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Nikita Naicker,1 Hylton Rodel,2 Rubeshan Perumal,1 Yashica Ganga,2 Mallory Bernstein,2 Ntombi Benede,2 Salim Abdool Karim,1,3 Nesri Padayacthi,1,3 Alex Sigal,2,4,5 Kogieleum Naidoo1,3 1Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; 2Africa Health Research Institute, Durban, South Africa; 3MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute; University of KwaZulu-Natal, Durban, South Africa; 4School of Laboratory Medicine and Medical Sciences; University of KwaZulu-Natal, Durban, South Africa; 5Max Planck Institute for Infection Biology, Berlin, GermanyCorrespondence: Nikita Naicker, Doris Duke Medical Research Institute, 2nd Floor, 719 Umbilo Road, Durban, 4041, South Africa, Tel +27843011636, Email nikita.naicker@caprisa.orgIntroduction: Current TB treatment regimens are pathogen-directed and can be severely compromised by the development of drug resistance. Metformin has been proposed as an adjunctive therapy for TB, however relatively little is known about how metformin modulates the cellular interaction between Mtb and macrophages. We aimed to characterize how metformin modulates Mtb growth within macrophages.Methods: We utilized live cell tracking through time-lapse microscopy to better understand the biological effect of metformin in response to Mtb infection. Furthermore, the potent first-line anti-TB drug, isoniazid, was used as a comparator and as a companion drug.Results: Metformin caused a 14.2-fold decrease in Mtb growth compared to the untreated control. Metformin combined with isoniazid controlled Mtb growth is slightly better than isoniazid alone. Metformin demonstrated the ability to regulate the cytokine and chemokine response over a 72 hour period, better than isoniazid only.Conclusion: We provide novel evidence that metformin controls mycobacterial growth by increasing host cell viability, and a direct and independent pro-inflammatory response to Mtb. Understanding the impact of metformin on Mtb growth within macrophages will advance our current knowledge on metformin as an adjunctive therapy, providing a new host-directed approach to TB treatment.Keywords: metformin, tuberculosis, host-directed therapy, INH, adjunctive therapy

OA18.03 E. Andersen-Nissen (1); V. Voillet (2); A. Naidoo (2); J. Kee (1); A. Fiore-Gartland (1); O. Dintwe (2); N. Grunenberg (1); L. Polakowski (3); L. Fleurs (4); I. Jani [...], Background: Vaccine adjuvants are detected by the innate immune system and influence adaptive immune responses. The modestly efficacious RV144 Thai trial used alum to adjuvant the gp120 protein boost, whereas the non-efficacious HVTN 702 South African trial used MF59. Volunteers enrolled in HVTN 107 (NCT03284710) were administered these adjuvants with a subtype C pox-protein vaccine, affording a unique opportunity to contrast systemic innate immune responses and potentially inform the results of HVTN 702. Methods: Eighteen volunteers were enrolled per group. T1, T2 and T4 received 2 doses of ALVAC-HIV followed by 3 doses of ALVAC-HIV plus subtype C gp120 administered with MF59 (T1), alum (T2), or un-adjuvanted (T4). T3 received 4 doses of ALVAC-HIV with MF59-adjuvanted gp120. Innate immune responses were measured pre-vaccination and at days 1, 3 and 7 after the first (T3) or third (T1,T2, T4) vaccinations. Alterations in circulating leukocytes were assessed by CBC. Thirty-one serum immunomodulatory mediators were quantitated. Results: Neutrophil concentrations increased on day 1 in all groups (FDR-p&apos;s < 0.02) and monocyte concentrations increased in T2,T3 and T4 (FDR-p&apos;s < 0.12); lymphocyte concentrations significantly decreased at day 1 only in T1 (FDR-p = 0.03). Serum cytokines were also significantly altered post-vaccination in all groups (FDR-p&apos;s < 0.2). On Day 1, nine cytokines were induced in T1, including pro-inflammatory IFN-g, CXCL10, TNF-a, IL-6, as well as CCL4 and IL-2, with many factors remaining elevated at Day 3 and returning to baseline on Day 7. In contrast, only IL-2 and IL-6 were induced in T2 on Day 1 and twelve factors were repressed on Day 7 relative to pre-vaccination, including IFN-g and monocyte-chemotactic factors CCL8, CCL13, and CCL22. Responses in the MF59 groups differed when co-administered at the first vaccination (T3) relative to the third vaccination (T1) with 12 cytokines repressed on Day 1 in T3. Conclusions: Alum-adjuvanted protein administered in a prime/boost regimen including ALVAC-HIV reduced early systemic serum cytokine and chemokine responses to the vaccine, in stark contrast to MF59, where induction of a diverse immunomodulatory cytokine profile was observed in Southern African volunteers. Work on elucidating the differential effect of these two adjuvants on the types of innate immune cell responses in humans continues.

Background. Proper handwashing can reduce the burden of diseases related to hand hygiene (HH) and so contribute reducing under-5 mortality. Preschoolers can benefit from HH interventions by the burden of disease and absenteeism being reduced. Objective. To perform a scoping review of literature to assess the types and effectiveness of HH interventions at preschools, with a view to providing a guideline for appropriate interventions for South African facilities. Methods. A literature search was conducted through the PubMed database to identify relevant studies. An iterative screening process to focus the review allowed for information on the type and effectiveness of interventions to be collated. An updated PubMed search was conducted to determine whether any interventions related to COVID-19 at preschools could be included. Results. No additional studies relating to COVID-19 were found. Of the 305 studies identified during the initial search, only 12 fitted the specific search criteria. Of these, 10 studies showed improvements in HH-related indicators following the interventions. Only two studies used health education as an intervention, whereas the others included the supply of HH products (to varying extents) as part of the intervention. Conclusion. HH interventions appear successful in reducing diseases spread by poor HH, improving general HH practices and reducing absenteeism among preschoolers. Studies using innovative, entertaining methods of educating children have shown to be successful in improving handwashing techniques and decreasing microbial growth on children's hands. HH interventions are suggested as an effective measure to improve HH during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

