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BackgroundScabies is a global health concern disproportionally affecting vulnerable population such as refugees and asylum seekers. Greece is a main geographical point of entry in Europe for refugees, but epidemiological data on scabies in this population is scarce. We aimed to evaluate the epidemiology of scabies, including trends over the study period.Methodology/Principal findingsData were collected from June, 2016 to July, 2020, using the surveillance system of the Greek National Public Health Organization. Staff at health centers for refugees/asylum seekers compiled daily reports on scabies and other infectious diseases. Observed proportional morbidity for scabies was calculated using consultations for scabies as a proportion of total consultations.There were a total of 13118 scabies cases over the study period. Scabies was the third most frequently observed infectious disease in refugees/asylum seekers population after respiratory infections and gastroenteritis without blood in the stool. The scabies monthly observed proportional morbidity varied between 0.3% (August 2017) to 5.6% (January 2020). Several outbreaks were documented during the study period. An increasing number of cases was observed from October 2019 until the end of the study period, with a peak of 1663 cases in January 2020, related to an outbreak at one center. Spearman correlation test between the number of reported scabies cases and time confirmed an increasing trend (ρ=0.67).Conclusions/SignificanceScabies is one of the most frequently reported infectious diseases by health care workers in refugee/asylum seekers centers in Greece. Consultations for scabies increased over time and there were several outbreaks. The current surveillance system effectively detects new cases in an early stage. Public health interventions, including mass drug administration, should be considered to reduce the burden of scabies in refugee/migrant populations.Author summaryScabies is a skin disease caused by ectoparasitic mite Sarcoptes scabiei var. hominis. A person infected by scabies manifests symptoms like itching and skin rash, while the most complicated forms of the infection can lead to bacterial infections and sepsis. Scabies is a global health concern and as of 2017, it is officially included in the portfolio of conditions prioritized by the Department of Neglected Tropical Diseases, according to the World Health Organization. Furthermore, scabies can disproportionally affect vulnerable population, such as refugees and asylum seekers. Greece is one of the main points of entry in Europe for refugees. However, the prevalence of scabies amongst refugees in Greece has not been thoroughly investigated. In this study, we utilized data weekly reported within the epidemiological surveillance in refugees/asylum seekers centers of the Greek National Public Health Organization, in order to obtain a clear overview of scabies epidemiology and identify any trends over time. Our findings confirmed the high prevalence of scabies among refugees and identified a clear trend of significant increase over time. Further public health interventions, like mass drug administration could help restrain the dissemination of the disease and lower its burden among refugees.

As coronavirus disease 2019 (COVID-19) pandemic unraveled, state-led preventative restrictions created a “new” normal through remote home-working. A long-planned follow-up qualitative research study on risk perceptions and experiences regarding Clay Ingestion among black African women during pregnancy, in London, was disrupted as England went into lockdown. Against this backdrop, we shifted to remote data collection which raised pertinent concerns around access to technology and participant digital skills. We share our experiences of navigating through remote fieldwork during the pandemic with black African mothers with caring responsibilities as well as the extra burden of homeschooling, the challenges we encountered and how we mitigate these and the lessons learnt. Thus, drawing from our remote qualitative research experiences, we refer to notable examples of challenges, mitigating strategies applied and potential lessons to inform future practice.

Background Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging. Methods and findings A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations. Conclusion While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area. Registration PROSPERO CRD42019137242.

