London School of Hygiene & Tropical Medicine

Timely discharge of patients who are clinically ready to be discharged from hospitals to the next point of care is a common health system challenge. Ensuring safe and effective discharge holds new urgency, given the backlogs and increased waiting times for inpatient services in many countries after the COVID-19 pandemic. The study aimed to identify policy options for addressing delayed discharges in six European countries (Denmark, France, Germany, the Netherlands, Norway, and Sweden), and to summarise available evidence on their effectiveness. Experts from the Health Systems and Policy Monitor (HSPM) network of the European Observatory on Health Systems and Policies and additional country experts identified relevant policies and initiatives up to November 2023. When evaluations were available, the experts also provided information on their findings. The data collection was followed by a qualitative, cross-country comparative analysis. A total of 17 policies or initiatives were identified in the study countries. Hospital-based initiatives included discharge planning and transitional care. Community and home care initiatives included municipal emergency beds, intensive home rehabilitation, and assisted discharge. Cross-sectoral initiatives ranged from coordination efforts at the regional and municipal levels to decision support systems and financial incentives. Several common factors or principles underpin many of the identified policies and initiatives. These include clarity of responsibility, effective planning and communication, resourcing of community-based capacity, possible unintended consequences of financial penalties, and the need to adopt a systemic approach.

Handwashing with soap (HWWS) is an effective public health preventive measure. Review studies indicate that interventions on handwashing with soap reduce the risk of diarrhoeal diseases by approximately 30% and respiratory tract infections by up to 17% (Ross, Bick, Ayieko, et al., 2023; Wolf, Hubbard, Brauer, et al., 2022). Studies have also shown that HWWS, combined with interventions on water and sanitation, results in improved growth outcomes among children under five (Bekele et al., 2020; George, Monira, Zohura, et al., 2021; Hasan, Asif, Barua, et al., 2023). The World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF) Joint Monitoring Program (JMP) estimated that by 2022, 75% of the global population had access to basic handwashing facilities (HWFs) measured by the presence of a handwashing facility with water and soap within the premises (UNICEF and WHO, 2023a). Access to a basic HWF is an indicator for HWWS, as studies have confirmed HWWS at critical times increases as a result of the presence of a HWF (Jetha, Bisserbe, McManus, et al., 2021; Mbakaya et al., 2020; Okello, Kapiga, Grosskurth, et al., 2019; White, Thorseth, Dreibelbis, et al., 2020; Wolde, Abate, Mandefro, et al., 2022). These JMP estimates indicate that Sub-Saharan Africa (SSA) had the lowest regional coverage of basic HWFs by 2022, with only 30% of the population having access to basic HWFs (UNICEF and WHO, 2023b). This limited coverage may indicate or lead to inadequate HWWS. In addition, significant disparities in access exist between urban and rural areas of Africa, with urban areas exhibiting higher access (32%) than rural areas (17%) (UNICEF and WHO, 2023a,b). Despite this advantage, urban areas of Africa have significant proportions of the population residing in Low Income Areas (LIAs) which are characterised by several challenges including intermittent water supply, high costs of water, lack of handwashing facilities, and a higher risk to hygiene related health outcomes (Beard & Mitlin, 2021; Corburn, Vlahov, Mberu, et al., 2020; Kisaakye et al., 2021). Research studies examining hindrances (barriers) and enablers of HWWS in LIAs of Africa are limited. However, studies conducted in LIAs in other regions have identified financial resources, availability of water and soap, and the presence of dirt on the hands as factors that promote HWWS (Kalam, Davis, Islam, et al., 2021; Khan, Chakraborty, Brown, et al., 2021; Rahman, Nizame, Unicomb, et al., 2017). Similar to other African countries, studies examining the enablers and barriers for HWWS in LIAs in Kenya are limited, with most of the available studies focusing on food hygiene or COVID-19 related knowledge regarding HWWS (Austrian, Pinchoff, Tidwell, et al., 2020; Davis, Cumming, Aseyo, et al., 2018; Mumma, Simiyu, Aseyo, et al., 2019; Robinson & Howland, 2022; Watson, Okumu, Wasonga, et al., 2024). This study builds on a prior survey in LIAs of Kenyan cities that examined determinants of access to basic HWFs and of HWWS (Simiyu et al., 2025). The study indicated a lower likelihood of access to basic HWFs and of HWWS among residents of Mombasa compared to residents in low-income areas of other cities in Kenya (Simiyu et al., 2025). This study, therefore, explores the barriers and enablers of HWWS in the low-income settlements of Mombasa and identifies intervention strategies for improvement of HWWS within these areas.

Dengue is a climate-sensitive infectious disease and the world's fastest-growing vector-borne disease. It disproportionately affects low- and middle-income countries (LMICs), with children most severely affected. Dengvaxia (CYD-TDV) and Qdenga (TAK-003) are the only two licensed dengue vaccines currently available, while Butantan-DV (TV003) is an advanced candidate with promising Phase 3 clinical trial results. Despite the commercial availability of dengue vaccines, coverage remains low in areas with the greatest need. This is driven by technical, social, and geopolitical challenges, as well as growing vaccine hesitancy. There is also an added layer of clinical complexity associated with vaccination against dengue due to the antibody-dependent enhancement (ADE) phenomenon, which can lead to vaccine-enhanced disease. Here, we review the current global landscape of dengue vaccine licensure and coverage, focusing on countries with the highest disease burden. We show that in many countries with a high dengue incidence, dengue vaccines have yet to be licensed, particularly in parts of Africa and South Asia. Even in regions where licensure is more widespread, such as Latin America and Southeast Asia, dengue vaccines are not well integrated into national immunisation programmes and can only be obtained through out-of-pocket payment. We therefore identify several state and market-driven systemic factors, as well as declining vaccine confidence, as barriers to scaling up dengue vaccine access in LMICs. These barriers must be addressed through creative solutions to ensure the equitable distribution of dengue vaccines to the populations and countries that need them the most.

