Glasgow Centre for Population Health

Abstract Aim/background Ethnic inequalities in stroke incidence are well-established, but long-term trends and the impact of socioeconomic status (SES) remain understudied. We estimated incidence rates by ethnicity over 30-years, and differences by SES, using the South London Stroke Register (1995–2024). Methods We conducted a population-based study including all residents of a geographically defined area of South London, calculating standardised incidence rates using census-derived denominators and the 2013 European Standard Population. The area-level Index of Multiple Deprivation was the indicator of SES. Poisson regression estimated incidence rate ratios comparing ethnic-minority vs White groups, adjusting for age, sex, and SES, with ethnicity-SES interaction testing and marginal rates derived by subgroup. Results Among 7,726 people with first-ever stroke, overall standardised incidence decreased 34% between 1995–1999 and 2010–2014 (198;[187.8–208] to 131;[122.4–138.9] per 100,000), then increased 13% in 2020–2024. Black-African and Black-Caribbean populations had higher baseline incidence persisting across all periods. Ethnic inequalities narrowed initially but subsequently widened, with incidence twice as high in Black-African (IRR=2.31;[2.03–2.62]) and Black-Caribbean (IRR=2.00;[1.73–2.31]) groups compared to White groups in 2020–2024. Patterns were consistent across stroke subtypes, with the largest inequalities in primary intracerebral haemorrhage. Ethnic differences in incidence attenuated on SES adjustment but remained significant. Within ethnic groups, most deprived Black-African and Black-Caribbean populations showed highest incidence. Conclusion Stroke incidence has risen sharply in the past five years, driven by rising incidence rates in Black-African and Black-Caribbean populations, with reduction in the White population. Achieving equity requires ensuring uptake of cardiovascular risk programmes across all socioeconomic and ethnic groups, with earlier risk management for groups who develop stroke 10-12 years younger than the general population.

Background/Objectives: Vaccination programs are highly effective public health interventions, yet parental hesitancy toward combination vaccines has led to growing demand for alternative vaccination schedules, defined in this study as parental requests to split or replace recommended combination vaccines with single-antigen vaccines for non-clinical reasons. While parental attitudes have been widely studied, little empirical evidence exists on the real-world use of single-antigen vaccines and their public health implications in countries with otherwise high coverage. This study examined the prevalence patterns and parental motivations for requesting such alternative vaccination schedules in Israel, where national guidelines recommend specific combination vaccines, including measles-mumps-rubella-varicella (MMRV) and the pentavalent diphtheria-tetanus-pertussis–inactivated polio–Haemophilus influenzae type b (DTaP+IPV+Hib) vaccines, but informal accommodations exist. Methods: A mixed-methods design was employed: a retrospective cohort analysis of vaccination data from 2018 to 2021 (before and during the COVID-19 pandemic) focused on measles (first dose at 12 months) and pertussis (four-dose primary series), followed by semi-structured interviews with Maternal and Child Health clinic providers, policymakers, and parents. Results: Alternative vaccination schedules involving single-antigen measles or pertussis vaccines are occasionally used despite official policy, accounting for less than 1% of vaccinations overall. Outcomes include delayed administration, lower uptake of combination vaccines, and incomplete protection in certain groups. Parents cited safety concerns, fear of immune overload, and mistrust of authorities. These concerns were often amplified by misinformation, while providers described balancing parental preferences with the need for adequate coverage. Conclusions: This study provides new evidence on how vaccine hesitancy translates into service utilization, highlights the tension between individualized parental decision-making and contribution to collective health, and underscores the need for communication, policy strategies and service designs that sustain high coverage while addressing community-specific concerns.

BackgroundFolate has been examined extensively in relation to carcinogenesis due to its role in one-carbon metabolism impacting the synthesis of DNA and RNA, methylation processes, and genomic integrity. Current evidence on the relationship between folate status and the risk of cancer is equivocal: low or deficient folate status may contribute to an increased risk of cancers, while high-dose folic acid supplementation may have adverse effects on carcinogenesis.MethodsWe searched MEDLINE, Embase, CINAHL, the Cochrane Library, and the Database of s of Reviews of Effects up to February 2024 for systematic reviews and meta-analyses investigating the associations of folate (measured as dietary intake, supplementation, or blood concentrations) with any specific cancer outcome. Screening, data extraction, and risk of bias assessment were performed in duplicate. We assessed the credibility of the evidence using predefined criteria.ResultsWe found 67 syntheses, of which 57 provided meta-analyses. Over half of the syntheses had a high risk of bias. We identified 168 unique associations (unique exposure – unique outcome – unique setting) across 10 cancer types, 3 system cancers, and total cancer. Of these, we assessed 15 directional associations (colorectal, oesophageal, and total cancers) to be at a highly suggestive level of credibility, and 17 directional and 10 null associations to be at a suggestive level of credibility.ConclusionsThe available evidence for each category of unique association was generally limited. Highly suggestive associations were found for oesophageal, colorectal, childhood brain and spinal tumours and total cancers. More robust primary studies are warranted to follow-up the signal of a positive relationship reported for prostate cancer warranting further research. Evidence was weak for all but colorectal and oesophageal cancers, or the central nervous system cancers in children.RegistrationPROSPERO: CRD42021265041.

