Abstract Background Migrants are at increased risk of infections including HIV, tuberculosis and viral hepatitis, with poorer outcomes. Early diagnosis and management can reduce morbidity, mortality and onward transmission. This systematic review summarises prevalence of HIV, latent and active tuberculosis and hepatitis B and C among UK migrants and evaluates associated risk factors. Methods PubMed/Medline, EMBASE, Web of Science and the Cochrane Library were systematically searched from 2004 to 11 June 2025. The review was conducted using PRISMA guidelines and registered with PROSPERO (registration CRD42024521191). Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. High heterogeneity (I2 = 95.2%, 99.2%, 87.2%, 96.9% and 91.6% for IGRA, active TB, HIV, HBV and HCV yields, respectively) indicated that meta-analysis was not appropriate. The impact of risk factors on prevalence was explored through meta-regression and descriptive analysis. Results Of 2033 identified records, 36 were included, reporting Interferon Gamma Release Assay (IGRA) (n = 13), active TB (n = 10), HIV (n = 12), HBV (n = 16) and HCV (n = 11) test yields. An additional two publications excluded from the main analysis for reporting duplicate study data were included in the risk factor analysis because they stratified prevalence by additional risk factors. Highest yield was for IGRA which, excluding one lower prevalence outlier (6.9% (n = 1617)), was 15.1%–22.1%. There was high heterogeneity in active TB prevalence: 62–1,484/100,000. HIV prevalence among larger studies (n > 200) was 0.18%–0.48%. HBV prevalence was 0.00%–8.93% (all studies) and 1.06%–4.75% for larger studies (n > 1000). HCV prevalence was lower: 0.00%–1.67%, with only two of 11 included estimates above 0.50%. There was considerable heterogeneity in risk factors analysed making comparisons difficult. Conclusions Despite heterogeneity, infection prevalence was generally high, particularly IGRA yield and HBV. This underscores the need to maintain effective monitoring, testing and treatment for key infections among migrant populations, especially given the rapidly evolving epidemiological and demographic landscape for this population.

Background Testing for Blood-Borne-Viruses (BBVs) such as the human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) is generally focused on specialist settings. However, people with undiagnosed infections are also present within the general population. We explore whether using machine-learning algorithms (MLAs) can identify people at heightened risk of HIV, HBV, HCV, or a composite 'any BBV' (defined as positivity for one or more of the three infections) in primary care settings.Methods From de-identified electronic health records data from 165 general practices in North East London we extracted risk factors for HIV, HCV and HBV and used them to train (75% data) and test (25% data) three MLAs: Logistic Regression (LR), AdaBoost with random under sampling (RUSBoost) and Balanced Random Forest classifier (BRFC). The ROC curves, ROC AUC, sensitivity and specificity values quantified the models' performance. Across the models the key features for each outcome were identified.Results A total of 1,987,954 patients were included in the study with no inclusion or exclusion criteria, from whom 75 predictive features were selected for HIV, 24 for HCV, 37 for HBV and 88 for any BBV outcome. Different models were optimal for individual BBVs positivity classification, depending on the accuracy metric. As a single infection, HCV was predicted most accurately across models and accuracy metrics. When targeting any BBV outcome, LR was the model with highest AUC value, BRFC was the most sensitive model and RUSBoost was the most specific model. The key identified features were similar across models with age the strongest predictor for both individual positivity and the composite outcome. A number of features were important for two of the BBV positive groups: Black African ethnicity (HIV and HBV), liver disease (HBV and HCV) and opiate and cocaine use (HBV and HCV). A number of individual features were important for individual BBVs positivity.Conclusion Our findings illustrate that combining digital technology with routinely available general practice data has promise in improving case-finding of targeted BBV testing. There are however challenges in identifying the optimal MLAs and the accuracy metrics for multiple HIV/HCV/HBV positivity. This underscores the importance of evaluating different models and applying a broad set of accuracy criteria when utilising digital technology for precision medicine.Clinical trial number Not applicable.

Migrants arriving in the United Kingdom (UK), many of whom experience vulnerability before and during migration, face a double burden of communicable and non-communicable diseases shaped by cumulative exposures in their countries of origin, across the migration journey, and compounded by fragmented access to care upon arrival. Despite improvements in pre-entry health assessments, post-arrival provision in reception centres remains inconsistent, with significant gaps in infectious disease screening, mental health support, medication continuity, and timely registration with a general practitioner (GP). Community-led initiatives like Doctors of the World’s Safe Surgeries and the Oxford Refugee Health Initiative promote inclusive healthcare access, yet remain limited in scale. Using a social determinants of health (SDH) lens, this perspective highlights how structural barriers—including overcrowded accommodation, language challenges, and unclear entitlements—undermine the effectiveness of existing health policies and widen inequalities. We propose an essential care package for UK migrant reception centres that integrates early screening, stable access to medicines, mental health assessment, environmental health measures, and robust continuity of care for non-communicable diseases through clear referral pathways into the National Health Service (NHS). Embedding this approach within current public health infrastructure would reduce preventable morbidity, strengthen health system efficiency, and advance the UK’s commitment to Sustainable Development Goals. Strengthening care at the point of arrival is therefore critical to promoting health equity and ensuring that no one is left behind.

