of HFRS epidemic in Jiangxi Province, characterized by geographical separation and heterogeneous incidence levels. We hypothesized that clinical severity and healthcare-seeking behaviors may vary across these clusters, and thus conducted a retrospective study to examine this hypothesis.</p> Methods <p>We retrospectively analyzed 4,614 HFRS cases (13-year period) from 63 counties. Cases were classified into four areas based on prior spatial study, representing distinct hilly and plain regions with different proximity to major water bodies and mountains. Data on HFRS cases were collected by county-level CDC staff using a nationally standardized case investigation questionnaire. Clinical severity and healthcare-seeking behaviors (hospital level, onset-to-visit interval) were compared.</p> Results <p>HFRS cases in Cluster I exhibited the highest clinical severity (22.41% severe, 6.65% critical), while cases in Cluster II were strikingly mild (2.62% severe, 1.31% critical). Median onset-to-visit interval was longest in Cluster II (5 days) vs others (2–4 days). Hospital preference varied: Cluster I primarily used Class II hospitals (65.88%); Cluster II showed near-equal use of Class II (48.44%) and III (47.01%); Cluster III and non-clustered areas favored higher-level hospitals.</p> Conclusion <p>Our findings confirmed that Jiangxi Province, though a mixed epidemic focus, exhibited distinct spatial heterogeneity in clinical severity, and healthcare-seeking behaviors. These findings underscore the need for regionally tailored strategies in HFRS prevention and control.</p> Laura Garcia Victor Yman Marie-Fabrice Gasasira Françoise Donnadieu Jason Rosado Lucie Cappuccio Damien Hoinard Philippe Desprès Stéphane Petres Jean-Claude Manuguerra In-Kyu Yoon Taweewan Hunsawong Maria Theresa P. Alera Emily S. Gurley Nikos Vasilakis Scott C. Weaver Ziaur Rahman Ilaria Dorigatti Chris Drakeley Inès Vigan-Womas Makhtar Niang Henrik Salje Jessica Vanhomwegen Michael White 10.1371/journal.pntd.0013704 2026-09-23T14:00:00Z 2026-09-23T14:00:00Z <p>by Laura Garcia, Victor Yman, Marie-Fabrice Gasasira, Françoise Donnadieu, Jason Rosado, Lucie Cappuccio, Damien Hoinard, Philippe Desprès, Stéphane Petres, Jean-Claude Manuguerra, In-Kyu Yoon, Taweewan Hunsawong, Maria Theresa P. Alera, Emily S. Gurley, Nikos Vasilakis, Scott C. Weaver, Ziaur Rahman, Ilaria Dorigatti, Chris Drakeley, Inès Vigan-Womas, Makhtar Niang, Henrik Salje, Jessica Vanhomwegen, Michael White</p> Arboviruses such as dengue virus (DENV) and chikungunya virus (CHIKV) pose major global health threats. To support serological surveillance and study cross-reactivity, an in-house multiplex bead-based immunoassay was developed to measure IgG responses against a wide panel of orthoflavivirus and alphavirus antigens. Samples from Senegal, France, the Philippines, and Bangladesh enabled analyses to be carried out in endemic and non-endemic regions. IgG kinetics following DENV1 and CHIKV infections revealed virus-specific temporal profiles and identified antigens, such as CHIKV E2 and VLP, as well as DENV1 EDIII and SNAP-tagged EDIII, as promising markers for serosurveillance. A two-step Random Forest model was used to classify PRNT-positive samples and predict PRNT titers. CHIKV showed a strong correlation between IgG and PRNT titers (R² = 0.71), while DENV1 showed weaker performance (R² = 0.42). These results support the use of multiplex serology for arbovirus surveillance and highlight the limitations of using binding antibodies to predict neutralisation, particularly for orthoflaviviruses. Lijuan Zheng Wenjing Zhi Mengjie Chu Xinyi Zhou Yong Fu Chen Xin Baoping Li Lingzhi Pengmao Zhendong Xin Yihui Wu Xuejun Ji Anni Zhang Changjie Qian Zhen Wang Chenye Jin Yun Han Zhijun Zhang Fuyun Chen Gongguan Liu 10.1371/journal.pntd.0014755 2026-09-22T14:00:00Z 2026-09-22T14:00:00Z <p>by Lijuan Zheng, Wenjing Zhi, Mengjie Chu, Xinyi Zhou, Yong Fu, Chen Xin, Baoping Li, Lingzhi Pengmao, Zhendong Xin, Yihui Wu, Xuejun Ji, Anni Zhang, Changjie Qian, Zhen Wang, Chenye Jin, Yun Han, Zhijun Zhang, Fuyun Chen, Gongguan Liu</p> Alveolar echinococcosis (AE) is a severe zoonotic parasitic