IssueThe Pandemic Agreement (PA) negotiation highlights the need for global coordination in pandemic prevention, preparedness, response, and recovery (PPRR). Its non-binding nature risks weaker global commitments essential for access to countermeasures, transnational regulation, multisectoral surveillance infrastructure and funding. Critical for Europe and beyond for global health security, this issue demands a human rights-based approach (HRBA) to enhance accountability and governance, offering a model for multilateral governance and State Parties to prioritise rights in PPRR implementation.Problem descriptionThis study analyses how HRBA can strengthen PA articles’ implementation, using critical analysis of PA text, human rights instruments, and case studies (e.g., TRIPS delays). Objectives include assessing HRBA's role in empowering the Conference of the Parties (COP), an international instrument, to develop compliance mechanisms for PA implementation. Questions: How can HRBA enhance COP's accountability for State Parties and global actors? What governance mechanisms support global, regional, and national PA implementation?ResultsHRBA facilitates multi-level governance for health policy action. It empowers WHO's international coordination of PA implementation via COP, leveraging UN human rights mechanisms, (e.g., treaty/charter bodies) to ensure State Parties prioritise PA articles. The European Convention on Human Rights (1950) and Revised European Social Charter (1996) fortify regional accountability, while national human rights institutions foster political consensus through parliamentary discussions. HRBA enhances institutional commitment and technical capacity, progressively realising health and other essential rights required for PPRR implementation.LessonsHRBA ensures global coordination for PPRR, offering a scalable governance framework for Europe and its global diplomacy to address health in international treaties and other agreements.Key messages• HRBA enhances PA’s compliance and accountability, supporting WHO’s efforts for global coordination of PPRR.• HRBA is a multi-level governance mechanism to safeguard the interests of health in multilateral/bilateral non-health affairs.

<bold>Background:</bold> The COVID-19 pandemic escalated the need for remote study procedures in clinical trials. Adaptations to the BenRex Study (Benralizumab Exacerbation Study) allowed for validation of video supported home spirometry against on site face-to-face sessions in severe asthma patients. <bold>Methods:</bold> At screening, participants received a Micro spirometer [Vitalograph, Buckingham, UK] and education on its use. A spirometry session was performed on site with face-to-face coaching from study staff, followed by a remote spirometry session within 24 hours, with coaching over video link at 3 visits. All Spirometry sessions had an over-read for quality assessment, by Respiratory Physiologists at Vitalograph, using the grading system per the ATS-ERS 2019 Standardisation of Spirometry Guidelines. Statistical summaries were produced to compare the acceptability grade of FEV₁ and FVC at each session. McNemar tests were used to compare acceptability. <bold>Results:</bold> There were 166 sessions in total with clinic and off site spirometry readings, from 82 subjects. An FEV1 grade of A or B (as per ATS/ERS 2019 guidelines) was achieved in 161 sessions (97%) conducted on site and 156 (94%) conducted at home (p=0.32). An FVC grade of A or B was achieved in 152 sessions (91.5%) on site and 148 (89.1%) conducted at home (p=0.68). <bold>Discussion:</bold> The results from the BenRex cohort suggest that there is a high level of reproducibility of technical quality for remote spirometry [FEV₁ and FVC] conducted via video coaching. This has implications for study design and may support remote decentralised asthma trials in broader populations limited by geographical or time constraints.

