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Alcohol use is especially problematic for people living with HIV (PLWH) and was likely to be impacted by the coronavirus disease (COVID-19) pandemic and its restrictions. In a study of PLWH with latent tuberculosis infection, we measured unhealthy alcohol use with the Alcohol Use Disorders Identification Test (AUDIT-C), phosphatidylethanol (PEth) and bar attendance. We analyzed data collected before and after COVID-19 restrictions, and used Generalized Estimating Equations (GEE) logistic regression models to evaluate changes in unhealthy alcohol use. While bar attendance declined from 57.0% before to 38.3% after the restrictions started, multivariable analysis controlling for bar use showed a significant increase in unhealthy alcohol use; the adjusted odds ratio for unhealthy drinking before versus after the restrictions started was 1.37 (95% CI: 0.89–2.12) which increased to 1.64 (95% CI: 1.08–2.50) when bar attendance was added to the model. Decline in bar attendance did not decrease unhealthy alcohol use.

Agricultural intensification and expanding protected areas are proposed sustainable development approaches. But, their consequences for mental health are poorly understood. This study aims to predict how forest conservation and contract farming may alter resource access and depression risk in rural Uganda. Residents (N = 695) in 11 communities in Masindi District were asked about their expectations under land management scenarios using scenario-based interviews, household characteristics and depression symptoms. Over 80% of respondents presented with a ‘business-as-usual forest access’ scenario expected reduced access to forest income and food over the next decade; this number climbed above 90% among ‘restricted forest access’ scenario respondents. Over 99% of those presented with two land access scenarios (‘business-as-usual land access’ and ‘sugarcane expansion land access’) expected wealthy households to gain land but poorer families to lose it, threatening to increase poverty and food insecurity among small-scale farmers. Bayesian structural equation modelling suggested that depression severity was positively associated with food insecurity (0.20, 95% CI = 0.12–0.28) and economic poverty (0.11, 95% CI 0.02–0.19). Decision-makers should evaluate the mental health impacts of conservation and agricultural approaches that restrict access to livelihood resources. Future research could explore opportunities to support mental health through sustainable use of nature.

BCFS receives core funding from the Royal Zoological Society of Scotland. The Budongo Snare Removal Project is funded by Oakland Zoo. PF was funded by the European Research Council project grant to CC (grant agreement number: 679787). DPD was funded by the National Science Centre (grant number: 2020/04/X/NZ8/00865). Since chimpanzee (Pan troglodytes) conservation often involves local human populations, conservation strategies must consider psychological factors that impact their behavior. In Budongo Forest, Uganda, for example, local communities commonly engage in snare trap (hereafter: snare) setting for wild meat. This illegal activity posits a substantial threat to wild chimpanzees, causing permanent wounds or death for those who are snared. Despite various schemes previously implemented to address snare setting?an activity that is fueled by poverty, the problem and its detrimental impact on chimpanzees persists. Here, we experimentally tested a novel intervention, a systematic display of specially designed warning signs aimed at local poachers. We monitored the presence of snares before and after introducing these signs over a total period of two years and compared it with that of a similar sized control area with no intervention. Results show that snares were less likely to be present during the ?sign? period than during the ?non-sign? period in the experimental but not in the control area. We discuss the potential of this cost-effective intervention for limiting illegal activities that pose a severe threat to chimpanzees and other species inhabiting tropical forests. Publisher PDF

Maël Leroux was funded via the Swiss National Science Foundation grant awarded to Simon W. Townsend (31003A_153065). Pawel Fedurek was funded via the European Research Council project grant awarded to Catherine Crockford (grant agreement number: 679787). Albinism- the congenital absence of pigmentation- is a very rare phenomenon in animals due to the significant costs to fitness of this condition. Both humans and non-human individuals with albinism face a number of challenges, such as reduced vision, increased exposure to ultraviolet radiation, or compromised crypticity resulting in an elevated vulnerability to predation. However, while observations of social interactions involving individuals with albinism have been observed in wild non-primate animals, such interactions have not been described in detail in non-human primates (hereafter, primates). Here, we report, to our knowledge, the first sighting of an infant with albinism in wild chimpanzees (Pan troglodytes schweinfurthii), including social interactions between the infant, its mother, and group members. We also describe the subsequent killing of the infant by conspecifics as well as their behavior towards the corpse following the infanticide. Finally, we discuss our observations in relation to our understanding of chimpanzee behavior or attitudes towards individuals with very conspicuous appearances. Publisher PDF