The experience of violent crime can have a significant impact on the physical and psychological well-being of victims and their families. This paper looks at household experience of violence in five impoverished sites in the city of Johannesburg, South Africa. Five sites were purposefully selected to reflect the prevailing housing profiles in settings of relative impoverishment in Johannesburg. A structured questionnaire was used to obtain information on demographic profiles, socioeconomic data, environmental conditions and health status. Bivariate analyses were conducted to assess the relationship between household experience of violence, and potential risk factors and health/social outcomes. Overall, members of 28% of households had been a victim of violence in the year preceding the study. Across sites, experience of violence within households ranged from 21% to 36%. Perceptions of drug abuse (p=0.01) and drug peddling (p=0.03) as being major problems in the neighbourhood, and living in a house of poor quality (p=0.01), were significantly associated with household experience of crime. In households with experience of violence, fear of crime (p=0.03) and depression (p<0.001) were elevated, and levels of exercise in men were decreased (p=0.05). This paper highlights the high prevalence of violence in impoverished urban areas in South Africa, and contributes to existing evidence regarding the associations between experience of violent crime and psychological ill health in affected communities. The high prevalence of violent crime, and the resultant health and social effects, demand a cross-sectoral intervention to reduce violence, with the health and social sectors playing key roles. [ABSTRACT FROM AUTHOR]

Background: Occupational injuries (OI) remains a global health issue, claiming approximately 1000 lives daily. More needs to be known about OI burdens among artisans in low-income settings. Therefore, this study assessed the factors influencing OIs among carpenters and bricklayers, who are informal artisans in Nigeria., Methods: This mixed-methods survey was conducted in Osun state, Nigeria. The quantitative component entailed a comparative cross-sectional study of 421 bricklayers and 425 carpenters selected via simple random sampling. Information on socio-demographics and OI prevalence was obtained using a semi-structured questionnaire. The qualitative aspect comprised 12 focus group discussions (FGD) among artisans who did not participate in the quantitative aspect of the study. Thematic analysis of the qualitative data was conducted to identify pertinent themes and subthemes. Binary logistic regression analysis was conducted to assess the factors influencing OIs, p-value less than 0.05 was taken as statistically significant., Results: All respondents were male. The mean age was 51.3.7 ± 14.7 years for bricklayers and 50.0 ± 11.5 years for carpenters. The 3-month prevalence of OI was 39.9% for bricklayers and 51.8% for carpenters. Factors associated with OI among bricklayers included being aged 20-39 years (AOR:6.9, 95% CI:3.1-15.3) and 40-59 years (AOR:2.9, 95% CI:1.5-5.6), earning less than N50,000 (US$67) monthly (OR:2.3, 95% CI:1.2-4.7), earning N50,000-N99,000 (US$67-US$133) monthly (AOR:2.5, 95% CI: 1.2-5.2), and handling ≥ 200 kg per day at work (AOR:2.1, 95% CI:1.3-3.5). For carpenters, factors associated with OI were being aged 20-39 years (AOR:4.1, 95% CI:2.0-8.5), age 40-59 years (AOR:2.1, 95% CI:1.2-3.6) and handling 100-199 kg per day at work (AOR:1.9, 95% CI:1.02-3.4). FGD findings revealed that the use of substandard building materials, poor use of personal protective equipment and working at heights may predispose to OIs., Conclusion: The burden of OI is high among informal construction artisans in Nigeria. Safety interventions should target persons < 60 years, those handling heavy weights at work (> 100 kg) and bricklayers earning < N100,000 (< US$134) monthly. Emphasis should also be placed on the use of safety equipment and ensuring standards of building materials., Competing Interests: Declarations. Ethics and consent to participate: Informed consent was obtained from all participants. Ethical approval to conduct the study was obtained from the Human Research Ethics Committee (Medical) of the University of Witwatersrand, South Africa (M221066) and from the Health Research and Ethics Committee of the Institute of Public Health, Obafemi Awolowo University, Nigeria. (IPHOAU/12/1766). In addition, the study was conducted in line with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards [63]. Permission to carry out the survey was obtained from the head of the artisans’ association in the selected LGAs. Written informed consent was obtained from all adult persons before participating in the survey after adequate explanation of the purpose of the study and the study risks and benefits. Participation was voluntary and confidentiality as well as data security was ensured. Respondents were informed of their rights decline or withdraw at any time without penalties. Data were stored on a computer that is password-protected and only accessible to the investigator. The clinical impression obtained from available information after survey assessements was communicated to individual repondents. All participants with clinical conditions detected on screening or those with other health complaints were subsequently referred after due counselling, to an appropriate formal healthcare provider of their choice with the aid of a printed study referral form. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: With limited access to mRNA COVID-19 vaccines in lower income countries, and people living with HIV (PLWH) largely excluded from clinical trials, Part A of the multicentre CoVPN 3008 (Ubuntu) study aimed to assess the safety of mRNA-1273, the relative effectiveness of hybrid versus vaccine immunity, and SARS-CoV-2 viral persistence among PLWH in East and Southern Africa during the omicron outbreak., Methods: Previously unvaccinated adults with HIV and/or other comorbidities associated with severe COVID-19 received either one (hybrid immunity) or two (vaccine immunity) 100-mcg doses of ancestral strain mRNA-1273 in the first month, depending on baseline evidence of prior SARS-CoV-2 infection. In a prospective cohort study design, we used covariate-adjusted Cox regression and counterfactual cumulative incidence methods to determine the hazard ratio and relative risk of COVID-19 and severe COVID-19 with hybrid versus vaccine immunity within six months. The ongoing Ubuntu study is registered on ClinicalTrials.gov (NCT05168813) and this work was conducted from December 2021 to March 2023., Findings: Between December 2021 and September 2022, 14,237 participants enrolled, and 14,002 (83% PLWH, 69% SARS-CoV-2 seropositive) were included in the analyses. Vaccinations were safe and well tolerated. Common adverse events were pain or tenderness at the injection site (26.7%), headache (20.4%), and malaise (20.3%). Severe adverse events were rare (0.8% of participants after the first and 1.1% after the second vaccination), and none were life-threatening or fatal. Among PLWH, the median CD4 count was 635 cells/μl and 18.5% had HIV viraemia. The six-month cumulative incidences in the hybrid immunity and vaccine immunity groups were 2.02% (95% confidence interval [CI] 1.61-2.44) and 3.40% (95% CI 2.30-4.49) for COVID-19, and 0.048% (95% CI 0.00-0.10) and 0.32% (95% CI 0.59-0.63) for severe COVID-19. Among all PLWH the hybrid immunity group had a 42% lower hazard rate of COVID-19 (hazard ratio [HR] 0.58; 95% CI 0.44-0.77; p < 0.001) and a 73% lower hazard rate of severe COVID-19 (HR 0.27; 95% CI 0.07-1.04; p = 0.056) than the vaccine immunity group, but this effect was not seen among PLWH with CD4 counts <350 cells/μl or HIV viraemia. Twenty PLWH had persistent SARS-CoV-2 virus at least 50 days., Interpretation: Hybrid immunity was associated with superior protection from COVID-19 compared to vaccine immunity with the ancestral mRNA-1273 vaccine. Persistent infections among immunocompromised PLWH may provide reservoirs for emerging variants., Funding: National Institute of Allergy and Infectious Diseases., Competing Interests: Peter B Gilbert received funds from NIAID/NIH, consulting fees from Curevo Vaccine Company and MinervaX Vaccine Company, served unpaid on a Moderna Advisory Board for Zika vaccines, AstraZeneca Vaccine SAB, Sanofi SAB, and Vaccine Company SAB. Lawrence Corey, Fatima Laher, Sharlaa Badal-Faesen, Sinead Delany-Moretlwe, Mina C Hosseinipour, Craig A Magaret, Erica Andersen-Nissen, Yunda Huang, M. Juliana McElrath, Cissy Kityo, Grace Mboya, and Jessica Andriesen received funding from NIAID/NIH paid to their institutions. Sufia Dadabhai and Noel Kayange report salary support from Johns Hopkins University. M. Juliana McElrath reports NIAID and Bill & Melinda Gate's Foundation payments to institution, payment from Stanford, CROI, NIH VRC, Ragon Institute. Richard Lessells is a current member of University of KwaZulu- Natal Biomedical Research Ethics Committee, one of the committees that reviewed and approved the CoVPN 3008 study, however he recused himself from decision making because of the conflict of interest. All other authors have nothing to declare., (© 2025 The Authors.)

