Training In Tropical Diseases Research Articles

Promoting implementation research and One Health approach to respond the four global health challenges: an interpretation of the Special Programme for Research and Training in Tropical Diseases (TDR) Strategy 2024-2029

Tropical diseases, notably neglected tropical diseases and infectious diseases of poverty, remain major health problems endangering the poorest and most-marginalized people in the world. The Special Programme for Research and Training in Tropical Diseases (TDR), which is co-sponsored by the World Health Organization, the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank, is an important programme that helps facilitate, support, guide and coordinate global efforts to combat tropical diseases. On July 2023, TDR formally issued its 2024-2029 strategy, which proposed the direction and proprieties of global tropical disease prevention and control in the next six years. Based on its original focus on supporting researchers and research institutions from low and middle-income countries to conduct research on tropical diseases and building their research capabilities, this strategy proposed some new developments, which mainly included incorporating tropical disease prevention and control into the overall framework of addressing major global health challenges and achieving the health goals set by the United Nations Sustainable Development Goals (SDGs) to combat tropical diseases and contribute to achieving health goals of SDGs in a collaborative and integrated manner; supporting implementation research and encouraging practitioners and social innovators to participate in research to enable generation of solutions that may be used to solve local health problems; promoting and encouraging the One Health concept and interdisciplinary and cross-departmental collaboration; shifting gradually its focus from disease prevention and control to addressing the health needs of the poorest and most-marginalized populations. These new developments deserve the attention of personnel and institutions in China dedicated to the prevention and control of tropical diseases in order to help their future researches and activities.

Training in eight low-and middle-income countries: lessons learned from a pilot study using the WHO-TDR dissemination and implementation massive open online course.

Non-communicable diseases (NCDs) are a leading cause of morbidity and mortality in low-and middle- income countries (LMICs). Despite this, a lack of funding, training and mentorship for NCD investigators in LMICs exists. In an effort to gain knowledge and skills to address these gaps, participants from the Global Research on Implementation and Translation Science (GRIT), a consortium of studies in eight LMICs and their networks, attended the dissemination and implementation (D&I) massive open online course (MOOC) developed by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization to strengthen D&I capacity building. Here, we report on the pilot of this MOOC, which was implemented during the SARS COVID-19 pandemic from April- November 2020. Participants completed pre-and post-training questionnaires to assess self-reported D&I competencies, general research skills, and research mentor access and quality. D&I competencies were measured by use of a scale developed for a US-based training program, with change in competency scores assessed by paired t test. We used univariate statistics to analyze the data for all other outcomes. Of the 247 participants enrolled, 32 (13%) completed all course requirements, 21 (9%) completed the pre-and post-surveys and are included in the analysis. D&I competency scores suggest improvement for those who had complete pre- and post-assessments. Trainee's average score on the full competency scale improved 1.45 points (0-5 scale) from pre- to post-test; all four subscales also showed evidence of improvements. There were small but not significant increases in competencies for grant writing, proposal/ manuscript writing and presentations from pre- to post-test assessment. 40% of trainees reported access to a research mentor and 12% reported access to a D&I specific mentor. Participants reported barriers (e.g., unstable internet access and challenges due to COVID-19) and facilitators (e.g., topical interests, collaboration with colleagues) to completing the MOOC. Although COVID-19 affected program usage and completion, the MOOC was feasible. We also had signals of effectiveness, meaning among LMIC participants completing the course, there was improvement in self-report D&I competency scores. Recommendations for future D&I trainings in LMICs include (1) adding more topic specific modules (i.e., NCD research, general research skills) for scalability; (2) fostering more collaboration with participants across LMICs; and (3) establishing partnerships with D&I mentors for course participants.

Praziquantel-related visual disorders among recipients in mass drug administration campaigns in schistosomiasis endemic settings: Systematic review and meta-analysis protocol.

