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As we approach World Asthma Day on the May 2, 2023, we reflect on the theme “ Asthma Care for All”. Prevalence of Asthma is increasing amongst children, adolescents and adults. Under-diagnosis, underutilization of inhaled corticosteroids, inaccessibility of treatment, and unaffordability of medicines are amongst the challenges that low-middle income countries are faced with. This commentary seeks to highlight the challenges, the resources available and to suggest recommendations that can be implemented to improve asthma care for all and reduce burden of asthma in Africa.

The use of self-reported race/ethnicity to interpret lung function measurements has historically assumed that the observed differences in lung function between racial and ethnic group were due to thoracic cavity size differences relative to standing height. Very few studies have considered the influence of environmental and social determinants on pulmonary function. Consequently, the use of race and ethnicity specific reference equations may further marginalize disadvantaged populations.To develop a race-neutral reference equation for spirometry interpretation.NHANES III data (n=6,984) were re-analyzed with sitting height and the Cormic index to investigate whether body proportions were better predictors of lung function than race and ethnicity. Further, the original Global Lung Function Initiative (GLI) data (n= 74,185) were re-analyzed with inverse-probability weights to create race-neutral GLI Global (2022) equations.The inclusion of sitting height slightly improved statistical precision of reference equations compared with using standing height alone, but did not explain observed differences in spirometry between the NHANES III race and ethnic groups. GLI-Global (2022) equations, which do not require the selection of race and ethnicity, had similar fit to the GLI-2012 'other' equations and wider limits of normal.The use of a single "Global" spirometry equation reflects the wide range of lung function observed within and between populations. Given the inherent limitations of any reference equation, the use of GLI Global equations to interpret spirometry requires careful consideration of an individual's symptoms and medical history when used to make clinical, employment, and insurance decisions.

The British Thoracic Society (BTS) launched a Global Health Group in 2019 in partnership with the Pan African Thoracic Society. This paper reports the third of a series of BTS Winter Meeting global lung health symposia addressing lung health in African children in the context of poverty. In this report, we summarize the two presentations included in the symposium. The first talk, by Refiloe Masekela, focused on the legacy of poor lung health across generations providing an overview of factors known to be important in child respiratory health. The second talk, by Kevin Mortimer, summarized the evidence to date on intervention studies of clean cookstoves and child lung health.

Multisystem inflammatory syndrome in children (MIS-C) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been infrequently described in Africa.To describe the clinical characteristics, outcomes and associations of severe disease in children hospitalized with MIS-C in KwaZulu-Natal.Retrospective multicenter study of children (0-13 years) who met the Centers for Disease Control and Prevention criteria for MIS-C. Children with shock were compared with children without shock to determine the characteristics of severe MIS-C.Twenty-nine children with MIS-C were identified, the mean age was 55 (SD ±45) months, 25 (86%) were Black-African, and 8 (28%) had pre-existing comorbidities. The predominant presenting symptoms included fever 29 (100%), gastrointestinal symptoms 25 (83%), skin rash 19 (65%), and shock 17 (59%). Children with shock had significantly increased CRP (P = 0.01), ferritin (P0.001), troponin-T (P = 0.02), B-type natriuretic peptide (BNP) (P = 0.01), and lower platelets (P = 0.01). Acute kidney injury (P = 0.01), cardiac involvement (P = 0.02), and altered levels of consciousness (P = 0.03) were more common in children with shock. The median length of hospital stay was 11 (IQR 7-19) days, with a mortality of 20.6%. Children who did not survive had significantly higher ferritin levels 1593 (IQR 1069-1650) ng/mL versus 540 (IQR 181-1156) ng/mL; P = 0.03) and significantly more required mechanical ventilation (OR 18; confidence interval 1.7-191.5; P = 0.005).Hospitalized children with MIS-C in KwaZulu-Natal had more aggressive disease and higher mortality than children in better-resourced settings. Markedly elevated biomarkers and critical organ involvement were associated with severe disease. Risk factors for poor outcomes include higher ferritin levels and the need for mechanical ventilation.