A.S.’s fieldwork was supported by the European Research Council project grant to C.C. (grant agreement number 679787). C.H. is supported by funding from the European Union’s 8th Framework Programme, Horizon 2020 (grant agreement number 802719). It has been suggested that non-human primates can respond to deceased conspecifics in ways that suggest they experience psychological states not unlike humans, some of which could indicate they exhibit a notion of death. Here, we report long-term demographic data from two East African chimpanzee groups. During a combined 40-year observation period, we recorded 191 births of which 68 died in infancy, mostly within the first year. We documented the post-mortem behaviour of the mothers and describe nine occasions where Budongo chimpanzee mothers carried infants for 1–3 days after their death, usually until the body started to decompose. We also observed three additional cases of extended carrying lasting for more than 2 weeks, one of which was followed by the unusual extended carrying of an object and another which lasted 3 months. In each case, the corpses mummified. In addition, we report four instances of recurring dead-infant carrying by mothers, three of whom carried the corpse for longer during the second instance. We discuss these observations in view of functional hypotheses of dead-infant carrying in primates and the potential proximate mechanisms involved in this behaviour. Publisher PDF

It has been suggested that non-human primates can respond to deceased conspecifics in ways that suggest they experience psychological states not unlike humans, some of which could indicate they exhibit a notion of death. Here, we report long-term demographic data from two East African chimpanzee groups. During a combined 40-year observation period we recorded 191 births of which 68 died in infancy, mostly within the first year. We documented the post-mortem behaviour of the mothers and describe nine occasions where Budongo chimpanzee mothers carried infants for 1-3 days after their death, usually until the body started to decompose. We also observed three additional cases of extended carrying lasting for more than two weeks, one of which was followed by the unusual extended carrying of an object and another which lasted three months. In each case, the corpses mummified. In addition, we report four instances of recurring dead infant carrying by mothers, three of whom carried the corpse for longer during the second instance. We discuss these observations in view of functional hypotheses of dead infant carrying in primates and the potential proximate mechanisms involved in this behaviour.

We thank the Royal Zoological Society of Scotland for providing core funding to the BCFS. We thank the ARCUS Foundation for funding the Chimpanzee Monitoring Programme. Funding for fieldwork was provided by the Institute of Biology and the Fonds des Donations of the University of Neuchâtel, as well as the M. Wüthrich and A. Mathey-Dupraz Foundation and an ERC grant (PRILANG 283871) to K. Zuberbühler. Many primate populations are severely threatened by human activity. Illegal hunting with snares frequently causes fatal injuries and permanent mutilations in wild primates. Traumatic injuries and stressful experiences can reduce the efficacy of the immune system to fight parasitic infections. Snare-related changes in primate behavior may also influence the probability of exposure to parasites. We hypothesized that primates with permanent snare-related injuries would have a higher prevalence of intestinal parasites than control individuals. We tested the relationship between snare injuries and the prevalence of intestinal parasites in wild chimpanzees (Pan troglodytes) of Budongo forest, Uganda. We collected 487 fecal samples from known individuals (70 control and 20 snare-injured chimpanzees) and used flotation and sedimentation to isolate helminth eggs and an immunochromatographic assay to identify protozoan cysts. We found that the prevalence of Strongylida nematodes was significantly higher in snare-injured chimpanzees than in control individuals. In contrast, we found no association between snare injuries and three other parasite taxa: Ascaris, cestode, and Cryptosporidium parvum. Our study suggests that snare-injured primates may have higher exposure and/or be more susceptible to developing infections with helminth parasites than control individuals. Future studies should investigate whether snare injuries influence parasite prevalence in other species of wild primates. Postprint

AEL was supported by a University of Kent 50th Anniversary scholarship. Infanticide is well documented in chimpanzees and various hypotheses have been proposed to explain this behaviour. However, since infanticide by chimpanzees is relatively rare, it has thus far not been possible to thoroughly test these hypotheses. Here we present an analysis of the largest dataset of infanticides from a single community of chimpanzees, a full record of all intra-community infanticides and failed attempts at infanticide over a 24-year period for the Sonso community of chimpanzees in the Budongo Forest, Uganda. We use these data to test four hypotheses for this behaviour: sexual selection, resource competition, meat acquisition and male mating competition. There were 33 attacks on 30 victims, 11 of which were ‘definite’ infanticides, four of which ‘almost certain’, and nine were ‘suspected’, while nine were ‘attempted’ infanticides. The majority of attacks where the perpetrators were known (23) had only male attackers and victims were disproportionally young (2/3 of victims with known ages were under one week old). Our data best support the sexual selection hypothesis for infanticide. Cannibalism was infrequent and partial, suggesting meat acquisition was a by-product of infanticide, and there was no evidence to suggest that infanticide was part of a male strategy to eliminate future competitors. Infanticide by females was rare, but we suggest sexual selection, operating through intra-sexual competition, may also be responsible for infanticide by females. Publisher PDF