Introduction: Scientific evidence shows that contemporary and emerging factors contribute to high blood lead concentrations in different populations. The study aimed to determine blood lead concentrations and risk factors associated with high blood lead concentrations among young males in conflict with the law., Methods: A cross-sectional analytical study was conducted among 192 conveniently selected participants from two youth secure (correctional) facilities in Gauteng Province, South Africa., Results: The study's overall blood lead concentration median was 3.30 μg/dl, ranging from 0.85 to 48.11 μg/dl. Young males born outside of South Africa (median = 8.78 μg/dl) and in villages (median = 4.95 μg/dl), working before coming to the facility (median = 5.23 μg/dl) and involvement in illegal mining (median = 9.00 μg/dl) had high blood lead concentrations in this study. Contemporary and emerging risk factors such as being born outside the country (AOR: 3.10, 95%CI: 1.01-1.88), involvement in illegal mining activities (AOR: 1.36, 95%CI: 1.14-1.91) and staying in a house with peeling paint on the outside (AOR: 2.26, 95%CI: 1.12-4.30) were found to influence blood lead concentration., Discussion: The study findings show that contemporary (co-existing) and emerging factors influence blood lead concentrations. Therefore, there is a need to investigate these factors further in communities that may be affected. Lastly, there is a need for a holistic approach involving multiple sectors to introduce human lead concentration screening and preventive programmes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2025 Mbonane, Swart, Mathee and Naicker.)

Limited studies have been conducted on the safety and effectiveness of heterologous COVID-19 vaccine boosting in lower income settings, especially those with high-HIV prevalence., The Sisonke Heterologous mRNA-1273 boost after prime with Ad26.COV2.S (SHERPA) trial evaluated a mRNA-1273 boost after Ad26.COV2.S priming in South Africa. SHERPA was a single-arm, open-label, phase 3 study nested in the Sisonke implementation trial of 500000 healthcare workers (HCWs). Sisonke participants were offered mRNA-1273 boosters between May and November 2022, when Omicron sub-lineages were circulating. Adverse events (AE) were self-reported, and co-primary endpoints (SARS-CoV-2 infections and COVID-19 hospitalizations or deaths) were collected through national databases. We used Cox regression models with booster status as a time-varying covariate to determine the relative vaccine effectiveness (rVE) of the mRNA-1273 booster among SHERPA versus unboosted Sisonke participants. Of 11248 SHERPA participants in the rVE analysis cohort (79.3% female, median age 41), 45.4% had received one and 54.6% two Ad26.COV2.S doses. Self-reported comorbidities included HIV (18.7%), hypertension (12.9%) and diabetes (4.6%). In multivariable analysis including 413161 unboosted Sisonke participants, rVE of the booster was 59% (95%CI 29-76%) against SARS-CoV-2 infection: 77% (95%CI 9-94%) in the one-Ad26.COV2.S dose group and 52% (95%CI 13-73%) in the two-dose group. Severe COVID-19 was identified in 148 unboosted Sisonke participants, and only one SHERPA participant with severe HIV-related immunosuppression. Of 11798 participants in the safety analysis, 228 (1.9%) participants reported 575 reactogenicity events within 7 days of the booster (most commonly injection site pain, malaise, myalgia, swelling, induration and fever). More reactogenicity events were reported among those with prior SARS-CoV-2 infections (adjusted odds ratio [aOR] 2.03, 95%CI 1.59-2.59) and less among people living with HIV (PLWH) (aOR 0.49, 95%CI 0.34-0.69). There were 115 unsolicited adverse events (AEs) within 28 days of vaccination. No related serious AEs were reported. In an immunogenicity sub-study, mRNA-1273 increased binding and neutralizing antibody titres and spike-specific T-cell responses 4 weeks after boosting regardless of the number of prior Ad26.COV2.S doses, or HIV status, and generated Omicron spike-specific cross-reactive responses. mRNA-1273 boosters after one or two Ad26.COV2.S doses were well-tolerated, safe and effective against Omicron SARS-CoV-2 infections among HCWs and PLWH. Trial registration: The SHERPA study is registered in the Pan African Clinical Trials Registry (PACTR): PACTR202310615330649 and the South African National Clinical Trial Registry (SANCTR): DOH-27-052022-5778., Competing Interests: KA and BL are employees of Moderna, Inc. and may hold stock/stock options in the company. The other authors declare no conflict of interests., (Copyright: © 2024 Garrett et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Occupational injuries are a growing public health problem. Approximately 1,000 workers die daily from occupational injuries globally. Artisans working in the informal sector of the construction industry in many low/middle income countries like Nigeria have a higher injury predisposition. This study will assess the determinants of occupational injuries and design a safety intervention for informal sector artisans in the Nigerian construction industry., Methods: A sequential mixed-methods design will be employed to study 840 bricklayers and carpenters (420 per artisan group) in Osun State, Nigeria. Quantitative data will be collected first while qualitative data will be collected thereafter. Thirdly, a modified Delphi-technique will be employed to co-design a safety education intervention. For the quantitative study, artisans will be recruited via multi-stage sampling and a semi-structured questionnaire will be administered to obtain information on artisans' socio-demographics, work-patterns and occupational injuries. A multivariable regression model will be used to determine the association between injury occurrence and independent variables. Twelve to sixteen focus group discussion (FGD) sessions will be conducted for artisans to obtain group perspectives about injuries and preferred safety training topics. From the FGD and quantitative study findings, a list of items for the safety training module will be compiled for the modified-Delphi process. Thereafter, the content validation index (CVI) will be derived and items with CVI of ≥0.80 will be included in the final safety training module., Conclusion: This paper describes the process required to assess the determinants of occupational injuries among artisans in the informal sector of the construction industry in Nigeria and further proposes the design of a context-relevant safety training intervention. The information from this study will be essential in promoting safe working environments for construction artisans., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ojo, Onayade and Naicker.)