Background\ud During the first wave of the influenza A(H1N1)pdm09 pandemic in England in 2009, morbidity and mortality were higher in patients of South Asian (Indian, Pakistani or Bangladeshi) ethnic minority groups.\ud \ud Objectives\ud This study aims to provide insights in the representation of this group among reported cases, indicating susceptibility and exposure.\ud \ud Methods\ud All laboratory‐confirmed cases including basic demographic and limited clinical information that were reported to the FluZone surveillance system between April and October 2009 were retrieved. Missing ethnicity data were imputed using the previously developed and validated South Asian Names and Group Recognition Algorithm (SANGRA). Differences between ethnic groups were calculated using chi‐square, log‐rank and t tests and rate ratios. Geographic clustering was compared using Ripley's K functions.\ud \ud Results\ud SANGRA identified 2447 (28%) of the total of 8748 reported cases as South Asian. South Asian cases were younger (P < .001), more often male (P = .002) and more often from deprived areas (P < .001) than cases of other ethnic groups. Time between onset of symptoms and laboratory sampling was longer in this group (P < .001), and they were less often advised antiviral treatment (P < .001), however, declined treatment less. The highest cumulative incidence was seen in the West Midlands region (32.7/10 000), London (7.0/10 000) and East of England region (5.7/10 000).\ud \ud Conclusions\ud People of South Asian ethnic groups were disproportionally affected by the first wave of the influenza pandemic in England in 2009. The findings presented contribute to further understanding of demographic, socioeconomic and ethnic factors of the outbreak and inform future influenza preparedness to ensure appropriate prevention and care.

Global health gains can be achieved through strengthening health systems to identify and address implementation challenges in low- and middle-income countries. Participatory research, that promotes joint problem and solution finding between communities and different health systems actors, supports policy implementation analysis at all levels. Within the neglected tropical disease programmes in Liberia and Nigeria, we applied participatory action research (PAR) to address programmatic and health system bottlenecks with health systems strengthening embedded. This paper shares learning from 20 interviews with co-researchers, from national and sub-national levels and academic researchers who worked collaboratively to understand challenges, co-create solutions and advocate for policy change. Through analysis and reflections of existing PAR principles, we inductively identified five additional guiding principles for quality, ethical standards and ongoing learning within PAR projects that aim to strengthen health systems. (1) Recognize communities as units of identity and define stakeholder participation to ensure equitable engagement of all actors; (2) enable flexible action planning that builds on existing structures whilst providing opportunities for embedding change; (3) address health systems and research power differentials that can impede co-production of knowledge and solution development; (4) embed relational practices that lead to new political forms of participation and inquiry within health systems and (5) develop structures for ongoing learning at multiple levels of the health system. PAR can strengthen health systems by connecting and co-creating potentially sustainable solutions to implementation challenges. Additional research to explore how these five additional principles can support the attainment of quality and ethical standards within implementation research using a PAR framework for health systems strengthening is needed.

OBJECTIVE: We assessed the impact of political conflict (Boko Haram) on tuberculosis (TB) case noti?cations in Adamawa State in North-east Nigeria. DESIGN: A retrospective analysis of TB case notifications from TB registers (2010-2016) to describe changes in TB notification, sex and age ratios by the degree of conflict by local government area. SETTING: Adamawa State. PARTICIPANTS: 21?076 TB cases notified. RESULTS: 21?076 cases (62% male) were noti?ed between 2010 and 2016, of which 19 604 (93%) were new TB cases. Areas affected by conflict in 2014 and 2015 had decreased case notification while neighbouring areas reported increased case notifications. The male to female ratio of TB cases changed in areas in conflict with more female cases being notified. The young and elderly (1-14 and >65 years old) had low notifications in all areas,with a small increase in case notifications during the years of conflict. CONCLUSION: TB case notifications decreased in conflict areas and increased in areas without conflict. More males were notified during peace times and more female cases were reported from areas in conflict. Young and elderly populations had decreased case notifications but experienced a slight increase during the conflict years. These changes are likely to reflect population displacement and a dissimilar effect of conflict on the accessibility of services. TB services in conflict areas deserve further study to identify resilient approaches that could reach affected populations., BMJ open, 10(9), art.no.e035263; 2020