According to the World Health Organisation, oral health (OH) diseases are a major global health issue and outcomes are consistently poorer among refugees and migrants than host populations in many high-income countries (HICs). In the UK, the Office for Health Improvement and Disparities recognises asylum seekers, refugees, undocumented migrants, low-wage migrants, unaccompanied minors, and victims of trafficking as vulnerable migrants. These groups face worse OH outcomes due to systemic, socio-economic, cultural, and lifestyle-related factors, alongside barriers to accessing dental services. This scoping review explores the barriers and facilitators to oral healthcare experienced by vulnerable migrants in HICs. We conducted a scoping review using the Arksey and O’Malley framework and reported findings in line with PRISMA-ScR. Embase and MEDLINE were searched from inception until April 30th 2024, for studies examining factors influencing access to oral healthcare services. Data were charted and thematically mapped onto the Dahlgren and Whitehead model of Social Determinants of Health (SDH). Of 3894 identified records, 17 studies (10 qualitative, 5 quantitative, and 2 mixed-methods) were included, covering 2653 participants across 8 HICs (USA, UK, Australia, Austria, Germany, Finland, Saudi Arabia and Canada). Barriers and facilitators were present across all SDH layers. At the socio-economic, cultural, and environmental level, financial barriers were most commonly reported (12/17 studies). Language difficulties, low awareness of services, and mistrust of healthcare providers mapped to living and working conditions, while acculturation and social support aligned with the social and community networks layer. Limited knowledge of prevention was noted under lifestyle factors, and lastly, gender roles under personal characteristics. Cultural and religious norms also shaped care-seeking, with spirituality and religious traditions supporting positive OH practices. We identified barriers and facilitators to oral healthcare access across personal, behavioural, social, and structural levels, contextualised within the SDH framework. Addressing these requires policies and practices that address structural barriers, integrate OH into national public health strategies, and emphasise inclusive, culturally competent care to improve access to OH services for these groups.

Diagnosing human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in general population settings is challenging. We conducted a systematic review and meta-analysis of prediction tools designed to help identify individuals at risk of these blood-borne viruses. We included studies on individuals of any age at risk of blood-borne viruses from healthcare, community settings, and national databases. We searched the Web of Science, MEDLINE, EMBASE, and CENTRAL databases (from database inception to 2023) and used the Prediction model Risk Of Bias ASsessment Tool (PROBAST) to evaluate the quality and systematic risk of bias of these studies. We extracted model accuracy using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. A mixed-effects model (for AUC) and bivariate random-effects model (for sensitivity/specificity) were used to generate pooled values for these studies. Of the 41,585 records, 71 were included, covering over 31 million participants and more than 65,000 cases of blood-borne viruses. We examined 67 models: 47 for HIV, 13 for HCV, 5 for HBV, and 2 from studies that assessed multiple viruses separately. The studies were conducted in 41 low- and middle-income and 30 high-income countries. They covered 11 different populations (including men who have sex with men, the general population, and women), 8 types of settings (including sexual health, secondary care, and primary care) and 7 types of risk factors (behavioural, clinical, and demographic). The methods comprised traditional regression (n = 50), machine-learning models (n = 17), and others (n = 4). The risk of bias was high in 64 studies and low in seven. Among 33 studies reporting mean and 95 I^2 = 74 I^2 = 86 I^2 = 93

