Background: Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. Objective: This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. Methods: This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies’ rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. Results: During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. Conclusions: PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

Background/Objectives: The Immunisation Agenda 2030 places sustained coverage and vaccine confidence at the centre of immunisation strategy. Less is known about the determinants of sec-ond-year-of-life vaccine uptake in sub-Saharan Africa. This study assessed the completion of vac-cines due after 12 months of age, caregiver confidence in newly introduced vaccines, and the factors associated with completion in three districts of Malawi. Methods: A mixed-methods cross-sectional survey of 1,177 caregivers in Chikwawa, Kasungu, and Mangochi assessed household wealth, food insecurity, and vaccination status. The primary outcome was caregiver-reported completion of all vaccines due after 12 months, assessed among children aged 18 months or older. Associations were examined using logistic regression. Focus group discussions with caregivers and key-informant in-terviews with community volunteers and leaders were then analysed thematically to explain the survey findings. Results: Among 1287 age-eligible children,1212 (94.2%) had completed second-year vaccines. Coverage ranged from about 94% for the measles-rubella vaccine to 61% for the Human papillomavirus (HPV) vaccine. Completion did not differ by household wealth, food insecurity, distance, or caregiver literacy. Health worker reminders were associated with vaccine completion (adjusted odds ratio 0.33, 95% confidence interval 0.17 to 0.62) Infertility concerns about the HPV vaccine were the most commonly reported concern (20.3 %). After excluding age-ineligibility, lack of vaccine awareness was the main reason for children missing newer vaccines. Conclusions: Sec-ond-year coverage was high and equitable. The main modifiable correlate of completion was health worker reminders and follow-up, a function that appears to be under-resourced.

BACKGROUND Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. OBJECTIVE This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. METHODS This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies’ rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. RESULTS During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. CONCLUSIONS PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

The autonomic nervous system (ANS) acts as a central regulator of socioemotional and physiological processes. Individual differences in ANS activity are associated with mental and physical health outcomes across the lifespan, stabilizing over the first 5 years of life. Thus, ANS activity has become a focus of developmental research. Current approaches to assessing ANS are often infeasible for deployment in large epidemiological studies and low resource settings, necessitating new approaches. The goal of the current study was to compare a “gold standard” system (BioRadio) to a new system (Mawi), which offers advantages of ease of use and automated scoring pipelines, in a sample of children in Malawi, an African country with one of the lowest per capita incomes in the world. Twenty-five children, aged 3 to 6 years, were assessed simultaneously with the two systems while participating in a standardized stressor protocol that included baseline, stressor, and recovery periods. Multiple ANS indicators outputted from each system were compared. Analyses assessed agreement in equivalent indices. Absolute heart rate scores were consistently higher from Mawi; consequently, other absolute scores were consistently higher or lower, depending on the index. After adjusting for index score mean differences between systems, agreement was good to excellent (ICC 0.75-0.97). There were no differences between systems in the detection of changes in ANS activity across the baseline, stressor, and recovery episodes of the protocol. The results provide initial evidence that the Mawi system produces data sufficiently similar to that of a gold standard to be considered valid. Thus, the Mawi system may be a feasible option for measuring ANS indicators, with particular utility under certain resource constraints. Future efforts to further validate the Mawi system should include testing in a variety of settings and contexts with larger sample sizes.

Background/Objectives: Vaccines delivered after infancy remain vulnerable to missed uptake. Less is known about the determinants of second-year-of-life vaccine uptake in Malawi. This study assessed the completion of vaccines due after 12 months of age, caregiver confidence in newer vaccines, and associated factors in three districts of Malawi. Methods: A mixed-methods cross-sectional study surveyed 1177 caregivers. Logistic regression examined factors associated with caregiver-reported completion of vaccines due after 12 months among age-eligible children. Focus group discussions with caregivers and key-informant interviews with community volunteers and leaders were then analysed thematically to explain the survey findings. Results: Among 1287 age-eligible children, 94.2% completed second-year vaccines, although coverage of the Human papillomavirus (HPV) vaccine was lower. Distance over 5 kilometres from a facility was associated with lower odds of completion, while health worker reminders were associated with higher odds of vaccine completion (adjusted odds ratio 3.03, 95% confidence interval 1.61 to 5.88). Qualitative accounts highlighted defaulter tracing and infertility concerns about HPV (22.2%). Conclusions: Second-year coverage was high among caregivers reached by immunisation services, but distance and lower uptake of newer vaccines remained important gaps. Strengthening geographical access, communication about newer vaccines, and adequately resourced health-worker follow-up may improve completion.