Background\ud Previous studies from Ethiopia detected disease clustering using broader geographic settings, but limited information exists on the spatial distribution of the disease using residential locations. An assessment of predictors of spatial variations of TB at community level could fill the knowledge gaps, and helps in devising tailored interventions to improve TB control.\ud \ud Objective\ud To assess the pattern of spatial distribution of pulmonary tuberculosis (PTB) based on geographic locations of individual cases in the Dale district and Yirga Alem town in southern Ethiopia.\ud \ud Methods\ud The socio-demographic characteristics of PTB cases were collected using a structured questionnaire, and spatial information was collected using geographic position systems. We carried out Getis and Ord (Gi*) statistics and scan statistics to explore the pattern of spatial clusters of PTB cases, and geographically weighted regression (GWR) was used to assess the spatial heterogeneities in relationship between predictor variables and PTB case notification rates (CNRs).\ud \ud Results\ud The distribution of PTB varied by enumeration areas within the kebeles, and we identified areas with significant hotspots in various areas ineach year. In GWR analysis, the disease distribution showed a geographic heterogeneity (non-stationarity) in relation to physical access (distance to TB control facilities) and population density (AICc = 5591, R2 = 0.3359, adjusted R2 = 0.2671). The model explained 27% of the variability in PTB CNRs (local R2 ranged from 0.0002–0.4248 between enumeration areas). The GWR analysis showed that areas with high PTB CNRs had better physical accessibility to TB control facilities and high population density. The effect of physical access on PTB CNRs changed after the coverage of TB control facilities was improved.\ud \ud Conclusion\ud We report a varying distribution of PTB in small and different areas over 10 years. Spatial and temporal analysis of disease distribution can be used to identify areas with a high burden of disease and predictors of clustering, which helps in making policy decisions and devising targeted interventions.

Background: In 2018 a large mumps epidemic coincided with an outbreak of diphtheria in refugee camps established in Bangladesh for the Rohingya people. These refugees did not receive a mumps containing vaccine.\ud Methods: Cases of mumps were reported to the World Health Organisation (WHO) Early Warning, Alert and Response System (EWARS) during the Rohingya refugee crisis. The authors present amalgamated epidemiological data of a major, previously unreported, mumps epidemic. \ud Results: In total 19 215 mumps cases across a total of 218 facilities were reported to EWARS during 2018. The attack rate was 2.1% of the whole population. 7 687 (40·0%) of these cases were in children under 5 years old. Mumps was more commonly seen among males than females. \ud Conclusion: Detailed reporting of outbreaks of all vaccine preventable diseases is essential to ensure appropriate vaccination decisions can be made in future humanitarian crises.

BACKGROUND:\ud National-level population size estimates (PSEs) for hidden populations are required for HIV programming and modelling. Various estimation methods are available at the site-level, but it remains unclear which are optimal and how best to obtain national-level estimates.\ud \ud SETTING:\ud Zimbabwe METHODS:: Using 2015-2017 data from respondent-driven sampling surveys (RDS) among female sex workers (FSW) aged 18+ years, mappings, and programme records, we calculated PSEs for each of 20 sites across Zimbabwe, using up to three methods per site (service and unique object multipliers, census, and capture-recapture). We compared estimates from different methods, and calculated site medians. We estimated prevalence of sex work at each site using census data available on the number of 15-49 year-old women, generated a list of all 'hotspot' sites for sex work nationally, and matched sites into strata in which the prevalence of sex work from sites with PSEs was applied to those without. Directly and indirectly estimated PSEs for all hotspot sites were summed to provide a national-level PSE, incorporating an adjustment accounting for sex work outside hotspots.\ud \ud RESULTS:\ud Median site PSEs ranged from 12,863 in Harare to 247 in a rural growth-point. Multiplier methods produced the highest PSEs. We identified 55 hotspots estimated to include 95% of all FSW. FSW nationally were estimated to number 40,491, 1.23% of women aged 15-49 years, (plausibility bounds 28,177-58,797, 0.86-1.79%, those under 18 considered sexually exploited minors).\ud \ud CONCLUSION:\ud There are large numbers of FSW estimated in Zimbabwe. Uncertainty in population size estimation should be reflected in policy-making.

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category ‘antibiotic’ does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a ‘Drug Bag’ method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method can produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples’ everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial.