Background Asthma is the most common chronic respiratory disease among children and adolescents worldwide. However, the burden of severe asthma is highest in Sub-Saharan Africa. This study aimed to explore teachers' perceptions of asthma care across six African countries. Methods We conducted focus group discussions (FGDs) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. FGDs were conducted in Accra (Ghana), Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda), and Harare (Zimbabwe) between 01 November 2020 and 30 June 2021. Results We identified two key themes related to asthma care: (1) barriers to asthma care and (2) suggestions to improve the care of asthma learners. Teachers reported a lack of knowledge and skills among themselves, learners, and caregivers. Some teachers believed that myths about asthma and restrictions on themselves administering care exacerbated challenges faced by learners with asthma. Most teachers identified a need for all-inclusive asthma training programmes for teachers, learners and caregivers, focusing on acute episodes and mitigating triggers. Utilising teachers with personal experiences with asthma to advocate and support these initiatives was suggested. Recommendations were made for annual screening to enable early identification of learners with asthma and clarity on restricting teachers administering asthma medications. Conclusions Teachers across African schools identify multiple barriers to asthma care. Structured school education programs and annual asthma screening are key to addressing some barriers to care.

Introduction. Severe pneumonia in infants who are HIV-infected is a common problem in many parts of the developing world, especially sub-Saharan Africa. What has been missing from previous studies of severe pneumonia in HIV-infected infants, however, is a description of the host inflammatory response and cytokine/chemokine profile that accompanies this disease.Objective. To describe the cytokine profiles associated with severe hypoxic pneumonia in HIV-infected infantsMethods. In a cohort of HIV-infected children diagnosed clinically with severe hypoxic pneumonia, paired serum and sputum cytokines were tested. A control group of HIV-infected children with bronchiectasis contributed matching controls.Results. A total of 100 infants (mean age 2.8 months) with a clinical diagnosis of severe hypoxic pneumonia were included in this study. IP-10 was markedly elevated in both sputum (mean 560.77pg/ml) and serum (mean 9091.14pg/ml), while IP-10 was elevated in serum (mean 39.55 pg/ml), with both these cytokines being significantly higher than in stable children with HIV-related bronchiectasis.Conclusion. This study of HIV-infected infants with severe hypoxic pneumonia suggests that IL-10 and IP-10 are associated with more severe lung disease. However, further investigation of this association is required.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Objectives: Despite bearing a substantial burden of respiratory diseases, low- and middle-income countries in Africa contribute little to the research literature. Since 2007, the Pan African Thoracic Society’s Methods in Epidemiologic, Clinical, and Operations Research (PATS-MECOR) program has been working to strengthen capacity in lung health research in Africa. The aim of this study was to assess the research productivity of previous PATS-MECOR participants. Materials and Methods: A systematic review of publications attributed to past PATS-MECOR participants up until 2018 was carried out using a systematic search strategy based on their names on PubMed database. Results: A total of 210 participants drawn from 21 African countries attended PATS-MECOR between 2007 and 2016, of which more than three-quarters (76.7%) had ever published. Of the total 1673 included publications, 303 (12.7%) had multiple course attendees as coauthors. The median publication per published participant was 5 (IQR 2–13) articles. The percentages of the first author, second authors, or last authors publications were 371 (22.2%), 239 (14.3%), and 99 (5.9%), respectively. The top three journals published in were PLOS One 108 (6.6%), Lancet 80 (4.9%), and the International Journal of Tuberculosis and Lung Disease 52 (3.2%). The median citation of their publications was 11 (4–26). There was approximately a double-fold rise in the publication output of participants in their 1st year following attendance to PATS-MECOR compared to the year before the course (123, 68.0% vs. 58, 32.0%). Conclusion: The PATS-MECOR training program has been successful in research capacity building for African investigators as evidenced by a growing publication track record. There is a need to ensure sustainability and for increased collaboration and networking among the trained critical mass of researchers in the continent.

The British Thoracic Society (BTS) launched a Global Health Group in the winter of 2019 in partnership with the Pan African Thoracic Society. This key meeting generated a lot of interest and areas of mutual benefit. Due to the overwhelming interest at the 2019 meeting, a virtual offering of the BTS Winter meeting February 2021, included a symposium by the Global Health Group on Africa’s Respiratory “Big Five.” The Winter meeting was free for PATS members and symposium had an excellent attendance, covering the following areas: Pneumonia in the under 5, impact of air pollution on lung health, post-TB lung disease, and non-communicable respiratory disease across the life course. This paper is a summary of the symposium and seeks to address research priority areas for lung health research on the African continent.