Hundreds of millions of doses of Praziquantel (PZQ) have been administered to persons with and without schistosomiasis living in schistosomiasis endemic settings, through the mass drug administration (MDA) strategy which started in the early 2000s. A recent publication suggested high risk of PZQ-related visual disorders, raising public health concerns. We aim to systematically synthesize evidence on the magnitude of PZQ-related visual disorders. We will search PubMed, Google Scholar, CINAHL, SCOPUS, CENTRAL and LILACS from 1977 (when the first human clinical trials on PZQ started) to 31st May 2024, with no language restrictions. The key search terms will include "Praziquantel", "PZQ", "visual disorder", "adverse events", "side effects", "blurry vision" and "visual impairment" together with alternative terms and synonyms. All the countries endemic for schistosomiasis will be included as search terms. We will also search HINARI, Africa Journals Online, Thesis Databases and Preprint Repositories. Where necessary, we will contact expert researchers working in the field of schistosomiasis, UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), pharmaceutical industries, country-specific Food and Drug Authorities (FDAs) and the European Medicines Agency databases. We will search Conference Proceedings and reference lists of relevant studies for additional studies. At least two authors will independently select studies, extract data and assess risk of bias in the included studies. Any disagreements or discrepancies will be resolved through discussion between the reviewers. Heterogeneity will be explored graphically, and statistically using the I2-statistic. We will conduct random-effects meta-analysis when heterogeneity is appreciable, and express dichotomous outcomes (visual adverse events including excessive lacrimation, blurry vision and visual impairments) as risk ratio (RR) or Odds Ratio (OR) with their 95% confidence interval (CI). We will perform subgroup analysis to assess the impact of heterogeneity, and sensitivity analyses to test the robustness of the effect estimates. The overall level of evidence will be assessed using GRADE. The present review expects to identify and categorize visual disorders occurring after administration of PZQ, alone or in combination with other drugs. By synthesizing the data from multiple studies, the review aims to present a quantitative assessment of the risk or odds of experiencing a visual disorder in different populations after ingesting PZQ. The review will also generate insights into whether PZQ in combination with other drugs are associated with increased odds of visual disorders and whether the occurrence of visual disorders correlates with dosage or treatment duration. Policymakers, public health experts and stakeholders could rely on the review findings to deliver context-sensitive preventive chemotherapy programs by adjusting drug combinations or dosing schedules to reduce risk of visual adverse effects in populations treated with PZQ. The review aims to identify gaps in the current evidence regarding visual disorders following PZQ administration in schistosomiasis endemic settings which can serve as the basis for future research on important but unanswered questions. The findings of this study will be disseminated through stakeholder forums, conferences, and peer-review publications. The review protocol has been registered in the International Prospective Register for Systematic Reviews (PROSPERO)- CRD42023417963.

XIth International EMCA Conference

The abstracts in this JEMCA Supplement is a collation of novel applied research and experimental development presented at the XIth International EMCA Conference (EMCA 2023) entitled ‘Shaping the future of vector control in Europe’, held in Palma de Mallorca, Spain. With regards to the concern for sustainable pest and vector management, the abstracts cover a wide range of topics addressing mosquitoes and other vectors, with particular emphasis on surveillance and management, the context of disease outbreaks, citizen involvement, challenges in One Health, mosquito control in the Mediterranean region, and innovative technologies and practices in vector control. A topic that is of great concern to the EMCA is the Best Practices for mosquito control in built-up areas, which is tackled in a round table at the conference, but also as a side event of the relative EMCA Working Group. This WG aims at publishing a Best Practices guidance document by early 2024, as a development of our EMCA Workshop held in 2022 in Mendrisio, Switzerland, and with the support of WHO-TDR-Special Programme for Research and Training in Tropical Diseases..

