Do WHO criteria for gestational diabetes fit a rural population in Tanzania? - A follow-up study assessing mother and child health six years after a pregnancy diagnosed with gestational diabetes.

AIMS AND METHODS: In low- and middle- income countries (LMICs) consequences of gestational diabetes (GDM) is understudied. Using a prospective cohort of mothers (n = 197)and children (n = 251), from rural north-eastern Tanzania, we assessed prediabetes and type 2 diabetes (T2D) prevalence six years after a pregnancy with/without GDM. RESULTS: The prevalence of prediabetes (49.4 % vs. 46.4 %) orT2D (20.0 % vs. 16.1 %), p ≥ 0.36, based on fasting plasma glucose (FPG) or HbA1clevels (prediabetes: 16.9 % vs. 13.8 % and T2D 1.2 % vs. 0 %, p = 0.47), andcardio-metabolic health parameters,weresimilar between women with/without previous GDM. These results were supported by similar perinatal outcomes and child health at follow-up.The overall prevalence ofprediabetes/T2D was high, but no differences in other cardio-metabolic risk markers were observed in women with prediabetes/T2D compared to women with normal glucose tolerance. CONCLUSIONS: Despite high prevalence of GDM amongTanzanian women, the diagnosis was not associated with adverse pregnancy outcomes, nor with increased risk of prediabetes or T2D at follow-up. FPG and HbA1c may be poor markers for diabetes in this population, and further follow-up studies with longer time intervals are warranted to evaluate which GDM diagnostic criteria are most optimal for women in rural Tanzania and similar LMIC settings.

Anaemia in the first trimester and poor physiological plasma expansion during pregnancy negatively impact foetal weight and newborn anthropometrics: An observational cohort study in Tanzania.

OBJECTIVES: Anaemia during pregnancy is a major health challenge affecting pregnancy outcome worldwide. The objectives of this study were to investigate the impact of severe-moderate anaemia in the first trimester, as well as changes in haemoglobin during pregnancy among non-anaemic women, on foetal weight, placental blood flow and newborn anthropometrics. METHODS: In a prospective cohort study, 346 women residing in rural Tanzania were followed throughout pregnancy with serial ultrasound and newborn anthropometrics assessed within 24 h of delivery. Associations between placental blood flow, foetal weight and newborn anthropometrics with either first trimester severe-moderate anaemia (haemoglobin≤9.5 g/dL) or changes in haemoglobin from the first to the third trimester among non-anaemic women, were assessed by mixed model regression and multiple linear regression, adjusting for maternal and foetal co-variables. Foetal weights and birthweight were converted to z-scores using a population based sex-specific weight reference. RESULTS: Severe-moderate anaemia in the first trimester was associated with significantly reduced foetal weight z-scores (adjusted mean difference (aMD) -0.44 (95% CI -0.81, -0.07)) and newborn anthropometric indices (birth weight z-score aMD -0.55 (-0.9, -0.13), abdominal circumference aMD -11 mm (95% CI -20, -3)). There were no association between first trimester severe-moderate anaemia and placental blood flow. Among women who were non-anaemic in the first trimester, women with the least reduction in haemoglobin (Δ ≥ -0.3 g/dL) delivered significantly smaller newborns (birthweight z-score aMD -0.55 (-0.91, -0.20), abdominal circumference aMD -10 mm (95% CI -17, -3), compared to women with the greatest reduction (Δ haemoglobin ≤ -1.4 g/dL)). CONCLUSIONS: Severe-moderate anaemia in early pregnancy was associated with smaller newborn anthropometrics which was reflected in smaller mean foetal weights in the second and third trimester. Furthermore, among women who were non-anaemic in the first trimester, there was an association between smaller newborn anthropometrics and limited haemoglobin decrease during pregnancy, possibly reflecting insufficient plasma expansion.

Cord Blood FGF-21 and GDF-15 Levels Are Affected by Maternal Exposure to Moderate to Severe Anemia and Malaria.