disease caused by the larval stage of <i>Echinococcus multilocularis</i>, for which early and accurate diagnosis remains challenging. In this study, we targeted <i>E. multilocularis</i> thioredoxin peroxidase (EmTPx), a highly abundant excretory/secretory protein conserved across the genus <i>Echinococcus</i>, for diagnostic development. Monoclonal antibodies (mAbs) against EmTPx were generated, and two linear B‑cell epitopes, ¹⁷⁴HPGSK¹⁷⁸ and ¹⁸⁹SFMSS¹⁹³, were identified. Both epitopes are strictly conserved within <i>Echinococcus</i> but markedly divergent from mammalian host sequences. Structural modeling revealed that the epitopes are surface‑exposed, with ¹⁷⁴HPGSK¹⁷⁸ located in a flexible loop and ¹⁸⁹SFMSS¹⁹³ adjacent to an α‑helix, conformations favorable for antibody recognition. Two ELISA methods were established using the epitope‑specific mAbs. The blocking ELISA showed moderate diagnostic performance. More importantly, the sandwich ELISA enabled direct detection of EmTPx antigen in fecal samples of intermediate hosts, revealing a detection rate of 85% in mouse feces at an early infection stage. With a linear range of 0–250 ng/mL, a cutoff of 0.1724, and intra‑ and inter‑assay precision below 10%, this sandwich ELISA demonstrated robust analytical performance. In conclusion, this proof-of-concept study identifies two evolutionarily conserved and structurally exposed EmTPx epitopes and demonstrates their potential utility for the development of monoclonal antibody-based approaches for non-invasive detection of echinococcosis. Elohor Oborevwori Kristjana Ásbjörnsdóttir Sean Galagan Katherine Sharrock Kumudha Aruldas Saravanakumar Puthupalayam Kaliapan Rachael Pullan Robin Bailey Khumbo Kalua James Simwanza Stefan Witek-McManus Moudachirou Ibikounlé Adrian J. F. Luty Sitara Swarna Rao Ajjampur Arianna Means Judd L. Walson 10.1371/journal.pntd.0014740 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Elohor Oborevwori, Kristjana Ásbjörnsdóttir, Sean Galagan, Katherine Sharrock, Kumudha Aruldas, Saravanakumar Puthupalayam Kaliapan, Rachael Pullan, Robin Bailey, Khumbo Kalua, James Simwanza, Stefan Witek-McManus, Moudachirou Ibikounlé, Adrian J. F. Luty, Sitara Swarna Rao Ajjampur, Arianna Means, Judd L. Walson</p> Background <p>Accurate measurement of treatment coverage is critical for the monitoring and evaluation of mass drug administration (MDA) programs, yet post-treatment coverage surveys are subject to multiple sources of bias and may not accurately reflect true individual-level treatment coverage. Using data from the DeWorm3 study, a multi-country randomized trial assessing the feasibility of interrupting soil-transmitted helminth (STH) transmission, we compared coverage estimates from treatment registers with post-treatment coverage surveys and identified factors associated with discordant treatment reporting.</p> Methods <p>The DeWorm3 trial analyzed individual-level treatment data across six rounds of biannual MDA with albendazole for STH in Benin, India, and Malawi (2018–2020). Coverage surveys and treatment registers were linked using unique identifiers. This analytic sample included 12,162 individuals with matched survey and register records and non-missing treatment status from the final round of the intervention-arm. Concordance was summarized using percent discrepancy and Cohen’s kappa, and site-specific logistic regression models assessed factors associated with discrepancy.</p> Results <p>While aggregate coverage was high (>95%) across all sites, individual-level discordance at round six occurred in 6.12% of individuals in Benin, 2.00% in India, and 4.39% in Malawi, driven predominantly by higher reporting in coverage surveys relative to register records. Kappa values were interpreted descriptively as treatment coverage was very high. Periurban/urban residence was associated with higher odds of discrepancy in Benin (OR: 3.65, 95% CI: 2.56–5.28) and Malawi (OR: 1.54, 95% CI: 1.11–2.12). In Malawi, male sex was also associated with higher discrepancy, while MDA awareness was associated with lower discrepancy. No covariates were significantly associated with discrepancy in India.