BACKGROUND\ud Human papillomavirus (HPV) infection is common among men who have sex with men (MSM), especially among Human Immunodeficiency Virus (HIV)-infected MSM. The prevalence of HPV among MSM, accounts for the higher incidence of HPV-related cancer observed in this population. It is well known that targeted HPV vaccination is an effective way to prevent HPV infection; an intervention which could be beneficial for a high-risk group such as MSM. The current study aimed to assess the attitudes towards and acceptability of the HPV vaccine among MSM in in Urumqi, China.\ud \ud METHODS\ud A total of 253 HIV-uninfected and 205 HIV-infected MSM (in Urumqi, China participated in the current cross-sectional study. Information on HPV-related knowledge, willingness to be vaccinated as well as demographic data were collected through a self-administered survey. A logistic regression model was applied to determine the predictors of HPV vaccine acceptability among the population.\ud \ud RESULTS\ud The survey results indicated that only 218 (47.6%) of MSM questioned were aware of the term HPV, nevertheless, once awareness was established the prevalence of acceptability of free HPV vaccine was recorded at 96.7% of the total MSM sample. However, HIV-uninfected and HIV-infected MSM demonstrated significantly different attitudes in regard to their acceptability of free HPV vaccination (94.9% vs. 99.0%, p

Objective\ud To compare predeparture tuberculosis (TB) screening policies, including screening criteria and screening tests, and visa requirements for prospective migrants to high-income countries that have low to intermediate TB incidence and high immigration.\ud Study design\ud Systematic review of policy documents.\ud Methods\ud We systematically identified high-income, high net-migration countries with an estimated TB incidence of

Background: HIV took off rapidly in Zimbabwe during the 1980s. Yet, between 1998 and 2003, as the economy faltered, HIV prevalence declined abruptly and without clear explanation.\ud \ud Methods: We reviewed epidemiological, behavioural, and economic data over three decades to understand changes in economic conditions, migrant labour and sex work that may account for observed fluctuations in Zimbabwe’s HIV epidemic. Potential biases related to changing epidemic paradigms and data sources were examined.\ud \ud Results: Early studies describe rural poverty, male migrant labour and sex work as conditions facilitating HIV/STI transmission. By the mid-1990s, as Zimbabwe’s epidemic became more generalized, research focus shifted to general population household surveys. Yet, less than half as many men than women were found at home during surveys in the 1990s, increasing to 80% during the years of economic decline. Other studies suggest that male demand for sex work fell abruptly as migrant workers were laid off, picking up again when the economy rebounded after 2009. Numbers of clients reported by sex workers, and their STI rates, followed similar patterns reaching a nadir in the early 2000s. Studies from 2009 describe a return to more active sex work, linked to increasing client demand, as well as a revitalized programme reaching sex workers.\ud \ud Conclusion: The importance of the downturn in migrant labour and resultant changes in sex work may be underestimated as drivers of Zimbabwe’s rapid HIV incidence and prevalence declines. Household surveys underrepresent populations at the highest risk of HIV/STI acquisition and transmission, and these biases vary with changing economic conditions.

UK guidelines no longer recommend routine screening of household contacts of adult patients with extrapulmonary TB (EPTB). From 27 March 2012 to 28 June 2016, we investigated the prevalence of active TB disease in household contacts of 1023 EPTB index cases in North West England, and compared estimates with: published new entrant migrant screening programme prevalence (~147/100 000 person-years); London-based contact screening data (700/100 000 contacts screened); and National Institute for Health and Care Excellence (NICE) new entrant TB screening thresholds (TB prevalence >40/100 000 people). Active TB disease prevalence in EPTB contacts was 440/100 000 contacts screened, similar to UK new entrant screening programmes, London EPTB contact prevalence and >10 times NICE’s threshold for new entrant screening. The decision to no longer recommend routine screening of EPTB contacts should be re-evaluated and cost-effectiveness analyses of screening strategies for EPTB contacts should be performed.

