Title: NIHR Global Health Research Group on Asthma Attacks Causes and Prevention Study in Urban Latin America at St George's, University of London
Funder: Department of Health and Social Care

Abstract: The NIHR Global Health Research Group (GHRG) will be based at St George’s University of London (SGUL) within a new Centre for Global Health within the Institute of Infection and Immunity [I&I], and be supported by the Public Health Research Institute [PHRI]) which has an extensive track record of epidemiologic and implementation research in the UK. We will build on these strengths through established links with Brazil (Universidade Federal da Bahia, UFBa) and Ecuador (Fundacion Ecuatoriana Para Investigacion en Salud [FEPIS] and Universidad Internacional del Ecuador [UIDE]) and by establishing new academic links in the UK (University of East Anglia [UEA]) and Ecuador (Universidad de Cuenca/Universidad de Azuay [UC&UA]). The PHRI at SGUL has played a key role in defining the global burden of asthma and asthma risk factors through the International Study of Asthma and Allergies in Childhood [ISAAC]), while UFBa (Prof Cruz) has led the development of reference centres for severe asthma in Salvador, Brazil, that reduced hospital admissions due to asthma in the entire City of 3 million inhabitants by 74% over a 3 year period [9]. Prof Cruz is a member of the Executive Committee of the WHO Global Alliance against Chronic Respiratory Diseases (GARD) and of the Board of Directors of the Global Initiative for Asthma (GINA). The NIHR investment will complement existing funding in asthma research at SGUL, UEA, UFBa, and UC&UA. Current asthma funding at these centres include: i) SGUL holds grants from the European Research Council and the Bill and Melinda Gates Foundation; ii) UEA holds NIHR grants for asthma research (Project: At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK); iii) UFBa holds grants from the State Agency for Research Support of Bahia (FAPESB) and the Brazilian National Research Council (CNPq); and iv) UC&UA holds grants from University research funds and RED CEDIA. The Group’s strategy will be: 1. Set up a Global Health Research Group at St George’s in collaboration with key partners in Brazil, Ecuador, and the UK. 2. Deliver on a programme of implementation and epidemiological research through: a. Prevention of severe asthma attacks among adults in Brazil (Salvador) and asthma attacks in children and adolescents in Ecuador (Quito, Cuenca, and Esmeraldas) through a strategy for provision of immediate specialized care at collaborating hospitals followed by guided reference within the primary health care system (in Brazil and a pilot study in Ecuador), offering free inhaled beclomethasone, salbutamol and spacers to guarantee efficient inhalation. These medications are listed as essential drugs by WHO and are expected to be offered for free in every country. In Brazil, this has started to happen over the past 4 years, justified partly through the success of programmes such Programa de Controle da Asma da Bahia (ProAR) in Salvador. In Ecuador, inhaled salbutamol and beclomethasone, although listed as essential drugs by the Ministry of Public Health, have limited availability within the public health system. An objective of the present programme will be to provide a local evidence base to justify the wide availability of both medications within the public health care system in Ecuador. The focus in Brazil will be on adults with untreated asthma who, through ProAR, were found to have high rates of attacks requiring ER visits and have been identified as a major unmet need for better asthma care. The studies in Ecuador will focus on children and adolescents with asthma attacks who represent the major burden of disease. b. Identification of risk factors associated with asthma attacks and recurrence of asthma attacks in one month, 6 months and 1 year as well as re-attendance at emergency rooms due to an asthma attack. 3. Collaborative links with LMIC partners: a. Strengthening existing links with Brazilian and Ecuadorian partners. b. Establish new links with academic institutions in Ecuador involved in asthma research and control in Quito and Cuenca. c. Establish/strengthen links with key stakeholders including Ministries of Public Health, municipal departments of health, national respiratory societies, other NGOs and patient groups in Ecuador and Brazil. d. Develop research capacity through short (i.e. ~2 weeks) to extended (i.e. 2-4 years for Masters and PhD levels, respectively) periods of research training and exchanges between Brazil and Ecuador. Short exchanges will be funded through this programme while extended periods will be funded through alternative sources within Brazil and Ecuador. The programme will focus on severe attacks in Salvador, Brazil where there is now provision for the control of severe asthma in a secondary care facility through the linked ProAR. However, in Ecuador where provision of asthma care is inadequate at all levels within the public health care system, all asthma attacks presenting to emergency rooms will be considered.

Lay abstract: Asthma affects over 330 million children and adults worldwide with a growing and disproportionate burden in low and middle-income countries (LMICs) particularly in Latin America where up to 30% of children have been reported to have asthma [1,2]. The prevalence of asthma and disease burden attributable to the disease has grown markedly over the last twenty years or so in LMICs [2,3]. Much of this increase has been associated with the effects of urbanization on lifestyle and living environments and persistently high levels of inequality [3,4]. Asthma at all ages has become a major burden to health systems and families in LMICs through the morbid, social, and economic costs of the disease [5]. The burden of asthma is most strongly felt among the urban poor among whom inadequate disease control and limited access to medicines and health care are reflected in high rates of morbidity and hospital attendance rates with asthma attacks [6,7]. There is a need to improve access to health services offering best evidence-based management and asthma medications among underprivileged urban populations in LMICs, to reduce asthma morbidity and the resultant economic costs to families and health services. We will establish a Global Health Research Group (GHRG) on asthma to focus on the growing problem of poorly controlled asthma in urban Latin America whose effects are felt greatest in marginalized urban populations [4,8]. The Group will be based at St George’s University of London (SGUL) in partnership with University of East Anglia (UEA]), and institutions in Brazil (Universidade Federal da Bahia [UFBa], Salvador), and Ecuador (Universidad Internacional del Ecuador [UIDE], Quito; Universidad de Cuenca & Universidad de Azuay [UC&UA], Cuenca; and Fundacion Ecuatoriana Para Investigacion en Salud [FEPIS], Esmeraldas). The GHRG will deliver a programme of epidemiological and implementation research designed to understand better the causality of asthma attacks and of their recurrence and to optimize strategies to improve asthma control and prevent asthma attacks. The programme will focus on underserved urban settings in two middleincome countries, Brazil and Ecuador, with high levels of inequality. The GHRG will build capacity for asthma care within health care systems to reduce morbidity and costs among patients associated with asthma attacks by: i) establishing specialized care teams for asthma within public hospitals and promoting the wider availability of essential asthma drugs within the public health system in Ecuador; ii) extending an established programme of specialized care from secondary level to primary care teams in Brazil; iii) understanding barriers and opportunities to improve asthma care among patients and health providers; iv) identifying modifiable risk factors that could be targeted for future asthma control interventions; and v) building research capacity for asthma research among public health scientists in Ecuador and Brazil. Although the research will be based in two middle-income countries, our findings are likely to be of direct relevance for LMICs at all levels of development where asthma is an emerging health problem.

Research activity codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: RESPIRATORY