BACKGROUND:Tuberculosis (TB) incidence and mortality in people living with HIV can be reduced by TB preventive treatment (TPT). However, low levels of screening and uptake, poor adherence, and loss to follow-up considerably reduce its effectiveness. We therefore aimed to assess the losses within all steps of the screening and treatment cascade. METHODS:We carried out a comprehensive, global systematic review of the TPT cascade of care in people living with HIV (PROSPERO: CRD42020162396). To enhance data generalisability we included articles which reported the proportion of people living with HIV completing any step of the TPT cascade in low and high TB burden countries published before March 2024. Random effects meta-analysis produced pooled estimates of the proportion proceeding to the next step along the cascade. Results were explored through subgroup analyses and meta-regression. RESULTS:Data from 368 cohorts containing 2.7 million participants were included. High levels of heterogeneity in outcomes were seen. Most participants were from Africa (80.6%). Isoniazid monotherapy was used for TPT in 92.6% of cohorts, usually for 6 months. Substantial loss to follow-up was found throughout the treatment cascade, with more than one in six patients lost at the following steps: initial screening, immunological testing, treatment start and completion. Regimens lasting <6 months had higher completion rates (88.4%) than those lasting 6-9 months (74.4%) or >9 months (61.6%). CONCLUSIONS:Our analysis highlights substantial loss to follow-up at multiple steps during the care cascade. This may significantly lower the reported effectiveness of TPT in real-world settings. Research and policy should focus on simplified care pathways and novel, shorter treatment regimens that optimise retention in care.

BACKGROUND:Migrants' participation in health research is essential to give voice to their needs and inform evidence-based practice. We conducted a mixed-methods study with migrants living in Leicester, United Kingdom, to understand their perceptions of participation in health research and factors influencing participation. METHODS:Our study included a questionnaire and focus groups with migrants. Interviews and focus groups were also conducted with key informants. The study was carried out at two sites in Leicester. Questionnaire data were analysed descriptively in R. The COM-B framework was used to thematically analyse interview and focus group transcripts. Workshops with public members of migrant origin helped with data interpretation and analysis. RESULTS:119 questionnaires and 4 focus groups (n = 28) were completed with migrants. Seven interviews and one focus group (n = 7) were conducted with key informants. Questionnaire respondents originated from 34 different countries, with a significant proportion (25%) identifying themselves as asylum seekers/refugees. Migrants in the focus groups were from 16 different countries and were mainly asylum seekers/refugees (n = 18). The three components of the COM-B model (Capability, Opportunity and Motivation) were identified as the main themes, and descriptive statistics from the questionnaire data have been used to supplement the 16 sub-themes. Individual capabilities encompassing awareness and perception of research, language abilities and skills in the use of technology significantly influenced participation. Simultaneously, the presence or absence of opportunities such as costs, competing needs and priorities, healthcare access and experiences in the United Kingdom, language barriers, opportunities for learning and taking part, precarious living conditions and socio-cultural norms and perceptions about health were found to be important for research participation. Motivations to take part in research included trust, context of the research, need-based research, altruism, desire to be heard and receiving incentives. CONCLUSION:Our study contributes to the limited evidence base exploring migrants' participation in health research. Our findings, grounded in the COM-B model, exhibit how migrants' motivations, influenced by a host of individual capabilities and environmental and social opportunities, can influence motivation and impact research participation behaviour. These findings may support the design of accessible, inclusive, equitable and impactful health research involving underserved groups. PATIENT OR PUBLIC CONTRIBUTION:Patient and Public Involvement and Engagement (PPIE) in the project was obtained through the EMBRACE (East Midlands Migrant Research Advisory Collaborative) group, which was created as a migrant specific advisory group in 2019. We recruited new migrant members into the group and involved them in the interpretation of the study results. We organised two workshops with the group, and in the first workshop, held in February 2024, nine members took part to review the preliminary results and offer insights in contextualising and interpreting the data. The research team took into consideration the feedback received at the workshop and integrated it into the analysis. The final analysis was presented to the group again in September 2024, and the discussions held at that workshop were instrumental in shaping this manuscript.