Context: Anemia and malaria are global health problems affecting >50% of pregnant women in sub-Saharan Africa and are associated with intrauterine growth restriction. The hormones fibroblast growth factor 21 (FGF-21) and growth differentiation factor 15 (GDF-15) are involved in metabolic regulation and are expressed in the placenta. No studies exist on FGF-21 and GDF-15 responses to exposures of malaria and anemia in pregnancy. Objective and Methods: Using a prospective, longitudinal pregnancy and birth cohort of women with an average age of 26 years from a rural region in northeastern Tanzania, we examined if FGF-21 and GDF-15 levels in maternal blood at week 33 ± 2 (n = 301) and in cord blood at birth (n = 353), were associated with anemia and malaria exposure at different time points in pregnancy and with neonatal anthropometry. Results: Among mothers at gestation week 33 ± 2, lower FGF-21 levels were observed after exposure to malaria in the first trimester, but not anemia, whereas GDF-15 levels at week 33 ± 2 were not associated with malaria nor anemia. In cord blood, moderate to severe anemia at any time point in pregnancy was associated with higher levels of FGF-21, whereas malaria exposure in the third trimester was associated with lower FGF-21 levels in cord blood. Negative associations were observed between cord blood FGF-21 and GDF-15 levels and neonatal skinfold thicknesses and birthweight. Conclusion: Our results suggest that moderate to severe anemia throughout pregnancy associates with higher FGF-21 levels, and malaria in last trimester associates with lower FGF-21 levels, in the neonates, thereby potentially affecting the future cardiometabolic health of the child.

Factors associated with continuity of care in hypertension and type 2 diabetes among forcibly displaced persons in the Bidibidi refugee settlement in Uganda: Protocol for a cross-sectional, mixed-methods study.

BACKGROUND: Non-communicable diseases in humanitarian settings are generally under-researched, particularly in Africa and have been called a neglected crisis. Little is known about factors affecting access to and (dis)continuity of care for chronic conditions, such as hypertension (HTN) and type 2 diabetes among forcibly displaced persons (FDPs) in Uganda. AIM: To investigate factors affecting access to and (dis)continuity of HTN and/or type 2 diabetes care among FDPs in the Bidibidi refugee settlement, Uganda. METHODS: A sequential explanatory mixed-methods design incorporating methodological and investigator triangulation will be conducted. The study aims to employ a community-based participatory research approach to equitably engage community members, researchers, and other stakeholders in the research process, recognising and maximising their diverse contributions. In phase 1, the quantitative arm of the study, 960 FDPs with HTN and/or type 2 diabetes will be interviewed about their sociodemographic characteristics, health status, migration experiences, social capital, and awareness, treatment, and control of these diseases. Participants will be purposively recruited from phase 1 as well as village health teams, healthcare providers, and policymakers to participate in phase 2, the qualitative study, in order to gain more insight into how mobility and social factors affect (dis)continuity of care among FDPs with HTN and/or type 2 diabetes. DISCUSSION: The findings from phase 1 and phase 2 of the study will be integrated through a triangulation process to provide a more holistic and comprehensive insight into the factors affecting access to and (dis)continuity for HTN and/or type 2 diabetes care among FDPs. Understanding these factors is expected to pave the way for conceptualizing health-enabling environments and strengthening health systems for FDPs with chronic conditions. It is anticipated that the study will generate baseline evidence that might be beneficial in developing and implementing HTN and diabetes care models for FDPs in the region.

Unmet needs for informal care among people with type 2 diabetes in rural communities in Vietnam.

