BACKGROUND:Higher than normal glucose concentrations have been linked to an increased risk of cancer. We aimed to describe the disease trajectories from prediabetes to cancer, accounting for the possible conversion to type 2 diabetes and risk of death. METHODS:We used the Clinical Practice Research Datalink primary care records linked to hospital and mortality records to identify individuals aged 18-100 years with newly diagnosed prediabetes between Jan 1, 1998, and Nov 30, 2018, in England. Individuals were followed from the diagnosis of prediabetes until death or Nov 30, 2018, with two intermediate outcomes: type 2 diabetes and cancer. In a multistate model, we estimated state occupancy probabilities and lengths of stay (sojourn times) across eight states and seven transitions (eg, one transition from the prediabetes state to the cancer state; or three transitions from the prediabetes state to the type 2 diabetes, cancer, and death state). FINDINGS:During a median follow-up of 7·7 years, 163 782 transitions occurred in 328 049 individuals. In both women and men, cancer incidence rates were greater in older individuals (aged ≥75 years at prediabetes diagnosis) and only marginally higher in those who developed type 2 diabetes versus those with prediabetes (over 10 years, the largest differences were 4·1 more cases per 1000 person-years in women and 4·8 more cases per 1000 person-years in men). 10 years after the diagnosis of prediabetes, the probability of remaining in the prediabetes state ranged from 23·2% (men aged ≥75 years at diagnosis) to 72·1% (men aged <55 years), the probability of death following prediabetes ranged from 1·2% (women aged <55 years) to 38·7% (women aged ≥75 years), the probability of developing type 2 diabetes and remaining in this state ranged from 7·9% (men aged ≥75 years) to 24·0% (women aged <55 years), and the probability of developing cancer and remaining in this state ranged from 1·9% (men aged <55 years) to 7·8% (men aged ≥65 to <75 years) in men and women. During the 10 years following the diagnosis of prediabetes, individuals spent between 5·34 years (men aged ≥75 years at diagnosis) to 8·34 years (men aged <55 years) in the prediabetes state. BMI, smoking, socioeconomic status, and ethnicity were associated with occupancy probabilities and sojourn times. INTERPRETATION:The trajectories of type 2 diabetes and cancer following a diagnosis of prediabetes varied substantially by age at prediabetes diagnosis and, to a lesser extent, other sociodemographic and lifestyle factors, with most younger individuals (aged <55 years) remaining in the prediabetes state. Strategies to improve the prevention and early identification of type 2 diabetes and cancer in individuals with prediabetes should be tailored to the age at which prediabetes is diagnosed. FUNDING:National Institute for Health and Care Research (NIHR) Applied Research Collaboration, East Midlands, NIHR Leicester British Retail Consortium, Hope Against Cancer.

Objective To estimate the association between glucose control, sulfonylureas, and insulin treatment with the risk of hospitalisation for falls and fractures in older adults with type 2 diabetes (T2D). Research Design and Methods This observational cohort study used UK Clinical Practice Research Datalink GOLD data linked to hospital and death records. Older adults (≥70 years) with T2D, identified between 2000-2017, were considered exposed if they had three consecutive HbA1c measurements <7% (53 mmol/mol) while on insulin or sulfonylureas. Each exposed individual was matched with up to three non-exposed individuals. Outcomes included hospitalisations for falls and fractures. Flexible parametric survival models, adjusted for sociodemographic and clinical factors, estimated relative (hazard ratio, HR) and absolute risks associated. Results Among 21,365 individuals (5,833 [27.3%] in the exposed group), the adjusted relative risks of hospitalisation for falls and fractures were marginally higher vs those non-exposed: HR 1.04 (95% CI: 0.96–1.11) and 1.07 (0.97–1.17), respectively. The 10-year absolute risk of hospitalisation for falls were slightly higher in the exposed (ranging from 15.6%–36.8% in those aged 70–85 years, respectively) than non-exposed (15.1%–36.0%, respectively) individuals. Absolute risk differences remained minimal (0.2%–0.6% at 5 years and 0.5%–0.8% at 10 years, respectively). Conclusions We found no evidence of an association between sustained HbA1c <7% while on insulin or sulfonylurea and clinically meaningful increased risks of falls or fractures in older adults with T2D. Clinicians should continue to balance the benefits of glycaemic control with the risks of complications in older adults.