Background: Adjuvants are widely used to enhance and/or direct vaccine-induced immune responses yet rarely evaluated head-to-head. Our trial directly compared immune responses elicited by MF59 versus alum adjuvants in the RV144-like HIV vaccine regimen modified for the Southern African region. The RV144 trial of a recombinant canarypox vaccine vector expressing HIV env subtype B (ALVAC-HIV) prime followed by ALVAC-HIV plus a bivalent gp120 protein vaccine boost adjuvanted with alum is the only trial to have shown modest HIV vaccine efficacy. Data generated after RV144 suggested that use of MF59 adjuvant might allow lower protein doses to be used while maintaining robust immune responses. We evaluated safety and immunogenicity of an HIV recombinant canarypox vaccine vector expressing HIV env subtype C (ALVAC-HIV) prime followed by ALVAC-HIV plus a bivalent gp120 protein vaccine boost (gp120) adjuvanted with alum (ALVAC-HIV+gp120/alum) or MF59 (ALVAC-HIV+gp120/MF59) or unadjuvanted (ALVAC-HIV+gp120/no-adjuvant) and a regimen where ALVAC-HIV+gp120 adjuvanted with MF59 was used for the prime and boost (ALVAC-HIV+gp120/MF59 coadministration)., Methods and Findings: Between June 19, 2017 and June 14, 2018, 132 healthy adults without HIV in South Africa, Zimbabwe, and Mozambique were randomized to receive intramuscularly: (1) 2 priming doses of ALVAC-HIV (months 0 and 1) followed by 3 booster doses of ALVAC-HIV+gp120/MF59 (months 3, 6, and 12), n = 36; (2) 2 priming doses of ALVAC-HIV (months 0 and 1) followed by 3 booster doses of ALVAC-HIV+gp120/alum (months 3, 6, and 12), n = 36; (3) 4 doses of ALVAC-HIV+gp120/MF59 coadministered (months 0, 1, 6, and 12), n = 36; or (4) 2 priming doses of ALVAC-HIV (months 0 and 1) followed by 3 booster doses of ALVAC-HIV+gp120/no adjuvant (months 3, 6, and 12), n = 24. Primary outcomes were safety and occurrence and mean fluorescence intensity (MFI) of vaccine-induced gp120-specific IgG and IgA binding antibodies at month 6.5. All vaccinations were safe and well-tolerated; increased alanine aminotransferase was the most frequent related adverse event, occurring in 2 (1.5%) participants (1 severe, 1 mild). At month 6.5, vaccine-specific gp120 IgG binding antibodies were detected in 100% of vaccinees for all 4 vaccine groups. No significant differences were seen in the occurrence and net MFI of vaccine-specific IgA responses between the ALVAC-HIV+gp120/MF59-prime-boost and ALVAC-HIV+gp120/alum-prime-boost groups or between the ALVAC-HIV+gp120/MF59-prime-boost and ALVAC-HIV+gp120/MF59 coadministration groups. Limitations were the relatively small sample size per group and lack of evaluation of higher gp120 doses., Conclusions: Although MF59 was expected to enhance immune responses, alum induced similar responses to MF59, suggesting that the choice between these adjuvants may not be critical for the ALVAC+gp120 regimen., Trial Registration: HVTN 107 was registered with the South African National Clinical Trials Registry (DOH-27-0715-4894) and ClinicalTrials.gov (NCT03284710)., Competing Interests: MK and OVDM are employed by GSK and hold shares in the company. MK reports grants from Bill & Melinda Gates Foundation and grants from NIH during the conduct of the study. NKT was an employee of GSK Biologicals and Novartis Vaccines & Diagnostics during the time of the trial. All other authors have nothing to declare., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Introduction: Human papillomavirus (HPV) infection is a leading cause of cervical cancer. Although this relies on infection and persistence of HPV in epithelial cells, often occurring in the context of other sexually transmitted infections (STIs) and bacterial vaginosis (BV), data on the relationships between these and their relative effects on epithelial barrier integrity in women remain sparse. This study describes the epidemiology of HPV combined with STI and/or BV prevalence and the relative impact on matrix metalloproteinases (MMPs) among South African women., Methods: Roche Linear Array was used for HPV genotyping in menstrual cup pellets of 243 HIV-negative women participating in the CAPRISA 083 cohort study. Vulvovaginal swabs were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using Xpert® CT/NG assay and lateral flow assay, and Gram staining was performed to diagnose BV using Nugent scoring criteria. Concentrations of 5 MMPs were measured in menstrual cup supernatants by multiplexed ELISA. Fisher's exact tests, Mann-Whitney U tests, and multivariable regression models determined associations between HPV infection, STI and/or BV, and MMP concentrations., Results: HPV was prevalent in 34% of women (83/243; median 23 years, interquartile range (IQR) 21-27 years). Low-risk (lr) (71%, 59/83) and high-risk (hr)-HPV infections (54.2%, 45/83) were common. Hr-HPV was frequently detected in STI and/or BV-positive women compared to women without STIs or BV (p = 0.029). In multivariable analysis, BV was associated with increased odds of hr-HPV detection (OR: 2.64, 95%CI: 1.02-6.87, p = 0.046). Furthermore, Gardasil®9 vaccine-type strains were more frequently detected in women diagnosed with STI and/or BV (55.2%, 32/58 vs 24%, 6/25; p = 0.009). Among STI and/or BV-positive women, HPV detection was significantly associated with increased MMP-10 concentrations (b = 0.55, 95% CI 0.79-1.01; p = 0.022)., Conclusion: Most women with hr-HPV had another STI and/or BV, emphasizing an urgent need for STI and BV screening and intensive scale-up of cervical cancer screening and HPV vaccination programmes. Furthermore, the study highlights the need for more extensive research to confirm and understand the relationship between HPV infection and barrier integrity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Qulu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Antimicrobial resistance (AMR) is a global challenge that has raised concern globally, owing to its detrimental effects on the health and economy of countries. The ever-growing threat of AMR and sources of AMR are still being investigated. Wastewater plays an important role as a habitat for bacteria and an environment conducive to gene transfer. The primary aim of this review was to highlight the contribution of wastewater to AMR., Methods: Evidence of AMR in wastewater was drawn from literature published in the last 10 years, from 2012 to 2022., Results: Wastewater from agricultural practices, pharmaceutical manufacturing plants, and hospital effluents was established to promote AMR. Furthermore, stress factors such as the presence of antibiotics, heavy metals, pH, and temperature initiate and propagate AMR in bacteria living in wastewater. AMR in bacteria from wastewater was established to be either natural or acquired. Wastewater treatment techniques such as membrane filtration, coagulation, adsorption, and advanced oxidation processes have been used to remove resistant bacteria with varying success levels., Conclusion: Wastewater is a major contributor to AMR, and an understanding of its role in AMR is necessary to find a lasting solution. In this regard, the spread of AMR in wastewater should be considered a threat that requires a strategy to stop further damage., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: High-dose isoniazid is recommended in the 9-12 months short-course regimen for multidrug-resistant tuberculosis with inhA mutation. However, there is insufficient evidence to support the assumption of genotypic-phenotypic concordance. This study aimed to identify the genetic mutations associated with high-level phenotypic isoniazid resistance., Methods: Clinical isolates from patients with drug-resistant tuberculosis were profiled by whole-genome sequencing and subjected to minimum inhibitory concentration (MIC) testing using MGIT based-method. MICs were performed in concentration ranges based on the mutation present: isolates with no isoniazid resistance-conferring mutations and H37Rv, 0.016-0.256 µg/ml; inhA, 0.256-4.0 µg/ml, katG 1.0-16.0 µg/ml; and inhA  +  katG, 4.0-64.0 µg/ml. Isolates demonstrating resistance at the upper limit of the concentration range were tested up to the maximum of 64.0 µg/ml. Bootstrap of the mean MICs was performed to increase the robustness of the estimates and an overlap index was used to compare the distributions of the MICs for each mutation profile., Results: A total of 52 clinical isolates were included in this analysis. Bootstrap MIC means for inhA , katG and inhA  +  katG were 33.64 (95% CI, 9.47, 56.90), 6.79 (4.45, 9.70) and 52.34 (42.750, 61.66) µg/ml, respectively. There was high overlap between inhA and inhA  +  katG mutations (eta = 0.45) but not with inhA and katG (eta = 0.19). Furthermore, katG showed poor overlap with inhA  +  katG mutations (eta = 0.09). Unexpectedly, 4/8 (50.0%) of all InhA mutants demonstrated high-level resistance, while 20/24 (83.3%) of katG mutants demonstrated moderate-level resistance., Conclusions: InhA mutations demonstrated unexpectedly high MICs and showed high overlap with inhA + katG . Contrary to the common belief that katG mutants are associated with high-level resistance, this mutation primarily showed moderate-level resistance., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Published by Elsevier Ltd.)

