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The COVID-19 pandemic has underlined the need to partner with the community in pandemic preparedness and response in order to enable trust-building among stakeholders, which is key in pandemic management. Citizen science, defined here as a practice of public participation and collaboration in all aspects of scientific research to increase knowledge and build trust with governments and researchers, is a crucial approach to promoting community engagement. By harnessing the potential of digitally enabled citizen science, one could translate data into accessible, comprehensible and actionable outputs at the population level. The application of citizen science in health has grown over the years, but most of these approaches remain at the level of participatory data collection. This narrative review examines citizen science approaches in participatory data generation, modelling and visualisation, and calls for truly participatory and co-creation approaches across all domains of pandemic preparedness and response. Further research is needed to identify approaches that optimally generate short-term and long-term value for communities participating in population health. Feasible, sustainable and contextualised citizen science approaches that meaningfully engage affected communities for the long-term will need to be inclusive of all populations and their cultures, comprehensive of all domains, digitally enabled and viewed as a key component to allow trust-building among the stakeholders. The impact of COVID-19 on people’s lives has created an opportune time to advance people’s agency in science, particularly in pandemic preparedness and response.

Investigation of the environmental impacts of armed conflict has been made easier in recent years with the development of new and improved methods for documenting and monitoring environmental damage and pollution. For decades, research into conflict-linked environmental damage and its links to human health have been overlooked and research underfunded, hindering a complete humanitarian response and effective post-conflict reconstruction. Recent developments in the field of open-source investigation have shown promising results due to the increased use of mobile phones, access to the internet and freely available methods for remote observation by satellite. Utilizing and analysing these sources of data can help us to understand how conflicts are associated with environmental damage, pollution and their negative impacts upon public health. Further research and development in this field will help to inform more effective humanitarian responses, mitigate risks to health and identify priorities for post-conflict reconstruction programs. Data-driven open-source research can also strengthen international discussions on state accountability for military activities and build a case for the responsibility of warring parties to protect the environment as well as the people who depend on it.

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Background Unenhanced chest computed tomography (CT) can assist in the diagnosis and classification of coronavirus disease 2019 (COVID-19), complementing to the reverse-transcription polymerase chain reaction (RT-PCR) tests; the performance of which has yet to be validated in emergency department (ED) setting. The study sought to evaluate the diagnostic performance of chest CT in the diagnosis and management of COVID-19 in ED. Methods This retrospective single-center study included 155 patients in ED who underwent both RT-PCR and chest CT for suspected COVID-19 from March 1st to April 1st, 2020. The clinical information, CT images and laboratory reports were reviewed and the performance of CT was assessed, using the RT-PCR as standard reference. Moreover, an adjudication committee retrospectively rated the probability of COVID-19 before and after the CT calculating the net reclassification improvement (NRI). Their final diagnosis was considered as reference. The proportion of patients with negative RT-PCR test that was directed to the referent hospital based on positive CT findings was also assessed. Results Among 155 patients, 42% had positive RT-PCR results, and 46% had positive CT findings. Chest CT showed a sensitivity of 84.6%, a specificity of 80.0% and a diagnostic accuracy of 81.9% in suggesting COVID-19 with RT-PCR as reference. Concurrently, corresponding values of 89.4%, 84.3% and 86.5% were retrieved with the adjudication committee diagnosis as reference. For the subgroup of patients with age > 65, specificity and sensitivity were 50% and 80.8%, respectively. In patients with negative RT-PCR results, 20% (18/90) had positive chest CT finding and 22% (4/18) of those were eventually considered as COVID-19 positive according to the adjudication committee. After CT, the estimated probability of COVID-19 changed in 10/104 (11%) patients with available data: 4 (4%) were downgraded, 6 (6%) upgraded. The NRI was 1.92% (NRI event −2.08% + NRI non-event 5.36%). No patient with negative RT-PCR but positive CT was eventually directed to hospital. Conclusion Chest CT showed promising sensitivity for diagnosing COVID-19 across all patients' subgroups. However, CT did not modify the estimated probability of COVID-19 infection in a substantial proportion of patients and its utility as an emergency department triage tool warrants further analyses.

Purpose: In Sub-Saharan Africa, an important proportion of incident HIV cases occur among heterosexual serodiscordant couples (HSDC) but the majority of HIV negative partners can remain seronegative. These are called HIV-exposed seronegative (HESN). We aimed to compare immune activation (IA) levels between HESN, their HIV infected counterparts (HIV+ partners) and HIV unexposed uninfected individuals (HIV-neg Controls) and to evaluate the association between sexual exposure to HIV (SEHIV) and IA. Methods: We conducted a cross-sectional study in Dakar, Senegal on 148 participants recruited between November 2013 and February 2014: 40 HIV-neg Controls, 54 HESN and 54 HIV+ Partners. SEHIV was evaluated individually using questionnaires. IA level was measured by plasma level of β2-microglobulin (β2m). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the different associations. Results: The median levels of β2m were 1.57 mg/l (IQR: 1.37 - 1.77), 2.14 mg/l (IQR: 1.76 - 2.43) and 2.24 mg/l (IQR: 1.80 - 3.17) for HIV-neg Controls, HESN and HIV+ partners, respectively. After adjustment, HESN had similar levels of IA with HIV+ partners but significantly higher than that of HIV-neg Controls (adjusted OR = 6.28; 95% CI: [2.19 - 18.00]). The association between IA and SEHIV was evaluated in the HIV negative individuals. High frequency of SEHIV was associated with a β2m > 2.2 mg/l (OR = 6.56; 95% CI: [1.71 - 25.21]); significantly more than median cut off value of >1.81 mg/l. Conclusions: Our study shows that, despite being uninfected with HIV, HESN individuals show a high level of IA, which was depended on the level of SEHIV.

