Portal de Periódicos da CAPES

Health-care provision for displaced populations arriving from Ukraine

2022; Elsevier BV; Volume: 22; Issue: 6 Linguagem: Inglês

10.1016/s1473-3099(22)00225-0

1474-4457

Alena Kamenshchikova, Ioana Margineau, Shazia Munir, Felicity Knights, Jessica Carter, Ana Requena‐Méndez, Yusuf Ciftci, Rosemary James, Miriam Orcutt, Karl Blanchet, Apostolos Veizis, Bernadette N. Kumar, Teymur Noori, Sally Hargreaves,

Economic Sanctions and International Relations

More than 4·2 million people, including 208 000 non-Ukrainians, have fled Ukraine to other European countries in recent weeks,1Migration Data PortalRefugees and Asylum Seekers.https://www.migrationdataportal.org/ukraine/crisis-movementsDate: 2022Google Scholar with the majority being women, children, and older people.2UN High Commissioner for RefugeesUNHCR warns of rising needs in Ukraine and neighbouring countries, calls for cessation of hostilities.https://www.unhcr.org/uk/news/briefing/2022/3/623453f14/unhcr-warns-rising-needs-ukraine-neighbouring-countries-calls-cessation.htmlDate: 2022Date accessed: March 24, 2022Google Scholar The current crucial objectives are to ensure that people can safely leave the conflict zone and access basic facilities such as housing, food, water, sanitation, and emergency care. However, going forward, it is important for the governments of receiving countries and transit countries to develop clear short-term and long-term strategies for the provision of health services.3WHOPrioritizing the health of refugees and migrants: an urgent, necessary plan of action for countries and regions in our interconnected world.https://www.euro.who.int/en/media-centre/sections/press-releases/2022/prioritizing-the-health-of-refugees-and-migrants-an-urgent,-necessary-plan-of-action-for-countries-and-regions-in-our-interconnected-worldDate: 2022Date accessed: March 24, 2022Google Scholar These strategies must include access to vaccination, maternal and child care services, screening programmes, and care for chronic conditions and mental health.Many EU and European Economic Area (EEA) countries have long since been grappling with questions about what level of health care should be offered to forcibly displaced migrants and other migrant groups, when and where in the migration trajectory provision should be made (ie should it be at borders, reception centres, once settled, via specialist or routine services, or left to non-governmental organisations), and what their subsequent level of right to access the mainstream health-care system should be. Overall, European countries do not have a uniform approach to the provision of health care for these populations, with some countries more inclusive than others, and wide discrepancies between policy and practice. In a recent survey of 25 355 people, who were mostly migrants from non-EU or non-EEA countries residing in European cities,4Medecins du MondeUCL2021 observatory report.https://www.doctorsoftheworld.org.uk/wp-content/uploads/2022/03/2021-Observatory-Report.pdf?download=1Date: 2021Date accessed: March 24, 2022Google Scholar 78% had no entitlement to access health services, most pregnant women were not able to access antenatal services, and 91% were living below the poverty line—highlighting that thousands of migrants in Europe are currently excluded from accessing basic primary health care. In addition, migrants are often overlooked in health programmes, with high levels of drop-out and poor linkage to care.In March, 2022, the European Centre for Disease Prevention and Control (ECDC) published a technical report that focuses on infectious disease vulnerabilities among displaced populations from Ukraine; the report summarises key infectious diseases that might be particularly relevant for this group.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar In the case of displaced people from Ukraine, as well as newly arrived migrants in general,6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar the ECDC report highlights the importance of a holistic approach to providing health care, echoing previous research, with key considerations for host health systems summarised in the panel.7Noori T Hargreaves S Greenaway C et al.Strengthening screening for infectious diseases and vaccination among migrants in Europe: what is needed to close the implementation gaps?.Travel Med Infect Dis. 2021; 39101715 Crossref PubMed Scopus (12) Google Scholar, 8Knights F Munir S Ahmed H Hargreaves S Providing initial health assessments for newly arrived migrants, refugees, and asylum seekers.BMJ. 2022; (in press).Crossref PubMed Scopus (5) Google Scholar To align with the principles of Universal Health Coverage and the Right to Health, such an approach requires that all migrants should have the same level of health care access as host populations. The key health risks in the next 3 months for the people