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Neurodevelopmental impairment is common in premature infants. We aimed to describe neurodevelopmental outcomes in very low birth weight (VLBW) infants at 12 months postmenstrual age (PMA) and correlated with maternal HIV status. A single-centre, prospective cohort study was conducted from 1 June 2017 to 31 January 2019 with follow-up to 12 months. In-born infants with birth weight1500 g were enrolled. Follow-up care was provided to 12 months PMA. Participants provided informed consent and ethics approval was obtained. A total of 279 patients were enrolled of which 84 (30.1%) died before 12 months and 91 (32.6%) were lost to follow-up. Neurodevelopmental assessment was performed on 104 participants. Mean general development quotient was 106.8, 2 (2.0%) patients had moderate-to-severe impairment and 1 (1.0%) mild impairment. HIV exposure was associated with lower developmental scores (104.3 vs. 109.0

Low-income and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs), including asthma, chronic obstructive pulmonary disease, bronchiectasis, and post-tuberculosis lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases (NCDs), and contribute to complex multi-morbidity, with major consequences for the lives and livelihoods of those affected. The relevance of CRDs to health and socioeconomic wellbeing is expected to increase in the decades ahead, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of NCDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals by 2030. In this Review, we focus on CRDs in LMICs. We discuss the early life origins of CRDs; challenges in their prevention, diagnosis, and management in LMICs; and pathways to solutions to achieve true universal health coverage.

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries.

The World Conferences on Research Integrity have produced significant collaborative conference statements including the Singapore Statement on Research Integrity and more recently the Hong Principles on Researcher Assessment. The 7th World Conference on Research Integrity (7WCRI) takes place in Cape Town from the 29th May 2022 to 1st June 2022. The theme of the conference is Fostering Research in an unequal world. We have proposed the Cape Town statement on Fostering Research Integrity through the promotion of fairness, equity and diversity in research collaborations and contexts as the major collaborative output for this conference. This paper serves to introduce the reader and conference attendees to the motivation and thinking behind this proposal which will be discussed further at the conference.The proposed Cape Town Statement needs to accomplish two aims. First it must clearly demonstrate why inequity and unfair practices in research collaborations and contexts is a research integrity (RI) matter. Second it must identify some key values or principles and action guides that will address the issue of equity and fairness in research within the context of the complete research life cycle from research agenda setting and call to proposal development, through grant application, allocation and management of funding, data production, analysis, management and sharing, to outputs, translation, and evaluation.This background paper serves to outline the rationale and justification for the proposed Cape Town Statement as a major collaborative output of the 7WCRI. It is not in itself the proposed statement but rather represents a summary of some of the thought processes and contributions thus far. We argue that the domain of RI and previous WCRI RI statements have focused the RI project primarily at a micro and meso or project level, with researchers and institutions being the main target for guidance. The Cape Town Statement project aims to widen the lens, bring in a macro perspective and ensure that other role players, including those that support global research structures and systems, are brought into focus, and encouraged to take accountability for their own spheres of influence.

LUNG HEALTH ACROSS THE life course is influenced by factors affecting airway and alveolar development and growth during antenatal and perinatal periods, throughout childhood and adolescence, and into adulthood. Lung function trajectories are set in early life and childhood deficits may predispose to non-communicable respiratory diseases, such as asthma and chronic obstructive pulmonary disease, in later years. Potential risk factors are common in many sub-Saharan African (sSA) countries; adverse antenatal environments cause in utero growth restriction and prematurity; HIV and respiratory infections, including TB are common; exposure to air pollution is widespread, including household air pollution from biomass fuel use, traffic-related pollution in rapidly expanding cities, and tobacco smoke exposure. Multiple disadvantages experienced in early life require an integrated approach that addresses reproductive, maternal and child health. Public health strategies need to tackle multiple risk factors, emphasising Universal Health Coverage, to maximise lung health in the world´s poorest, most vulnerable populations. This review explores potential determinants of lung health across the life course. Due to the extensive topic and wide range of related literature, we prioritised more recent citations, especially those from sSA, focusing on risk factors for which there is most information, and which are most prevalent in the region.