Background: Uganda is among the 10 countries in the sub-Saharan Africa region that have the highest prevalence of diarrhoeal disease. Evidence suggests that the severity of childhood diarrhoeal disease is escalated through various sociodemographic and environmental factors., Objectives: To assess prevalence of diarrheal illness in children below the age of 5 years in Uganda in 2016 and associated factors., Methods: A cross-sectional study was employed that analyzed secondary data from the 2016 Uganda Demography and Health Surveys. Children with and without diarrhea were compared. A logistic regression was used to determine sociodemographic and environmental factors associated with diarrheal illness in children with statistical significance at p < 0.05., Results: The prevalence of childhood diarrhoeal illness for children below the age of 5 years in Uganda was 20.9% (n = 2838/13,753). There was a statistically significant difference when comparing children diarrhoeal with the following sociodemographic factors: caregiver's age, child's age and gender and duration of breastfeeding (p < 0.0001). Children with a caregiver aged between 15 and 24 years (aOR;1.42; 95% CI:1.24-1.62) and 25-34 years (aOR;1.19; 95% CI:1.04-1.37) were more likely to report diarrhoeal disease, compared to those with a caregiver aged 35-49 years. For environmental factors, households using springs water, access to health facility and children who received a dose of vitamin A had a decreased risk of reporting children diarrhoeal., Conclusion: Significant factors in the study like caregiver's age, gender and duration of breastfeeding will create the opportunity for all interventions to shift their focus to these factors thus a better evidence-based approach to reducing of diarrhoeal disease will be achieved in the country., (© 2023. The Author(s).)