displaced from Ukraine include morbidity and mortality from cardiovascular diseases (ie, heart attack and stroke), chronic respiratory diseases, diabetes, mental health distress, and chronic infectious diseases (ie, tuberculosis, HIV, hepatitis B and C) due to disruption to the supply of medication and poor access to health-care professionals.9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar In 2020, Ukraine reported the second-highest number of tuberculosis cases in the WHO European region, and 27·2% of new tuberculosis cases were multidrug resistant (Ukraine is included in the ten countries globally with the highest rates of multidrug-resistant tuberculosis).10WHOTB profile, Ukraine.https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22UA%22Date: 2022Date accessed: March 9, 2022Google Scholar As has been observed during other humanitarian crises, the risk for tuberculosis increases when people are placed in crowded settings and have poor access to health services, making tuberculosis a crucial concern for migrants coming from Ukraine. Data from 2020 highlight that cases of tuberculosis and HIV coinfection in Ukraine are among the highest in Europe (23% of coinfections are among new and relapsed tuberculosis cases), which should be considered by health-care providers. In addition, careful consideration should be given to mental distress and trauma because of the uncertainties of a life as a refugee and long stays in camp and transit conditions.11Bjertrup PJ Bouhenia M Mayaud P Perrin C Ben Farhat J Blanchet K A life in waiting: refugees' mental health and narratives of social suffering after European Union border closures in March 2016.Soc Sci Med. 2018; 215: 53-60Crossref PubMed Scopus (41) Google ScholarPanelCurrent key considerations for health systems in host countries•Universal access to health systems in host countries is paramount.•Facilitate access to health-care professionals immediately on arrival to address interruptions in supply of medicines and avoid excess morbidity and mortality from cardiovascular diseases (ie, heart attack, stroke), chronic respiratory diseases, diabetes, mental health, and chronic infectious diseases (tuberculosis, HIV, hepatitis B and C).•Ensure full access to vaccination systems in host countries as a key priority. Ukraine has historic and current low childhood vaccination coverage; therefore, consider offering routine and catch-up vaccinations (with a focus on measles, mumps, rubella; and tetanus, diphtheria, and polio) to all new arrivals (children, adolescents, and adults).•Ensure access to COVID-19 vaccines given the current low coverage in Ukraine.•The majority of people displaced will be women and children. Ensure access to appropriate services such as antenatal care, health visitors, and vaccination.•Careful consideration should be given to mental distress and trauma, which are common during humanitarian crises, and the impact of the migration process on peoples' wider health.•Health-care professionals will need to invest time and effort into building trust with displaced communities to design and deliver health and vaccine services.Addressing vaccine-preventable infectious diseases such as polio, measles, and COVID-19 will be an important priority.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar An outbreak of polio was reported in Ukraine in 2021, with the country reporting the second-highest number of measles cases in Europe in the same year. Childhood vaccination coverage in Ukraine is among the lowest in the WHO European region,5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar which could mean that catch-up vaccinations for older age groups are warranted, with a focus on measles, mumps, rubella, tetanus, diphtheria, and polio.6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar Temporary reception centres across Europe are known to have had outbreaks involving adults who missed vaccinations, doses, and boosters in their home countries as children.12Deal A Halliday R Crawshaw AF et al.Migration and outbreaks of vaccine-preventable diseases in Europe.Lancet Infect Dis. 2021; 21: e387-e398Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar For individuals who express uncertainty about the vaccinations they have had, ECDC recommends considering them as unvaccinated and offering a new course of routine vaccines.