Objectives: The objective of this study was to identify determinants associated with unmet needs for informal support among people with type-2 diabetes in rural communities of Vietnam in order to inform development of effective interventions aimed at bridging the gap between community members and resource constrained health systems. Study design: A cross-sectional survey was conducted from December 2018 to February 2019 in a rural area of northern Vietnam. Methods: From 2 districts in northern Vietnam, 806 people with type-2 diabetes participated in a survey to assess who were their most important informal caregivers (ICGs) and to measure the association between demographic and socio-economic predictors and unmet needs of informal support of relevance for diabetes self-care using bivariate and multivariate analyses. Results: The spouse was reported as the most important ICG (62.9%) followed by a daughter or son (28.4%). 32.0% reported at least one type of unmet need for informal support. The most commonly reported unmet needs of informal care were: transport to health facilities and company when seeking formal care (20.5%), financial support related to costs of diabetes self-management (18.5%), and reminders to engage in physical exercise (14.5%). People living alone reported the highest odds ratio (OR) for unmet need of informal care (OR = 4.41; CI95%: 2.19-8.88), followed by those being poor (OR = 3.79; CI95%: 1.25-11.52) and those being unemployed (OR = 2.85; CI95%: 1.61-5.05). Conclusions: Almost one-third of people with type-2 diabetes reported at least one type of unmet need for informal care. These findings provide a basis for development of new modalities for strengthening support provided by ICGs in rural communities in Vietnam and in other low- and middle-income countries.

High anti-SARS-CoV-2 seroprevalence among unvaccinated mother-child pairs from a rural setting in north-eastern Tanzania during the second wave of COVID-19.

Background: The reported infection rates and burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in low- and middle-income countries, including those in sub-Saharan Africa, are relatively low compared to the rates and burden in Europe and America, partly due to limited testing capability. Unlike many countries, Tanzania has implemented neither mass screening nor restrictive measures such as lockdowns to date. The prevalence of SARS-CoV-2 infection in rural mainland Tanzania is largely unknown. Methods: A cross-sectional study was conducted between April and October 2021 to assess the anti-SARS-CoV-2 seroprevalence among mother-child pairs (n = 634 children, n = 518 mothers) in a rural setting in north-eastern Tanzania. Results: A very high prevalence of anti-SARS-CoV-2 antibody titres was found, with seroprevalence rates ranging from 29% among mothers and 40% among children, with a dynamic peak in seropositivity incidence at the end of July/early August being revealed. Significant differences in age, socioeconomic status, and body composition were associated with seropositivity in mothers and children. No significant associations were observed between seropositivity and comorbidities, including anaemia, diabetes, malaria, and HIV. Conclusions: The transmission of SARS-CoV-2 in a rural region of Tanzania during 2021 was high, indicating a much higher infection rate in rural Tanzania compared to that reported in the UK and USA during the same period. Ongoing immune surveillance may be vital to monitoring the burden of viral infection in rural settings without access to molecular genotyping, where the load of communicable diseases may mask COVID-19. Surveillance could be implemented in tandem with the intensification of vaccination strategies.

Opportunistic non-communicable diseases in times of COVID-19.

We previously proposed the term 'opportunistic non-communicable diseases (NCDs)' to raise awareness of how NCDs thrive in societies with inadequate healthcare services. However, we did not anticipate that within the next year the new coronavirus disease (COVID-19) would sweep the globe. Lockdowns became the primary strategy for mitigation in most countries. However, the extensive restrictions and allocation of resources towards the containment of the pandemic have likely served as a catalyst of NCDs, especially in populations, societies and individuals already at high risk. We are presenting evidence to qualify two primary factors responsible for the potential impact on the development of NCDs during the COVID-19 pandemic. The first is disrupted healthcare services including avoidance and postponement of healthcare visits. The second is effects of changing lifestyle and living conditions including isolation, loss of job and income. The accumulated effect of these factors will likely further accelerate the development of NCDs and impair their management, especially in low- and middle-income countries. Insufficient vaccination coverage due to inequality in vaccine distribution and vaccine hesitancy left room for the incubation of immune-evasive variants that threatened to sustain or reinitiate the pandemic. We believe the concept of opportunistic NCDs and the potential catalytic effect that pandemics may have on the development of NCDs and their management, should be used as further arguments to secure equal vaccine distribution, promote global vaccine acceptance and to speed up and increase investments in primary health care in low- and middle-income countries to cope with the already existing NCD crisis and to prepare for future epidemics.