IntroductionIs achievement of Sustainable Development Goal (SDG) 16 (building peaceful societies) a precondition for achieving SDG 3 (health and well-being in all societies, including conflict-affected countries)? Do health system investments in conflict-affected countries waste resources or benefit the public’s health? To answer these questions, we examine the maternal, newborn, child and reproductive health (MNCRH) service provision during protracted conflicts and economic shocks in the Republic of South Sudan between 2011 (at independence) and 2015.MethodsWe conducted two national cross-sectional probability surveys in 10 states (2011) and nine states (2015). Trained state-level health workers collected data from households randomly selected using probability proportional to size sampling of villages in each county. County data were weighted by their population sizes to measure state and national MNCRH services coverage. A two-sample, two-sided Z-test of proportions tested for changes in national health service coverage between 2011 (n=11 800) and 2015 (n=10 792).ResultsTwenty-two of 27 national indicator estimates (81.5%) of MNCRH service coverage improved significantly. Examples: malaria prophylaxis in pregnancy increased by 8.6% (pConclusionHealth system strengthening is not a uniform process and not necessarily deterred by conflict. Despite the conflict, health system investments were not wasted; health service coverage increased.

BACKGROUND\ud Global health policy prioritizes improving the health of women and girls, as evident in the Sustainable Development Goals (SDGs), multiple women's health initiatives, and the billions of dollars spent by international donors and national governments to improve health service delivery in low-income countries. Countries recovering from fragility and conflict often engage in wide-ranging institutional reforms, including within the health system, to address inequities. Research and policy do not sufficiently explore how health system interventions contribute to the broader goal of gender equity.\ud \ud METHODS\ud This paper utilizes a framework synthesis approach to examine if and how rebuilding health systems affected gender equity in the post-conflict contexts of Mozambique, Timor Leste, Sierra Leone, and Northern Uganda. To undertake this analysis, we utilized the WHO health systems building blocks to establish benchmarks of gender equity. We then identified and evaluated a broad range of available evidence on these building blocks within these four contexts. We reviewed the evidence to assess if and how health interventions during the post-conflict reconstruction period met these gender equity benchmarks.\ud \ud FINDINGS\ud Our analysis shows that the four countries did not meet gender equitable benchmarks in their health systems. Across all four contexts, health interventions did not adequately reflect on how gender norms are replicated by the health system, and conversely, how the health system can transform these gender norms and promote gender equity. Gender inequity undermined the ability of health systems to effectively improve health outcomes for women and girls. From our findings, we suggest the key attributes of gender equitable health systems to guide further research and policy.\ud \ud CONCLUSION\ud The use of gender equitable benchmarks provides important insights into how health system interventions in the post-conflict period neglected the role of the health system in addressing or perpetuating gender inequities. Given the frequent contact made by individuals with health services, and the important role of the health system within societies, this gender blind nature of health system engagement missed an important opportunity to contribute to more equitable and peaceful societies.

This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.

During the 2nd World War, large numbers of allied military personnel in south-east Asia became prisoners-of-war (POWs) of the Japanese. During their internment of three and a half years, they suffered undernutrition, exposure to tropical diseases and frequently overwork. Perhaps the harshest POW experience was the construction of the railway between Thailand and Burma. This paper explores the medical conditions during Far East imprisonment, and in particular on the Thai-Burma Railway, as well as the long-term health effects in post-war decades.

Source at https://doi.org/10.1007/s10461-018-2038-0. A community-based HIV self-testing study in Blantyre, Malawi demonstrated that not all individuals living in couples tested with their partner. We describe factors dissuading individuals in couples from self-testing with their partner. Data were drawn from qualitative study exploring consequences of HIV self-testing within couples. In-depth interviews were conducted with 33 individuals living in couples who tested alone. Participants expressed fear of dealing with HIV-discordant relationships. Failure to self-test with a partner was correlated with gender, with more men than women overtly declining or unconsciously unable to have joint HIV self-test. Men feared exposure of infdelity and were often not available at home for economic reasons. Barriers to uptake of couple HIV self-testing seemed to be shaped by gendered dichotomies of social-relationships. To help achieve the frst 90% of the UNAIDS 90:90:90 goals, it is important to overcome structural barriers to realise the full potential of HIV self-testing.

Humanitarian agencies working in refugee camp settings require rapid assessment methods to measure the needs of the populations they serve. Due to the high level of dependency of refugees, agencies need\ud to carry out these assessments. Lot Quality Assurance Sampling (LQAS) is a method commonly used in development settings to assess populations living in a project catchment area to identify their greatest\ud needs. LQAS could be well suited to serve the needs of refugee populations, but it has rarely been used in humanitarian settings. We adapted and implemented an LQAS survey design in Batil refugee camp, South Sudan in May 2013 to measure the added value of using it for sub-camp level assessment.