</p> Conclusions <p>Individual-level discordance between coverage surveys and treatment registers was present across all sites and rounds, with surveys consistently estimating higher levels of treatment. Predictors varied by site, suggesting measurement error is driven by site-level programmatic and contextual factors rather than individual demographic characteristics. Programs should implement systematic validation approaches as high aggregate coverage estimates may mask meaningful individual-level measurement error.</p> Matshepo Elizabeth Rakaki Adriano Mendes Paul Wichgers Schreur Martin H. Groschup Markus Keller Nicolette Marie Du Plessis Maryke De Villier Theunis Avenant Marietjie Venter 10.1371/journal.pntd.0014738 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Matshepo Elizabeth Rakaki, Adriano Mendes, Paul Wichgers Schreur, Martin H. Groschup, Markus Keller, Nicolette Marie Du Plessis, Maryke De Villier, Theunis Avenant, Marietjie Venter</p> Shuni Virus (SHUV) is a reemerging zoonotic orthobunyavirus in the Peribunyaviridae family associated with neurological infections and birth defects in humans and animals in Africa and has emerged in the Middle East in the past 10 years. Limited epidemiological data exist in humans, partially due to a lack of clinical awareness and availability of diagnostic assays to determine the incidence of clinical cases and seroprevalence in the population. The goal of this study was to establish serologic and molecular diagnostic assays for SHUV for hospital-based surveillance and to investigate the clinical epidemiology in humans in South Africa. The incidence of SHUV infections was investigated in patients with acute fever of unknown cause with or without neurological signs (AFDUC/N) during the arbovirus season (January-June, 2019–2021). IgM and IgG ELISAs for SHUV were established using baculovirus-expressed glycoproteins and validated against virus-neutralization tests (VNT) positive sera. Orthobunyavirus quantitative RT-PCR (RT-qPCR) and IgM ELISA were used to identify acute infections, and IgG ELISA to define the seroprevalence in patients and healthy control groups in hospitals in Gauteng and Mpumalanga provinces in South Africa. In total, 3/349 (0.84%) AFDUC/N cases tested positive by RT-qPCR and confirmed as SHUV by sequencing. In total, 22/225 (9.7%) AFDUC/N patients had SHUV neutralising antibodies (VNT), of which 11/22 (50.00%) were IgM positive, with an IgM seropositivity of 4.89% (11/225 (4.89%)). Of the RT-PCR and double IgM + VNT+ patients, 60% presented with seizures and 40% with meningitis, of which 36.36% were children and 63.63% were adults, respectively. In total, 9/112 (8%) of the healthy control group tested positive on the IgG ELISA assay. These findings suggest that SHUV is a missed cause of acute neurological infections in hospitalized children and adults in South Africa and should be investigated in humans in Africa and other regions. Charles J. Gerardo Ashish Bhalla Chitta R. Mohanty Badal K. Sahu Surendra Kumar Suneil Agrawal Manu Ayyan S Eileen Shu Travis Deuson Madhu Kumar R Norman L. Beatty Peter D. Akpunonu Farshad M. Shirazi Sarah Watkins Anne-Michelle Ruha Shawn M. Varney Anil K. Goel Medhavi Gautam Justin Arnold Chanaveerappa Bammigatti Samuel J. Francis Suresh Selvam Harish Kumar Adiel Aizenberg Andrew Micciche Rylee S. Bledsoe Ginger Boatright Suraj C. Oomman Stephen P. Samuel Janet T. Wittes Rebecca W. Carter Matthew R. Lewin Timothy F. Platts-Mills 10.1371/journal.pntd.0014736 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Charles J. Gerardo, Ashish Bhalla, Chitta R. Mohanty, Badal K. Sahu, Surendra Kumar, Suneil Agrawal, Manu Ayyan S, Eileen Shu, Travis Deuson, Madhu Kumar R, Norman L. Beatty, Peter D. Akpunonu, Farshad M. Shirazi, Sarah Watkins, Anne-Michelle Ruha, Shawn M. Varney, Anil K. Goel, Medhavi Gautam, Justin Arnold, Chanaveerappa Bammigatti, Samuel J. Francis, Suresh Selvam, Harish Kumar, Adiel Aizenberg, Andrew Micciche, Rylee S. Bledsoe, Ginger Boatright, Suraj C. Oomman, Stephen P. Samuel, Janet T. Wittes, Rebecca W. Carter, Matthew R. Lewin, Timothy F. Platts-Mills</p> Background <p>Snakebite envenoming causes an estimated 81,000–138,000 deaths and more than 400,000 cases of permanent disability each year, disproportionately affecting low-resource regions. Antivenom is the only approved treatment but requires intravenous administration. We evaluated intravenous followed by oral varespladib as adjunctive therapy to antivenom in hospitalized patients with snakebite envenoming.