Roads have broadly adverse impacts on wildlife, including nonhuman primates. One direct effect is mortality from collisions with vehicles. While highly undesirable, roadkills provide valuable information on the health and condition of endangered species. We present a case report of a wild chimpanzee (Pan troglodytes schweinfurthii) killed crossing a road in Bulindi, Uganda, where chimpanzees inhabit forest fragments amid farmland. Details of the collision are constructed from eyewitness accounts of pedestrians. Physical examination of the cadaver indicated good overall body condition; at 40 kg, the deceased female was heavier than usual for an adult female East African chimpanzee. No external wounds or fractures were noted. Coprological assessment demonstrated infection by several gastrointestinal parasites commonly reported in living wild chimpanzees. Histopathology revealed eosinophilic enteritis and biliary hyperplasia potentially caused by parasite infection. However, eosinophilia was not widely spread into the submucosa, while egg/cyst counts suggested low-intensity parasite infections compared to healthy female chimpanzees of similar age in nearby Budongo Forest. No behavioral indicators of ill health were noted in the deceased female in the month prior to the accident. We conclude that cause of death was acute, i.e., shock from the collision, and was probably unrelated to parasite infection or any other underlying health condition. Notably, this female had asymmetrical polythelia, and, while nursing at the time of her death, had one functioning mammary gland only. In Uganda, where primates often inhabit human-dominated landscapes, human population growth and economic development has given rise to increasing motor traffic, while road development is enabling motorists to travel at greater speeds. Thus, the danger of roads to apes and other wildlife is rising, necessitating urgent strategies to reduce risks. Installation of simple speed-bumps-common on Ugandan roads-would be effective in reducing risks to wildlife, and would also make roads safer for human pedestrians.

Background: Tuberculosis among non-UK-born Black Africans has been gradually recognized as a public health problem in the UK despite the various interventions implemented. Objectives: To explore the perceptions of non-UK-born Black Africans about TB health risk; to explore the health seeking behavior of the non-UK-born Black Africans in relation to TB and to explore lay views on TB health education and screening as opportunities for health promotion. Methodology and Study Design: A qualitative methodology was used on a purposively selected sample of 12 non-UK-born Black Africans living in Leeds. Face-to-face interviews were conducted to explore the lay perceptions about TB. Thematic analysis was used to derive important themes in accordance to the study objectives. Ethical approval was provided by Leeds Metropolitan University. Setting: Community setting of non-UK-born Black Africans in Leeds, UK. Results: This population holds mixed views and perceptions about tuberculosis, few facilitators and many barriers existed to current TB prevention efforts. The barriers included: language barriers, barriers related to services and systems, immigration status and stigma despite the benefits involved. The potential for black African communities to readily increase the likelihood of behavior change was found as an important finding for this study. Conclusions: Tuberculosis is a preventable public health problem. Involvement of the non-UK-born black Africans communities in the TB prevention may be beneficial for reducing and tackling TB rates in this population. Such an approach is potentially inexpensive and more readily implementable than other suggested strategies such as changes to immigration policies.

The conservation of chimpanzees (Pan troglodytes) faces complex and dynamic threats, deriving mostly from anthropogenic factors such as high density and poverty in local human populations. One specific threat is poaching, which contributes to both permanent physical disabilities in chimpanzees and cross-species disease transmission. In the Sonso chimpanzee community, Budongo forest, Uganda, over 20% chimpanzees are permanently disabled by indiscriminate poachers’ snare-trap. While severe injuries can sometimes result in death, little is known about the long-term health impacts of poaching to chimpanzees or possible effective mitigation measures. To combat and monitor the complexities of conservation threats, a holistic transdisciplinary approach is required and as a result, the Budongo Conservation Field Station (BCFS) has implemented a comprehensive strategy. Instead of focusing solely on chimpanzee health, our multi-faced tit-for-tat approach also incorporates education and action measures for local communities living adjacent to the forest. To reduce poaching, we provide alternative livelihood sources, veterinary services and education while concurrently employing their local indigenous knowledge of poaching practices to more effectively locate snares/traps in the forest. To mitigate disease transmission across species, beneficiaries in incentive programs must have functional sanitation facilities. To consistently monitor threats and conservation impacts, we routinely collect data on snare recovery and infectious disease prevalence in chimpanzees, humans and livestock. Our preliminary results, since the programs’ inception, show a reduction in respiratory and gastrointestinal infections coupled with an increase in snare recovery from the forest. These findings suggest that our holistic approach is effective in mitigating the threats to chimpanzees in Budongo forest.