The provision of gifts and payments for healthy volunteer subjects remains an important topic in global health research ethics. This paper provides empirical insights into theoretical debates by documenting participants' perspectives on an Ebola vaccine trial in West Africa. This trial provided hundreds of Africans with regular payments, food packages and certificates for participation. The researchers conducting the trials considered these socioeconomic provisions to be gifts in accordance with contemporary ethical standards and principles. Trial participants viewed them differently, however, approaching trial participation as a means for training and employment in what was from their perspective a new job market: the post-Ebola expansion of research and health care systems. This paper analyses participation in contemporary research by viewing the context-specific histories of trial participants through the lens of prior interventions, specifically participatory reintegration programmes conducted in Anglophone West Africa to overcome civil war crises. In particular, we argue that participation in the Ebola vaccine trial was inadvertently shaped by the design and outcomes of past reintegration programmes. Our results highlight the need to investigate existing socioeconomic landscapes which surround and indeed permeate clinical research as a prerequisite for understanding the participatory motives of vulnerable participants in West Africa and elsewhere.

SUMMARYWe examined the association between a history of smallpox vaccination and immune activation (IA) in a population of antiretroviral therapy-naïve people living with HIV (PLHIV). A cross-sectional study was conducted in Senegal from July 2015 to March 2017. Smallpox vaccination was ascertained by the presence of smallpox vaccine scar and IA by the plasma level ofβ-2-microglobulin (β2m). The association was analysed using logistic regression and linear regression models. The study population comprised 101 PLHIV born before 1980 with a median age of 47 years (interquartile range (IQR) = 42–55); 57·4% were women. Smallpox vaccine scar was present in 65·3% and the medianβ2m level was 2·59 mg/l (IQR = 2·06–3·86). After adjustment, the presence of smallpox vaccine scar was not associated with aβ2m level ⩾2·59 mg/l (adjusted odds ratio 0·94; 95% confidence interval 0·32–2·77). This result was confirmed by the linear regression model. Our study does not find any association between the presence of smallpox vaccine scar and theβ2m level and does not support any association between a previous smallpox vaccination and HIV disease progression. In this study, IA is not a significant determinant of the reported non-targeted effect of smallpox vaccination in PLHIV.

Background A functioning Viral Haemorrhagic Fever (VHF) surveillance system in countries at risk for outbreaks can reduce early transmission in case of an outbreak. Surveillance performance depends on the application of suspect case definitions in daily clinical practice. Recommended suspect case criteria during outbreaks are designed for high sensitivity and include general symptoms, pyrexia, haemorrhage, epidemiological link and unexplained death in patients. Non-outbreak criteria are narrower, relying on the persistence of fever and the presence of haemorrhagic signs. Methods This study ascertains VHF suspect case prevalence based on outbreak and non-outbreak criteria in a Guinean regional hospital for a period of three months. The study further describes clinical trajectories of patients who meet non-outbreak VHF suspect case criteria in order to discuss challenges in their identification. We used cross-sectional data collection at triage and emergency room to record demographic and clinical data of all admitted patients during the study period. For the follow-up study with description of diagnostic trajectories of VHF suspect cases, we used retrospective chart review. Results The most common symptoms of all patients upon admission were fever, tiredness/weakness and abdominal pain. 686 patients met EVD outbreak criteria, ten adult patients and two paediatric patients met study-specific non-outbreak VHF suspect case criteria. None of the suspect cases was treated as VHF suspect case and none tested positive for malaria upon admission. Their most frequent discharge diagnosis was unspecific gastrointestinal infection. The most common diagnostic measures were haemoglobin level and glycaemia for both adults and for children; of the requested examinations for hospitalized suspect cases, 36% were not executed or obtained. Half of those patients self-discharged against medical advice. Conclusions Our study shows that the number of VHF suspect cases may vary greatly depending on which suspect case criteria are applied. Identification of VHF suspect cases seems challenging in clinical practice. We suggest that this may be due to the low use of laboratory diagnostics to support certain diagnoses and the non-application of VHF suspect case definitions in clinical practice. Future VHF suspect case management should aim to tackle such challenges in comparable hospital settings.