Contribution of the World Health Organization/ the special program for research and training in tropical disease (WHO/TDR’s) in institution building: lessons from Ethiopia

BackgroundWorld Health Organization/Tropical Disease Research (WHO/TDR) has enduring investment in transfers of skills critical to sustaining resilient health research systems through postgraduate training, clinical research and development fellowship (CRDF), bioethics, and grants to neglected tropical disease research. TDR has a long history of partnership with Armauer Hansen Research Institute (AHRI) in Ethiopia. The collaboration started with individuals and lead to institution survival and success. Therefore, the purpose of this study was to explore the impact and lessons learned of TDR initiatives in Ethiopia.MethodThis study was guided by the ‘TDR Impact Pathways’. A total of thirteen in-depth, and five key informant interviews were conducted with individuals who are currently working in Addis Ababa, Gondar, Jimma Universities and AHRI. In addition to the interviews, reports, written communications and publications were reviewed. Interviews were audio recorded, transcribed verbatim, inductively coded, and analyzed thematically. The results were presented following the themes with supportive verbatim quotes.ConclusionTDR’s seed grants, training opportunities and technical support catalyzed individual, institutional and national research capacity in Ethiopia. This is a useful indication of how long-term collaboration between individuals could have broader institutional implication as evidenced from the TDR-AHRI complementary partnership.

Improving understanding of disease control implementation research through a mooc with participants from low- and middle-income countries: Evaluating participant reactions and learning.

The Special Programme for Research and Training in Tropical Diseases developed a massive open online course (MOOC) on implementation research with a focus on infectious diseases of poverty (IDPs) to reinforce the explanation of implementation research concepts through real case studies. The target MOOC participant group included public health officers, researchers and students. By reshaping institutions and building resilience in communities and systems, implementation research will allow progress towards universal health coverage and sustainable development goals. This study evaluates learners' knowledge in implementation research after completing the MOOC using anonymous exit survey responses. Of the almost 4000 enrolled in the two sessions of the MOOC in 2018, about 30% completed all five modules and the assessments, and were awarded certificates. The majority of the participants were early to mid-career professionals, under the age of 40, and from low- and middle-income countries. They were slightly more likely to be men (56%) with a Bachelor or a Master's degree. Participants were public health researchers (45%), public health officers (11%) or students (11%). On completion of the course, an exit survey revealed that 80.9% of respondents indicated significant improvement to strong and very strong implementation research knowledge. This evaluation clearly shows the usefulness of the MOOC on implementation research for reaching out to field researchers and public health practitioners who are facing problems in the implementation of control programmes in low- and middle-income countries.

A new online toolkit to support implementation research to enhance the use of digital innovations to End TB.

Digital technologies are playing an increasing role in the global response to tuberculosis (TB), however their effectiveness and impact are often shaped in the context in which they are implemented. Implementation research can help facilitate the effective introduction of digital health technologies in TB programmes. In 2020, the Implementation Research for Digital Technologies and TB online toolkit (IR4DTB) was developed and launched by the Special Programme for Research and Training in Tropical Diseases, and the Global TB Programme at the World Health Organization (WHO), to build local capacity for IR and promote the effective use of digital technologies within TB programmes. This paper describes the development and piloting of the IR4DTB toolkit, a self-learning tool designed for TB programme implementers. The toolkit comprises six modules reflecting key steps of the IR process, practical instructions and guidance on how to complete these steps, and real-word case studies to illustrate key learning points. This paper also describes the launch of the IR4DTB during a five-day training workshop with TB staff from China, Uzbekistan, Pakistan, Malaysia. The workshop included facilitated sessions on the IR4DTB modules, and provided an opportunity for participants to work with facilitators to develop a comprehensive IR proposal addressing an identified challenge related to the implementation and/or scale-up of digital health technologies for TB care in their home country. Post-workshop evaluation revealed high level of satisfaction among participants with the workshop content and format. The IR4DTB toolkit is a replicable model which can be used to strengthen the TB staff capacity to innovate within a culture of continuous collection of evidence. Through continued trainings and adaptation of the toolkit alongside the integration of digital technologies within TB prevention and care, this model has the potential to contribute directly to all components of the End TB Strategy.