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar COVID-19 vaccine uptake in Ukraine has to date been low, with only 34% population coverage with two doses (and 2% coverage with the booster dose), and there are high levels of vaccine hesitancy; therefore, host countries will need to devise strategies to ensure access to COVID-19 vaccines.9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar, 13ECDCGuidance for the prevention and control of COVID-19 in temporary reception centres in the context of the large numbers of people fleeing Ukraine.https://www.ecdc.europa.eu/en/publications-data/guidance-prevention-control-covid-19-temporary-reception-centres-people-fleeing-ukraineDate: 2022Date accessed: March 24, 2022Google ScholarA holistic and patient-centred approach to health is vital, and several countries, including Ireland and Poland, have promised free access to health services for Ukrainians. When organising health service delivery, health-care professionals will need to invest time and effort into building trust with displaced communities. The EU's decision to offer temporary protection for 1 year to people fleeing Ukraine, which implies the right to residency, to work, and to free health care, is essential.14European CouncilUkraine: council unanimously introduces temporary protection for persons fleeing the war.https://www.consilium.europa.eu/en/press/press-releases/2022/03/04/ukraine-council-introduces-temporary-protection-for-persons-fleeing-the-war/Date: 2022Date accessed: March 10, 2022Google Scholar Yet, this policy raises many unanswered questions about the levels of provision currently afforded to the thousands of other forcibly displaced migrants who are already in the EU. Opening national borders and providing refuge to Ukrainians must go hand in hand with building sustainable and long-term access to health care for all migrant groups, informing and training health-care professionals, and ensuring that displaced populations are aware of their rights and the routes to receiving care. More than 4·2 million people, including 208 000 non-Ukrainians, have fled Ukraine to other European countries in recent weeks,1Migration Data PortalRefugees and Asylum Seekers.https://www.migrationdataportal.org/ukraine/crisis-movementsDate: 2022Google Scholar with the majority being women, children, and older people.2UN High Commissioner for RefugeesUNHCR warns of rising needs in Ukraine and neighbouring countries, calls for cessation of hostilities.https://www.unhcr.org/uk/news/briefing/2022/3/623453f14/unhcr-warns-rising-needs-ukraine-neighbouring-countries-calls-cessation.htmlDate: 2022Date accessed: March 24, 2022Google Scholar The current crucial objectives are to ensure that people can safely leave the conflict zone and access basic facilities such as housing, food, water, sanitation, and emergency care. However, going forward, it is important for the governments of receiving countries and transit countries to develop clear short-term and long-term strategies for the provision of health services.3WHOPrioritizing the health of refugees and migrants: an urgent, necessary plan of action for countries and regions in our interconnected world.https://www.euro.who.int/en/media-centre/sections/press-releases/2022/prioritizing-the-health-of-refugees-and-migrants-an-urgent,-necessary-plan-of-action-for-countries-and-regions-in-our-interconnected-worldDate: 2022Date accessed: March 24, 2022Google Scholar These strategies must include access to vaccination, maternal and child care services, screening programmes, and care for chronic conditions and mental health. Many EU and European Economic Area (EEA) countries have long since been grappling with questions about what level of health care should be offered to forcibly displaced migrants and other migrant groups, when and where in the migration trajectory provision should be made (ie should it be at borders, reception centres, once settled, via specialist or routine services, or left to non-governmental organisations), and what their subsequent level of right to access the mainstream health-care system should be. Overall, European countries do not have a uniform approach to the provision of health care for these populations, with some countries more inclusive than others, and wide discrepancies between policy and practice. In a recent survey of 25 355 people, who were mostly migrants from non-EU or non-EEA countries residing in European cities,4Medecins du MondeUCL2021 observatory report.https://www.doctorsoftheworld.org.uk/wp-content/uploads/2022/03/2021-Observatory-Report.pdf?download=1Date: 2021Date accessed: March 24, 2022Google Scholar 78% had no entitlement to access health services, most pregnant women were not able to access antenatal services, and 91% were living below the poverty line—highlighting that thousands of migrants in Europe are currently excluded from accessing basic primary health care. In addition, migrants are often overlooked in health programmes, with high levels of drop-out and poor linkage to care. In March, 2022, the European Centre for Disease Prevention and Control (ECDC) published a technical report that focuses on infectious disease vulnerabilities among displaced populations from Ukraine; the report summarises key infectious diseases that might be particularly relevant for this group.