The overlooked paradox of the coexistence of overweight/obesity and anemia during pregnancy.

Globally, the prevalence of overweight and obesity, including among pregnant women, has substantially increased in the past three decades. This has been fueled by, among other factors, an increase in the consumption of high energy-dense foods and a decrease in physical activity. Additionally, global prevalence of anemia among pregnant women remains a public health concern. Overweight/obesity as well as anemia in pregnancy are independently associated with adverse health outcomes for the mother and offspring. In some pregnant women, the two conditions coexist. Yet current knowledge in this field, including prevalence rates, risk factors, and health consequences for mother and offspring being exposed to these conditions, is staggeringly sparse. In this review we describe the current evidence on prevalence rates, risk factors, and effects for mother and offspring regarding coexistence of overweight/obesity and anaemia in pregnant women based on a systematic literature search. We also highlight research gaps and suggest avenues for future research.

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study).

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study.

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen - safe and respectful clinical childbirth care - is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Clinical-demographic markers for improving diabetes mellitus diagnosis in people with tuberculosis in Tanzania.

BACKGROUND: Tuberculosis (TB) control is threatened by an increasing prevalence of diabetes mellitus (DM), particularly in endemic countries. Screening for DM is not routinely implemented in Tanzania; therefore, we aimed to screen for DM at TB diagnosis using clinical-demographic markers. METHODS: Our cross-sectional study recruited TB patients who received anti-TB treatment between October 2019 and September 2020 at health care facilities in three regions from Tanzania. Patients were screened for DM using DM symptoms (polydipsia, polyphagia and polyuria) and random blood glucose (RBG) testing. Patients with a history of DM and those with no history of DM but an RBG ≥ 7.8 mmol/L had point-of-care glycated haemoglobin (HbA1c) testing, and were considered to have DM if HbA1c was ≥ 48 mmol/mol. RESULTS: Of 1344 TB patients, the mean age was 41.0 (± 17.0) years, and 64.7% were male. A total of 1011 (75.2%) had pulmonary TB, and 133 (10.4%) had at least one DM symptom. Overall, the prevalence of DM was 7.8%, of which 36 (2.8%) TB patients with no history of DM were newly diagnosed with DM by RBG testing. TB/DM patients were older than those with only TB (50.0 ± 14.0 years vs 40.0 ± 17.0 years, p < 0.001). Patients with RBG ≥ 7.8 mmol/L were more likely to have pulmonary TB (p = 0.003), age ≥ 35 years (p = 0.018), and have at least one DM symptom (p < 0.001). There was a substantial agreement (Kappa = 0.74) between the on-site glucometer and point-of-care HbA1c tests in detecting DM range of hyperglycemia. CONCLUSION: The implementation of clinical-demographic markers and blood glucose screening identified the overall prevalence of DM and those at risk of DM in TB patients. Clinical-demographic markers are independent predictors for DM range hyperglycemia and highlight the importance of further diagnostic testing and early co-management of TB and DM.

Mapping the Cord Blood Transcriptome of Pregnancies Affected by Early Maternal Anemia to Identify Signatures of Fetal Programming.

CONTEXT: Anemia during early pregnancy (EP) is common in developing countries and is associated with adverse health consequences for both mothers and children. Offspring of women with EP anemia often have low birth weight, which increases risk for cardiometabolic diseases, including type 2 diabetes (T2D), later in life. OBJECTIVE: We aimed to elucidate mechanisms underlying developmental programming of adult cardiometabolic disease, including epigenetic and transcriptional alterations potentially detectable in umbilical cord blood (UCB) at time of birth. METHODS: We leveraged global transcriptome- and accompanying epigenome-wide changes in 48 UCB from newborns of EP anemic Tanzanian mothers and 50 controls to identify differentially expressed genes (DEGs) in UCB exposed to maternal EP anemia. DEGs were assessed for association with neonatal anthropometry and cord insulin levels. These genes were further studied in expression data from human fetal pancreas and adult islets to understand their role in beta-cell development and/or function. RESULTS: The expression of 137 genes was altered in UCB of newborns exposed to maternal EP anemia. These putative signatures of fetal programming, which included the birth weight locus LCORL, were potentially mediated by epigenetic changes in 27 genes and associated with neonatal anthropometry. Among the DEGs were P2RX7, PIK3C2B, and NUMBL, which potentially influence beta-cell development. Insulin levels were lower in EP anemia-exposed UCB, supporting the notion of developmental programming of pancreatic beta-cell dysfunction and subsequently increased risk of T2D in offspring of mothers with EP anemia. CONCLUSIONS: Our data provide proof-of-concept on distinct transcriptional and epigenetic changes detectable in UCB from newborns exposed to maternal EP anemia.