</p> Methods and findings <p>In this multicenter, randomized, double-blind, placebo-controlled phase II trial in India (CTRI/2023/10/058782) and the USA (NCT05717062), patients with snakebite envenoming were randomly assigned (1:1) to receive varespladib or placebo, both in addition to standard of care including antivenom. For elapid envenoming, the primary endpoint was time to recovery of 5-second head-lift. For viper envenoming, the primary endpoint was area under the curve (AUC) from baseline to Day 14 of a 3-item Snakebite Severity Score (SSS). Between June 3^rd, 2023, and October 19^th, 2024, 140 patients were randomized and 139 were analyzed (73 varespladib; 66 placebo). Study drug was initiated a mean of 7.3 hours after the bite and 3.3 hours after antivenom. Among elapid-bite patients, mean time to head-lift recovery was 27.6 hours with varespladib vs. 36.2 hours with placebo (p = 0.6). Among viper-bite patients, SSS AUC to Day 14 was 660 with varespladib vs. 629 with placebo (p = 0.7). No serious adverse event occurred with varespladib.</p> Conclusions <p>In this trial in which varespladib was initiated on average 7 hours after snakebite and several hours after antivenom, late adjunctive varespladib did not meet the primary endpoint. Interpretation of these results is limited by heterogeneity in the snake species responsible for envenoming and the associated differences in venom composition, clinical manifestations, and antivenom treatments.</p> Younjung Kim Junjie Chen Alex Yan Tarek Alrefae Sumali Bajaj Christl A. Donnelly 10.1371/journal.pntd.0014731 2026-09-21T14:00:00Z 2026-09-21T14:00:00Z <p>by Younjung Kim, Junjie Chen, Alex Yan, Tarek Alrefae, Sumali Bajaj, Christl A. Donnelly</p> Estimating the global burden of human rabies is notoriously challenging because the infection is often misdiagnosed or not reported. Although rare, instances of donor-derived human-to-human rabies transmission have been identified after organ or tissue transplantation. Here, we present a statistical framework leveraging these instances to estimate both the probability that a death from rabies is diagnosed for an infected individual and the number of total deaths from rabies. Of the 33 canine-rabies-endemic and 13 canine-rabies-free countries assessed, rabies was identified among deceased donors after transplantation in China (n = 4) between 2015 and 2024 and the United States of America (US) (n = 3) between 2000 and 2024. Assuming the same proportion of deaths from rabies among deceased donors and decedents in the general population, we estimated that China and the US diagnosed rabies in only 28.7% (95%CI: 14.8–56.5%) and 6.1% (95%CI: 2.4–21.1%) of rabies decedents, respectively, during the study years. In 2024, these corresponded to 581 (95%CI: 308–1,056) and 75 (95%CI: 19–242) estimated total deaths from rabies compared to 167 and 4 reported deaths from rabies, respectively. Although parameters were imprecisely estimated for the remaining countries, for countries with a relatively large number of deceased donors, our framework provided informative upper confidence bounds on total deaths from rabies, which can inform the design of surveillance and control measures. For example, in 2023, this upper bound was estimated to be 2,227 deaths from rabies for India. Parameter estimates were sensitive to the assumed relative risk of rabies between deceased donors and decedents in the general population, highlighting the need for future research to estimate this quantity and improve inference within our framework. Our findings show substantial underreporting of human deaths from rabies in both canine-rabies-endemic and canine-rabies-free countries, underscoring the need to strengthen surveillance and diagnostic capacity and raise risk awareness.