BACKGROUND:Healthcare workers' (HCW) health and wellbeing directly affect patient care, yet little is known about their health-related quality of life (HRQoL) in the United Kingdom (UK). Using data from a nationwide study conducted during the COVID-19 pandemic in the UK (December 2020 to March 2021), we evaluated self-reported HRQoL among HCWs and its variation by sociodemographic characteristics. METHODS:HRQoL was measured using the five-dimension-five-level EuroQoL (EQ-5D-5L) questionnaire, covering five health dimensions. We explored differences in reported HRQoL by age, sex, Index of Multiple Deprivation (IMD) quintile, ethnicity, migration status and occupational group. Each HRQoL dimension was collapsed into a binary outcome (any problems versus none) and associations analysed using logistic regression. We also examined EQ-5D-5L visual analogue scale (VAS) scores using linear regression. RESULTS:Among 12,026 HCWs, 75.9% were female, 26.7% overseas-born and 29.9% from non-White ethnic groups. HCWs reported high levels of pain/discomfort and anxiety/depression (43.7% and 46.1% reporting at least slight problems, respectively). Women were more likely than men to report problems across all EQ-5D-5L dimensions. Reporting health problems increased with increased deprivation. Asian overseas-born and Black HCWs were less likely than White UK-born HCWs to report anxiety/depression. Compared to the Medical group, other HCW types reported more problems with pain/discomfort (32.2% Medical, 55.4% Nursing, 45.4% Allied Health Professionals, 49.8% Ambulance groups) and anxiety/depression (36.8% Medical, 52.9% Nursing, 50.5% Ambulance groups). Nurses and ambulance workers showed particularly high rates of pain/discomfort. Overall, all HCWs reported more problems with anxiety/depression, usual activities and pain/discomfort than the Medical group. Similar associations were demonstrated in a parallel analysis of VAS scores. CONCLUSIONS:In the largest study of HRQoL in HCWs to date, EQ-5D-5L VAS scores were lower than those reported elsewhere for the general UK population (for ages up 45 years), with high levels of anxiety/depression and pain/discomfort and substantial heterogeneities across EQ-5D-5L dimensions by sex, occupation and deprivation level. However, HCWs' circumstances during the COVID-19 pandemic may have influenced their reporting of HRQoL. Our findings highlight the need for further research to understand the causes of lower HRQoL, particularly among women and certain occupational groups, and to inform targeted interventions.

Little is known about multiple long-term conditions (MLTCs) patterns in migrants. To aimed to synthesise evidence on the burden of MLTCs among migrant populations in high-income countries. We searched five databases for studies reporting the prevalence of two or more health conditions among migrants in high-income countries between 2012 and 2024. The identified conditions were grouped into three categories: communicable, non-communicable-physical, and mental health. We explored the most commonly reported combined patterns of MLTCs (clusters) and summarised the findings using narrative synthesis and forest plots. We included 165 studies reporting co-prevalence of two or more conditions in 3,491,883 migrants. The migrants were from a wide range of countries, but most studies were conducted in 22 countries mostly in Europe (97/165, 58.8%) and North America (53/165, 32.1%). 61.2% (101/165) reported on communicable-related clusters, 44.8% (74/165) on non-communicable-physical conditions clusters, and 33.3% (55/165) on mental health clusters. The most common clusters were communicable conditions: HIV-tuberculosis (TB) (32/101, 32%) and HIV-viral hepatitis (29/101, 29%). Highest in the non-communicable-physical cluster were diabetes-TB (10/74, 14%) and diabetes-hypertension (8/74, 11%). Mental health conditions were not often reported alongside non-communicable or communicable conditions, and common clusters were depression-PTSD (18/55, 32%) and depression-anxiety (17/55, 31%). Narrative review showed that migrant status, poor living conditions, time to diagnosis, and length of stay in the resident country were significant risk factors for developing and managing several conditions. Migrants experience a significant burden of MLTCs, particularly a high burden of long-term communicable diseases. Mental health disorders appeared to be under-investigated in the context of other health needs. Interventions to address MLTCs in migrants must consider communicable diseases and mental health needs in addition to non-communicable diseases and integrate a holistic approach acknowledging the structural, systemic, and social determinants of health driving comorbid health needs.

Background:Migrants are at increased risk of chronic infections and have poorer outcomes, being more likely to present late. Early diagnosis and management can reduce morbidity, mortality and onward infection transmission. Methods:We evaluated the effectiveness of an integrated approach to screening migrants for exposure to tuberculosis (TB) with an interferon gamma release assay (IGRA) test, HIV, hepatitis B virus (HBV, using hepatitis B surface antigen testing) and hepatitis C virus (HCV, using antibody testing with confirmatory PCR test) infection when patients first registered with general practices (GPs) in Leicester, UK, using test yields (test positivity rates), numbers of new diagnoses and numbers linked to care. Findings:Of 4004 migrant GP patients referred for testing 2016-2019, test yields were 0.48% (17/3545, 95% CI 0.30-0.77%, HIV), 3.34% (117/3502, 95% CI 2.80-3.99%, HBV), 0.18% (6/3402, 95% CI 0.08-0.38%, HCV) and 19.38% (496/2560, 95% CI 17.89-20.95%, IGRA). Of IGRA-positive patients attending clinic, 7% (31/437) had active TB and 92% (403/437) had latent TB infection. Seventeen (55%) active TB, 397 (99%) latent TB, 71 (61%) HBV, six (35%) HIV and five (83%) HCV infections were new diagnoses. There were high rates of linkage to care for those newly diagnosed. 98% (390/397) of new latent TB patients were offered chemoprophylaxis, of whom 94% (366/390) started treatment and of these, 95% (346/366) completed the course. 100% (6/6), 97% (69/71) and 100% (5/5) of newly HIV-, HBV- and HCV-diagnosed patients attended follow-up, respectively. Interpretation:This first primary care-based combined infection testing programme for recent migrants found high test yields for latent/active TB, HBV and HIV, substantial numbers of new diagnoses for these infections and excellent linkage to care. To influence UK screening guidelines, its cost-effectiveness and acceptability to other primary care settings must be evaluated. Funding:NIHR, Gilead Sciences.