A main concern of farmers worldwide is how to reduce crop losses to wildlife. Some potentially lethal crop protection methods are non-selective. It is important to understand the impact of such methods on species of conservation concern. Uganda has important populations of Endangered eastern chimpanzees Pan troglodytes schweinfurthii. Farmers sometimes use large metal mantraps to guard their fields against crop-raiding wildlife, particularly baboons Papio anubis and wild pigs Potamochoerus sp.. Chimpanzees that range onto farmland also step in these illegal devices and without rapid veterinary invention face severe injury or eventual death. Unlike inadvertent snaring of great apes in African forests, the problem of mantraps in forest–farm ecotones has received little attention. We report 10 cases of entrapped chimpanzees in the cultivated landscape surrounding Uganda's Budongo Forest during 2007–2011, undoubtedly only a portion of the actual number of cases. Mantraps currently present a substantial threat to ape populations in this important conservation landscape. Our data underscore the need for conservation programmes to consider the techniques used by rural farmers to protect their livelihoods from wild animals.

Quality health management requires timely and accurate data, and paper-based reporting does not fill this role adequately. The introduction of malaria rapid diagnostic tests and the availability of wireless communications present an opportunity to open direct data transmission and feedback between peripheral health workers and central managers. In November 2009, the Uganda Ministry of Health deployed a short message service-based reporting system in two districts. At a set-up cost of $100/health facility, local technician support of $ 400 per month, and a cost of $0.53/week/clinic, the SMS reporting system was started at more than 140 clinics. Positivity rates for rapid diagnostic tests and artemisinin combination therapy stock outs were 48% and 54% in Kabale and 71% and 54% in Gulu, among other reports, at more than 85% health facilities reporting weekly and without monetary incentives or additional supervision. The SMS-based reporting systems have potential to improve timeliness in reporting of specific, time-sensitive metrics at modest cost, while by-passing current bottlenecks in the flow of data. With the development of specific capacity to manage stock data at district level, the availability of timely data offers potential to address commodity distribution problems and reduce stock-outs.

(See the major article by Polley et al on pages 637–44.) Accurate detection of malaria is of increasing importance as the malaria prevalence declines across much of its range [1, 2], with surveillance and screening becoming increasingly important in program management [3–5]. Microscopy and antigen-detecting rapid diagnostic tests (RDTs), when performed correctly, provide accurate diagnosis for case management [6] but cannot reliably detect lower-density parasitemia that may occur in asymptomatic individuals, who then represent reservoirs of infection. Such low-density infections with Plasmodium species are widely documented [7–12] and may contribute to transmission [13–15]. To eliminate malaria and prevent reintroduction, sustaining the capacity to detect such infections will be critical. The development of field-ready assays that can detect foci of infection in a way timely enough to enable treatment is therefore recognized as a major priority for malaria elimination [3, 16, 17]. Such highly sensitive assays could also benefit antimalarial drug efficacy monitoring, vaccine studies, and screening of vulnerable populations, such as pregnant women, in which low-density infections may have significant clinical consequences [18–20]. Polymerase chain reaction (PCR) detects parasite DNA, can identify infections below the threshold of detection for microscopy and RDTs, and is commonly considered the gold standard to detect malaria infection. However, PCR requires sophisticated laboratory infrastructure and advanced training, making it challenging and costly to implement in most malaria-endemic areas. Although PCR is used in some cases for focal screening and treatment strategies [11, 21], its restriction to central reference laboratories, often far from the sampled population, greatly limits its usefulness. Loop-mediated isothermal amplification (LAMP) may offer a practical alternative. Like PCR, LAMP is a molecular technique that amplifies nucleic acids but uses simpler equipment and is less time intensive. A prototype LAMP assay designed for use in resource-constrained settings was developed through a public/private collaboration between the Foundation for Innovative New Diagnostics, Switzerland, and Eiken Chemical Co., Ltd., Japan. The assay forms the basis for a CE-marked product commercially released in July 2012 as the Loopamp Malaria Pan/Pf Detection Kit, list number LMC562 (Eiken Chemical). It is consistent with a recent description of “an ideal LAMP detection format” [22], and the kit consists of vacuum-dried reagents stable at ambient temperature. The assay's primers target Plasmodium genus or P. falciparum–specific sequences. Assay performance includes either of 2 simple blood-processing methods, a 40-minute reaction time in a closed amplification unit, and a visual readout. The result is essentially qualitative. The relative simplicity and robustness of LAMP opens the potential for sustainable nucleic acid amplification in laboratories and near-patient locations in malaria-endemic countries. An evaluation of the LAMP test kit in a United Kingdom reference laboratory, reported in the article by Polley et al in this issue of the Journal, showed that LAMP sensitivity approximated that of nested PCR [23]. This article presents results of the same kit evaluated in a rural clinic in Uganda.