BACKGROUND: The antiretroviral nevirapine is associated with hypersensitivity reactions in 6%-10% of patients, including hepatotoxicity, maculopapular exanthema, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). OBJECTIVES: To undertake a genome-wide association study (GWAS) to identify genetic predisposing factors for the different clinical phenotypes associated with nevirapine hypersensitivity. METHODS: A GWAS was undertaken in a discovery cohort of 151 nevirapine-hypersensitive and 182 tolerant, HIV-infected Malawian adults. Replication of signals was determined in a cohort of 116 cases and 68 controls obtained from Malawi, Uganda and Mozambique. Interaction with ERAP genes was determined in patients positive for HLA-C*04:01 In silico docking studies were also performed for HLA-C*04:01 RESULTS: Fifteen SNPs demonstrated nominal significance (P

INTRODUCTION: Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV than other women of reproductive age. Social, legal, and structural barriers influence their access to care. Little is known about the HIV diagnosis and care cascade in most countries in Southern Africa. We aimed to describe the HIV diagnosis and care cascade among FSW in Zimbabwe. METHODS: We conducted cross-sectional respondent driven sampling (RDS) surveys of FSW in 14 sites across Zimbabwe as the baseline for a cluster-randomised controlled trial investigating a combination HIV prevention and care package. We administered a questionnaire, tested women for HIV and measured viral load. We report the mean, minimum, and maximum respondent-driven sampling-2 weighted site values. RESULTS: The survey included 2722 women, approximately 200 per site. The mean HIV prevalence was 57.5% (42.8-79.2 site minimum and maximum). Of HIV-positive women, 64.0% (51.6-73.7) were aware of their status, 67.7% (53.4-84.1) of these reported taking antiretroviral therapy, and 77.8% (64.4-90.8) of these had a suppressed HIV viral load (

ObjectivesThe circumstances of people living in refugee camps means that they have distinct medical care requirements. Our objective is to describe clinical guidance in published WHO guidelines that refer to people living in refugee camps; and how evidence and context are used and reported in making recommendations.DesignSystematic review and analysis of WHO guidelines approved by the organisation’s quality oversight body and published between 2007 and 2018. We sought for key terms related to camps and humanitarian settings, and identified text that included guidance. We compared this to Mèdecins Sans Frontièrs (MSF) guidelines.ResultsNo WHO guideline published in the last 10 years focused exclusively on clinical guidance for healthcare in camp settings. Seven guidelines contained guidance about camps; three made recommendations for camps—but only two used formal evidence summaries. We did not find any structured consideration of the situation in camps used in the decision-making process. We examined seven WHO guidelines and six chapters within guidelines that concerned humanitarian settings: none of these documents contained recommendations based on formal evidence summaries for camp settings. One of the eight MSF guidelines was devoted to clinical care in refugees and the authors had clearly linked the health problems and recommendations to the setting, but this guideline is now >20 years old.ConclusionsThere is an absence of up-to-date, evidence-based medical treatment guidelines from WHO and MSF that comprehensively address the clinical needs for people living in camps; and there is no common framework to help guideline groups formulate recommendations in these settings. WHO may wish to consider context of special populations more formally in the evidence to decision-making approach for clinical guidelines relevant to primary care.