Background:Bacterial antimicrobial resistance (AMR) is a leading cause of death globally. However, there has been no data synthesis on whether it influences mortality within hospital settings. We conducted a systematic review and meta-analysis to quantify the prevalence and risk of mortality associated in hospitalised patients with AMR, compared to patients with infections not classified as AMR. Methods:Databases (MEDLINE, EMBASE, and Cochrane library) were searched from inception up to 14th April 2025 for studies that reported the prevalence of AMR in patients who acquired infections in hospitals and mortality (PROSPERO CRD42023420609). We calculated pooled prevalence estimates of AMR as well as unadjusted and adjusted estimates of the effect of AMR on mortality using a random-effects model. Study quality was assessed using the Joanna Briggs Quality Appraisal Tool, risk of bias using DOI plots and LFK index and certainty of evidence of mortality using GRADE criteria. Findings:We identified 34 studies (20,658 patients with resistant organisms) from 18 countries-namely the USA, China, the UK, Canada, Israel, Japan, Malaysia, Korea, Brazil, and Singapore. Of these, 33 were observational studies whilst two studies (one observational study and one purely modelling study) mechanistically modelled risk of mortality in relation to transmission. No studies were conducted in the African subcontinent, the Middle-East, Russia, and India. The prevalence of AMR was high in patients in hospital (pooled prevalence: 36.5%, 95% CI: 29%-44%, I 2 = 99%) and associated with higher mortality (unadjusted pooled risk ratio [RR]: 1.64, 95% CI: 1.37-1.97, I 2 = 96.22%, τ2 = 0.20; adjusted pooled RR: 1.58, 95% CI: 1.33-1.87, I 2 = 85.9%, τ2 = 0.13) compared to non-AMR organisms.Sensitivity analyses showed particularly elevated risks for in-hospital mortality and for AMR-associated bacteraemia. Study quality was generally rated to be high, but there was evidence of publication bias in estimates of both prevalence and mortality. Overall certainty of evidence of mortality was graded to be low. Interpretation:AMR is highly prevalent within hospital settings globally and associated with increased in-hospital mortality. Crucially, no data was identified from the India subcontinent, African subcontinent, the Middle East, and Russia, and only two studies used mechanistic modelling to explore how transmission of AMR affects mortality. Further research is required, particularly in underrepresented regions to inform interventions aimed at reducing both AMR transmission and its related mortality within hospital settings. Funding:Pacific Life.

Objectives:Ethnic minority and migrant healthcare workers (HCWs) constitute 24% of the UK's National Health Service. Migration status, often overlooked in Human Resources records, is associated with their placement within the Agenda for Change (AfC) pay bands. Therefore, we analysed the association between ethnicity, migration status, and AfC pay bands using data from the UK-REACH cohort study. Design:Cross-sectional study. Setting:UK-REACH cohort using baseline data collected via online questionnaires across various healthcare settings. Participants:Healthcare workers from a broad range of professional roles across the UK, recruited between December 2020 and February 2021. Main outcome measures:We used multivariable generalised ordered logistic regression models to examine the associations between ethnicity, migration status and AfC pay bands, adjusting for sex, education level, job role, and years qualified. Results:We found that Overseas-born ethnic minority HCWs were less likely to be in higher AfC pay bands compared to their White UK-born counterparts. Specifically, Asian Overseas-born and Black Overseas-born HCWs reported significantly lower odds of being in higher pay bands compared to White UK-born workers. Conclusions:Overseas-born HCWs from ethnic minorities resided in lower paid roles than White UK HCWs. Our study is the first to highlight a link between migration status and the AfC pay band and to explore interactions between ethnicity and migration within this context. Our data highlights the need for policymakers to incorporate migration status into NHS-wide electronic records to address career progression and pay inequities.