Since September 2023, England's national immunisation programme has offered the recombinant zoster vaccine (RZV) to adults aged 65-79 as a preventative measure against shingles (herpes zoster) and its complications. However, adults aged 80 and over are currently not eligible for the vaccine. We aimed to evaluate the feasibility and cost-effectiveness of providing RZV to adults aged 80 and older in England. This cost-utility analysis employs a static cohort model considering herpes zoster (HZ) cases and severe cases leading to post-herpetic neuralgia, HZ-related hospitalisation, and deaths from the perspective of the National Health Service. The long-term impacts of RZV are assessed using the model, accounting for changing population demographics and the previously-offered live zoster vaccine (ZVL). We consider different eligibility scenarios for RZV focusing on the older population (80+ years old) and provide comparisons to the pre-2023 programme. Expanding the current programme to offer a single dose of RZV to people aged 80 and up is likely to be cost-effective relative to the current programme. Offering two doses to this group would be less cost-effective but would offer greater protection against HZ. For preventing health-related quality of life loss, it is most efficient to vaccinate 60-69-year-olds, but for averting hospitalisation costs, it is most efficient to vaccinate 80-89-year-olds. Providing one or two doses of RZV for older adults can be cost-effective and would reduce the healthcare burden of shingles.

Street space reallocation measures, such as Low Traffic Neighbourhoods (LTNs), have attracted substantial controversy in the UK and elsewhere, for instance around reported poor engagement with residents and local actors. However, limited attention has been given to the political-economic context shaping scheme implementation, such as the impacts of reduced resources or the use of short-term, contingent funding. Based on 37 interviews with officers and councillors who implemented or sought to implement LTNs in 12 English local authorities, and part of a larger project investigating the impacts of LTNs in London, this paper addresses the gap. It shows how challenges to design, engagement and delivery are often linked to funding scarcity and processes of projectification, advancing the literature on transport governance and controversy. • Limited attention has been paid to the political-economic context shaping the implementation of Low Traffic Neighbourhood schemes • Existing approaches to funding active travel schemes, which in the context of austerity urbanism exacerbate the negative aspects of projectification, affect the success of schemes • Schemes require significant investment in terms of staff time and knowledge • They would also benefit from more funding to deliver greening aspects • The effects of austerity and projectification are exacerbated within uneven geographical areas • Local authorities with access to additional internal resources were able to implement and sustain schemes and learn from mistakes • Less resrouceful local authorities saw initial failures translate into increasing challenges for future schemes and an overall inability to implement successfully

Introduction: Ovarian cancer is a leading cause of gynaecological cancer mortality. Ca125, the most widely used serum biomarker, has limited sensitivity for early-stage and type I tumours, prompting evaluation of additional blood-based markers. This umbrella review assesses the diagnostic and prognostic performance of serum and blood biomarkers in ovarian cancer.

Current diagnostics for tuberculosis (TB) rely on sputum or site-specific specimen collection, posing critical limitations in certain populations. Urine has emerged as an alternative specimen, as demonstrated by urine lipoarabinomannan (LAM) testing. Beyond LAM, no urine-based tests are established for clinical use, and evidence for non-LAM urine antigen tests and urine-based nucleic acid amplification tests (NAATs) remains inconsistently synthesized. This scoping review aimed to comprehensively map current evidence and identify gaps in urine-based diagnostic tests for TB. We conducted a scoping review across three databases (PubMed, Scopus, and Embase) of studies evaluating urine-based diagnostic tests for TB and reporting diagnostic performance metrics, extracting data on urine test type, country, TB disease type, study population, and HIV status. Findings were summarized descriptively and visualized to illustrate trends. We also extracted technical approaches for urine-based NAATs and urine concentration methods. In total, 208 publications reporting 274 urine-based tests published between 1995 and 2024 were included. Most studies were conducted in high-burden settings and focused on pulmonary TB (44.7%), adult populations (62.5%), and people living with HIV (31.3%). LAM-based tests dominated the literature, accounting for 49.3% (n = 135) of all tests, primarily in lateral flow formats. Non-LAM urine antigen tests were evaluated less frequently (n = 26), typically in small cohorts and laboratory-based assays. Urine-based NAATs showed wide variability in technical approaches. Only a few studies (n = 10) evaluated urine concentration methods. Evidence for urine-based diagnostic tests for TB remains limited for extrapulmonary TB, children, and non-HIV individuals, despite substantial unmet need. Although urine LAM is the most established assay, evaluations of non-LAM urine antigen tests and urine-based NAATs remain exploratory, with few studies, small cohorts, and predominantly laboratory-based assays. Further research is needed to identify and validate reliable, broadly applicable urine-based diagnostic tests to address these gaps.