Many treatment recommendations for invasive mould infections, particularly those caused by rare moulds, rely on non-randomised comparative effectiveness research (CER), which is vulnerable to design and analytical limitations that can bias effect estimates. We systematically reviewed 117 non-randomised studies evaluating interventions for aspergillosis, mucormycosis, fusariosis, scedosporiosis, lomentosporiosis, or phaeohyphomycosis published from 2003 to 2024. We assessed structural susceptibility to bias from misalignment of eligibility, treatment assignment, and start of follow-up, and approaches to confounding adjustment. 112 (96%) of 117 studies had at least one timepoint misalignment. Of 140 evaluable CER questions, 116 (83%) were susceptible to immortal time bias, 47 (34%) to selection bias from post-baseline eligibility, and 13 (9%) to prevalent-user bias. 76 (65%) of 117 studies adjusted for confounding but variable selection often relied on statistical methods and 26 (34%) of those 76 studies included post-baseline variables. This structural susceptibility to bias was present across all pathogen groups, not only rare moulds. Only one study avoided timepoint misalignment and accounted for confounding without incorporating post-baseline variables. These findings could provide a framework to improve the design of future non-randomised CER studies.

Working definitions of a sexually transmitted infection (STI) exist, but no universally agreed operational classification links those definitions to programme, funding, and surveillance decisions. The boundary of the STI category determines which infections enter surveillance, receive programme funding, and are included in testing and screening. Yet, the fields of microbiology, clinical medicine, and public health each define this boundary differently. Contested conditions, including bacterial vaginosis, vulvovaginal candidiasis, scabies, mpox, and sexually transmissible enteric pathogens, expose the inadequacy of the current binary classification. In this Personal View, we propose a three-tiered classification framework: core STIs, sexually associated infections, and incidental sexually transmissible infections, anchored on four explicit classification dimensions. The framework is intended to guide programme mandates and funding, clinical and diagnostic service delivery, and disease surveillance, while accommodating conditions that might shift between tiers as evidence evolves and as local epidemiology dictates. We also discuss the unintended consequences a formal classification could have for equity, stigma, and resource allocation. A graded classification acknowledging degrees of sexual transmissibility is more useful than a binary classification that forces false clarity.

Emerging viruses continue to pose serious public health threats across Africa, with recurrent outbreaks exposing gaps in diagnostics and surveillance systems. Nucleic acid amplification tests (NAATs) and genome sequencing are increasingly important for diagnostics and outbreak responses; however, their routine implementation is fragmented. This scoping review examines NAATs and genome sequencing technologies for viral detection and surveillance in Africa from 2019 to 2024, mapped to the 2024 updated WHO R&D Blueprint for Epidemics pathogen priority list. We identified 117 studies from 34 African countries reporting applications across 20 virus families, including ten designated as priorities by WHO. PCR-based assays were the most frequently reported NAATs. Illumina platforms predominated sequencing, and Oxford Nanopore Technologies were commonly used in outbreak investigations. Genome sequencing applied to priority viruses was largely reactive. NAAT-capable mobile laboratories were reported in 13 countries. Our findings underscore the need for proactive integration of NAATs into diagnostic and surveillance systems to strengthen decentralised testing, sustain genomic surveillance beyond outbreak periods, and improve early detection and preparedness for viral threats.