Objectives: Antimicrobial resistance (AMR) is a major global public health concern. Although low-income countries are disproportionately affected by AMR, certain underserved groups in high-income countries (HICs), such as migrants and ethnic minorities, disproportionately bear the burden of AMR. This may be driven by socio-cultural factors including differences in health literacy. This review aimed to investigate the level of antibiotic knowledge amongst different ethnic minority groups in HICs. Study design: This was a mixed-methods systematic literature review. Methods: We searched four databases (MEDLINE, EMBASE, the Cochrane library, CINAHL) to May 5, 2023, for primary studies on knowledge of antibiotics in different ethnic groups in HICs. We included studies in English using qualitative, quantitative and/or mixed-methods approaches and reporting on antibiotic knowledge by ethnicity. We used the convergent integrated approach for data synthesis and the Mixed-Methods Appraisal tool for quality assessment. Results: 3935 articles were screened and 24 studies (17 quantitative, 5 qualitative, and 2 mixed-methods) were included, comprising 52778 participants from 8 countries (USA, UK, Australia, New Zealand, Netherlands, Greece, Sweden, Germany). Overall, participants from ethnic minority groups were able to identify common names of antibiotics and were aware of risks of antibiotics and side effects. However, participants thought antibiotics would treat viral-type illnesses. Ethnic minority groups generally had lower levels of knowledge compared to ethnic majority groups. Conclusions: Although ethnic minority communities possessed good levels of knowledge on certain aspects of antibiotics (e.g. being able to identify names of antibiotics), there were gaps in other areas (e.g. misperception that antibiotics are used for viral infections). The lower level of knowledge in ethnic minority groups compared to majority groups may be a contributing factor to health inequalities, which calls for co-designed, culturally competent, educational interventions.

Background Antimicrobial resistance (AMR) is a critical global health concern. A previous systematic review showed that migrants in Europe are at increased risk of AMR. Since the COVID-19 pandemic there have been rapid changes in patterns of antibiotic use, AMR, and migration. We aimed to present an updated evidence synthesis on the current distribution of AMR among migrants in Europe. Methods We carried out a systematic review and meta-analysis in accordance with PRISMA guidelines (PROSPERO ID: CRD42022343263). We searched databases (MEDLINE, Embase, PubMed and Scopus) from 18 January 2017 until 18 January 2023 to identify primary data from observational studies reporting any laboratory-confirmed AMR among migrants in the European Economic Area (EEA) and European Union-15 (EU-15) countries using over 7 key search terms for migrants and over 70 terms for AMR and countries in Europe. Outcomes were infection with, or colonisation of AMR bacteria. Methodological quality was assessed using Joanna Briggs Institute Critical Appraisal Checklist for Observational Studies. We meta-analysed the pooled-prevalence of infection and/or colonisation of AMR organisms. Findings Among 630 articles, 21 observational studies met the inclusion criteria and were included in this review. The pooled prevalence for any detected AMR was 28.0% (95% CI 18.0%–41.0%, I2 = 100%) compared to a 25.4% seen in the previous review; gram-negative bacteria 31.0% (95% CI 20.0%–44.0%, I2 = 100%), and methicillin-resistant staphylococcus aureus 10.0% (95% CI 5.0%–16.0%, I2 = 99%). Drug-resistant bacteria were more prevalent in community settings in large migrant populations (pooled prevalence: 41.0%, 95% CI 24.0%–60.0%, I2 = 99%) than in hospitals (21.0%, 95% CI 12.0%–32.0%, I2 = 99%). AMR estimates in ‘other’ migrants were 32.0%, (95% CI 12.0%–57.0%, I2 = 100%) and 28.0% (95% CI 18.0%–38.0%, I2 = 100%) in forced migrants. No firm evidence of AMR acquisition with arrival time or length of stay in the host country was found. Interpretation Studies investigating AMR in migrants are highly heterogenous. However, since the COVID-19 pandemic, migrants may be at higher risk of acquiring resistant bacteria, particularly gram-negative bacteria, within community settings such as refugee camps and detention centres in Europe. Our study highlights the importance of infrastructure and hygiene measures within these settings, to mitigate transmission of resistant pathogens. Policy-makers should screen for AMR in migrants prior to departure from countries of origin, where feasible, and upon arrival to a new country to ensure optimal health screening, infection control and effective treatment. Funding There was no funding source for this study.

The COVID-19 pandemic has resulted in disproportionate consequences for ethnic minority groups and Indigenous Peoples. We present an application of the Priority Public Health Conditions (PPHC) framework from the World Health Organisation (WHO), to explicitly address COVID-19 and other respiratory viruses of pandemic potential. This application is supported by evidence that ethnic minority groups were more likely to be infected, implying differential exposure (PPHC level two), be more vulnerable to severe disease once infected (PPHC level three) and have poorer health outcomes following infection (PPHC level four). These inequities are driven by various interconnected dimensions of racism, that compounds with socioeconomic context and position (PPHC level one). We show that, for respiratory viruses, it is important to stratify levels of the PPHC framework by infection status and by societal, community, and individual factors to develop optimal interventions to reduce inequity from COVID-19 and future infectious diseases outbreaks.