Background While feasibility of new health technologies in well-resourced healthcare settings is extensively documented, it is largely unknown in low-resourced settings. Uganda's decision to deploy and scale up malaria rapid diagnostic tests (mRDTs) in public health facilities and at the community level provides a useful entry point for documenting field experience, acceptance, and predictive variables for technology acceptance and use. These findings are important in informing implementation of new health technologies, plans, and budgets in low-resourced national disease control programmes. Methods A cross-sectional qualitative descriptive study at 21 health centres in Uganda was undertaken in 2007 to elucidate the barriers and facilitators in the introduction of mRDTs as a new diagnostic technology at lower-level health facilities. Pre-tested interview questionnaires were administered through pre-structured patient exit interviews and semi-structured health worker interviews to gain an understanding of the response to this implementation. A conceptual framework on technology acceptance and use was adapted for this study and used to prepare the questionnaires. Thematic analysis was used to generate themes from the data. Results A total of 52 of 57 health workers (92%) reported a belief that a positive mRDT result was true, although only 41 of 57 (64%) believed that treatment with anti-malarials was justified for every positive mRDT case. Of the same health workers, only 49% believed that a negative mRDT result was truly negative. Factors linked to these findings were related to mRDT acceptance and use, including the design and characteristics of the device, availability and quality of mRDT ancillary supplies, health worker capacity to investigate febrile cases testing negative with the device and provide appropriate treatment, availability of effective malaria treatments, reliability of the health commodity supply chain, existing national policy recommendations, individual health worker dynamism, and vitality of supervision. Conclusions mRDTs were found to be acceptable to and used by the target users, provided clear policy guidelines exist, ancillary tools are easy to use and health supplies beyond the diagnostic tools are met. Based on our results, health workers' needs for comprehensive case management should be met, and specific guidance for managing febrile patients with negative test outcomes should be provided alongside the new health technology. The extent, to which the implementation process of mRDT-led, parasite-based diagnosis accommodates end user beliefs, attitudes, perceptions, and satisfaction, as well as technology learnability and suitability, influences the level of acceptance and use of mRDTs. The effectiveness of the health system in providing the enabling environment and the integration of the diagnostic tool into routine service delivery is critical.

Background The training of health workers in the use of malaria rapid diagnostic tests (RDTs) is an important component of a wider strategy to improve parasite-based malaria diagnosis at lower level health care facilities (LLHFs) where microscopy is not readily available for all patients with suspected malaria. This study describes the process and cost of training to attain competence of lower level health workers to perform malaria RDTs in a public health system setting in eastern Uganda. Methods Health workers from 21 health facilities in Uganda were given a one-day central training on the use of RDTs in malaria case management, including practical skills on how to perform read and interpret the test results. Successful trainees subsequently integrated the use of RDTs into their routine care for febrile patients at their LLHFs and transferred their acquired skills to colleagues (cascade training model). A cross-sectional evaluation of the health workers’ competence in performing RDTs was conducted six weeks following the training, incorporating observation, in-depth interviews with health workers and the review of health facility records relating to tests offered and antimalarial drug (AMD) prescriptions pre and post training. The direct costs relating to the training processes were also documented. Results Overall, 135 health workers were trained including 63 (47%) nursing assistants, a group of care providers without formal medical training. All trainees passed the post-training concordance test with ≥ 80% except 12 that required re-training. Six weeks after the one-day training, 51/64 (80%) of the health workers accurately performed the critical steps in performing the RDT. The performance was similar among the 10 (16%) participants who were peer-trained by their trained colleagues. Only 9 (14%) did not draw the appropriate amount of blood using pipette. The average cost of the one-day training was US$ 101 (range $92-$112), with the main cost drivers being trainee travel and per-diems. Health workers offered RDTs to 76% of febrile patients and AMD prescriptions reduced by 37% six weeks post-training. Conclusion One-day training on the use of RDTs successfully provided adequate skill and competency among health workers to perform RDTs in fever case management at LLHF in a Uganda setting. The cost averaged at US$101 per health worker trained, with the main cost drivers being trainee travel and per diems. Given the good peer training noted in this study, there is need to explore the cost-effectiveness of a cascade training model for large scale implementation of RDTs.