We aimed to investigate socio-economic inequalities in second primary cancer (SPC) incidence among breast cancer survivors. Using Data from cancer registries in England, we included all women diagnosed with a first primary breast cancer (PBC) between 2000 and 2018 and aged between 18 and 99 years and followed them up from 6 months after the PBC diagnosis until a SPC event, death, or right censoring, whichever came first. We used flexible parametric survival models adjusting for age and year of PBC diagnosis, ethnicity, PBC tumour stage, comorbidity, and PBC treatments to model the cause-specific hazards of SPC incidence and death according to income deprivation, and then estimated standardised cumulative incidences of SPC by deprivation, taking death as the competing event. Multiple imputation was performed to account for missing data. Among 649,905 included women, 47,399 SPCs and 171,223 deaths occurred during 4,269,042 person-years of follow-up. Income deprivation was consistently associated with an increased rate of SPC incidence (cause-specific hazard ratio for the most vs. least deprived quintile: 1.29; 95% CI: 1.25, 1.33) and of death (1.36; 1.34, 1.38), translating into an absolute risk difference (the most vs. least deprived quintile) of 1.3% (95% CI: 1.0, 1.5) for SPC incidence and 4.9% (95% CI: 4.6, 5.1) for death at 10 years. Women with PBC from deprived areas in England faced a substantially higher risk of SPC than their counterparts. Future research is warranted to understand mechanisms for observed inequalities to inform strategies to monitor, prevent, and identify SPC in women with PBC.

Abstract Missing general practice (GP) appointments represent an important challenge for healthcare systems. In England and Wales, reducing the number of missed appointments would benefit both the National Health Service (NHS) and the patients, avoiding delay in diagnosis and treatment. Since the COVID-19 pandemic, appointment mode has shifted substantially, and many GP practices have started scheduling online appointments in place of face-to-face meetings. In this context, our aim was to build and compare prediction models for the probability of missing a GP appointment, as a function of appointment’s characteristics and the level of deprivation of the area where the GP practice is located. We examined all English GP appointments in 2021 and used two different statistical approaches for prediction: a generalized linear model (logistic regression) and a machine learning approach (Extreme gradient boosting). Predictions were further validated with 2022 data. Both approaches provided comparable predictions in term of calibration, with the advantage that results from the logistic regression can be interpreted as odds ratios. Longer time between booking and appointment plays an important role, as well as deprivation. Deprived areas, which already tend to have lower healthcare standards, may also be losing more resources from cancelled and unattended appointments compared to their less deprived counterparts. Investigating the role of contextual factors behind these inequalities (both within and outside the healthcare system) would be an important step forward.

Aims/hypothesis The aim of this study was to describe the long-term trends in cancer mortality rates in people with type 2 diabetes based on subgroups defined by sociodemographic characteristics and risk factors. Methods We defined a cohort of individuals aged ≥35 years who had newly diagnosed type 2 diabetes in the Clinical Practice Research Datalink between 1 January 1998 and 30 November 2018. We assessed trends in all-cause, all-cancer and cancer-specific mortality rates by age, gender, ethnicity, socioeconomic status, obesity and smoking status. We used Poisson regression to calculate age- and calendar year-specific mortality rates and Joinpoint regression to assess trends for each outcome. We estimated standardised mortality ratios comparing mortality rates in people with type 2 diabetes with those in the general population. Results Among 137,804 individuals, during a median follow-up of 8.4 years, all-cause mortality rates decreased at all ages between 1998 and 2018; cancer mortality rates also decreased for 55- and 65-year-olds but increased for 75- and 85-year-olds, with average annual percentage changes (AAPCs) of –1.4% (95% CI –1.5, –1.3), –0.2% (–0.3, –0.1), 1.2% (0.8, 1.6) and 1.6% (1.5, 1.7), respectively. Higher AAPCs were observed in women than men (1.5% vs 0.5%), in the least deprived than the most deprived (1.5% vs 1.0%) and in people with morbid obesity than those with normal body weight (5.8% vs 0.7%), although all these stratified subgroups showed upward trends in cancer mortality rates. Increasing cancer mortality rates were also observed in people of White ethnicity and former/current smokers, but downward trends were observed in other ethnic groups and non-smokers. These results have led to persistent inequalities by gender and deprivation but widening disparities by smoking status. Constant upward trends in mortality rates were also observed for pancreatic, liver and lung cancer at all ages, colorectal cancer at most ages, breast cancer at younger ages, and prostate and endometrial cancer at older ages. Compared with the general population, people with type 2 diabetes had a more than 1.5-fold increased risk of colorectal, pancreatic, liver and endometrial cancer mortality during the whole study period. Conclusions/interpretation In contrast to the declines in all-cause mortality rates at all ages, the cancer burden has increased in older people with type 2 diabetes, especially for colorectal, pancreatic, liver and endometrial cancer. Tailored cancer prevention and early detection strategies are needed to address persistent inequalities in the older population, the most deprived and smokers. Graphical abstract