INTRODUCTION:Understanding how RNA viral load changes (viral load kinetics) during acute infection in SARS-CoV-2 can help to identify when and which patients are most infectious. We seek to summarise existing data on the longitudinal RNA viral load kinetics of SARS-CoV-2 sampled from different parts of the respiratory tract (nose, nasopharynx, oropharynx, saliva and exhaled breath) and how this may vary with age, sex, ethnicity, immune status, disease severity, vaccination, treatment and virus variant. METHODS AND ANALYSIS:We will conduct a systematic review and meta-analysis, using studies identified through MEDLINE and EMBASE (via Ovid). All research studies reporting primary data on longitudinal RNA viral load kinetics of infected patients with SARS-CoV-2 will be included. Methodological quality will be assessed using a validated checklist for longitudinal studies as well as predefined quality criteria for assessment of individual-level RNA viral load. Should the data allow, we will aim to perform individual patient-level meta-analysis. Our primary outcomes are duration to, and quantity of peak RNA viral load, and total duration of viral load shedding within different respiratory compartments. Secondary outcomes include duration of lateral flow antigen and virus culture positivity and variation of RNA viral load by age, immune status, disease severity, vaccination, treatment, lateral flow tests, viral culture positivity and SARS-CoV-2 variant. Study-level effects affecting observations, but not related to properties of the patient, such as the PCR platform and gene target will also be recorded. Random-effects models will estimate the population mean and individual-level variation in viral shedding conditional on the aforementioned variables. Finally, we will summarise the key mechanistic models used in the literature to reconstruct individual-level viral kinetics and estimate how different factors shape viral dynamics over time. ETHICS AND DISSEMINATION:Ethical approval is not needed as data will be obtained from published articles or studies with data that have already received and ethical review for analysis. Manuscript(s) will be prepared for publication. SYSTEMATIC REVIEW PROTOCOL REGISTRATION:PROSPERO ID: CRD42023385315.

Background:In the United Kingdom, onsite religious services were halted during COVID-19 lockdowns, which were followed by various levels of restrictions on communal worship including social distancing, mandatory wearing of face masks, adequate ventilation and a ban on congregational singing and chanting. The aim of our study was to evaluate the impact of closures and changes within places of worship in response to the first lockdown in 2020, to assess the effect of the pandemic on religious practice and worshippers' wellbeing and religious coping. Methods:Participants were regular worshippers in the UK, recruited through an online survey using convenience sampling. Respondents were asked about their attitudes to changes to places of worship in the UK and their wellbeing and mental health, including assessment of their risk of depression and anxiety using the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder Assessment (GAD-7) measures. Questionnaires were completed August to November 2020. Findings:939 participants were included in the analysis. Median age was 52.7 years and 66.1 % were female. 80.7 % identified as Christian. 165 (19.3 %) had mild, 45 (5.3 %) moderate, 25 (2.9 %) moderately severe and 10 (1.2 %) severe depression, and 192 (22.5 %) had mild, 55 (6.4 %) moderate and 27 (3.2 %) severe anxiety, according to PHQ-9 and GAD-7 scores, respectively. Nearly half (46.4 %) reported that their mood and anxiety levels had worsened and 16.6 % reported that they felt the things they were doing in their lives were not worthwhile. The vast majority of respondents (92.7 %) reported that prayer had helped them cope with the way they had felt during lockdown: 29.2 % and 47.0 % reported that it helped moderately and a great deal, respectively. This 76.2 % had significantly lower levels of moderate/severe depression and anxiety (adjusted odds ratio: depression 0.37 (95%CI 0.22-0.63), anxiety 0.52 (95%CI 0.31-0.88). Interpretation:Our study demonstrates the significant impact of COVID-19 on communal worshippers' mental health and reinforces the benefits of positive religious coping during the first UK lockdown. Barriers to communal worship participation during lockdowns, including access to appropriate technology, need to be recognised and facilitators identified.