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar In the case of displaced people from Ukraine, as well as newly arrived migrants in general,6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar the ECDC report highlights the importance of a holistic approach to providing health care, echoing previous research, with key considerations for host health systems summarised in the panel.7Noori T Hargreaves S Greenaway C et al.Strengthening screening for infectious diseases and vaccination among migrants in Europe: what is needed to close the implementation gaps?.Travel Med Infect Dis. 2021; 39101715 Crossref PubMed Scopus (12) Google Scholar, 8Knights F Munir S Ahmed H Hargreaves S Providing initial health assessments for newly arrived migrants, refugees, and asylum seekers.BMJ. 2022; (in press).Crossref PubMed Scopus (5) Google Scholar To align with the principles of Universal Health Coverage and the Right to Health, such an approach requires that all migrants should have the same level of health care access as host populations. The key health risks in the next 3 months for the people displaced from Ukraine include morbidity and mortality from cardiovascular diseases (ie, heart attack and stroke), chronic respiratory diseases, diabetes, mental health distress, and chronic infectious diseases (ie, tuberculosis, HIV, hepatitis B and C) due to disruption to the supply of medication and poor access to health-care professionals.9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar In 2020, Ukraine reported the second-highest number of tuberculosis cases in the WHO European region, and 27·2% of new tuberculosis cases were multidrug resistant (Ukraine is included in the ten countries globally with the highest rates of multidrug-resistant tuberculosis).10WHOTB profile, Ukraine.https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22UA%22Date: 2022Date accessed: March 9, 2022Google Scholar As has been observed during other humanitarian crises, the risk for tuberculosis increases when people are placed in crowded settings and have poor access to health services, making tuberculosis a crucial concern for migrants coming from Ukraine. Data from 2020 highlight that cases of tuberculosis and HIV coinfection in Ukraine are among the highest in Europe (23% of coinfections are among new and relapsed tuberculosis cases), which should be considered by health-care providers. In addition, careful consideration should be given to mental distress and trauma because of the uncertainties of a life as a refugee and long stays in camp and transit conditions.11Bjertrup PJ Bouhenia M Mayaud P Perrin C Ben Farhat J Blanchet K A life in waiting: refugees' mental health and narratives of social suffering after European Union border closures in March 2016.Soc Sci Med. 2018; 215: 53-60Crossref PubMed Scopus (41) Google Scholar •Universal access to health systems in host countries is paramount.•Facilitate access to health-care professionals immediately on arrival to address interruptions in supply of medicines and avoid excess morbidity and mortality from cardiovascular diseases (ie, heart attack, stroke), chronic respiratory diseases, diabetes, mental health, and chronic infectious diseases (tuberculosis, HIV, hepatitis B and C).•Ensure full access to vaccination systems in host countries as a key priority. Ukraine has historic and current low childhood vaccination coverage; therefore, consider offering routine and catch-up vaccinations (with a focus on measles, mumps, rubella; and tetanus, diphtheria, and polio) to all new arrivals (children, adolescents, and adults).•Ensure access to COVID-19 vaccines given the current low coverage in Ukraine.•The majority of people displaced will be women and children. Ensure access to appropriate services such as antenatal care, health visitors, and vaccination.•Careful consideration should be given to mental distress and trauma, which are common during humanitarian crises, and the impact of the migration process on peoples' wider health.•Health-care professionals will need to invest time and effort into building trust with displaced communities to design and deliver health and vaccine services. •Universal access to health systems in host countries is paramount.•Facilitate access to health-care professionals immediately on arrival to address interruptions in supply of medicines and avoid excess morbidity and mortality from cardiovascular diseases (ie, heart attack, stroke), chronic respiratory diseases, diabetes, mental health, and chronic infectious diseases (tuberculosis, HIV, hepatitis B and C).•Ensure full access to vaccination systems in host countries as a key priority. Ukraine has historic and current low childhood vaccination coverage; therefore, consider offering routine and catch-up vaccinations (with a focus on measles, mumps, rubella; and tetanus, diphtheria, and polio) to all new arrivals (children, adolescents, and adults).•Ensure access to COVID-19 vaccines given the current low coverage in Ukraine.