Background Individual and tumour factors only explain part of observed inequalities in colorectal cancer survival in England. This study aims to investigate inequalities in treatment in patients with colorectal cancer. Methods All patients diagnosed with colorectal cancer in England between 2012 and 2016 were followed up from the date of diagnosis (state 1), to treatment (state 2), death (state 3) or censored at 1 year after the diagnosis. A multistate approach with flexible parametric model was used to investigate the effect of income deprivation on the probability of remaining alive and treated in colorectal cancer. Results Compared to the least deprived quintile, the most deprived with stage I–IV colorectal cancer had a lower probability of being alive and treated at all the time during follow-up, and a higher probability of being untreated and of dying. The probability differences (most vs. least deprived) of being alive and treated at 6 months ranged between −2.4% (95% CI: −4.3, −1.1) and −7.4% (−9.4, −5.3) for colon; between −2.0% (−3.5, −0.4) and −6.2% (−8.9, −3.5) for rectal cancer. Conclusion Persistent inequalities in treatment were observed in patients with colorectal cancer at every stage, due to delayed access to treatment and premature death.

Introduction: Contemporary differences between South Asian and White ethnicities in the incidence of end-stage kidney disease (ESKD) and mortality are poorly described.ethods: Data for all South Asian patients who had an estimated glomerular filtration rate (eGFR) mea -sure after January 1, 2006, and 1 million randomly selected participants of other ethnicities were extracted from the Clinical Practice Research Datalink (CPRD). All participants were followed-up with from index date until ESKD, all-cause mortality, or end of study. All-cause mortality rate and ESKD incidence rate by age were described among Whites and South Asians, and adjusted hazard ratios (HRs) of these 2 outcomes by baseline eGFR estimated using Cox proportional hazard model. Results: A total of 40,888 South Asians and 236,634 Whites were followed for a median of 5.3 and 9.4 years for ESKD incidence and mortality outcomes, respectively. All-cause mortality rates were higher among Whites than South Asians; South Asian women aged between 70 and 85 years had a slightly higher ESKD incidence rate compared to their White counterparts. Compared to Whites with a baseline eGFR of 90 ml/ min per 1.73 m2, adjusted HRs for all-cause mortality were significantly lower among South Asians than Whites; however, adjusted HRs for ESKD incidence by baseline eGFR were similar in both ethnicities. Calculating South Asian eGFRs using an ethnicity-specific equation had no impact on the results. Conclusions: South Asians experience lower mortality than Whites but not substantially higher rates of ESKD. Further research is warranted to better understand the reasons for these ethnic differences and possible impacts on chronic kidney disease (CKD) service delivery and patient outcomes.