Acinetobacter baumannii has become increasingly resistant to leading antimicrobial agents since the 1970s. Increased resistance appears linked to armed conflicts, notably since widespread media stories amplified clinical reports in the wake of the American invasion of Iraq in 2003. Antimicrobial resistance is usually assumed to arise through selection pressure exerted by antimicrobial treatment, particularly where treatment is inadequate, as in the case of low dosing, substandard antimicrobial agents, or shortened treatment course. Recently attention has focused on an emerging pathogen, multi-drug resistant A. baumannii (MDRAb). MDRAb gained media attention after being identified in American soldiers returning from Iraq and treated in US military facilities, where it was termed “Iraqibacter.” However, MDRAb is strongly associated in the literature with war injuries that are heavily contaminated by both environmental debris and shrapnel from weapons. Both may harbor substantial amounts of toxic heavy metals. Interestingly, heavy metals are known to also select for antimicrobial resistance. In this review we highlight the potential causes of antimicrobial resistance by heavy metals, with a focus on its emergence in A. baumanni in war zones.

PurposeThel’Actuel PrEP Cohortwas established to monitor the uptake, effectiveness, safety and changes in sexual risk behaviours among individuals receiving pre-exposure prophylaxis (PrEP) for the prevention of HIV. This prospective dynamic cohort is based at Clinique médicale l’Actuel, a large sexual health clinic located in Montreal, Canada.ParticipantsSince the cohort inception in January of 2013 through June 2018, 2156 individuals consulted for PrEP as participants in the l’Actuel PrEP Cohort. Median age was 35 years (IQR: 29–44 years) and the majority (96%) were men who have sex with men. Among 1551 individuals who initiated PrEP care, the median duration of follow-up was 9.2 months (IQR: 3.7–19.6), with substantial variation based on year of cohort entry. Thel’Actuel PrEP Cohortcontains both daily and intermittent ‘on-demand’ PrEP users and has the largest reported population of intermittent PrEP users (n=406) in North America.Findings to dateNo incident HIV infections have occurred among individuals using PrEP over 1637 person-years of follow-up. However, retention in PrEP care is essential as three individuals who discontinued PrEP subsequently acquired HIV, translating to an HIV incidence of 3.9 cases per 100 person-years (95% CI: 1.3 to 12.1). Among a sample of participants with 1 year of follow-up before and after PrEP initiation (n=109), a moderate increase in sexually transmitted infections was observed following PrEP start.Future plansThel’Actuel PrEP Cohortcontinues to grow with new participants starting PrEP monthly and extended follow-up for existing users. The cohort data will be used for ongoing monitoring of PrEP and for population-level modelling of the impact of PrEP on HIV incidence in Montreal.

An Epidemic of Suspicion Since the 2014 Ebola epidemic, key technical advances have been made. Yet mortality remains stubbornly high because the trust between the affected communities and international responders is breaking down. Medical innovations need social traction to deliver results.

The pre-exposure prophylaxis (PrEP) drug Truvada is a new HIV prevention technology that is predominantly promoted as relevant to HIV-negative gay men. This paper explores what PrEP represents for HIV-positive gay men living in Paris, based upon data collected through interviews and ethnographic research. While HIV-positive gay men do not directly consume Truvada through PrEP, they nonetheless hold opinions and understandings of this drug, specifically as it relates to their own sexuality. This paper expands the representations and meanings of this new technology in a different light through the voices of gay men living with HIV in Paris. The main argument of this article is that PrEP as an additional HIV prevention tool blurs the lines between science, technologies and human sexuality.

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Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to 'DIY PrEP', purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club.

Objective: Use of preexposure prophylaxis (PrEP) for HIV raises concerns about sexually transmitted infection (STI) incidence because of decreased condom use among MSM. This study examines whether PrEP is associated with STIs in the 12 months following PrEP prescription relative to the 12 months prior to PrEP and if STI rates are higher among PrEP users relative to individuals receiving postexposure prophylaxis (PEP). Design: Retrospective cohort study including PrEP users with more than 12 months of follow-up before PrEP prescription and individuals receiving PEP from 2010 to 2015 at Clinique l’Actuel (Montréal, Canada). Methods: Incidence of chlamydia, gonorrhoea, syphilis and hepatitis C virus over 12 months was compared before and after PrEP; and for PrEP versus PEP users using Poisson models to generate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) and adjusted IRRs (aIRRs) controlling for frequency of STI-screening visits. Models comparing PrEP and PEP users were further adjusted for age and education. Results: One hundred and nine PrEP and 86 PEP users were included. Increased rates of STIs were observed in the 12 months after PrEP relative to the 12 months prior (IRR: 1.72, CI: 1.22–2.41; aIRR: 1.39, CI 0.98–1.96). PrEP users were also at higher STI risk relative to PEP users (IRR: 2.18, CI: 1.46–3.24; aIRR: 1.76, CI: 1.14–2.71). Conclusion: Increased rates of STIs among individuals after initiation of PrEP may suggest greater risk behaviours during the first year on PrEP. Further studies are needed to measure long-term trends in STI acquisition following PrEP initiation.