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The accumulation of drug resistance mutations with time on ART needs further attention, and surveillance should be reinforced in ART programs in sub-Saharan Africa.

A rubella antibody seroprevalence assessment was conducted using serum collected during 2008-2009 from 1,605 pregnant women aged 15-46 years attending 7 antenatal care sites in 3 of DRC's provinces. Estimates of age-and site-specific rubella antibody seroprevalence, population, and fertility rates were used in catalytic models to estimate the incidence of CRS per 100,000 live births and the number of CRS cases born in 2013 in DRC.Overall 84% (95% CI 82, 86) of the women tested were estimated to be rubella antibody seropositive. The association between age and estimated antibody seroprevalence, adjusting for study site, was not significant (p=0.10). Differences in overall estimated seroprevalence by study site were observed indicating variation by geographical area (p<=0.03 for all). Estimated seroprevalence was similar for women declaring residence in urban (84%) versus rural (83%) settings (p=0.67). In 2013 for DRC nationally, the estimated incidence of CRS was 69/100,000 live births (95% CI 0, 186), corresponding to 2886 infants (95% CI 342, 6395) born with CRS.In the 3 provinces, rubella virus transmission is endemic, and most viral exposure and seroconversion occurs before age 15 years. However, approximately 10%-20% of the women were susceptible to rubella virus infection and thus at risk for having an infant with CRS. Per World Health Organization recommendations, introduction of RCV should be accompanied by a campaign targeting children 9 months to 14 years and vaccination of women of child bearing age through routine services. Please find below our responses (in italics in blue below each reviewer's comments) to the comments and the details describing how the manuscript was revised to address each.Reviewer #1: This manuscript provides estimates of Congenital Rubella Syndrome (CRS) for the Democratic Republic of Congo (DRC) using seroprevalence data obtained from existing blood specimens from antenatal clinics. It provides an idea of the occurrence of CRS in a country with little rubella data and that has not yet introduced a rubella-containing vaccine, thus shedding light on an issue that is relevant when discussing vaccine introduction and vaccination strategies. The paper is well written and the supplemental material useful to understand the models used.Specific comments: Abstract 1. What % of the population live in the selected provinces 193-199, lines 206-211, and lines 252-257). Additional details regarding a number of elements of DRC's population have been incorporated into the Methods section of the manuscript (Please see lines Clarify that the estimated CRS incidence and cases in 2013 is for all of DRCThe abstract has been revised to read "In 2013 for DRC nationally, the estimated incidence of CRS was 69/100,000 live births (95% CI 0, 186), corresponding to 2886 infants (95% CI 342, 6395) born with CRS."

This spatiotemporal analysis strongly suggests that the 2010-2011 outbreaks of WPV1 infection affecting young adults were caused by a PV type 1 immunity gap in Kinshasa and Bandundu due to insufficient exposure to PV type 1 through natural infection or vaccination. Poliovirus immunity gaps in this age group likely persist in DRC.

Objectives To determine COVID‐19 antibody positivity rates over time and relationships to pregnancy outcomes in low‐ and middle‐income countries (LMICs). Design With COVID‐19 antibody positivity at delivery as the exposure, we performed a prospective, observational cohort study in seven LMICs during the early COVID‐19 pandemic. Setting The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population‐based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (two sites), and Guatemala. Population Pregnant women enrolled in an ongoing pregnancy registry at study sites. Methods From October 2020 to October 2021, standardised COVID‐19 antibody testing was performed at delivery among women enrolled in MNHR. Trained staff masked to COVID‐19 status obtained pregnancy outcomes, which were then compared with COVID‐19 antibody results. Main Outcome Measures Antibody status, stillbirth, neonatal mortality, maternal mortality and morbidity. Results At delivery, 26.0% of women were COVID‐19 antibody positive. Positivity increased over the four time periods across all sites: 13.8%, 15.4%, 21.0% and 40.9%. In the final period, positivity rates were: DRC 27.0%, Kenya 33.1%, Pakistan 32.8%, Guatemala 37.0%, Zambia 37.8%, Bangladesh 47.2%, Nagpur, India 57.4% and Belagavi, India 62.4%. Adjusting for site and maternal characteristics, stillbirth, neonatal mortality, low birthweight and preterm birth were not significantly associated with COVID‐19. The adjusted relative risk (aRR) for stillbirth was 1.27 (95% CI 0.95–1.69). Postpartum haemorrhage was associated with antibody positivity (aRR 1.44; 95% CI 1.01–2.07). Conclusions In pregnant populations in LMICs, COVID‐19 antibody positivity has increased. However, most adverse pregnancy outcomes were not significantly associated with antibody positivity.

BackgroundThe performance of the WHO recommendations for pediatric antiretroviral treatment (ART) in resource poor settings is insufficiently documented in routine care.MethodsWe compared clinical and immunological criteria in 366 children aged 0 to 12 years in Kinshasa and evaluated a simple computation to estimate CD4 percent, based on CD4 count, total white blood cell count and percentage lymphocytes. Kappa (κ) statistic was used to evaluate eligibility criteria and linear regression to determine trends of CD4 percent, count and total lymphocyte count (TLC).ResultsAgreement between clinical and immunological eligibility criteria was poor (κ = 0.26). One third of children clinically eligible for ART were ineligible using immunological criteria; one third of children immunologically eligible were ineligible using clinical criteria. Among children presenting in WHO stage I or II, 54 (32%) were eligible according to immunological criteria. Agreement with CD4 percent was poor for TLC (κ = 0.04), fair for total CD4 count (κ = 0.39) and substantial for CD4 percent computational estimate (κ = 0.71). Among 5 to 12 years old children, total CD4 count was higher in younger age groups (-32 cells/mm3 per year older), CD4 percent was similar across age groups.ConclusionAge-specific thresholds for CD4 percent optimally determine pediatric ART eligibility. The use of CD4 percent computational estimate may increase ART access in settings with limited access to CD4 percent assays.

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