Publishing data to support the fight against human vector-borne diseases.

Vector-borne diseases are responsible for more than 17% of human cases of infectious diseases. In most situations, effective control of debilitating and deadly vector-bone diseases (VBDs), such as malaria, dengue, chikungunya, yellow fever, Zika and Chagas requires up-to-date, robust and comprehensive information on the presence, diversity, ecology, bionomics and geographic spread of the organisms that carry and transmit the infectious agents. Huge gaps exist in the information related to these vectors, creating an essential need for campaigns to mobilise and share data. The publication of data papers is an effective tool for overcoming this challenge. These peer-reviewed articles provide scholarly credit for researchers whose vital work of assembling and publishing well-described, properly-formatted datasets often fails to receive appropriate recognition. To address this, GigaScience's sister journal GigaByte partnered with the Global Biodiversity Information Facility (GBIF) to publish a series of data papers, with support from the Special Programme for Research and Training in Tropical Diseases (TDR), hosted by the World Health Organisation (WHO). Here we outline the initial results of this targeted approach to sharing data and describe its importance for controlling VBDs and improving public health.

ICOPA 2022: living with parasites, collaborating globally, and breaking a glass ceiling

ICOPA 2022: living with parasites, collaborating globally, and breaking a glass ceiling

Crowdfunding for health research: a qualitative evidence synthesis and a pilot programme

BackgroundMany low-income and middle-income country (LMIC) researchers have disadvantages when applying for research grants. Crowdfunding may help LMIC researchers to fund their research. Crowdfunding organises large groups of people to...

Parasites and priorities: the early evolution of ‘neglected disease’ initiatives and the history of a global health agenda

This article explores the development and evolution of ‘neglected tropical diseases’ (NTDs) as an operative and imaginative category in global public health, focusing on the early intellectual and institutional development...

Evaluating results of the implementation research MOOC using Kirkpatrick’s four-level model: a cross-sectional mixed-methods study

IntroductionAn implementation research (IR) massive open online course (MOOC) was developed by the Special Programme for Research and Training in Tropical Diseases, to address the scarcity of training in low-income...

The Early Warning and Response System (EWARS-TDR) for dengue outbreaks: can it also be applied to chikungunya and Zika outbreak warning?

BackgroundIn the Americas, endemic countries for Aedes-borne diseases such as dengue, chikungunya, and Zika face great challenges particularly since the recent outbreaks of CHIKV and ZIKV, all transmitted by the same insect vectors Aedes aegypti and Ae. albopictus. The Special Program for Research and Training in Tropical Diseases (TDR-WHO) has developed together with partners an Early Warning and Response System (EWARS) for dengue outbreaks based on a variety of alarm signals with a high sensitivity and positive predictive value (PPV). The question is if this tool can also be used for the prediction of Zika and chikungunya outbreaks.MethodologyWe conducted in nine districts of Mexico and one large city in Colombia a retrospective analysis of epidemiological data (for the outbreak definition) and of climate and entomological data (as potential alarm indicators) produced by the national surveillance systems for dengue, chikungunya and Zika outbreak prediction covering the following outbreak years: for dengue 2012–2016, for Zika 2015–2017, for chikungunya 2014–2016. This period was divided into a “run in period” (to establish the “historical” pattern of the disease) and an “analysis period” (to identify sensitivity and PPV of outbreak prediction).ResultsIn Mexico, the sensitivity of alarm signals for correctly predicting an outbreak was 100% for dengue, and 97% for Zika (chikungunya data could not be obtained in Mexico); the PPV was 83% for dengue and 100% for Zika. The time period between alarm and start of the outbreak (i.e. the time available for early response activities) was for Zika 4–5 weeks. In Colombia the sensitivity of the outbreak prediction was 92% for dengue, 93% for chikungunya and 100% for Zika; the PPV was 68% for dengue, 92% for chikungunya and 54% for Zika; the prediction distance was for dengue 3–5 weeks, for chikungunya 10–13 weeks and for Zika 6–10 weeks.ConclusionEWARS demonstrated promising capability of timely disease outbreak prediction with an operational design likely to improve the coordination among stakeholders. However, the prediction validity varied substantially across different types of diseases and appeared less optimal in low endemic settings.