ObjectivesSouth Africa has a double burden of high neonatal mortality and maternal HIV prevalence. Common to both is a proinflammatory in utero and perinatal milieu. The aim of this study was to determine cytokine profiles in HIV exposed (HE) and HIV unexposed (HU) very low birthweight (VLBW) infants and to determine whether these were associated with predischarge outcomes.DesignSingle-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019.PatientsInborn infants with birth weight of Outcome measuresThe primary outcome was umbilical cord cytokine levels according to maternal HIV status. Secondary outcomes included death and/or serious neonatal infection, necrotising enterocolitis, intraventricular haemorrhage, periventricular leucomalacia, chronic lung disease and haemodynamically significant patent ductus arteriosus before discharge.ResultsA total of 279 cases were included with 269 cytokine assays performed on 122 HEs and 147 HUs. Median IL-6 levels were 53.0 pg/mL in HEs and 21.0 pg/mL in HUs (p=0.07). Median TNF-α levels were 7.2 pg/mL in HEs and 6.5 pg/mL in HUs (p=0.6). There was significantly more late-onset sepsis in the HE group compared with the HU group (41.2% vs 27.9%) (p=0.03). IL-6 levels were significantly higher for those with any adverse outcome (p=0.006) and death and/or any adverse outcome (p=0.0001). TNF-α levels did not differ according to predischarge outcomes.ConclusionThere is no significant difference in IL-6 and TNF-α levels in cord blood of HE compared with HU VLBWs. However, IL-6 levels are significantly higher in VLBWs with adverse predischarge outcomes, and VLBW HEs are at increased risk of adverse predischarge outcomes compared with HUs, particularly late-onset sepsis.

BACKGROUND Clinical presentations of coronavirus disease 2019 (COVID-19) among children with asthma have rarely been investigated. This study aimed to assess clinical manifestations and outcome of COVID-19 among children with asthma, and whether the use of asthma medications was associated with outcomes of interest. METHODS The Global Asthma Network (GAN) conducted a global survey among GAN centres. Data collection was between November 2020 and April 2021. RESULTS Fourteen GAN centres from 10 countries provided data on 169 children with asthma infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was asymptomatic in 58 (34.3%), mild in 93 (55.0%), moderate in 14 (8.3%) and severe/critical in 4 (2.4%). Thirty-eight (22.5%) patients had exacerbation of asthma and 21 (12.4%) were hospitalized for a median of 7 days (interquartile range 3-16). Those who had moderate or more severe COVID-19 were significantly more likely to have exacerbation of asthma as compared to those who were asymptomatic or had mild COVID-19 (adjusted odds ratio (adjOR) 3.97, 95% CI 1.23-12.84). Those who used inhaled bronchodilators were significantly more likely to have a change of asthma medications (adjOR 2.39, 95% CI 1.02-5.63) compared to those who did not. Children who used inhaled corticosteroids (ICS) did not differ from those who did not use ICS with regards to being symptomatic, severity of COVID-19, asthma exacerbation and hospitalization. CONCLUSIONS Over dependence on inhaled bronchodilator may be inappropriate. Use of ICS may be safe and should be continued in children with asthma during the pandemic of COVID-19.

As co-signatories on a consensus statement released this week (see B. Morton et al. Anaesthesia doi: 10.1111/anae.15597; 2021), we call upon all scientific journals to adopt a similar system to promote fairness in author contribution assessments for research conducted in low-to-middle income countries (LMICs) by teams that include author(s) from institutions in high-income countries (HICs).\ud \ud The system consists of a structured reflexivity statement that asks authors to answer a series of open-ended questions that broadly follow established authorship criteria (see www.icmje.org). These help to ensure that LMIC researchers and other disadvantaged groups such as women and early-career researchers are properly represented.\ud \ud Progress in addressing such imbalances has been slow (A. I. Obasi Lancet 396, 651-653; 2020 doi:10.1016/S0140-6736(20)31536-1). For example, a fifth of papers on COVID-19 in Africa contain no African authors and, among those that do, HIC authors almost always occupy the coveted first and last positions (A. V. Naidoo et al. Br. Med. J. Glob Health 6, doi:10.1136/bmjgh-2020-004612; 2021).\ud \ud Such reflexivity statements will encourage inclusive and open discussion of issues affecting equity, including capacity strengthening and research legacy in host countries.