Introduction The WHO has issued the global target of reducing maternal mortality rates by two-thirds of 2010 baseline levels by 2030. In low-income settings, high birth rates and a relative lack of medical resources mean that an efficient use of resources and skilled staff is important in ensuring quality of intrapartum and postpartum care. Methods We use a stochastic, individual-based model to explore whether WHO resourcing benchmarks are sufficient to ensure consistent quality of care. We simulate all deliveries occurring in a region over a year, with date and time of presentation of each woman delivering at a facility assigned at random. Each woman stays in the delivery room for an assigned duration before her delivery, then moves to the maternity ward, followed by discharge. We explore the potential impact of seasonality of births on our findings and then apply the model to a real-world setting using 2014 data from Emergency Obstetric Care (EmOC) facilities in Zanzibar, United Republic of Tanzania. Results We find that small EmOCs are frequently empty, while larger EmOCs are at risk of temporarily falling below minimum recommended staff-to-patient ratios. Similarly for Zanzibar, capacity of EmOCs in terms of beds is rarely exceeded. Where over-capacity occurs, it is generally smaller, basic EmOCs (BEmOCs) that are affected. In contrast, capacity in terms of staffing (skilled birth attendants:women in labour ratio) is exceeded almost 50% of the time in larger Comprehensive EmOCs (CEmOCs). Conclusions Our findings suggest that increasing staffing levels of CEmOCs while maintaining fewer small BEmOCs may improve quality of care (by increasing the staff-to-patient ratio for the most frequently used facilities), provided that timely access to EmOCs for all women can still be guaranteed. Alternatively, BEmOCs may need to be upgraded to ensure that women trust and choose these facilities for giving birth, thus relieving pressure on CEmOCs.

Background/objective Refugees and migrants to the World Health Organization (WHO) European Region are disproportionately affected by infections, including tuberculosis (TB), human immunodeficiency virus (HIV) and hepatitis B and C (HBV/HCV) compared with the host population. There are inequities in the accessibility and quality of health services available to refugees and migrants in the Region. This has consequences for health outcomes and will ultimately impact the ability to meet Regional infection elimination targets. Methods We reviewed academic and grey literature to identify national policies and guidelines for TB/HIV/HBV/HCV specific to refugees and migrants in the Member States of the WHO European Region and to identify: (i) evidence informing policy and (ii) barriers and facilitators to policy implementation. Results Relatively few primary national policy/guideline documents were identified which related to refugees and migrants and TB [14 of 53 Member States (26%), HIV (n = 15, 28%) and HBV/HCV (n = 3, 6%)], which often did not align with the WHO recommendations, and for some countries, violated refugees' and migrants’ human rights. We found extreme heterogeneity in the implementation of the WHO- and European Centre for Disease Prevention and Control (ECDC)-advocated policies and recommendations on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection among migrants across the Member States of the WHO European Region. There is great heterogeneity in implementation of WHO- and ECDC-advocated policies on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection in refugees and migrants across the Member States in the Region. Conclusion More transparent and accessible reporting of national policies and guidelines are required, together with the evidence base upon which these policy decisions are based. Political engagement is essential to drive the changes in national legislation to ensure equitable and universal access to the diagnosis and care for infectious diseases.

Introduction: In lower tuberculosis (TB) incidence countries (<100 cases/100,000/year), screening and preventive treatment (PT) for latent TB infection (LTBI) among people living with HIV (PLWH) is often recommended, yet guidelines advising which groups to prioritise for screening can be contradictory and implementation patchy. Evidence of LTBI screening cost-effectiveness may improve uptake and health outcomes at reasonable cost. Methods: Our systematic review assessed cost-effectiveness estimates of LTBI screening/PT strategies among PLWH in lower TB incidence countries to identify model-driving inputs and methodological differences. Databases were searched 1980-2020. Studies including health economic evaluation of LTBI screening of PLWH in lower TB incidence countries (<100 cases/100,000/year) were included. Results: Of 2,644 articles screened, nine studies were included. Cost-effectiveness estimates of LTBI screening/PT for PLWH varied widely, with universal screening/PT found highly cost-effective by some studies, while only targeting to high-risk groups (such as those from mid/high TB incidence countries) deemed cost-effective by others. Cost-effectiveness of strategies screening all PLWH from studies published in the past five years varied from US$2828 to US$144,929/quality-adjusted life-year gained (2018 prices). Study quality varied, with inconsistent reporting of methods and results limiting comparability of studies. Cost-effectiveness varied markedly by screening guideline, with British HIV Association guidelines more cost-effective than NICE guidelines in the UK. Discussion: Cost-effectiveness studies of LTBI screening/PT for PLWH in lower TB incidence settings are scarce, with large variations in methods and assumptions used, target populations and screening/PT strategies evaluated. The limited evidence suggests LTBI screening/PT may be cost-effective for some PLWH groups but further research is required, particularly on strategies targeting screening/PT to PLWH at higher risk. Standardisation of model descriptions and results reporting could facilitate reliable comparisons between studies, particularly to identify those factors driving the wide disparity between cost-effectiveness estimates. Registration: PROSPERO CRD42020166338 (18/03/2020).