ИМПЛЕМЕНТАЦИОННОЕ ИССЛЕДОВАНИЕ В ПРОФИЛАКТИКЕ И КОНТРОЛЕ ТУБЕРКУЛЁЗА С ЛЕКАРСТВЕННОЙ УСТОЙЧИВОСТЬЮ В ПЕРИОД ПАНДЕМИИ COVID-19 В ДУШАНБЕ

Objective: To assess an implementation study (IS) aimed at improving the epidemiological surveillance of tuberculosis (TB) and drug-resistant TB (DRTB) in Dushanbe during the COVID-19 pandemic. Methods: IS assessment was carried out according to the RE-AIM framework and WHO recommendations for reporting on IS. To assess the effectiveness of the action taken, official statistics and reports from the City Center for Protection of Population from Tuberculosis were used. Results: IS was a qualitative study. The study was supported by the WHO Special Program for Research and Training in Tropical Diseases (TDR). A multidisciplinary team led by the Dushanbe City Health Department has undertaken the following measures: introduction of a system of weekly epidemiological surveillance for TB at the primary health care (PHC) level from the second week of 2021; involvement of students of basic and advanced field epidemiology programs (FETP) in the assessment of the TB epidemiological surveillance system; tracking of registered patients with laboratory confirmation of TB; application of data from the quarterly reports in tracking the diagnostic trends and evaluation of the effectiveness of DR-TB treatment. All materials received were documented and used to train TB doctors and PHC workers. Only 66% of TB doctors were involved in capacity building in Dushanbe PHC: 24.4% of PHC workers were trained in the basics of TB diagnosis and treatment. Stabilization of TB and DR-TB rate was achieved in 2021 compared to 2020 (morbidity growth rates were 2.7% and 11.9%, respectively); effectiveness of treatment of TB with preserved sensitivity of M. tuberculosis (MBT) to anti-TB drugs in the 2020 cohort increased, but efficacy of DR-TB treatment in the 2019 cohort decreased. Conclusion: IS has identified major barriers to achieving the TB elimination goals. Although the data indicate stabilization of TB and DR-TB incidence rates and increased effectiveness of drug-sensitive TB treatment in Dushanbe, further monitoring and achievement of sustainable results are required. Keywords: COVID-19, tuberculosis, drug resistance, implementation study, TDR.

Special Programme for Research and Training in Tropical Diseases-coordinated Multicountry Study to Determine the Burden and Causes of Residual Malaria Across Different Regions.

The burden and causes of residual malaria were investigated between 2015 and 2019 through 5 research projects coordinated by the Special Program for Research and Training in Tropical Diseases (TDR), cosponsored by the United Nations Development Programme, UNICEF, the World Bank, the World Health Organization (WHO) and the WHO Global Malaria Programme. The 5 projects included 10 countries in 4 WHO regions: Africa, the Americas, South-East Asia, and the Western Pacific. The countries represented a range of malaria endemicities, from low to high levels of transmission. The main findings of the projects indicate that overall the core malaria vector control tools (long-lasting insecticidal nets [LLIN] and indoor residual spraying) were not deployed in the optimal way and/or not efficient in many settings of the supported projects. Furthermore, vector biting behavior and human activity–associated factors strongly contributed to malaria persistence. Changes in vector species composition and abundance, with an increase in outdoor biting, were also reported. Some of these factors may be an adaptation of the vectors to the deployment of the tools and/or can be linked to other sectors, such as agricultural practices, environmental changes, social factors, and water management. Human behaviors and sleeping habits that included activities and sleeping outside villages in unprotected dwellings were another part of the problem. The evidence collated demonstrates the need for new approaches, such as the multisectoral one and new vector control tools, all adapted to the local contexts and integrated into current malaria programs.