Drug-resistant tuberculosis (DR-TB) remains a global crisis due to the increasing incidence of drug-resistant forms of the disease, gaps in detection and prevention, models of care, and limited treatment options. The DR-TB treatment landscape has evolved over the last 10 years. Recent developments include the remarkable activity demonstrated by the newly approved anti-TB drugs bedaquiline and pretomanid against Mycobacterium tuberculosis. Hence, treatment of DR-TB has drastically evolved with the introduction of the short-course regimen for multidrug-resistant TB (MDR-TB), transitioning to injection-free regimens and the approval of the 6-month short regimens for rifampin-resistant TB and MDR-TB. Moreover, numerous clinical trials are under way with the aim to reduce pill burden and shorten the DR-TB treatment duration. While there have been apparent successes in the field, some challenges remain. These include the ongoing inclusion of high-dose isoniazid in DR-TB regimens despite a lack of evidence for its efficacy and the inclusion of ethambutol and pyrazinamide in the standard short regimen despite known high levels of background resistance to both drugs. Furthermore, antimicrobial heteroresistance, extensive cavitary disease and intracavitary gradients, the emergence of bedaquiline resistance, and the lack of biomarkers to monitor DR-TB treatment response remain serious challenges to the sustained successes. In this review, we outline the impact of the new drugs and regimens on patient treatment outcomes, explore evidence underpinning current practices on regimen selection and duration, reflect on the disappointments and pitfalls in the field, and highlight key areas that require continued efforts toward improving treatment approaches and rapid biomarkers for monitoring treatment response.

Objectives: This study describes the characteristics of admitted HCWs reported to the DATCOV surveillance system, and the factors associated with in-hospital mortality in South African HCWs., Methods: Data from March 5, 2020 to April 30, 2021 were obtained from DATCOV, a national hospital surveillance system monitoring COVID-19 admissions in South Africa. Characteristics of HCWs were compared with those of non-HCWs. Furthermore, a logistic regression model was used to assess factors associated with in-hospital mortality among HCWs., Results: In total, there were 169 678 confirmed COVID-19 admissions, of which 6364 (3.8%) were HCWs. More of these HCW admissions were accounted for in wave 1 (48.6%; n  = 3095) than in wave 2 (32.0%; n  = 2036). Admitted HCWs were less likely to be male (28.2%; n  = 1791) (aOR 0.3; 95% CI 0.3-0.4), in the 50-59 age group (33.1%; n  = 2103) (aOR 1.4; 95% CI 1.1-1.8), or accessing the private health sector (63.3%; n  = 4030) (aOR 1.3; 95% CI 1.1-1.5). Age, comorbidities, race, wave, province, and sector were significant risk factors for COVID-19-related mortality., Conclusion: The trends in cases showed a decline in HCW admissions in wave 2 compared with wave 1. Acquired SARS-COV-2 immunity from prior infection may have been a reason for reduced admissions and mortality of HCWs despite the more transmissible and more severe beta variant in wave 2., (© 2022 The Author(s).)

Introduction: The role of cockroaches in the cause of disease or human infections is not immediately obvious. The present study aimed to review the currently available research on the potential role of cockroaches in the transmission of pathogenic bacteria and bacteria with antibiotic resistance., Methodology: A scoping review included the studies published for a period between January 2001 and December 2020. A search was performed through five databases, namely, PubMed, Sage, Springer, Sabinet, and Science Direct. A search strategy used was conducted according to the principles of Preferred Reporting Item for Systemic Reviews and Meta-Analyses (PRISMA). From 97 studies identified, 32 studies were included in the scoping review., Results: The findings indicate that cockroaches may be a potential vector for a diverse range of pathogenic bacterial agents. Most bacterial agents isolated are antidrug-resistant and antibiotic-resistant which is considered the greatest threat to public health in the current period., Conclusions: Cockroach infestation should be considered as a serious concern, given the possible role of cockroaches as reservoirs of antibiotic-resistant bacteria. Further research is needed which can provide a comprehensive understanding of the role of cockroaches in transmitting human infections., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2022 Mapula Luckyjane Molewa, Tobias Barnard, Nisha Naicker.)

Background: We aimed to evaluate the analytic performance of 3 rapid HIV viral load assays: the novel Xpert HIV-1 VL XC (Xpert XC), Xpert HIV-1 VL (Xpert VL), and m-PIMA HIV-1/2 VL (m-PIMA)., Setting: Two South African clinics., Methods: We conducted a prospective diagnostic accuracy study. Site-laboratory technicians and nurses used the Xpert XC, Xpert VL, and m-PIMA to test plasma samples from people with HIV receiving antiretroviral therapy. We compared results with the Roche cobas HIV-1 reference assay. We determined accuracy to detect viraemia at the World Health Organization (WHO) failure threshold of 1000 copies/mL on all 3 assays, and 50 and 200 copies/mL on the Xpert assays. We assessed the agreement using Bland-Altman plots., Results: We enrolled 140 participants (98 [70%] women, median age 37 years), who provided 189 paired samples at one or more timepoints. We tested 174 samples with the Xpert XC, 188 with the Xpert VL, and 128 with the m-PIMA. At 1000 copies/mL, sensitivity and specificity (95% confidence intervals) were 97% (82 to 100) and 98% (93 to 99) (Xpert XC), 100% (87 to 100) and 96% (91 to 98) (Xpert VL), and 92% (72 to 99) and 99% (93 to 100) (m-PIMA) respectively. At 50 copies/mL, sensitivity and specificity were 93% (81 to 98) and 96% (91 to 99) (Xpert XC), and 95% (84 to 99) and 95% (90 to 98) (Xpert VL) respectively. Mean bias was -0.10 (-0.54 to 0.34) log10 copies/mL (Xpert XC), 0.07 (-0.37 to 0.52) log10 copies/mL (Xpert VL), and -0.26 (-0.83 to 0.31) log10 copies/mL (m-PIMA)., Conclusions: In these South African clinics, the accuracy of all 3 assays was clinically acceptable to detect viraemia at the WHO failure threshold, whereas both Xpert assays were also accurate at detecting low-level viraemia., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Construction workers, mineworkers and manufacturing employees in South Africa must report occupational injuries and illnesses to their employer as stipulated in section 14 of the Occupational Health and Safety Act and section 22 of the Mine Health and Safety Act. However, under-reporting of workplace injuries and illnesses is common globally.This protocol seeks to ascertain if macro-environment factors impact reporting of workplace injuries and illnesses and compare reporting between low-income and middle-income workers., Methods and Analysis: To achieve the objectives of the study, a sequential mixed-methods research design will be adopted. A questionnaire will be distributed among low-income and middle-income workers from nine companies in Gauteng from the construction, mining and manufacturing sectors to establish macro-environment factors that impact their reporting. In addition, a data extraction sheet will be submitted to compensation fund administrators who receive and process workers' compensation claims to determine reporting patterns by low-income and middle-income workers. In-depth interviews will be conducted with occupational health and safety subject matter experts in South Africa to ascertain their opinion regarding factors that impact reporting. Data will be analysed using SPSS V.27., Ethics and Dissemination: Prior to the commencement of the study, ethical approval and permission will be obtained from the University of Johannesburg Faculty of Health Sciences Research Ethics Committee. The researcher intends to publish the results of the study in peer-reviewed journals and present research papers at scientific conferences and provide feedback to employers and employees across all three industries. The study shall determine associations in reporting between the manufacturing, mining and construction sectors and establish interventions employers can implement for workers to report injuries and illnesses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