Aims To understand geographical and temporal patterns in the diabetes gap, the excess mortality risk associated with type 2 diabetes (T2D), in three high-income countries. Methods Using databases from Canada (Ontario), Spain (Catalonia) and the UK (England), we harmonized the study design and the analytical strategy to extract information on subjects aged over 35 years with incident T2D between 1998 and 2018 matched to up to five subjects without diabetes. We used Poisson models to estimate age-specific mortality trends by diabetes status and rate ratios and rate differences associated with T2D. Results In more than 6 million people, 694 454 deaths occurred during a follow-up of 52 million person-years. Trends in all-cause mortality rates differed between Ontario and England; yet, the diabetes gaps were very similar in recent years: in 2018, we estimated 1.3 (95% confidence interval: 0.8, 1.8) and 0.8 (0.2, 1.5) more deaths per 1000 person-years in 50-year-old men with diabetes in Ontario and England, respectively, and 8.9 (6.1, 11.7) and 12.1 (9.1, 15.1) in 80-year-old men; between-country differences were small also in women. In Catalonia, rate ratios comparing T2D with no diabetes in men in 2018 were 1.53 (1.11, 2.11) at 50 years old, 0.88 (0.72, 1.06) at 60 years old, 0.74 (0.60, 0.90) at 70 years old and 0.81 (0.66, 1.00) at 80 years old, indicating lower mortality rates in men with T2D from the age of 60 years; rates were similar in women with and without diabetes at all ages. The diabetes gaps in cardiorenal mortality mirrored those of all-cause mortality: we observed consistent reductions in the proportions of cardiorenal deaths in subjects aged 80 years but variations in subjects aged <= 70 years, regardless of the presence of diabetes. Conclusions By reducing the confounding impact of epidemiological and analytical differences, this study showed geographical similarities and differences in the diabetes gap: an excess risk of all-cause and cardiorenal mortality in subjects with T2D is still present in Ontario and England in recent years, particularly in elderly subjects. Conversely, there were very small gaps in young men with T2D or even lower mortality rates in older subjects with T2D in Catalonia.

Objective To investigate the association between duration of type 2 diabetes and cancer incidence. Research Design and Methods In the Clinical Practice Research Datalink database, we identified 130,764 individuals with type 2 diabetes aged ≥35 years at diagnosis linked to hospital and mortality records. We used sex-stratified Royston-Parmar models with two time scales to estimate incidence rates of all cancers, the four commonest cancers in the UK (colorectal, lung, prostate, breast), and the obesity-related cancers (e.g., liver, ovary) between 1/1/1998 and 14/1/2019, by age and diabetes duration. Results During 1,089,923 person-years, 18,977 incident cancers occurred. At the same age, in men and women rates of all cancers did not vary across durations ranging from diagnosis to 20 years; conversely, for any duration, there was a strong, positive association between age and cancer rates. In men, the rate ratio comparing 20 to 5 years of duration was 1.18 (95% CI: 0.82, 1.69) at 60 years of age and 0.90 (0.75, 1.08) at 80 years; corresponding ratios in women were 1.07 (0.71, 1.63) and 0.84 (0.66, 1.05). This pattern was observed also for the four commonest cancers. For obesity-related cancers, although rates were generally higher in individuals with a higher body mass index, there was no association with duration at any level of body mass index. Conclusions In this study, we did not find evidence of an association between duration of type 2 diabetes and risk of cancer, with the higher risk observed for longer durations related to ageing.

To assess whether glycaemic control is associated with prognosis in people with cancer and pre-existing diabetes. In this pre-registered systematic review (PROSPERO: CRD42020223956), PubMed and Web of Science were searched on 25th Nov 2021 for studies investigating associations between glycosylated haemoglobin (HbA1c) and prognosis in people with diabetes and cancer. Summary relative risks (RRs) and 95% Confidence Intervals (CIs) for associations between poorly controlled HbA1c or per 1-unit HbA1c increment and cancer outcomes were estimated using a random-effects meta-analysis. We also investigated the impact of potential small-study effects using the trim-and-fill method and potential sources of heterogeneity using subgroup analyses. Fifteen eligible observational studies, reporting data on 10,536 patients with cancer and pre-existing diabetes, were included. Random-effects meta-analyses indicated that HbA1c ≥ 7% (53 mmol/mol) was associated with increased risks of: all-cause mortality (14 studies; RR: 1.14 [95% CI: 1.03–1.27]; p-value: 0.012), cancer-specific mortality (5; 1.68 [1.13–2.49]; p-value: 0.011) and cancer recurrence (8; 1.68 [1.18–2.38; p-value: 0.004]), with moderate to high heterogeneity. Dose-response meta-analyses indicated that 1-unit increment of HbA1c (%) was associated with increased risks of all-cause mortality (13 studies; 1.04 [1.01–1.08]; p-value: 0.016) and cancer-specific mortality (4; 1.11 [1.04–1.20]; p-value: 0.003). All RRs were attenuated in trim-and-fill analyses. Our findings suggested that glycaemic control might be a modifiable risk factor for mortality and cancer recurrence in people with cancer and pre-existing diabetes. High-quality studies with a larger sample size are warranted to confirm these findings due to heterogeneity and potential small-study effects. In the interim, it makes clinical sense to recommend continued optimal glycaemic control. • Diabetes is a common comorbidity in newly-diagnosed cancer patients. • The impact of glycaemic control in people with both cancer and diabetes is unclear. • In this meta-analysis, cancer prognosis is worse in those with poor HbA1c control. • More studies with larger sample sizes are warranted to confirm these findings. • Clinicians should continue to ensure HbA1c control in cancer patients with diabetes.