Implementation research training for learners in low- and middle-income countries: evaluating behaviour change after participating in a massive open online course

BackgroundImplementation research (IR) can play a critical role in the delivery of disease control interventions, particularly in low- and middle-income countries (LMICs). The growing demand for IR training has led to the development of a range of training programmes and university courses, the majority of which can not be accessed by learners in LMICs. This article reports on the evaluation of the massive open online course (MOOC) developed by the Special Programme for Research and Training in Tropical Diseases hosted by WHO on the topic of IR with a focus on infectious diseases of poverty. This study followed the Kirkpatrick Model to evaluate training programmes with a specific focus on post-training changes in behaviour.MethodsMOOC participants were invited to take part in an anonymous online survey examining their knowledge of IR and how they applied it in their professional practice approximately 1–1.5 years after completing their course. The survey contained 43 open-ended, multiple choice and Likert-type questions. Descriptive statistics were calculated for the quantitative data and responses to the open-ended questions were thematically coded.ResultsA total of 748 MOOC participants responded to the survey. The demographic profile of the survey respondents aligned with that of the MOOC participants, with nearly 70% of respondents originating from Africa. Responses to the quantitative and open-ended survey questions revealed that respondents’ knowledge of IR had improved to a large extent as a result of the MOOC, and that they used the knowledge and skills gained in their professional lives frequently and had consequently changed their professional behaviour. Respondents most often cited the problem-solving aspect of IR as a substantial area of behavioral change influenced by participating in the MOOC.ConclusionsThese findings indicate that the MOOC was successful in targeting learners from LMICs, in strengthening their IR knowledge and contributing to their ability to apply it in their professional practice. The utility of MOOCs for providing IR training to learners in LMICs, where implementation challenges are encountered often, makes this platform an ideal standalone learning tool or one that could be combined with other training formats.

The value and impact of embedded implementation research: insights from Latin America and the Caribbean

[Extract ] Embedded research is carried out as an integrated and systematic part of health decisions and policymaking and implementation (1). It means continuous collaboration between decision-makers, researchers, and communities. Embedded research focuses on systems-level challenges and illuminates context-specific factors for real-world health programs, policy, and system decisions. It improves ownership and implementation (2). With this in mind, a joint initiative between the Alliance for Health Policy and Systems Research (Alliance HPSR), the Pan American Health Organization (PAHO), and the World Health Organization (WHO) Special Programme for Research and Training in Tropical Diseases (TDR) issued an open call for researchers and policy and decision-makers to identify challenges requiring embedded research to accelerate progress towards the SDGs in the Latin American and the Caribbean (LAC) region and provided technical cooperation throughout the process.[...]

Break Down the Silos: A Conceptual Framework on Multisectoral Approaches to the Prevention and Control of Vector-Borne Diseases.

The need for multisectoral approaches (MSAs) in prevention and control of vector-borne diseases (VBDs) has been identified. VBD programs often involve collaborations between health and nonhealth sectors; however, a systematic framework describing the process, requirements, challenges, and benefits of MSAs has been missing. A recent guidance document from UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases provides a framework to implement MSAs for prevention and control of VBDs. This article gives an introduction to the guidance document and describes the conceptual framework and coordination process. The next steps will be to test the framework through implementation research in specific VBD cases studies. The guidance document will thus be refined based on iterative and comprehensive monitoring and evaluation systems to assess the performance and impact of MSAs. The advocacy for MSA and necessary capacity building will be integrated into the testing of the framework.