•The majority of people displaced will be women and children. Ensure access to appropriate services such as antenatal care, health visitors, and vaccination.•Careful consideration should be given to mental distress and trauma, which are common during humanitarian crises, and the impact of the migration process on peoples' wider health.•Health-care professionals will need to invest time and effort into building trust with displaced communities to design and deliver health and vaccine services. Addressing vaccine-preventable infectious diseases such as polio, measles, and COVID-19 will be an important priority.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar An outbreak of polio was reported in Ukraine in 2021, with the country reporting the second-highest number of measles cases in Europe in the same year. Childhood vaccination coverage in Ukraine is among the lowest in the WHO European region,5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar which could mean that catch-up vaccinations for older age groups are warranted, with a focus on measles, mumps, rubella, tetanus, diphtheria, and polio.6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar Temporary reception centres across Europe are known to have had outbreaks involving adults who missed vaccinations, doses, and boosters in their home countries as children.12Deal A Halliday R Crawshaw AF et al.Migration and outbreaks of vaccine-preventable diseases in Europe.Lancet Infect Dis. 2021; 21: e387-e398Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar For individuals who express uncertainty about the vaccinations they have had, ECDC recommends considering them as unvaccinated and offering a new course of routine vaccines.5ECDCOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/en/publications-data/operational-public-health-considerations-prevention-and-control-infectiousDate: 2022Date accessed: March 10, 2022Google Scholar, 6ECDCPublic health guidance on screening and vaccination for infectious diseases in newly arrived migrant within the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/public-health-guidance-screening-and-vaccination-infectious-diseases-newlyDate: 2018Date accessed: March 10, 2022Google Scholar COVID-19 vaccine uptake in Ukraine has to date been low, with only 34% population coverage with two doses (and 2% coverage with the booster dose), and there are high levels of vaccine hesitancy; therefore, host countries will need to devise strategies to ensure access to COVID-19 vaccines.9Health Cluster UkrainePublic health situation analysis—short form.https://reliefweb.int/sites/reliefweb.int/files/resources/ukraine-phsa-shortform-030322.pdfDate: 2022Date accessed: March 10, 2022Google Scholar, 13ECDCGuidance for the prevention and control of COVID-19 in temporary reception centres in the context of the large numbers of people fleeing Ukraine.https://www.ecdc.europa.eu/en/publications-data/guidance-prevention-control-covid-19-temporary-reception-centres-people-fleeing-ukraineDate: 2022Date accessed: March 24, 2022Google Scholar A holistic and patient-centred approach to health is vital, and several countries, including Ireland and Poland, have promised free access to health services for Ukrainians. When organising health service delivery, health-care professionals will need to invest time and effort into building trust with displaced communities. The EU's decision to offer temporary protection for 1 year to people fleeing Ukraine, which implies the right to residency, to work, and to free health care, is essential.14European CouncilUkraine: council unanimously introduces temporary protection for persons fleeing the war.https://www.consilium.europa.eu/en/press/press-releases/2022/03/04/ukraine-council-introduces-temporary-protection-for-persons-fleeing-the-war/Date: 2022Date accessed: March 10, 2022Google Scholar Yet, this policy raises many unanswered questions about the levels of provision currently afforded to the thousands of other forcibly displaced migrants who are already in the EU. Opening national borders and providing refuge to Ukrainians must go hand in hand with building sustainable and long-term access to health care for all migrant groups, informing and training health-care professionals, and ensuring that displaced populations are aware of their rights and the routes to receiving care. We declare no competing interests. AK is funded by the Niels Stensen Fellowship. SH acknowledges funding from the National Institute for Health Research (NIHR Advanced Fellowship NIHR300072), The Academy of Medical Sciences (SBF005\1111), Novo Nordisk Foundation/La Caixa Foundation (Mobility – Global Medicine and Health Research grant), and WHO. FK is supported by a Health Education England, National Institute for Health Research Academic Clinical Fellowship. AR-M is funded by the Strategic Research Program in Epidemiology at the Karolinska Institutet.