Abstract Aims/Introduction The aim of this study was to examine ethnicity‐specific associations between type 2 diabetes mellitus and the risk of a cardiovascular disease (CVD) event as well as risk of specific CVD phenotypes in England. Methods We obtained data from the Clinical Practice Research Datalink for adults with and without type 2 diabetes mellitus diagnosed 2000–2006. The outcome was the first CVD event during 2007–2017 and the following components: aortic aneurysm, cerebrovascular accidents, heart failure, myocardial infarction, peripheral vascular disease and other CVD‐related conditions. Flexible parametric survival models were used to estimate ethnicity‐specific adjusted hazard ratios. Results A total of 734,543 people with and without type 2 diabetes mellitus (29,847; 4.1%) were included; most were of white ethnicity (93.0% with and 92.3% without type 2 diabetes mellitus) followed by South Asian (3.2 and 4.6%). During a median follow‐up period of 11.0 years, 67,218 events occurred (6,156 in individuals with type 2 diabetes mellitus). Type 2 diabetes mellitus was associated with a small increase in CVD events (adjusted hazard ratio 1.06, 95% confidence interval 1.02–1.09) in individuals of white ethnicity; whereas the adjusted hazard ratios were considerably higher in individuals of South Asian ethnicity (1.28, 95% confidence interval 1.09–1.51), primarily due to an increased risk of myocardial infarction (1.53, 95% confidence interval 1.08–2.18). Conclusions Despite universal access to healthcare, there are large disparities in CVD outcomes in people with and without type 2 diabetes mellitus. Other non‐traditional risk factors might play a role in the higher CVD risk associated with type 2 diabetes mellitus in individuals of South Asian ethnicity.

Objective: To estimate the relative and absolute risk of severe hypoglycemiaand mortality associated with glucose control, sulphonylurea and insulin treatmentin elderly people with type 2 diabetes. Research Design and Methods: We identified elderly subjects (≥70 years) withtype 2 diabetes between 2000 and 2017 in the UK CPRD primary care database withlinkage to hospitalization and death data. Subjects with three consecutive HbA1c<7% (53 mmol/mol) while on insulin and/or sulphonylurea within 60 days priorto the third HbA1c (exposed) were matched to not exposed. Hazardratios (HRs) and absolute risks were estimated for hospitalizations for severehypoglycemia and cardiovascular and non-cardiovascular-related mortality. Results: Among 22,857 included subjects (6288 [27.5%] exposed, of which5659 [90.0%] on sulphonylurea), 10,878 (47.6%) deaths and 1392 (6.1%) severe hypoglycemicepisodes occurred during the follow-up. Compared to non-exposed, the adjusted HRin exposed was 2.52 (95% CI: 2.23, 2.84) for severe hypoglycemia; 0.98 (0.91,1.06) for cardiovascular mortality; and 1.05 (0.99, 1.11) for non-cardiovascularmortality. In a 70-, 75-, 80- and 85-year-old subject, the 10-year risk ofsevere hypoglycemia was 7.7%, 8.1%, 8.6%, and 8.4% higher than non-exposed whiledifferences for non-cardiovascular mortality ranged from 1.2% (-0.1, 2.5) in a70-year-old to 1.6% (-0.2, 3.4) in an 85-year-old subject. Sulphonylurea and insulinwere more relevant predictors of severe hypoglycemia and death than glucoselevels.Conclusions: Elderlysubjects with type 2 diabetes and low HbA1c on sulphonylurea orinsulin treatment experienced a substantially higher risk of hospitalizationfor severe hypoglycemia but had no clear evidence of increased risks ofmortality.