Unmet needs for social support and diabetes-related distress among people living with type 2 diabetes in Thai Binh, Vietnam: a cross-sectional study.

BACKGROUND: Diabetes-related distress (DRD) refers to negative emotional and affective experiences from daily demands of living with diabetes. People who received social support seem less likely to experience DRD. The prevalence of T2D in Vietnam is rapidly increasing. Yet, DRD and its association with social support have not been investigated. This study investigates DRD and how it is associated with unmet needs for social support in people with T2D in Thai Binh Province, Vietnam. METHODS: A total of 806 people, age ≥ 40 years, treated for T2D at primary hospitals in Thai Binh Province, Vietnam, completed a questionnaire-based cross-sectional survey. DRD was self-reported, based on the Problem Areas In Diabetes scale 5 (PAID5). We assessed 6 types of unmet needs for social support from family/friends/community including: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support. Multivariable logistic regression was used to model DRD as an outcome of each type of unmet need for social support, and as an outcome of the number of unmet needs for social support, adjusted for three sets of covariates. RESULTS: In this study, 50.0% of people with T2D experienced DRD. Odds for DRD were higher among those who had any unmet need for social support. After adjustment for household economic status, only unmet needs for emotional and financial support were associated with higher odds ratios of DRD (OR = 2.59, CI95%: 1.19-5.63 and OR = 1.63, CI95%: 1.10-2.40, respectively). People who had ≥2 type of unmet need were not a higher risk of experiencing DRD as compared to those with no unmet need. CONCLUSIONS: Half of the people with T2D experienced DRD. The results suggest that having enough finances may decrease most needs for social support with the exception of emotional support. Thus, social support to financial and emotional of diabetes aspects may contribute to prevent or reverse DRD.

Polypharmacy among people living with type 2 diabetes mellitus in rural communes in Vietnam.

OBJECTIVES: People with diabetes are at high risk of polypharmacy owing to complex treatment of diabetes and comorbidities. Polypharmacy is associated with increased risk of adverse reactions and decreased compliance. Therefore, the objectives of this study were to assess polypharmacy in people with type 2 diabetes (T2D) and associated diabetes-related factors in rural areas in Vietnam. METHOD: People with T2D (n = 806) who had received treatment for diabetes at a district hospital were invited to participate in a questionnaire-based cross-sectional survey. Polypharmacy was defined as ≥5 types of medicine and assessed as a) prescription medicine and non-prescription/over the counter (OTC) medicine and b) prescription medicine and non-prescription/OTC, herbal and traditional medicine, and dietary supplement. Multiple logistic regression was used to investigate the association between polypharmacy and diabetes specific factors: duration, comorbidities and diabetes-related distress. RESULTS: Of the people with T2D, 7.8% had a medicine use corresponding to polypharmacy (prescription medicine and non-prescription/OTC), and 40.8% when herbal and traditional medicine, and dietary supplement were included. Mean number of medicine intake (all types of medicines and supplements) were 3.8±1.5. The odd ratios (ORs) of polypharmacy (medicine and supplements) increased with diabetes duration (<1-5 years OR = 1.66; 95%CI: 1.09-2.53 and >5 years OR = 1.74; 95%CI: 1.14-2.64 as compared to ≤1-year duration of diabetes), number of comorbidities (1-2 comorbidities: OR = 2.0; 95%CI: 1.18-3.42; ≥3 comorbidities: OR = 2.63;95%CI: 1.50-4.61 as compared to no comorbidities), and suffering from diabetes-related distress (OR = 1.49; 95%CI: 1.11-2.01) as compared to those without distress. CONCLUSIONS: In rural northern Vietnam, persons with longer duration of T2D, higher number of comorbidities and diabetes-related stress have higher odds of having a medicine use corresponding to polypharmacy. A high proportion of people with T2D supplement their prescription, non-prescription/OTC medicine with herbal and traditional medicine and dietary supplements.