While the global COVID-19 pandemic has been widely acknowledged to affect the mental health of health care workers (HCWs), attention to measures that protect those on the front lines of health outbreak response has been limited. In this cross-sectional study, we examine workplace contextual factors associated with how psychological distress was experienced in a South African setting where a severe first wave was being experienced with the objective of identifying factors that can protect against HCWs experiencing negative impacts. Consistent with mounting literature on mental health effects, we found a high degree of psychological distress (57.4% above the General Health Questionnaire cut-off value) and a strong association between perceived risks associated with the presence of COVID-19 in the healthcare workplace and psychological distress (adjusted OR = 2.35, p < 0.01). Our research indicates that both training (adjusted OR 0.41, 95% CI 0.21−0.81) and the reported presence of supportive workplace relationships (adjusted OR 0.52, 95% CI 0.27−0.97) were associated with positive outcomes. This evidence that workplace resilience can be reinforced to better prepare for the onset of similar outbreaks in the future suggests that pursuit of further research into specific interventions to improve resilience is well merited.

Background: In South Africa, women continue to face a high burden of Human Immunodeficiency Virus (HIV) infection and the possible complications thereof during pregnancy. We assessed pregnancy incidence rates and outcomes in a longitudinal HIV cohort study over a 15-year period., Methods: We evaluated pregnancies among women ≥ 18 years between 2004 and 2019 in the CAPRISA 002 study. We analysed pregnancy rates following HIV acquisition, CD4 counts and HIV viral load dynamics and pregnancy outcomes. We used linear regression to assess if the mean CD4 and log 10 viral load close to delivery increases or decreases linearly across three different timepoints., Results: In total 245 women enrolled into the HIV negative study phase, 225 into the HIV infection phase and 232 in the antiretroviral therapy (ART) phase. Median follow-up time was 2.0 years [Interquartile Range (IQR) 0.8-2.0] during the HIV negative phase, 2.6 years; (IQR) 1.2-4.8] during HIV infection and 3.7 years (IQR 1.8-5.0) on ART, with maximum follow-up time of 2, 10 and 6 years respectively. Overall, 169 pregnancies occurred in 140 women, of which 16 pregnancies were observed during acute or early HIV infection [Incidence Rate (IR) 8.0 per 100 women-years; 95% confidence interval (CI): 4.6-12.9], 48 during established infection [IR 9.3; (CI 6.8-12.3)] and 68 on ART [IR 8.9; (CI: 7.0 - 11.4)]. Birth outcomes from 155/169 (91.7%) pregnancies were 118 (76.1%) full term live births, 17 (10.9%) premature live births, 9 (5.8%) therapeutic/elective miscarriages, 8 (5.1%) spontaneous miscarriages and 3 (1.9%) spontaneous foetal deaths or stillbirths. Six mother-to-child transmission events occurred, with four documented prior to 2008. Over time, mean CD4 count in pregnant women increased from 395 cells/µL (2004-2009) to 543 cells/µL (2010-2014) and to 696 cells/µL (2015-2019), p < 0.001. Conversely, the viral load declined from 4.2 log 10 copies/ml to 2.5 log 10 copies/ml and to 1.2 log 10 copies/ml (p < 0.001) for the corresponding periods., Conclusions: Pregnancy rates following HIV acquisition were high, emphasising a need for timeous ART provision and contraception counselling in women recently diagnosed with HIV. CD4 count and HIV viral load trajectories reflect improvements in treatment guidance for pregnant women over time., (© 2022. The Author(s).)

Healthcare workers (HCWs) are among the most vulnerable in regard to contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Comorbidities are reported to increase the risk for more severe COVID-19 outcomes, often requiring hospitalization. However, the evidence on disease severity and comorbidities among South African HCWs is lacking. This retrospective study analyzed the prevalence of comorbidities among HCW hospitalized with COVID-19 and its association with the severity of outcomes. Data from public and private hospitals in nine provinces of South Africa were extracted from the national hospital surveillance database for COVID-19 admissions. A total of 10,149 COVID-19 HCWs admissions were reported from 5 March 2020 to 31 December 2021. The risk of disease severity among HCWs increased with age, with those older (≥60 years) having seven times the odds of disease severity (aOR 7.0; 95% CI 4.2-11.8) compared to HCWs in the younger age (20-29 years) group. The most commonly reported comorbidity was hypertension (36.3%), followed by diabetes (23.3%) and obesity (16.7%). Hypertension (aOR 1.3; 95% CI 1.0-1.6), diabetes (aOR 1.6; 95% CI 1.3-2.0), and HIV (aOR 1.6; 95% CI 1.2-2.1) were significantly associated with disease severity. In conclusion, age, gender, and existing comorbidities were strong predictors of the prognosis of severe COVID-19 among HCWs in South Africa. The information is important in the development of occupational health policies and vulnerability risk assessments for HCWs in light of future COVID-19 waves or similar outbreaks.