Introduction to a Landscape Analysis of Multisectoral Approaches for Prevention and Control of Infectious and Vector-Borne Diseases.

The Swiss Development Cooperation, Canada’s International Development Research Centre, the Swiss Tropical Public Health Institute, and the UNICEF/United Nations Development Programme (UNDP)/World Bank/World Health Organization (WHO) Special Programme for Research and Training in Tropical Diseases (TDR) collaborated on a project to review, understand and promote the use of multisectoral approaches (MSAs) in the prevention and control of vector-borne diseases (VBDs). The objectives of the project were to support a landscape analysis of how MSAs have been used in the prevention and control of VBDs; to develop a theoretical framework for guiding the implementation of interventions; and to test the recommendations in real-life conditions. To realize these objectives, the project supported several activities, including commissioning a series of scientific reviews on MSAs in 5 thematic areas, sharing the key findings of these reviews in workshops and events, and developing a guidance framework for the implementation of MSAs. These activities have produced the theoretical framework that will be tested in real-life conditions through the support of case studies. The collaboration on implementing multisectoral activities against VBDs will continue among TDR, the Swiss Tropical Public Health Institute, and new partners such as the WHO Water Sanitation and Hygiene Group, UNDP, and UN-Habitat, in order to face the challenges identified and propose solutions tailored to specific contexts. The prevention and control of VBDs require strong and adapted MSAs with the full participation of all relevant sectors.

The Effect of BCG on Mortality Beyond Infancy: 30-Year Follow-Up of a Double-Blind Randomised Placebo-Controlled Trial of BCG Re-Vaccination in Malawi

Background: Trials of BCG to prevent COVID-19 are taking place in adults, some of whom have been previously vaccinated, but evidence of BCG’s beneficial non-specific effects come largely from data on mortality in infants, and from in vitro and animal studies. We assess all-cause mortality following a large BCG re-vaccination trial in Malawi. Methods: A population-based double-blind randomised trial comparing BCG re-vaccination vs placebo to prevent tuberculosis and leprosy was initiated in Karonga District, Malawi, in 1986-9, in individuals aged 3 months to 75 years. Active follow-up was carried out in northern areas of the district in 1991-94 and in a southern area in 2002-2018 covering 15.8% (7389 individuals) and 12.0% (5616 individuals) of the trial population respectively. Year of death or leaving the area were recorded for those not found. We used survival analysis to estimate all-cause mortality rates. Findings: There was no difference in mortality rate between the BCG and placebo group in either follow-up, overall or by age group. Mortality rates in the northern areas were 6.6/1000 person years at risk (pyar), 95% confidence interval 5.5-7.8, and 7.0/1000pyar (5.9-8.2) for those who received BCG and placebo, respectively. In the southern area they were 6.3/1000 pyar, (5.5-7.1), and 5.9/1000 pyar, (5.2-6.8), respectively. Interpretation: We found no evidence of any beneficial effect of BCG re-vaccination on all-cause mortality. The high proportion of deaths attributable to non-infectious causes beyond infancy, and the long time interval since BCG for most deaths, may obscure any benefits. Funding Statement: The original trial was funded by primarily by the British Leprosy Relief Association (LEPRA), with assistance from the International Federation of Anti-Leprosy Organizations (ILEP), and the Immunology of Leprosy component of the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (IMMLEP/TDR), with support of the Malawian Ministry of Health. The later follow-up was funded by The Wellcome Trust There was no specific funding for this analysis.Declaration of Interests: We declare no competing interests.Ethics Approval Statement: The trial protocol was approved in 1985 by the Health Sciences Research Committee of the Malawi Ministry of Health, the Standing Committee on Research in Human Subjects of WHO, and the Ethics Committee of the London School of Hygiene & Tropical Medicine. Follow-up of the population has been approved in the context of other studies by the Health Sciences Research Committee of the Malawi Ministry of Health and the Ethics Committee of the London School of Hygiene & Tropical Medicine.