The injustice of unfit clinical practice guidelines in low-resource realities.

To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.

[Development and use of vaccines from the 18th century to the SARS-CoV 2 period].

This review is about the development and use of vaccines from the early smallpox vaccine in the 18th century to the forthcoming SARS-CoV 2 vaccines. Immunisations have been of paramount importance for childhood mortality and public health in general, but some obstacles have also been encountered such as vaccine failures and vaccine scepticism. This calls for continued emphasis on large phase three studies not only for demonstration of efficacy but also for safety and possible side effects. The rapid approval of SARS-CoV 2 vaccines requires special attention.

Perceived knowledge on type-2 diabetes of informal caregivers in rural communities of Thai Binh, Vietnam: Implications for health education.

Objectives: Informal caregivers' (ICGs') knowledge has substantial influence on the quality of caregiving. This study aims to identify caregivers' perceived knowledge status and analyse associations between their characteristics and perceived knowledge on how to care for individuals with type-2 diabetes (T2D). Study design: Cross-sectional study. Methods: Data were collected using a face-to-face survey with ICGs and perceived knowledge was evaluated on the 5-point Likert scale (ranging from 0 to 4). Results: Between April and July 2019, 1238 eligible ICGs were enrolled in the study. The mean age of participants was 48.3 years, about half (48.8%) were males and the majority (83.3%) were spouses or children of the person they cared for. ICGs mean knowledge score on overall activities was 2.48 (SD = 0.90); the highest score was seen for diet preparation (2.74 ± 0.85) and lowest for foot care (1.76 ± 1.45). Multivariate analyses showed that the following ICG characteristics were significantly more likely to result in a low level of T2D-related knowledge (mean score ≤2): age <40 years, educational level below high school, farming occupation, low economic status and caring for an individual with mild or moderate T2D. Conclusions: The level of perceived knowledge on T2D among ICGs was particularly low for the care of T2D complications. Development of targeted and tailored educational interventions for ICGs is recommended.

High Prevalence of Gestational Diabetes Mellitus in Rural Tanzania-Diagnosis Mainly Based on Fasting Blood Glucose from Oral Glucose Tolerance Test.

Gestational diabetes mellitus (GDM) is associated with poor pregnancy outcomes and increased long-term risk of metabolic diseases for both mother and child. In Tanzania, GDM prevalence increased from 0% in 1991 to 19.5% in 2016. Anaemia has been proposed to precipitate the pathogenesis of GDM. We aimed to examine the prevalence of GDM in a rural area of Tanzania with a high prevalence of anaemia and to examine a potential association between haemoglobin concentration and blood glucose during pregnancy. The participants were included in a population-based preconception, pregnancy and birth cohort study. In total, 538 women were followed during pregnancy and scheduled for an oral glucose tolerance test (OGTT) at week 32-34 of gestation. Gestational diabetes mellitus was diagnosed according to the WHO 2013 guidelines. Out of 392 women screened, 39% (95% CI: 34.2-44.1) had GDM, the majority of whom (94.1%) were diagnosed based solely on the fasting blood sample from the OGTT. No associations were observed between haemoglobin or ferritin and glucose measurements during pregnancy. A very high prevalence of GDM was found in rural Tanzania. In view of the laborious, costly and inconvenient OGTT, alternative methods such as fasting blood glucose should be considered when screening for GDM in low- and middle-income countries.