ObjectivesTo ascertain the extent of socioeconomic and health condition inequalities in people with diagnosed and undiagnosed diabetes and impaired glucose regulation (IGR) in random samples of the general population in England, as earlier diagnosis of diabetes and treatment of people with IGR can reduce adverse sequelae of diabetes. Various screening instruments were compared to identify IGR, in addition to undiagnosed diabetes.Design5, annual cross-sectional health examination surveys; data adjusted for complex survey design.SettingRandom selection of private homes across England, new sample annually 2009–2013.Participants5, nationally representative random samples of the general, free-living population: ≥1 adult interviewed in 24 254 of 36 889 eligible addresses selected. 18 399 adults had a valid glycated haemoglobin (HbA1c) measurement and answered the diabetes questions.Main outcome measuresDiagnosed diabetes, undiagnosed diabetes (HbA1c ≥48 mmol/mol), IGR (HbA1c 42–47 mmol/mol).ResultsOverall, 11% of the population had IGR, 2% undiagnosed and 6% diagnosed diabetes. Age-standardised prevalence was highest among Asian (19% (95% CI 16% to 23%), 3% (2% to 5%) and 12% (9% to 16%) respectively) and black participants (17% (13% to 21%), 2% (1% to 4%) and 14% (9% to 20%) respectively). These were also higher among people with lower income, less education, lower occupational class and greater deprivation. Education (OR 1.49 (95% CI 1.27 to 1.74) for no qualifications vs degree or higher) and income (1.35 (1.12 to 1.62) for lowest vs highest income quintile) remained significantly associated with IGR or undiagnosed diabetes on multivariate regression. The greatest odds of IGR or undiagnosed diabetes were with increasing age over 34 years (eg, OR 18.69 (11.53 to 30.28) aged 65–74 vs 16–24). Other significant associations were ethnic group (Asian (3.91 (3.02 to 5.05)), African-American (2.34 (1.62 to 3.38)) or ‘other’ (2.04 (1.07 to 3.88)) vs Caucasian); sex (OR 1.32(1.19 to 1.46) for men vs women); body mass index (3.54 (2.52 to 4.96) for morbidly obese vs not overweight); and waist circumference (2.00 (1.67 to 2.38) for very high vs low).ConclusionsSocial inequalities in hyperglycaemia exist, additional to well-known demographic and anthropometric risk factors for diabetes and IGR.

ObjectivesComplications from sexually transmitted infections (STIs) can result in severe morbidity and mortality. To date, no STI population studies have been conducted on the Bijagos Islands, Guinea Bissau. Our objective was to estimate the prevalence of and identify risk factors for Chlamydia trachomatis (Ct), Neisseria gonorrhoea (Ng), Mycoplasma genitalium (Mg), Trichomonas vaginalis (Tv) and Treponema pallidum (Tp) on Bubaque, the most populated island.MethodsA cross-sectional survey was conducted on the island of Bubaque among people aged 16–49 years. Participants were asked to answer a questionnaire on STI risk factors, to provide urine samples (men and women) and vaginal swabs (women) for PCR testing for Ct, Ng, Mg and Tv, and to provide dry blood spots for Tp particle agglutination assays. Data were analysed to estimate the prevalence of STIs and logistic regression was used to identify risk factors.ResultsIn total, 14.9% of participants were found to have a curable STI, with the highest prevalence being observed for Tv (5.9%) followed by Ct (3.8%), Ng (3.8%), Mg (1.9%) and Tp (0.8%). Significant risk factors for having any STI included being female, younger age and concurrent partnership. Having had a previous STI that was optimally treated was a protective factor.ConclusionsThis study demonstrates that there is a considerable burden of STI on the Bijagos Islands, stressing the need for diagnostic testing to facilitate early detection and treatment of these pathogens to stop ongoing transmission. Moreover, these results indicate the need to conduct further research into the STI burden on the Bijagos Islands to help inform and develop a national STI control strategy.

There are many outstanding questions about how to control the global COVID-19 pandemic. The information void has been especially stark in the World Health Organization Africa Region, which has low per capita reported cases, low testing rates, low access to therapeutic drugs, and has the longest wait for vaccines. As with all disease, the central challenge in responding to COVID-19 is that it requires integrating complex health systems that incorporate prevention, testing, front line health care, and reliable data to inform policies and their implementation within a relevant timeframe. It requires that the population can rely on the health system, and decision-makers can rely on the data. To understand the process and challenges of such an integrated response in an under-resourced rural African setting, we present the COVID-19 strategy in Ifanadiana District, where a partnership between Malagasy Ministry of Public Health (MoPH) and non-governmental organizations integrates prevention, diagnosis, surveillance, and treatment, in the context of a model health system. These efforts touch every level of the health system in the district—community, primary care centers, hospital—including the establishment of the only RT-PCR lab for SARS-CoV-2 testing outside of the capital. Starting in March of 2021, a second wave of COVID-19 occurred in Madagascar, but there remain fewer cases in Ifanadiana than for many other diseases (e.g., malaria). At the Ifanadiana District Hospital, there have been two deaths that are officially attributed to COVID-19. Here, we describe the main components and challenges of this integrated response, the broad epidemiological contours of the epidemic, and how complex data sources can be developed to address many questions of COVID-19 science. Because of data limitations, it still remains unclear how this epidemic will affect rural areas of Madagascar and other developing countries where health system utilization is relatively low and there is limited capacity to diagnose and treat COVID-19 patients. Widespread population based seroprevalence studies are being implemented in Ifanadiana to inform the COVID-19 response strategy as health systems must simultaneously manage perennial and endemic disease threats.

Geographic distance is a critical barrier to healthcare access, particularly for rural communities with poor transportation infrastructure who rely on non-motorized transportation. There is broad consensus on the importance of community health workers (CHWs) to reduce the effects of geographic isolation on healthcare access. Due to a lack of fine-scale spatial data and individual patient records, little is known about the precise effects of CHWs on removing geographic barriers at this level of the healthcare system. Relying on a high-quality, crowd-sourced dataset that includes all paths and buildings in the area, we explored the impact of geographic distance from CHWs on the use of CHW services for children under 5 years in the rural district of Ifanadiana, southeastern Madagascar from 2018–2021. We then used this analysis to determine key features of an optimal geographic design of the CHW system, specifically optimizing a single CHW location or installing additional CHW sites. We found that consultation rates by CHWs decreased with increasing distance patients travel to the CHW by approximately 28.1% per km. The optimization exercise revealed that the majority of CHW sites (50/80) were already in an optimal location or shared an optimal location with a primary health clinic. Relocating the remaining CHW sites based on a geographic optimum was predicted to increase consultation rates by only 7.4%. On the other hand, adding a second CHW site was predicted to increase consultation rates by 31.5%, with a larger effect in more geographically dispersed catchments. Geographic distance remains a barrier at the level of the CHW, but optimizing CHW site location based on geography alone will not result in large gains in consultation rates. Rather, alternative strategies, such as the creation of additional CHW sites or the implementation of proactive care, should be considered.