AimWhether the relative risk of cancer incidence and mortality associated with diabetes has changed over time is unknown.Data synthesisOn August 12th, 2020, we electronically searched for observational studies reporting on the association between diabetes and cancer. We estimated temporal trends in the relative risk of cancer incidence or mortality associated with diabetes and calculated the ratio of relative risk (RRR) comparing different periods. As many as 193 eligible articles, reporting data on 203 cohorts (56,852,381 participants; 3,735,564 incident cancer cases; 185,404 cancer deaths) and covering the period 1951–2013, were included. The relative risk of all–site cancer incidence increased between 1980 and 2000 [RRR 1990 vs.1980: (1.24; 95% CI: 1.16, 1.34); 2000 vs.1990: (1.23; 1.15, 1.31)] and stabilised thereafter at a relative risk of 1.2; the relative risk of all–site cancer mortality was constant at about 1.2 from 1980 to 2010. Both magnitudes and trends in relative risk varied across cancer sites: the relative risk of colorectal, female breast, and endometrial cancer incidence and pancreatic cancer mortality was constant during the observed years; it increased for bladder, stomach, kidney, and pancreatic cancer incidence until 2000; and decreased for liver while increased for prostate, colon and gallbladder cancer incidence after 2000.ConclusionsAlongside the increasing prevalence of diabetes, the temporal patterns of the relative risk of cancer associated with diabetes may have contributed to the current burden of cancer in people with diabetes.

Background: Whether the associationbetween type 2 diabetes (T2D) and cancer is causal remains controversial.Purpose: To assess howrobust are the observational associations between (T2D) and cancer tounmeasured confounding.Data sources: PubMed, Web of Science, and theCochrane library were systematically searched on January 10th, 2019.Study selection: Observationalstudies investigating associations between T2D and cancer incidence ormortality.Data extraction: Cohort-level relativerisk (RR). Data Synthesis: RRs werecombined in random-effects meta-analyses and pooled estimates used in biasanalyses. A total of 151 cohorts (over 32 million people, 1.1 million cancer casesand 150,000 cancer deaths) were included. In meta-analyses, T2D was associatedwith incidence of several cancers, from prostate (RR 0.83; 95% CI: 0.79, 0.88)to liver (2.23; 1.99, 2.49); and mortality of pancreatic cancer (1.67; 1.30,2.14). In bias analyses, assuming an unmeasured confounding associated withboth T2D and cancer with a RR of 1.5, the proportion of studies with a trueeffect size larger than a RR of 1.1 (i.e., 10% increased risk in individualswith T2D) was nearly 100% for liver, pancreatic, and endometrial; 86% forgallbladder; 67% for kidney; 64% for colon; 62% for colorectal; and less than50% for other cancer incidence, and 92% for pancreatic cancer mortality. Limitations: Biases other than unmeasured confounding were not analytically assessed. Conclusions: Our findingsstrongly suggest a causal association between T2D and liver, pancreatic, and endometrialcancer incidence, and pancreatic cancer mortality; conversely, associationswith other cancers were less robust to unmeasured confounding.

To develop and internally validate prognostic models on the long‐term durability of glycaemic control in patients with type 2 diabetes after metformin failure.

BACKGROUND As people with intellectual disabilities (ID) are now living longer, they are more at risk of developing non-communicable diseases, including type 2 diabetes mellitus. However, understanding of factors associated with diabetes for targeted management and prevention strategies is limited. This study aimed to investigate prevalence of diabetes in adults (aged ≥18 years) with ID and its relationship with demographic, lifestyle, independence and health factors. METHOD This was a cross-sectional analysis of interview data from 1091 adults with ID from the Leicestershire Learning Disability Register from 1 January 2010 to 31 December 2016. Logistic regression models were used to identify factors associated with diabetes in the study population. RESULTS The study population did not have healthy lifestyles: just under half reported having lower physical activity levels than people without ID of a similar age; one-quarter consumed fizzy drinks daily; and 20% consumed five or more fruit and/or vegetables per day. Prevalence of carer/self-reported diabetes was 7.3% (95% confidence interval 5.9-9.0). After adjustment, diabetes was positively associated with South Asian ethnicity (P = 0.03) and older age groups (P < 0.001). Diabetes was less common in people living with family members (P = 0.02). We did not find a relationship between any of the lifestyle, independence and health factors investigated. CONCLUSIONS A significant proportion of people with ID are living with diabetes. Diabetes management and prevention strategies should be tailored to individuals' complex needs and include consideration of lifestyle choices. Such strategies may want to focus on adults of South Asian ethnicity and people living in residential homes where prevalence appears to be higher.