BACKGROUND\ud Tuberculosis (TB) case notification rates are usually higher in men than in women, but notification data are insufficient to measure sex differences in disease burden. This review set out to systematically investigate whether sex ratios in case notifications reflect differences in disease prevalence and to identify gaps in access to and/or utilisation of diagnostic services.\ud \ud METHODS AND FINDINGS\ud In accordance with the published protocol (CRD42015022163), TB prevalence surveys in nationally representative and sub-national adult populations (age ≥ 15 y) in low- and middle-income countries published between 1 January 1993 and 15 March 2016 were identified through searches of PubMed, Embase, Global Health, and the Cochrane Database of Systematic Reviews; review of abstracts; and correspondence with the World Health Organization. Random-effects meta-analyses examined male-to-female (M:F) ratios in TB prevalence and prevalence-to-notification (P:N) ratios for smear-positive TB. Meta-regression was done to identify factors associated with higher M:F ratios in prevalence and higher P:N ratios. Eighty-three publications describing 88 surveys with over 3.1 million participants in 28 countries were identified (36 surveys in Africa, three in the Americas, four in the Eastern Mediterranean, 28 in South-East Asia and 17 in the Western Pacific). Fifty-six surveys reported in 53 publications were included in quantitative analyses. Overall random-effects weighted M:F prevalence ratios were 2.21 (95% CI 1.92-2.54; 56 surveys) for bacteriologically positive TB and 2.51 (95% CI 2.07-3.04; 40 surveys) for smear-positive TB. M:F prevalence ratios were highest in South-East Asia and in surveys that did not require self-report of signs/symptoms in initial screening procedures. The summary random-effects weighted M:F ratio for P:N ratios was 1.55 (95% CI 1.25-1.91; 34 surveys). We intended to stratify the analyses by age, HIV status, and rural or urban setting; however, few studies reported such data.\ud \ud CONCLUSIONS\ud TB prevalence is significantly higher among men than women in low- and middle-income countries, with strong evidence that men are disadvantaged in seeking and/or accessing TB care in many settings. Global strategies and national TB programmes should recognise men as an underserved high-risk group and improve men's access to diagnostic and screening services to reduce the overall burden of TB more effectively and ensure gender equity in TB care.

BACKGROUND\ud There is increasing interest amongst donors in investing in the health sectors of fragile and conflict-affected states, although there is limited research evidence and research funding to support this. Agreeing priority areas is therefore critical. This paper describes an 18-month process to develop a consultative research agenda and questions for health systems research, providing reflections on the process as well as its output.\ud \ud METHODS\ud After a scoping review had been conducted, primary data was collected from August 2014 to September 2015. Data was collected using a mixture of methods, including an online survey (n = 61), two face-to-face group sessions (one with 11 participants; one with 17), email consultation (n = 18), a webinar (n = 65), and feedback via LinkedIn. Two steering committees of purposively selected experts guided the research process - a core steering committee (n = 10) and broad steering committee (n = 20). The process moved from developing broad topics and lists of research needs to grouping and honing them down into a smaller, prioritised agenda, with specific research questions associated to each topic.\ud \ud RESULTS\ud An initial list of 146 topics was honed down to 25 research needs through this process, grouped thematically under transition and sustainability, resilience and fragility, gender and equity, accessibility, capacity building, actors and accountability, community, healthcare delivery, health workforce, and health financing. They were not ranked, as all health system areas are interdependent. The research agenda forms a starting point for local contextualisation and is not definitive.\ud \ud CONCLUSIONS\ud A wide range of stakeholders participated in the different stages of this exercise, which produced a useful starting point for health systems research agenda setting in fragile and conflict-affected states. The process of engagement may have been as valuable for building a community of researchers as the product. It is now important to drive forward the research agenda. Without both a higher profile and deeper focus for this area, there is a real risk that fragile and conflict-affected states will continue to fall behind in global health and development goals.

The aim of this study was to assess the status of cardiovascular health among a rural population in Northwest China and to determine the associated factors for cardiovascular health. A population-based cross-sectional study was conducted in the rural areas of Hanzhong in Northwest China. Interview, physical examination, and fasting blood glucose and lipid measurements were completed for 2693 adults. The construct of cardiovascular health and the definitions of cardiovascular health metrics proposed by the American Heart Association were used to assess cardiovascular health. The proportions of subjects with cardiovascular health metrics were calculated, adjusting for age and sex. The multiple logistic regression model was used to evaluate the association between ideal cardiovascular health and its associated factors. Only 0.5% (0.0% in men vs 0.9% in women, P = 0.002) of the participants had ideal cardiovascular health, whereas 33.8% (18.0% in men vs 50.0% in women, P