Background: An association between blood-lead levels and aggression has been demonstrated in children and adolescent youth in South Africa. However, there are limited studies that have assessed aggression as an outcome for cumulative lead exposure using bone lead concentration. This study aims to assess the association between bone lead concentration and aggressive behaviour among a sample of youth in South Africa., Methods: Bone lead in 100 participants (53 males and 47 females) recruited and followed in the Birth to Twenty (BT20) Cohort were measured using 109 Cd-based, K-shell X-ray fluorescence (KXRF). The Buss-Perry Aggression questionnaire was used to measure aggressive behaviour. Linear regression models were fitted to determine the association between aggression score for physical, verbal, anger and hostility and bone lead, adjusting for known confounders., Results: A one-microgram-per-gram increase in bone lead was found to increase the score for all four scales of aggression, but significantly only for anger (β = 0.2 [95% CI 0.04-0.370]). Psychosocial factors such as a history of family violence and exposure to neighbourhood crime were significant predictors for aggression., Conclusions: The study provides a preliminary overview of the relationship between cumulative lead exposure and behavioural problems such as aggression. A larger sample, across exposed communities, may prove more definitive in further investigating the association between these two important public health factors and to maximize generalizability.

Introduction: Substantial improvements in viral suppression among people living with HIV (PLHIV) are needed to end the HIV epidemic, requiring extensive scale-up of low-cost HIV monitoring services. Point-of-care (POC) tests for monitoring antiretroviral therapy (ART) adherence and viral load (VL) may be efficient and effective tools for real-time clinical decision making. We aim to evaluate the effects of a combined intervention of POC ART adherence and VL testing compared with standard-of-care on ART adherence, viral suppression and retention at 6 and 18 months post-ART initiation among PLHIV., Methods and Analysis: Simplifying TREAtment and Monitoring for HIV (STREAM HIV) is a two-arm, open-label, randomised controlled superiority trial of POC urine tenofovir (POC TFV) and VL monitoring in PLHIV. We aim to enrol 540 PLHIV initiating a first-line ART regimen at a public HIV clinic in South Africa. Participants will be randomised 1:1 to the intervention or control arm. Intervention arm participants will receive monthly POC TFV testing for the first 5 months and POC VL testing at months 6 and 12. Intervention arm participants will also receive reflex POC TFV testing if viraemic and reflex HIV drug resistance testing for those with viraemia and detectable TFV. Control arm participants will receive standard-of-care, including laboratory-based VL testing at months 6 and 12. Primary outcomes include ART adherence (TFV-diphosphate concentration) at 6 months and viral suppression and retention at 18 months. Secondary outcomes include viral suppression and retention at 6 months, TFV-diphosphate concentration at 18 months, cost and cost-effectiveness of the intervention and acceptability of the intervention among PLHIV and healthcare workers., Ethics and Dissemination: STREAM HIV has received ethical approval from the University of Washington Institutional Review Board (STUDY00007544), University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC/00000833/2019) and Division of AIDS Regulatory Support Center (38509). Findings will be disseminated at international conferences and in peer-reviewed journals., Trial Registration Number: NCT04341779., Competing Interests: Competing interests: The point-of-care urine tenofovir tests used in this study are provided by Abbott at no cost. The AsantéTM HIV-1 Rapid Recency assays used for exploratory analyses in this study are provided by Sedia Biosciences (Beaverton, Oregon, USA) at no cost., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cardiovascular disease (CVD) is the leading cause of death among non-communicable diseases in South Africa. Several metabolic risk factors contribute to the development of CVD. Informal workers such as waste pickers could be unhealthy lifestyle naive, and most public health research on CVD does not include this understudied population. This study estimated the 10-year risk of fatal CVD and its association with metabolic risk factors in an understudied study population of waste pickers in Johannesburg, South Africa., Methods: A cross-sectional survey was conducted among waste pickers in two landfill sites in Johannesburg. We used the Systematic Coronary Risk Evaluation (SCORE) risk charts to estimate the 10-year risk of fatal CVD. We then employed ordinary least squares regression to assess the association between the 10-year risk of fatal CVD with metabolic risk factors. Other variables adjusted in the regression model were HIV status, education, income, injuries from work, clinic visits in the previous 12 months, and alcohol consumption., Results: A total of 370 waste pickers were included in this analysis, 265 (73.41%) were males. The mean age of the participants was 34 years. The majority were between the age of 20 and 39 years. More than 55% of the waste pickers did not visit a clinic in the previous 12 months, and 68.57% were smoking. The 10-year survival probability from CVD was more than 99% for both males and females. In the multivariable regression model, elevated blood glucose showed a non-significant increase in the mean percentage of 10-year risk of fatal CVD. Waste pickers who were overweight/obese, and hypertensive had high statistically significant mean percentages of the 10-year risk of fatal CVD compared to those who did not have the metabolic risk factors., Conclusions: Prevention of 10-year risk of fatal CVD in this understudied population of waste pickers should target the control of obesity, hypertension, and diabetes. Health awareness and education for waste pickers will be an important step in reducing the burden of these metabolic risk factors. We further recommend that health systems should recognize waste pickers as a high-risk group and consider extensive CVDs surveillance., (© 2021. The Author(s).)

Illegal mining is a major public health and societal concern. Recent scientific evidence indicates elevated blood-lead levels in illegal gold miners and associated communities. Yet, there is little research in this regard from low- to middle-income countries (LMICs), where illegal mining is growing. This case series is extracted from a cross-sectional study of lead exposure in incarcerated juveniles in greater Johannesburg. From survey records (blood-lead levels and questionnaires), three males had elevated blood-lead levels and presented with health conditions and behavioural problems putatively linked with lead poisoning. Based on the record review, all three juveniles were in a secure facility due to illegal mining-related activities. All three cases had high blood-lead levels and demonstrated a tendency toward aggressive or violent behaviour. They also presented with conditions associated with lead poisoning, such as anaemia, respiratory illness, abdominal disorders, and musculoskeletal conditions. Juveniles involved in illegal mining are at risk of exposure to heavy metals such as lead, and there is a need for relevant preventative action and health care programmes in this group.