Increased attention to and funding for malaria promises to improve access to effective treatment, but Heidi Hopkins, Caroline Asiimwe, and David Bell argue that without diagnostic testing much of this effort will be wasted

Background Malaria rapid diagnostic tests (RDTs) are increasingly used by remote health personnel with minimal training in laboratory techniques. RDTs must, therefore, be as simple, safe and reliable as possible. Transfer of blood from the patient to the RDT is critical to safety and accuracy, and poses a significant challenge to many users. Blood transfer devices were evaluated for accuracy and precision of volume transferred, safety and ease of use, to identify the most appropriate devices for use with RDTs in routine clinical care. Methods Five devices, a loop, straw-pipette, calibrated pipette, glass capillary tube, and a new inverted cup device, were evaluated in Nigeria, the Philippines and Uganda. The 227 participating health workers used each device to transfer blood from a simulated finger-prick site to filter paper. For each transfer, the number of attempts required to collect and deposit blood and any spilling of blood during transfer were recorded. Perceptions of ease of use and safety of each device were recorded for each participant. Blood volume transferred was calculated from the area of blood spots deposited on filter paper. Results The overall mean volumes transferred by devices differed significantly from the target volume of 5 microliters (p < 0.001). The inverted cup (4.6 microliters) most closely approximated the target volume. The glass capillary was excluded from volume analysis as the estimation method used is not compatible with this device. The calibrated pipette accounted for the largest proportion of blood exposures (23/225, 10%); exposures ranged from 2% to 6% for the other four devices. The inverted cup was considered easiest to use in blood collection (206/226, 91%); the straw-pipette and calibrated pipette were rated lowest (143/225 [64%] and 135/225 [60%] respectively). Overall, the inverted cup was the most preferred device (72%, 163/227), followed by the loop (61%, 138/227). Conclusions The performance of blood transfer devices varied in this evaluation of accuracy, blood safety, ease of use, and user preference. The inverted cup design achieved the highest overall performance, while the loop also performed well. These findings have relevance for any point-of-care diagnostics that require blood sampling.

Maternal cannibalism has been reported in several animal taxa, prompting speculations that the behavior may be part of an evolved strategy. In chimpanzees, however, maternal cannibalism has been conspicuously absent, despite high levels of infant mortality and reports of non-maternal cannibalism. The typical response of chimpanzee mothers is to abandon their deceased infant, sometimes after prolonged periods of carrying and grooming the corpse. Here, we report two anomalous observations of maternal cannibalism in communities of wild chimpanzees in Uganda and Ivory Coast and discuss the evolutionary implications. Both infants likely died under different circumstances; one apparently as a result of premature birth, the other possibly as a result of infanticide. In both cases, the mothers consumed parts of the corpse and participated in meat sharing with other group members. Neither female presented any apparent signs of ill health before or after the events. We concluded that, in both cases, cannibalizing the infant was unlikely due to health-related issues by the mothers. We discuss these observations against a background of chimpanzee mothers consistently refraining from maternal cannibalism, despite ample opportunities and nutritional advantages. We conclude that maternal cannibalism is extremely rare in this primate, likely due to early and strong mother–offspring bond formation, which may have been profoundly disrupted in the current cases. Electronic supplementary material The online version of this article (10.1007/s10329-019-00765-6) contains supplementary material, which is available to authorized users.

Background Early and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda. Methods All health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre - post' and 'intervention - control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices. Results A total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value = 0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value Conclusion Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.