Introduction: Hypertension is associated with a chronic inflammatory state and aberrant immune system activity. Interleukin-33/suppression of tumorigenicity 2 (IL-33/ST2) signalling axis is important in the modulation of atherosclerosis and cardiovascular fibrosis. We aimed to evaluate the modulation of IL-33 and ST2 in hypertensive mouse models and patients. Methods and Results: Hypertension was induced by a 14-day infusion of Ang-II (490ng/min/kg) in 12-week-old WT C57BL/6, ST2KO, IL33KO mice. IL-33 and ST2 mRNA and protein were evaluated using qPCR and Western blot in WT mice. Ang II-infusion significantly increased IL-33 and ST2 protein expression in target organs related to hypertension, particularly the aorta (1.0±0.1 vs 2.8±0.2, p&lt;0.0001, and 0.963±0.068 vs 2.094±0.231, p=0.002, respectively). Further, mRNA expression of IL-33 and ST2 was elevated in hypertensive aortas when compared with control (1.0±0.053 vs 1.76±0.271, p=0.0185 and 1.0±0.039 vs 1.978±0.221, p=0.0039, respectively). IHC from WT mice illustrated the localisation of IL-33 and ST2 in Ang-II aortas in ECs and SMCs. Further in human hypertensive mammary arteries, the localisation was. In-vivo, IL33KO and ST2KO mice showed no altered BP at baseline or after 14 days of Ang-II compared to WT littermates. ST2KO Ang-II mice showed protection against endothelial dysfunction compared to WT Ang-II mice through isometric tension studies (p=0.0317). Additionally, Ang-II-induced IL33KO and ST2KO mice worsen cardiac fibrosis compared to WT littermates (p=0.0005,p&lt;0.0001, respectively). Conclusion: Both IL-33 and its receptor, ST2 are increased in the vascular and perivascular tissues in hypertension. Additionally, the IL-33/ST2 axis has a role in regulating cardiac fibrosis.

Objective: This study aims to quantify the proportion of population with inappropriate arterial stiffness measured by pulse wave velocity (PWV) and BP level including its associated characteristics. Design and method: This observational monocentric cohort study utilised data from Hôpital européen Georges-Pompidou (HEGP), Assistance Publique-Hôpitaux de Paris (APHP) that includes 5,186 (57.2% male, mean age 53 years) participants. 1,203 participants had a second PWV measurement. Residuals from log-transformed piecewise regression model for PWV prediction based on mean BP values were employed to define participants with inappropriate PWV. A multinomial regression analysis was conducted to find the associated clinical characteristics. Results: There are 522 participants with inappropriately high PWV and 517 participants with inappropriately low PWV, defined as 10th and 90th percentile of residuals. In the multinomial analysis, younger age, higher body mass index (BMI), and presence of diabetes mellitus (DM) are associated with inappropriately high PWV group. In participants with follow-up visit (n = 1,203), we found that classification into groups of inappropriate PWV was consistent, with 78% concordance. Conclusions: This study generates a classification method to define inappropriate HMOD compared to BP levels. Screening especially of younger patients for HMOD irrespective of their BP level may lead to early detection of organ damage and identifications of patients for targeted preventive strategies.

Leptospira, the spirochaete causing leptospirosis, can be classified into >250 antigenically distinct serovars. Although knowledge of the animal host species and geographic distribution of Leptospira serovars is critical to understand the human and animal epidemiology of leptospirosis, current data are fragmented. We aimed to systematically review, the literature on animal host species and geographic distribution of Leptospira serovars to examine associations between serovars with animal host species and regions and to identify geographic regions in need of study. Nine library databases were searched from inception through 9 March 2023 using keywords including Leptospira, animal, and a list of serovars. We sought reports of detection of Leptospira, from any animal, characterised by cross agglutinin absorption test, monoclonal antibody typing, serum factor analysis, or pulsed-field gel electrophoresis to identify the serovar. We included 409 reports, published from 1927 through 2022, yielding data on 154 Leptospira serovars. The reports included data from 66 (26.5%) of 249 countries. Detections were from 144 animal host species including 135 (93.8%) from the class Mammalia, 5 (3.5%) from Amphibia, 3 (2.1%) from Reptilia, and 1 (0.7%) from Arachnida. Across the animal host species, Leptospira serovars that were detected in the largest number of animal species included Grippotyphosa (n = 39), Icterohaemorrhagiae (n = 29), Pomona (n = 28), Australis (n = 25), and Ballum (n = 25). Of serovars, 76 were detected in a single animal host species. We created an online database to identify animal host species for each serovar by country. We found that many countries have few or no Leptospira serovars detected from animal host species and that many serovars were detected from a single animal species. Our study highlights the importance of efforts to identify animal host species of leptospirosis, especially in places with a high incidence of human leptospirosis. We provide an updated resource for leptospirosis researchers.